 Good day and welcome to Issues and Answers, a production of the Government Information Service. I am your host for today, Mr. Jacques Henson-Conton. So today we're here to talk about the, very briefly, the St. Lucia Health Systems Strengthening Project, which is a collaborative effort of the World Bank and the Government of St. Lucia. But more specifically, we're going to talk about the monitoring and evaluation of an initiative within the project called Performance-Based Financing. And with me to talk about this is Ms. Ira Isaacs, who is the Monitoring and Evaluation Specialist of the St. Lucia Health Systems Strengthening Project. Welcome Ms. Isaacs. Thank you for having me this morning. So let me just start off by very briefly having you explain about what the St. Lucia Health Systems Strengthening Project is, in very brief terms. Very brief terms. So a few years ago, and I have to say a few years ago, maybe like ten, five years, let's just say that, we identified that there were some gaps in the health sector. We needed to have strengthened those gaps to improve the quality and the efficiency of our healthcare services. And so we came together with a framework, part of that was National Health Insurance, the Performance-Based Financing Project that you're a speaker of. And we recognized that we had really needed to improve our service delivery. And so the project aims to do that in many different aspects. Yes. Okay. So also, now I want to talk about monitoring and evaluation, your responsibility. Yes. What exactly is monitoring and evaluation? You know, you ask that question and it's always a little ticklish to say exactly what it is. It's just a very broad thing. Very good. Yes. But I think I would like to explain it in a way that other persons would understand. Let's say you want to cook a meal on a Sunday. Yeah, yeah, I like to use very simple terms. Let's say you want to cook a meal on a Sunday. You know all the ingredients that you need. You go to the supermarkets. Before you do that, you write a list of things that you're going to get. You want to ensure that you get everything so you don't get back home and you didn't accomplish your shopping. That's why I need a list because most times I'll forget. Very good. So that is called putting together a framework to ensure that the recipe, yeah, based on the recipe, you get to the supermarket. Maybe you have to look at, do you have enough funds, do you have enough money in your pocket? And if you don't, that means we're going to have to leave something behind. Yeah, but what do you leave behind when you have a recipe, right? A strict recipe. So monitoring what it really does, it looks at the framework. What do you want to do? What are your resources that are existing? Can we skip something to just to get it working? And we will monitor over time, but did we get all the ingredients that we need? Evaluation says, what did we learn after we cook this meal? Maybe we shouldn't have missed that salt. Maybe we should have added an extra couple of seasonings. Yeah. So it's a very kind of a trial and error. So while an initiative is being launched, or even before so, and while it goes on into its life, you are evaluating how effective it might be. Right. So for the healthcare sector, let me explain it this way. We want to increase screening for diabetes and hypertension. We said we want to have the ages 18 and above. So the screen asks the question, how many of those 18-year-olds and above did you capture, came for screening? But did you reach them? Were they satisfied with the services that you give them? And all that is part of evaluation, because if they are not satisfied, what did we do wrong? Or what did we do right? And so this is what monitoring evaluation does, but it strictly depends on collecting information. You remember I said we need to get that recipe. So the collection of information says, did we actually do the things we were supposed to do for the persons who we are supposed to do it for? Did we do it at the right time? Did we inconvenience them in any way? And so we will go back and reevaluate, because what we are focusing on in quality, improving the quality of our services, is that it's not just that it's convenient to me as a healthcare professional, but it's also convenient to the public as well. The families, the communities. And so it calls for what we call co-design. It calls for co-design. And co-design says that we will not just say, okay, we're coming to do screening for diabetes and hypertension, but at what times can we come to you? Where are some of the places that we can come to you? Maybe you're going to the barbershop a lot, the salons, the market, and so it gives us the ability to just evaluate our services and how could we get it more accessible to the people without inconvenience in them. So monitoring helps. We have what we call indicators, so I want to maybe screen 50% of the population who is eating and above. Now after I identify, where am I going to meet them? And then when I've identified that and I've gone maybe to the barbershop market, would it please with it? If they won't please, how do we fix that? So a lot of your monitoring evaluation or your M&E process, it might involve interviewing