1. Anguilla’s Health Reform:
Towards Strengthening Health Systems and Improving Health Care Provision
Presented by Dr. Bonnie Richardson-Lake
Permanent Secretary Health & Social Development

2. Outline
Background
Establishment of the Health Authority of Anguilla (HAA)
New Role for the Ministry of Health
The National Health Fund
Other Initiatives

3. Background United Kingdom Overseas Territory
Most Northerly of the Leeward Islands
United Kingdom Overseas Territory
A Governor appointed by the Queen presides over an Executive Council made up of 4 Local Government Ministers, the Deputy Governor and the Attorney General
35 Square miles
2001 Census--11,561
2006 Population Estimate—14,000

4. Economic Activity GDP per capita-US$ 6,718 in 2005
5% of GDP was spent on health care in 2005(approx 15% of total govt budget)
Tourism sector makes the largest contribution to GDP—28%
Government Sector--18.7%
Finance Sector--14.4%
Less than 1% unemployment

5. Health Indicators 2005 Infant mortality rate 18.0
No maternal deaths
Birth Rate 11.4 per 1,000 (2003)
Male life expectancy
Female life expectancy--81.1
You can see from these indicators that overall health is relatively good. However Anguilla like most countries in the region continue to struggle with the control of Chronic non-communicable disease like diabetes, hypertension and cancers

6. Top Causes of Death (2004)
Cancer
Diabetes
Heart Disease
Stroke

7. Health Care System
Health care system is comprised of both private and public sector
Public sector health care is delivered by the Health Authority of Anguilla
Primary Health Care is provided in five health centres throughout the three health districts

8. Primary Health Care Health Centres are staffed by: Physicians
Pharmacist
Dentist
Public Health nurses
Nurse midwives
Physiotherapist
Community health aides
Clinic aides

9. Primary Health Care Services provided: Maternal and Child health
Family Planning
Immunization,
Nutrition advice
Care of the elderly
Management of chronic diseases
Health education.
Pharmacy Services
Physiotherapy
Home Visiting
General Medical Care
Community Mental Health

10. Secondary Care
Princess Alexandra Hospital is a 36-bed facility which provides:
Emergency treatment
Surgical Care
General medical
Pediatric
Gynecological and obstetric care
Laboratory services
Radiological and Diagnostic services
Pharmacy services
Physiotherapy

11. Secondary Care Long-term Care—16 bed senior citizen’s home
A 12 bed in-patient psychiatric wing is currently under construction and should be commissioned by the end of this year
The unit will provide services to those with acute psychiatric illness

12. Anguilla’s Health Care Reform
In 2000 the Government of Anguilla (GoA) took the decision to place the delivery of health care services under a semi-autonomous statutory body—The Health Authority of Anguilla (HAA)

13. Anguilla’s Health Reform
GoA was committed to attaining the most productive use of resources and a more timely response to the overall requirements of the health service.
One of the main objectives of the reform was to attain a greater degree of efficiency in health services and an improvement in the delivery of quality health care
Having HAA separate from the Ministry of Health (MoH) removed much of the bureaucracy typically associated with the general Public Service

14. Anguilla’s Health Reform
Management responsibilities delegated to the HAA included:
Financial
Human Resource
Operational Delivery of Health Care Services

15. Advantages of a Decentralized Model
The devolution of the health services has several advantages:
Increased speed and clarity in decision-making and implementation
Health care can best be administered within the framework that allows institutions to manage their resources (both financial and human) directly
More empowered health officials with greater responsibility for the outcome of decisions
Decisions are made at the service delivery or board level
Dept heads control their own budgets—programme budgeting

16. Advantages of a Decentralized Model
Increased Sustainability
Improved Equity
Increased Quality

17. Preparatory Work
Before the HAA could be commissioned several critical activities had to be undertaken. These include:
Establishment of a Health Authority Project Board to recommend an implementation strategy and later the establishment of a Shadow Board
Governance Structure of the HAA
Legislative Framework—a bill for the establishment of HAA was developed with the assistance of an international legal experts

