KINGSTON. Wednesday, 2004 June 9
|Minister of Health,
The Hon. John Junor
Last year was a watershed year for health care in Jamaica with the establishment of the National Health Fund (NHF), the Child Development Agency (CDA) and the promulgation of the Child Care and Protection Act. This Act was passed after years of deliberation and together with the CDA created a new deal for Jamaica's children.
Through the establishment of the NHF a significant source of supplemental financing has been provided to assist in meeting the challenge of rising health care costs.
The Fund provides a lifeline for out-of-pocket health costs for the individual as well as support for the promotion of healthy lifestyles and will go a far way in addressing some of the shortfalls we have faced in other areas of health care.
It was also a year in which the resilience, dedication and proficiency of the island's health workers shone through. I pay tribute to all categories of staff for their contribution in delivering health care to the people of Jamaica albeit with limited resources. I also wish to single out the health staff in Portland and the NERHA and the Ministry, who had to go beyond the call of duty to deal with the Haitian refugees who landed on our shores.
I acknowledge with sincerity the contribution of Ambassador Marjorie Taylor, who recently retired from her post as Special Envoy-Children. The Ambassador, despite ill health sometimes, made a sterling contribution to the work of various agencies related to children. She worked assiduously over many years in the development of the child Care and Protection Bill and represented Jamaica is various international forums.
My special thanks to Prime Minister, the Most Hon. P. J. Patterson who continues to entrust confidence in me, to my Cabinet and Parliamentary Colleagues and also to my constituents and comrades in the political process for their unrelenting support and assistance in carrying out my duties.
my wife Urla, my children and grandchildren thanks for your support, love and understanding for allowing me the time to devote myself to the service of
THE HEALTH VISION
In the health sector a core role of government is ensuring that the population has access to a well-functioning health system that promotes disease prevention and delivers appropriate health care. This health system has to be based on evidence of empirical data and it must impact on those factors which affect health outcomes. Among the factors which affect health outcomes are the availability of financial resources and trained health professionals.
Yet while government and other health providers seek to ensure a well functioning health system - though policies, legislation and actions to impact health outcomes, increasingly the challenges we face today require the individual to be informed, and ultimately to make choices that will determine their own health status.
In addition achieving health and wellness for all in Jamaica, requires the active participation of communities and collaboration of all sectors - housing, water, business.
The vision we in the Ministry have for health in Jamaica therefore is that
there will be:
1. More informed individuals taking responsibility for health with practicing a healthy lifestyle
2. Caring families and communities
3. A healthy physical and social environment - nurturing body, mind & spirit
4. Good health care at low cost
5. A health service which is client-oriented
THE HEALTHY LIFESTYLE POLICY
The health of the average Jamaican resident is comparable to their relatives and friends in more developed countries of the United States, Canada and the United Kingdom. The 2003 PAHO Report on Basic Indicators shows that in Jamaica life expectancy at birth is 75.9 years. This compares to 77.3 years for the United States and Barbados, and 79.5 for Canada. We also reflect favourably when compared to Trinidad with a life expectancy at birth of 71.1 years.
Jamaica has been able to accomplish relatively good health indicators as a result of a focus on preventive care and environmental sanitation as well as our efficiency in stretching the health dollars received to deliver health care.
The challenge for us is to maintain these gains while grappling with the increasing burden of chronic diseases, the threat of HIV/AIDS and death and injuries from violence and motor vehicle accidents. Based on the evidence gathered and which has been previously articulated the Ministry will be expanding its programme of health promotion and disease prevention to combat these threats to our health.
At the just concluded 57th World Health Assembly in Geneva, a resolution was adopted for a global strategy on diet and physical activity. Once again Jamaica is at the forefront of health policy development as we are the only country in the developing world that has already developed such a policy incorporating the two areas identified. I am happy to bring to Parliament today, The National Policy for the Promotion of Healthy Lifestyle in Jamaica.
• The aim of this policy is to incorporate all Jamaicans in the process of adopting healthy lifestyles, by tackling the major risks of unhealthy diet, sedentary lifestyle, tobacco use, unhealthy sexual practices and aggressive behaviours.