patients. Right. And so this is something we want persons to understand. We will take just a touch extra time. Yeah, a touch extra time. Because sometimes persons come and we may spend 20 minutes giving them care. Because we need to collect the accurate information, the nurses would ask, your name, who is your next-of-family? What are your email address? What are your contact numbers? Where do you live? Other than here, where else do you stay? And I know people think you're trying to pry into my business. No, we're trying to collect as much information so that we can identify where you are, when you need us. And when we think that we need to come and meet you. So it does take time to collect this information. And we have a system called SLUIS. Most persons who have already accessed the care at the health facilities know that, you know, we're always on the computer tablet, something taking information that is collecting information. And it will take some time for us to ask you the questions. We are asking, please, that you be as honest as possible with the questions. So that when we are doing interventions, and when I say interventions, let's say that there is a program where we say we are going to give monitors for checking blood pressures. And we said we want to give these to our clients who we know have hypertension. Where are they? So we will put together that list based on the information that we have already gathered and then we will come to you. We will put a notice out, yes, but we want to move away from that aspect where the clients are always coming to us, the patients are always coming to us. Why can't we come to you and you need to help us come to you by giving us the correct information? So it does take time, yes, collecting that information. Now that you briefly a while ago kind of touched on diabetes and hypertension, which is very interesting and integral to PBF or performance based financing. So briefly, before we go on to our next break, just explain what performance based financing is. So some persons would hear the term result based financing and performance based financing. So the performance based financing, we set what you call quality parameters. Quality parameters and one of them might be client satisfaction. They're satisfied with what you're doing for them. It might be how many persons did you actually screen in a day? So based on the quality parameters, we evaluate, we monitor and evaluate the healthcare service that is rendered by the healthcare professionals and the providers. And what we do is that based on your services, based on your quality of the services that you're giving, then an incentive is given to you. Okay, let me just put you on pause just for a few moments. We'll do for a break. I'm Jacques Kingston Compton. You're watching Issues and Answers. Stay tuned until we return. The Department of Finance has introduced the Electronic Government Procurement System, EGP. The EGP system has many benefits for stakeholders involved in government procurement. And government seeks to adopt a strategic approach to its purchasing process. Electronic government procurement improves efficiency of procurement and enhances data capture. The EGP is innovative and will automate the sequence from notification, receiving and evaluation of submissions to final contract award. It improves communication between vendors and government agencies, provides greater transparency and builds confidence in the vendor community through increased access to information. To participate, vendors, suppliers, and contractors must register on the Electronic Government Procurement Platform. EGP, Improvement Efficiency and Transparency in the acquisition of goods, works, and services. Welcome back to Issues and Answers. I am here with Ms. Ira Isaacs, the Monitoring and Evaluation Specialist of the St. Lucia Health Systems Strengthening Project. And what we're talking about right now is monitoring and evaluation of an upcoming initiative in the St. Lucia Health sector called Performance-Based Financing. Yes, so Ms. Isaacs, before we went on the break, you were talking about what exactly is the Performance-Based Financing initiative. Yeah, so we call it Pay for Performance. Meaning to say, as I was explaining, based on your performance as a healthcare provider, we give you the dimensions. So we say we want integrity in your services. We want the clients or patients to be satisfied. We want to look at the waiting time, how many persons, when you treat them, come back to you. So those are deciphered things that we will be looking at and based on that, we will be giving them an incentive. What I would say, though, is not just looking at it from the client's perspective or patient's perspective, but also the healthcare professional's perspective. We want to know the interventions and the support that we're giving you in the project, is it really helping improve the quality of your services? And so when we look at value for money, that is something we're going to compare it to. And so remember I said about cooking a meal. What if after you've cooked the meal, based on the, let's say you paid what, $200 for a nice, good cooked meal? But then it didn't really come out the way you wanted it and it's not every