1. Anguilla Monitoring Health Systems Change/Health Reform Presented by Dr. Bonnie Richardson-Lake

2. Background 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 2003 Population Estimate--12,200

3. Economic Activity GDP per capita-- EC$20,733 or US$7,736 in 2003 Tourism sector makes the largest contribution to GDP—28% Government Sector--18.7% Finance Sector--14.4% According to the 2001 census 75% of those 15 and older were a part of the workforce.

4. Health Indicators 2005 Infant mortality rate 18.0 No maternal deaths 2001-2005 Birth Rate 11.4 per 1,000 (2003) Male life expectancy--76.52 Female life expectancy--81.1

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

6. 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

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

8. 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

9. 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

10. 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

11. 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)

12. 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

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

14. 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

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

16. 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

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

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 Minister of Health HAA Board Chief Executive Officer Director of Nursing Services Human Resource Manager Finance Manager Facilities Manager Director of Medical Services Coordinator of Health Promotion

22. MoH Minister of Health PS Health Health Planner National AIDS Programme Coordinator Director of Quality Management/CNO Quality Management Officer

23. 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.

24. 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

25. 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.

26. 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

27. 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.

28. HEALTH AUTHORITY OF ANGUILLA HEALTH SYSTEM ACCREDITATION ACHIEVING IMPROVED MEASUREMENT (A.I.M.) WITH CANADIAN COUNCIL ON HEALTH SERVICES ACCREDITATION

29. OBJECTIVES OF ACCREDITATION PROVIDES A BASIS FOR ENSURING MINIMUM STANDARD OF CARE BENCHMARKED AGAINST INTERNATIONAL STANDARDS SERVES AS VECHILE FOR DRIVING CONTINUOUS QUALITY IMPROVEMENTS SERVES AS A BASIS FOR PROMOTING ORGNAIZATIONAL TRANSFORMATION AND CHANGE ESTBALISHES A BASIS FOR SUSTAINED SYSTEMS DEVELOPMENT

30. OBJECTIVES OF ACCREDITATION (CON’T) TOOL FOR ESTABLISHMENT OF GOOD QUALITY AND INCREASED PUBLIC CONFIDENCE IN PUBLIC HEALTH SERVICES INCREASED ORGANIZATIONAL CREDIBILITY AND ACCOUNTABILITY

31. 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.

32. 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.

33. 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

34. 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 Quality Management Unit

35. 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

36. 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) being implemented

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

38. Access 200320042005 Facilities with a doctor (PHC) 022 Pharmacy133 Immunization Coverage 100%

39. Equity 200320042005 Spending on PHC 3,145,0002,960,0003,445,000 Spending on secondary 7,200,0006,050,0006.820,000 Capital Investment 395,000375,000700,000

40. EFFECTIVENESS 200320042005 Crude Birth Rate 14.114.514.3 Crude Death Rate 5.65.55.4 In-patient deaths 3223

41. Efficiency 200320042005 Bed Occupancy 41%31%21% Average length of stay (days) 543 % of expenditure on personnel 61%79%69%

42. Sustainability 200320042005 % of spending from Government 100%77%79% Current Ratio NA1.6:11.7:1 Working Capital NA582,000817,000 Health spending to GDP 5.4%5.3%5.4%

43. 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

44. “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