Five major steps to good health are being promoted:
1. Moderate levels of physical activity practiced for a minimum of 30 minutes daily by everyone.
2. Eating right by increasing the amount of fruits & vegetables and reduce the amount of fat, sugar and salt and reducing the overall intake of food. This should be supported by the production and marketing of healthy foods
3. Practice safer sex
4. Build self-esteem, resiliency and life skills to reduce also violence and
5. Quit tobacco smoking
The Ministry is pursuing the ratification of the historic treaty - The Framework Convention on Tobacco Control Tobacco - this was recently before the Human Resource Committee of Parliament. We hope for a speedy process of legislation and we know that history will not prove wrong, the bold steps we are taking to stamp out the anti-social behaviour of tobacco smoking with its burdensome and deleterious effects.
Through the healthy lifestyle programme we are aiming to reach Jamaicans where they are at school, in the workplace and in communities:
• Teaching healthy lifestyle practices in schools is essential. How we behave is learnt early in life and what is learnt at school influences youths, their families and communities at large. We will continue to work with The Ministry of Education to expand the healthy schools programme as well as incorporate other stakeholders in education.
• Assisting communities to become involved in practicing healthy living by creating supportive and safe places for work, play and leisure activities of community members.
• The workplace offers many opportunities for creating workplace wellness programmes and we are encouraging healthy smoke-free environments, increased physical activity, and healthy food offerings in company cafeterias at the
o A baseline survey pertaining to the working Jamaican population - its physical activity and eating behaviour was completed and preliminary date shows that there is a low level of physical activity especially in the female working population and more will be said about this survey shortly.
• Sensitising food processing and fast food retail industries of their responsibility to provide healthy alternatives to the present fare will be done as well as encouraging them to adopt marketing strategies, which enable consumers to make healthier food choices.
In laying this Policy for Healthy Lifestyles on the Table of the House, we fully recognise that there are no quick fix solutions as behaviour change takes
time to induce but we must continue and intensify our efforts to encourage healthy attitudes and behaviours. I invite every single Member of Parliament to consider it carefully and give it their full support and personal commitment. Remember
healthy lifestyle slogan - "It's All About What I Put In, What I Keep Out And How Much I Do!"
The Ministry will be looking to the National Health Fund to provide funding support for the implementation of its health promotion programmes.
THE NATIONAL HEALTH FUND
Funding the health sector requires innovative sources of financing and the NHF is a sustainable alternate source which is making a significant impact on health
outcomes. The Fund is providing for the improved pharmaceutical care of persons diagnosed with 14 chronic diseases; and also providing dedicated resources for enhancing the availability and quality of health services.
Since it began operations in August 2003 and up until early May a total of 45,000 persons have registered for individual benefits with the National Health Fund.
The uptake of this benefit has begun slowly and to date 28,600 claims have been processed. The total value of the prescriptions was in the region of $15.4
million and the NHF on average provided a total subsidy of 34%.
While there may be concerns about the number of individuals applying for this benefit we should be aware of the fact that research has shown that a significant number of persons are unaware that they have a chronic disease and of those who are aware only a portion are actively treating their condition. For example the Lifestyle Survey 2000 showed that only 60% of persons with high blood pressure knew they had the condition and of those who knew less than half are managing the condition.
The thrust on individual responsibility for health is to increase health- seeking behaviour in the population and thereby also increase the number of persons who are aware of their condition and are doing something about it.
We anticipate that as more persons become aware of their chronic condition and take responsibility for their health that the number of persons applying for and using their NHF benefit will increase over time.
An analysis was done of the amount of subsidy received by patients using the NHF health card and this revealed that the subsidy ranges from 12%-49% for the various illness covered.
The NHF subsidy is calculated using as reference the best available price of the drug based on private sector distributors selling price.
In determining the subsidy by the NHF for each drug, factors taken into consideration include:
• The best available price of the drug,
• The estimated cost of treatment per year using the reference source item.
The NHF subsidy is a fixed contribution per unit towards the cost of the item, for all brands, delivering the same drug and quantity.