18. Preparatory Work
Development of personnel policies and transition arrangements
Development of financial management systems
Communication Plan for staff and public
Development of a National Strategic Plan for Health and subsequent service plans
Development of service agreements and new performance measurement systems
Selecting and training of key managers and Board Members
Officers were not given a choice in transfer, but were moved up a step in the pay scale. Legislation is written so that public officers who moved to HAA are not worse off than before the transfer.
Strat plan provided direction for the development of the operational plans of each of the departments under the HAA

19. Preparatory Work
All of the activities were coordinated by regional consultant funded by DFID

20. HAA
The HAA was commissioned in December 2003 and became operational in January 2004 under the Health Authority of Anguilla Act

21. Structure of HAA

22. MoH
This represents just the health portion of the Ministry of Social Development.

23. Role of the MoH
After the devolution of the health services to the HAA, MoH maintained the following functions:
Policy direction
Strategic Planning for Health
Regulatory/licensing functions
Monitoring & Evaluation

24. Strengthening the capacity of MoH
The MoH has sourced a consultant to assist with the following objectives:
Development of a performance measurement framework
Examination and assistance in improving the Anguilla MoH Quality Management program including staff training.

25. Strengthening the capacity of MoH
Integrate epidemiology to enhance the use of information and the effectiveness of policy making, program development, and assessment related to population health.
Evaluate and help improve the Ministry’s Health Planning functions.

26. Strengthening Health Systems
National Health Fund:
It is proposed that a National Health Fund (NHF) is created to purchase health care for the whole population of Anguilla as clinically needed and in an equitable manner.
The NHF is based on a primary health care model

27. Pre-requisites for the Establishment of the NHF
The provision of the Health Services be removed from political interference
Establishment of the HAA
Quality of health services improved
Accreditation of the HAA by the Canadian Council on Health Services Accreditation
NHF management must be free from political interference
Establishment of the NHF Board and the recruitment of the NHF Director

28. National Health Fund
The NHF has been based on the guiding principles of social health insurance which include:
solidarity - pooling the financial risk for the whole population
sustainability - creating an independent funding mechanism able to match revenue to needs

29. NHF
equity - introducing a prospective payment system removing financial barriers to access
efficiency - avoiding the fragmentation and high overheads of multiple funding sources
effectiveness - developing technical purchasing capacity in the NHF
accountability - including mechanisms transparency and consumer involvement.

30. NHF
The Fund will be managed to ensure that money is spent on high-quality, value-for-money services, and not wasted on unnecessary treatment. Individuals will contribute to the Fund when they are economically active, but the Fund will pay for care for everyone as it is needed, including children and the retired

31. NHF It will be financed by a combination of:
Contributions from employers and employees based on income
An annual GoA contribution from the Consolidated Fund (which may result in a new levy or levies on the consumption of selected items)
Any other sources as may be decided by ExCo from time to time.

32. Financing Options
Contributions of 5% of monthly income; 2.5% from employers and 2.5% from employees
an annual GoA contribution from the Consolidated Fund which will include
Monies used to pay for health coverage for Civil Servants
Monies allocated to medical treatment overseas
Monies currently paid to the Health Authority of Anguilla
Any other sources as may be decided by GoA Executive Council from time to time

33. Anguilla NHF Operations
The Fund will buy health care services from providers offering services to a standard acceptable to the Fund
It will be managed by a technical capacity able to negotiate quality and prices with providers.

34. Anguilla NHF Operations
Providers will include the HAA and approved private practitioners.
Selected overseas hospitals will provide specialist tertiary care that cannot be provided adequately on-island

35. Payment for Procedures
Primary care will be purchased by the Fund for consumers
Providers will be contracted (through an annual service agreement) based on the number of consumers registered with them, and not on a fee-per-item-of-service reimbursement basis.

36. Anguilla NHF Operations
Access to hospital and specialist care paid for by the Fund will be through referral by approved primary care providers only.
Access to sub-specialist care overseas paid for by the Fund will be only through referral by approved secondary care providers – in practice, the HAA.

37. Anguilla NHF Operations
Overseas specialist care will be purchased on a fee-for-service basis but under pre-agreed unit rates. Charges, utilisation rates and the validity of treatment will be monitored by the Fund to maintain quality and value-for-money, and to stay within budget.