Sunday you can't do it because it's expensive, right? That's called value for money, right? So this is what we want to ensure that it's not just that we're giving you something, but that we're giving it to you in a manner in which we can continue to give it to you. And this is something that has been happening to us in healthcare. How do you place value on people's lives? How do you place value on doing something that's going to improve the quality of somebody's life? And so that is why the PBF, as we call it, performance-based financing for non-communicable disease, which is hypertension and diabetes. We want to ensure that we don't come and just do something. We do it right. We do it for the people who actually need it and that we can sustain it and that it actually has a benefit for you, for your family, for your community, in your workplace, national development, contributing back to our economical development. So these are the things that we really need to take into consideration. It's a new project. It has never been implemented before in St. Lucia or the rest of the Caribbean, per se. You find this model in healthcare being implemented in middle to higher development countries, not a developing country like St. Lucia. So this is our first time, so we really do have to look at it, monitor and evaluate it very closely. So can you go into a little bit more detail why and how it's going to be monitored and evaluated? Like, why does PBF, in a broader sense, need to be monitored and evaluated? Well, as I said, it's new. And anything new needs to be evaluated on the impact. So we said we are going to improve screening and patient management for diabetes and hypertension. The reason why we are monitoring it, as you said, is that we want to ensure that we capture the right amount of persons, that we are not doing any harm to you, that we learn our lessons as we go forward to do risk management. That's important. Managing the risk. Are we overspending? Are we spending enough? Are we actually capturing the right needs of the patients and their families, the community? Are we overburdening the healthcare professionals? We need to monitor that. We need to monitor that. And as we learn the lessons in the evaluation aspect of it, we will make our changes. There is a model that is usually termed. And anyone who has done quality management system, and I'm saying to Betty Cumbia and the Rourof Standard now, I'm calling their names, they have been improving the understanding of persons in what quality is. And we have a model we call PLAN. You do it, you check, and then you act. So we have already planned what we are going to do. Then we are going to actually do it. Based on what we say we are going to do, we're going to check the monies, how our professionals and our patients feeling, how is it impacting the community? And in any way we will, best practices, great, we've got that down. Practices that are not doing well, let's reevaluate it. Let's go back to the drawing table and that's the act. The act says if it's not going well, let's go back to the table and see how we can improve or change to make it better. So there's also a lot of engagement with internal stakeholders like the medical staff and patients all that. Yes, and that is why we coined the term co-design, because it's not us sitting at a table in an office, putting things on paper and then saying, do this. No, no, no, no. We go and I really want to say thank you to the nurses and the doctors who have been helping us along the way so far. They sit down and say, this is what we do now. And so we compare it to what we call guidelines. So this is what you do, but what is the minimum requirement? So we improve you, we improve your services, we improve the facilities, we improve your competencies to a level of where it should be, even at the international market, on the original market. And then as we improve that services, as we improve the services, then we will decide, okay, you know what, they're doing well. They're doing well. So the co-design says we're working with both the healthcare professionals and then as we go along, we are listening as well to the patients. And that is where we do survey, questionnaires. And that's why I say it's going to take a little bit of time, people, but we need to get your feedback because it's based on your feedback, we will know if we're doing what we're supposed to do and we're doing it well. So could you speak a little bit about what sort of impact let's say that you think may occur with regards to, let's say, your social, economic, environmental impacts of PBF? That's a big question, Mr. Compton. Like why, I mean, you may, what you say now may be wrong, but is there anything that you expect? I know PBF is relatively new to the Eastern Caribbean, but do you see any, other than it, do you see any negative impacts of the launching PBF initiative or do you mostly see any positives? Just positives. So we are going to make assumptions here. And that's okay to make assumptions because they do formulate the pattern for risk analysis going forward. And I'm trying to make, I'm trying to stay as simple as possible so that the public and everyone understands what we're trying to do. Impact socially, let's go to the social aspect. We are trying to be more, as I said, accessible and have a community-based interventions. So we want to hear the voices and that is bringing us together. I would say it's more for unity and togetherness, health is in all policies. And so when we look at the social aspects of it, for instance, I'm just going to give a key scenario. An individual of 25 years, they come to us in the news screen and we realize, hmm, you're at risk right now for your borderline to be in a hypertensive. 