The NHF subsidy is based on the ability of the NHF to sustain the estimated liability taking into consideration the estimated cost of treatment and the number of cases to be treated.
However complaints have been received from beneficiaries of the Fund on the low coverage that is provided for some prescription items. The Board of the NHF is actively considering increasing the subsidy offered for some drugs as well as the possibility of expanding the number of conditions covered. However there are some concerns currently preventing the introduction of these increases and expansion.
The concerns are firstly that in some instances distributors have raised prices and while this is expected from time to time we need to ensure that these increases are not outside of the normal increases. Secondly some pharmacies are charging patients for using the NHF card often without patients being aware of such charges.
These practices are negating the benefit to the patient of reducing the out of pocket expenditure at the point of service.
The situation is being examined to ensure that the increases in benefit will accrue to the patient and if necessary legislation may be introduced to curtail these practices.
In addition the board is of the view that an increase in the number of public pharmacies with wider coverage across the island will give consumers greater addresses the House.that consumers enjoy the intended benefits of any contemplated increase.
In the area of institutional benefits the Fund began accepting proposals after the Institutional Benefit Sub-Committee was appointed in February. So far the Board has approved a range of projects valued at over $100 million. These projects approved are in keeping with the Essential Public Health Functions and cover such areas as equipment for Public Health Inspectors, renovation of an Accident & Emergency department, improvement in waste disposal, installation of a communications system.
In addition the NHF has carried out extensive upgrading in sixteen (16) public sector pharmacies. This was accomplished through the provision of equipment, civil works improvements and training, at a cost of $23.17 million.
The applications to the NHF for funding support for the public health sector for this financial year will be based on the priorities of training, pharmaceuticals and medical equipment. These are the areas which we believe will assist in achieving the strategic goals of the Ministry. These include meeting the UN Millennium Development Goals among which is the requirement of reducing the maternal mortality rate.
The target of the UN Millennium Development Goal for maternal mortality is a reduction of 75% for all countries by 2015. The Maternal Mortality Rate for Jamaica has remained constant for the past 20 years at 106-110 per 100,000 live births. The Maternal Mortality rate for the United States is 9.8 per 100,000 and Cuba 41.8 per 100,000.
To meet the MDGs would mean that Jamaica is expected to reduce our maternal mortality to 27 per 100,000 by 2015. While this goal looks formidable the Reproductive Health Strategic Plan articulates a gradual reduction in deaths from direct causes of maternal mortality thereby increasing safe motherhood.
The major causes of death for mothers in Jamaica continue to be hypertensive disease/ eclampsia, haemorrhage and sepsis. However, these direct causes have been declining over the past 4 years and indirect causes such as HIV/AIDS, violence, and other chronic conditions such as obesity and cardiac disease have been increasing. Life stresses and their impact on mental health has also come to the fore.
An important element of this is lowering of total fertility rate from 2.8 to 2.4
Total fertility rate has declined to 2.5 and of significance is the fact that teenage fertility has also shown a decrease from 112 per 1,000 to about 70 per 1,000. However there are still thousands of teenagers getting pregnant each year and effective family planning methods are among the initiatives crucial in lowering the rate.
The attendance of every birth by skilled health personnel is central to reducing the maternal morbidity and mortality and perinatal mortality. The proportion of hospital births has increased from 86% in 1996 to 95% in 2001. This indicates that women have become more aware of the need for essential obstetric care. They are moving away from midwife only services in homes, rural maternity centres and community hospitals in favour of facilities which provide a more comprehensive and specialist maternal and newborn care.
To achieve our goal of significantly reducing maternal morality rates we will be increasing the number of midwives in training and provide on-going training for obstetric care. The vacancy rate for midwives in the public sector stands at 51% in 2003. However there are now in training 30 direct entry midwives at VJH and training of midwives is slated to begin at Spanish Town Hospital in October when an additional 30 direct entry midwives will be accepted for the programme.
Improvement is also expected in the basic supplies and equipment and appropriate technology for monitoring in the obstetric units of some hospitals. Various funding proposals have been developed to seek extra budgetary support for in patient services. The use of Partographs (instrument to monitor the progress of labour) will be piloted in at least one hospital per region this year, with funding support from the European Union and UNFPA.