38. Patient Registration
Providers will be accredited to provide services under the NHF subject to the satisfaction of the Director of the NHF that services provided are of a sufficiently high standard

39. Patient Registration
Consumers will be required to register at one primary care provider within 3 months of registering with the NHF
They may do this at the start of the Fund’s operations or when they visit a provider for the first time.

40. Patient Registration
All dependents and family members will register with the same provider and providers will be limited by a maximum list size in order to ensure quality of care
The maximum list size will be decided by the Fund but is likely not to exceed 2,000 persons to include NHF-funded and non-NHF patients.

41. Patient Registration
Providers are prohibited from excluding patients wishing to register with them until the maximum list size of patients has been reached.

42. Patient Registration
Patients may register with another provider under the following conditions:
the receiving provider has space on his/her register for the entire family
at least 30 days notice
changes cannot exceed more than 3 in a calendar year

43. Other Interventions to Strengthen Health Systems
Establishment of a Department of Health Protection including the appointment of a Chief Medical Officer, Surveillance Officer, and Epidemiologist
Updating of Environmental Health Legislation

44. Other Interventions to Strengthen Health Systems
Development of legislation to regulate health professionals
HAA surveillance officer identified and dedicated specifically to surveillance activities
Establishment of Directorate of Health Services Quality Management

45. Expansion of MoH Human Resources
Approval of post for Surveillance Officer for the Ministry
Establishment of a Health Planner post separate from planning in other social sectors
Expansion of the Directorate of Health Services Quality Management
Expansion of the National AIDS Programme

46. New Approaches to Health Systems Management
Annual Services Agreement in effect
Performance Appraisal Process implemented
Recognition and Reward programme established
Quarterly reviews in effect
Operational planning framework implemented
Full delegation of budget to managers

47. New Approaches to Health Systems Management
Board Committees established – Patient care, Nursing, Human Resources and Finance
Management Committees established – Quality and Audit, Health and Safety, Disaster Management and Information Management being implemented
Instrument of Communication (MoH/HAA)

48. Framework of Objectives to evaluate Health Sector Reform
Access
Equity
Quality
Effectiveness
Efficiency
Sustainability

49. Access
2003
2004
2007
Facilities with a doctor (PHC) 2 3
Pharmacy 1
Immunization Coverage
100%

50. Access
The reorganization and expansion of primary health care, more patients have access to core basic package of primary medical care
The establishment of health districts and the availability of a health team comprised of family physicians and professional nursing staff, these centres now provide a more sustained and reliable package of services from 8.00 a.m. to 4.00 p.m.
The result has been a decrease in the number of non-emergency cases in the A&E

51. Equity
2003
2004
2005
Spending on PHC
3,145,000
2,960,000
3,445,000
Spending on secondary
7,200,000
6,050,000
6.820,000
Capital Investment
395,000
375,000
700,000

52. EFFECTIVENESS 2003 2004 2005 Crude Birth Rate 14.1 14.5 14.3
Crude Death Rate
5.6
5.5
5.4
In-patient deaths 32 23

53. Efficiency 2003 2004 2005 Bed Occupancy 41% 31% 21%
Average length of stay (days) 5 4 3
% of expenditure on personnel
61%
79%
69%

54. Sustainability 2003 2004 2005 100% 77% 79% Current Ratio NA 1.6:1
% of spending from Government
100%
77%
79%
Current Ratio NA
1.6:1
1.7:1
Working
Capital
582,000
817,000
Health spending to GDP
5.4%
5.3%

55. Client Satisfaction
80% of patients view doctors as professional and caring
78% of patients described the food as very good / good on taste, appearance and choice
94% of patients viewed the physical environment as very good / good compared to 64% in 2004
95% of dental patients felt their needs were met
85% of dental patients viewed staff as prompt and helpful in 2005 compared to 73% in 2004
Source: Health Information Department

56. “There is a need for change to ensure quality, efficiency, equity, cost containment, financial sustainability, and inter-sectoral collaboration. The outcome of this new dispensation of change seeks to give the people of Anguilla greater access to health services and empower individuals and communities to assume responsibility for their health.”
---Source: Anguilla’s National Strategic Plan for Health