25 years, what could you be stressing about like that? This requires us now to take some interventions such as counseling. Let me just hold off on you right there. Just hold on to that thought. We're due for another break. This is Issues and Answers. I'm Jacques Kingston Compton. Just stay tuned, we'll be back in a bit. Come back to Issues and Answers. I'm Jacques Kingston Compton and we're here talking with Ms. Ira Isaacs, the Monitoring and Evaluation Specialist of the St. Lucia Health Systems Strengthening Project. And we are talking about monitoring and evaluation of the performance-based financing system in the healthcare sector. So yes, you were speaking about... The social aspects. So the impact that we're hoping to have and we're assuming is that to have more community-based interventions. And the community-based interventions meaning we want to have a partnership with our communities, our patients, in how we are giving them care. It shouldn't be just based on, yes, the science is good, but there's a social aspect of it. People are also, they have their own opinions, quality of life, and we've seen it. A person who is 25 years, borderline, hypertensive, you're 25. And this is a reality in some cases that we are seeing. Our persons are getting younger and younger with diabetes and hypertension. COVID-19 showed that there is something happening in our society. But we're waiting for them to come to us. We now need to go to them because waiting on them to come to us, it's taking a bit, we capturing them when they're almost at a point where they have in the onset of the disease. And we need to do some preventative measures. So that brings me to a couple of questions. One, why are you specifically targeting diabetes and hypertension? And do we, the St. Lucia as a culture have an issue with coming to the doctor first? Or do we just like to wait? Do you find in your research that patients like to wait until the very last moment when there's something wrong? There's so many dynamics to that question. There's so many dynamics. You see, one, we have to have a real, let's have an honest conversation on the fact that we do have a shortage of healthcare professionals. And so as much as I'm sitting here and say, we want to come to you, the same nurse that you're meeting in the wellness center at the health centers, as you call it, is the same nurse who's going in the communities most of the time. And so when we look at it, it needs that we need a restructure and we need to bolster our response in the sense that we need to start training other persons. And maybe we don't need to just look at it from an aspect of it has to be a nurse. Yeah, we can train other persons to help us be the frontline in the communities doing an assessment. Persons don't come to us a lot of the times because they're busy working. Most of the time a person works from eight to five. Eight to five. And for them to come to us or to seek healthcare, they need to leave their jobs, come to the health center. I'm talking about a working class. And persons have their lives living for whatever reasons. So it's a case where now we are looking at, it's from an aspect where we're doing this, is how do we really meet them where they are without burning the healthcare professionals and bringing them, not going to them, meeting them with occupational health in the workplace is something that we would look at as well. Money, finances, persons have their lives living and they might not be able to afford care. Now a person might say when you go to the public health facilities, it's free. Some aspects of it is free, not all of it. But then what if a person is getting paid by the hour? So then they have to leave what? Two, three hours to come to us and then that's the revenue that they're losing. For the person who's 25 and probably having issues, do you need counseling? So this is patient management. It goes way further. You might say you're just checking some body pressure but when you check the pressure there's going to be and there's something wrong. We need to see how to fix it. I'm sorry to put in a fix because I don't think people are broken. I just think they need help. But that's it. How do we help you get to the best health? So, other than- I don't know if I answered the question because you asked, you asked why. But there are so many reasons why. But do you also find that there's a high prevalence of diabetes and hypertension in the country? Is that really what you're trying to tackle? Yeah, yes there is. And COVID-19 showed us that. And a lot of persons did not know they were hypertensive and diabetic. And I remember Dr. Sear was here once and she was speaking to it and she said, we're seeing more and more persons who are