The health of mothers is a cornerstone of public health. When we ensure safe
motherhood we are protecting the health of the nation and this will be a priority
area for the Ministry in the coming years.
The HIV/AIDS epidemic in Jamaica continues to increase and so does its impact
on individuals, families, communities and workplaces. One indicator of this
is the HIV prevalence rate among mothers visiting Ante Natal Clinics. This rate
increased from 1.43% in 2002 to 1.67% in 2003. In addition every year one thousand
Jamaicans are developing AIDS- this translates to 2-3 Jamaicans developing AIDS
every day, and these are persons who have HIV and are not aware of it.
Effectively tackling HIV/AIDS remains an urgent public health challenge. Behaviour change with respect to safer sex practices has reached a plateau among Jamaicans. There has been little increase in the age of sexual debut or practice of abstinence. In addition 25% of men since 1992 and 34% of women since 1996 who have sex with a non-regular partner fail to use a condom at last sex. In recent years condom sales have fallen albeit marginally.
The HIV rates points to the need for individuals to take responsibility for their own health and make healthy choices to preserve their life. The Ministry
will be exploring new approaches to increase safer sex practices in Jamaica and one approach is training of health behaviour specialist to ensure the development of effective programmes.
Although there are signs of increasing involvement outside of the health sector discrimination and stigma remain widespread in the society at all levels. A mass media "Live Positive Campaign" was launched in April 2003 to reduce the stigma and discrimination towards people living with HIV and AIDS. A number of national personalities donated their time and voices for TV advertisements as well as posters. We will be calling on Parliamentarians to play a far greater role in the fight against HIV/AIDS.
The response of the Regional Health Authorities, other key government Ministries and the Parish AIDS Committees has significantly improved, but must become more effective if we are to overcome the threat of HIV/AIDS. Collaboration and the involvement of community groups, civil society groups in prevention, treatment care and support efforts are crucial for future progress in the fight against HIV/AIDS.
Among the initiatives pursued to meet the increasing challenge of HIV/AIDS support of persons living with HIV/AIDS, training and community based interventions. And significant achievements were made in these areas.
Jamaica's proposal to the UN Global Fund was successful, a regional training centre was established at Comprehensive Health Centre with the support of USAID, the Priorities for Local Aids Control Efforts (PLACE), has been implemented in Montego Bay, Negril, Kingston and Spanish Town, the HADDS fund was set up, hundreds of staff were trained.
Priorities for Local Aids Control Efforts (PLACE), is a major new initiative introduced in 2003, to identify persons most at risk of HIV infection. The method seeks to identify places or sites where people go to meet new sex partners and obtain information on sexual practices. The data collected is extremely useful in guiding targeted prevention interventions at these sites and in providing a baseline for measuring the effectiveness of interventions.
The method has been introduced in Montego Bay, Negril, Kingston and Spanish Town with areas with the highest number of HIV/AIDS cases.
Until now, treatment has been among our weakest response to the disease. HIV is preventable and it is also treatable. Anti-retroviral Therapy holds out hope for longer and better lives for those already infected. The UN Global Fund Grant of one billion three hundred and eighty million dollars ($1.38B) for five years, was signed in Geneva last month and will provide resources to develop a public access program for Anti Retroviral treatment of persons living with AIDS. The prices to be accessed for drugs and diagnostics tests are those negotiated by the Clinton Foundation with whom we shall shortly sign an agreement. The programme aims to supply Anti Retroviral Therapy to 2,000 persons in the first two years. In the second phase approximately 5,000 persons living with AIDS will receive ART. This programme will also enable us to protect people from a wide range of opportunistic infections.
Funds obtained to deal with the HIV/AIDS challenge will also strengthen our health system and thereby improve overall health care delivery. For example there will be improvements to the National Public Health Laboratories and the National Blood Transfusion Services, including a Laboratory Information System and disposal of infectious waste.
In addition funds received from the Global Fund will also strengthen the Health Information system and infrastructure improvements of health centres across the island.
The use of information systems technology is critical for improving access to cost-efficient, quality health care; service operations and management. The Ministry's video conferencing environment was developed and successfully used in holding meetings between the head Office and the Regions, thereby reducing travelling and other costs. In terms of the expansion of LAN/WAN, all four Regional Health Authorities have installed frame relay connection at the MOH, which replaced the existing leased lines and are faster and cheaper to operate.
A CLIENT ORIENTED SYSTEM
Confronting the health challenges we face requires a strong health system that is client oriented; where institutions, people and other resources ensures quality health care for all and equitable access. This implies geographic access as well as economic access - so that no matter where you are in the island or the amount of money you earn you should be able to get good health care. This is the ideal situation.
Establishing and maintaining such health systems costs money especially in the face of increasing demand - as we have been experiencing in the public health sector. The Hospital Monthly Statistical Reporting System showed a total of 727,977 visits an increase of just over 47,000 visits for the previous year. I'll select a few areas to demonstrate the increases:
The total number of clients using public sector pharmacies increased from 688,801 in 2002 to 733,882 in 2003.
The radiography units in the public sector conducted 245,936 examinations on 223,478 clients in 2003. These figures represented increases of 17.8 percent and 13.3 percent respectively.
A total of 38,530 operations were done in public hospitals in 2003, an increase of 7.0 percent over the previous year's figure of 36,008
In order to evaluate our level of client satisfaction, last year a survey was conducted which focused on among other things: Accessibility, Satisfaction, Cost/Affordability/Payment.
In terms of Accessibility, nearly two-thirds of the respondents agreed "somewhat" and "strongly" on being able to easily access medical services. An even higher percentage (88.6%) indicated that they were satisfied with the quality of service, but expressed displeasure with having to wait for hours before being attended.
As it relates to the financial burden of medical service and prescription responses were split. About 56% of respondents said paying for medical services was not a financial burden and 43.7% felt that it was.
On the other hand the Regional Health Authorities now in their sixth year of operation are meeting the increased demands for services despite not receiving the levels of funding required. In fact the increased level of services provided has implications for staffing levels and the need for equipment and supplies
I am happy to report that there has been a general decline in the vacancy rate of some health groups when compared to 2002. The total Registered Nurses declined by 5 percentage points (from 22% in 2002 to 17% in 2003). Lesser number of nurses migrated and in addition nurses returned to the system from CARICOM and other countries in the region. The vacancy rate is expected to go down further as a result of increased training from intake in 2000, with the exception of course any major recruitment drives from overseas.
While we are encouraged by the declining vacancy rates in some areas, we are also mindful of the great shortages in others and the increased demand for services, which is putting pressure on existing staff. In addition the global health workforce crisis also results in our losing trained professionals to overseas health systems. In this regard I salute the Unions in the health sector for signing the MOU with the government. In the health sector remuneration makes up over 90% of the budget received from the Government. Further increases in salaries at this time would impact severely on the provision of health care and revert health gains and health outcomes. We anticipate that despite the challenges that we face in health that members will remain committed to the sector locally with the signing of the MOU.
As we seek to further develop the health sector and meet the demand for services and the objectives of equity of access and improved quality with wellness for all, there is a need to scale up training for health professionals at various levels and skill categories.
In this regard a review of the infrastructure of the Kingston School of Nursing and the Cornwall School of Nursing is being undertaken to see how we can expand the facilities to increase the intake for training of nurses in these institutions. In addition we are also forging links to strengthen the capacity of other local training institutions to increase output of trained nurses. This involves providing clinical sites in public health facilities to accommodate practical/clinical training. A number of clinics are to be upgraded for this purpose. But increased funding must be found to make local expansion of training possible to meet local demand this is why the direction to NHF prioritises training. This year we also intend to finalize arrangements for offshore training of health professionals.
The Health Ministry is also seeking to expand the total number of scholarships being offered for training especially in the primary health care including nursing, pharmacy, environmental health and those areas such as diagnostic radiography where there are dire shortages.
In the meanwhile we continue to recruit from other countries. A total of 44 nurses, 4 cytotechnicians and 6 pharmacists were recruited from Cuba under the Jamaica/Cuba Technical Cooperation Agreement to bolster the health cadre.