younger, getting, coming in with onset of diabetes and hypertension. And that young group is adding now, because before diabetes and hypertension was a coin, I don't think people are old. That's sort of an older person's disease kind of thing. I don't believe people are old. I just think they mature. But yeah, it was supposed to be one of those diseases you don't have to worry about until you were 50, 60. And now you're 25 and 30 and younger sometimes. And so yes, we've seen that it is green in the population and it's an open door for other things. Kidney failure, strokes. These are some of the things, obesity. So it's not just diabetes and hypertension. If it's not managed and managed well, there are other complications. So your M&E process will also help determine why people at that age, so much younger and now suffering from hypertension especially. Right, and this is where when you sit with the person, you ask questions. Again, we're not trying to pry into your business. We're trying to see what's actually happening. Is it work? Is it your diets? Is it lack of exercise? So that gives us the ability to ask you question and if you can please honor it as honest as possible, then we can say, okay, these are what you need, these interventions, so we can get you a social worker. We can liaise with someone to get you the assistance that you need. So it's like creating a whole new model of how we deal with our patients. So it's not nurse, I stress at home. Okay, so we need to find your psychologist or a counselor. Why haven't you taken your medications this morning? Nurse, when I take it on an empty stomach, I don't feel well. Why are you taking it on an empty stomach? Well, you know the children had to go to school and I didn't want to have to eat the bread, so I wanted to give, you know, you find the sacrifices that people make. So then, okay, we need a social intervention. This is somebody who doesn't have enough to eat at home. What can we do? It gives us the ability to look for help for you. Monetary evaluation helps with that. Are we really meeting your needs? It's not just healthcare. There are social needs, there's emotional needs, there's psychological needs. We want to look at a person who, listically, yeah, we want to help you as an individual, all aspects of you. And to do that, you need to let us help you by giving us the information that we need. Exactly. Now we're coming closer to the end of the program and I just want to ask you just one final question. So I know performance-based financing or PBF will eventually lead to the implementation or development of a national health insurance program or universal healthcare. How does your M&E process help in that regard? Very good question. So we only have a few facilities now that we are piloting the PBF, the performance-based financing model. And so what we will do is that it carries the same, we call it an essential package, yeah, essential baskets of package, anything you want to coin it like that, is that we have a list of services that we want to give you. And we want to look at how well are the services responding to your needs, to the health sector, to the persons. And so when we evaluate it, we can say yes, it is a very good program. It is preventing persons from becoming or from leading to more complications. They're coming back, they're managing well, the diabetes and the hypertension are manageable. And so we can say, okay, so this is a really good program. It's working for our people. It's working for our healthcare professionals. And so we can upgrade it or what you see scale up to other facilities, implement it elsewhere. Why is that important? Because it is really taking the same coin of what the national health insurance does. The national health insurance gives a set of surfaces that you pay some, we pay the rest, whatever the model looks, but it is based on your needs. As a community, as a people, as a nation, making it affordable, accessible. And so that gives us the idea, before we go into the NHI, what are some of the areas that we need to strengthen? Competency of our healthcare professionals, equipment at the healthcare facilities, the layout of our healthcare facilities, because we really are, is our demographic, is getting a bit mature, not old as I would say, but mature. So maybe we need to put ramps, we need to look at the chairs that we're giving in the waiting room. Comforts, comforts is, and just being, I would say, not just comfortable coming to us, but feeling like, you know what? I'm happy I'm here and that you will return. So I want to thank you very much for your time with us. I've actually learned a lot, and I hope St. Lucia has as well. And I really hope that the performance-based financing initiative works well for our healthcare in the future. But thank you very much for coming. You're welcome, and I know the terms. I'm trying to make it as simple as possible. This is not the first time you'll be seeing this. Yes, because I actually hope that you will come back later and talk to us about the development of the program as it goes along. Yes, definitely. And thank you for staying tuned. This is Issues and Answers, a production of the Government Information Service. And we hope you see you again next time.