Providing for the increased demands and improvement in customer satisfaction also requires replacement of old equipment with more modern technologies and in addition an efficient and effective maintenance system.
It goes without saying that improvements in the area of infrastructure, staffing and other resources cost money, and raising fees for services is inevitable. The Ministry will ensure however that the fees charged at the point of service will not be obstacles to obtaining the necessary care.
HEALTH CORPORATION SERVICES
Health Corporation Limited (HCL), is also playing a major role in fulfilling the vision of providing good health at low cost. It is the major supplier of pharmaceuticals and medical sundries for the public hospitals and health departments. The majority of HCL's procurement is through an efficient, international competitive tender system, which facilitates access to the highest quality products at internationally competitive prices. Suppliers are awarded contracts for an 18-month period during which time they agree to maintain their prices. The current tender period began in January 2004. As part of its post tender activities, HCL conducts a comparative analysis with prices from the previous period to determine the effectiveness of the tender exercise.
The comparative analysis revealed that 76% and 87% of prices for pharmaceuticals and medical sundries, respectively, were the same or lower than prices for the previous tender period. This represents a J$41.3 million savings in the cost to the Ministry of Health due to the competitive bidding process. Additionally, when the awarded prices were compared with the next lowest bid the difference in price amounted to J$271 million. The implications are that without the international competitive tender system the country could be paying in excess of J$271 million more for pharmaceuticals and medical sundries.
In keeping with the focus of a client-oriented service the Agencies of the Ministry of Health are all working towards this goal and recent reports have been brought to parliament on the work of these Agencies including:
The National Family Planning Board
The National Council on Drug Abuse
The Pesticides Control Authority
The Child Development Agency
In this regard I just want to mention that the Child Development Agency will on June 1, 2004 start the nation wide use of the CDA care plan. This will ensure that case management for each client is conducted to required standards and that clients are afforded proper supervision and intervention.
REGISTRAR GENERAL DEPARTMENT
During the year the Agency centralized its electronic database of vital events, which facilitates improved management of the database with timely and efficient production of reports and speedier processing of applications. This electronic system is on par with the methodology used by the Centre for Disease Control of the USA.
The Registrar General's Department during the last fiscal year received 282,073 applications and satisfied 283,715. This of course included some applications prior to that time.
In order to improve customer satisfaction, Same Day Service was replaced by Next Day Delivery. Customers pay and leave and have the certificates delivered to them on the following day. In addition island-wide delivery of certificates is also available for other services. This has resulted in a significant reduction in waiting time at the RGD's offices island-wide.
The challenge of providing a strong health system does not lie in our ability to only find money, train people and get across to Jamaicans the concepts of individual responsibility. It requires a change in some of the myths about the delivery of health care - That providing sufficiently for the population requires a clinic in every community and that if one sees a doctor, the presence of the doctor means that one is able to get the best of care. The fact is that one also has to look at the utilization rate how many persons are actually using the centre/service in that location. It may be more efficient if one were to transport patients to a central centre where there are trained health personnel/specialist and biomedical equipment to assist in quality diagnosis and treatment. Take neurosurgery for example - it is not feasible to have a neurosurgery centre in every major hospital. Spending health dollars wisely may require centralization of specialist and other health care.
I want to take this opportunity to challenge professionals in the health sector to become more involved in national debate on health issues- National Advisory Council which was recently approved by Cabinet should ensure a broad base of inputs for the development of health policy.
Much progress has been made in the health sector in Jamaica and we've also had some setbacks. Our aim is to use these lessons to improve client services while we maintain the gains of the past and reduce the burden of chronic diseases, HIV/AIDS, and injuries from violence and motor vehicle accidents.
Lee Jong-wook the Director General of The WHO in his message for the 2003 World Health Report says, "Effective action to improve population health is possible in every country but it takes local knowledge and strength to turn that possibility into reality."
Together we can build a strong and healthy Jamaica with intensified collaboration among all partners. We can make progress that will mean longer healthier lives and lay the foundation for improved health for generations to come.
People's National Party
89 Old Hope Road
Kingston 6, Jamaica W.I.