 Hello and welcome to another installment of Issues and Answers, a production of the Government Information Service. My name is Jessie Leigh-Anne, and for the next half hour or so, I will be engaging performance based financing coordinator within the St. Lucia Health System Strengthening Project Implementation Unit. Quite a mouthful, but a pleasure nonetheless to have him in studio. Good day, Mr. Neyamjeevatist. Thank you. Thank you for having me. Thank you for being here. I want to start with you providing for the benefit of our viewers a definition, a succinct definition of this project to the St. Lucia Health System Strengthening Project and the brushstroke that is performance based financing in this masterpiece. Yes. So the St. Lucia Health System Strengthening Project is a project which is funded by the World Bank, but it's a very, very strong collaboration between the World Bank and the Ministry of Health. What this project aims to do is to strengthen health systems, all of the health systems in the country. You would appreciate first to achieve health, it's not just to prevent disease, there are other systems around which other systems around the achievement of health that we also have to ensure that it's working and ensure that you get a positive outcome from it. So the project itself, there are four components. The first one is to design and implement a package of services. The second one has to do with seeking to strengthen the efficiency of that package of service in the implementation. The third one has to do with the management of the whole project itself and the fourth one has to do with Billings and Lucia's resilience with respect to getting prepared for disasters and that type of thing. So these are the four main components. The PBF component is part of the second component which seeks to strengthen the efficiency of the health service and the PBF component focuses more on the primary healthcare setting and dealing with non-communicable diseases, specifically diabetes and hypertension. Okay, speak to performance-based financing as a precursor to universal healthcare and also national health insurance for St. Lucia. So universal healthcare, there are two main components of universal healthcare. One is the package of services that, and you would recall that I just mentioned, that part of the project is to design that package of services and the second component of universal healthcare is the financing of the implementation of that package of services and that's where the national health insurance comes in. So you develop a package of services and then you finance the package of services. And so the PBF component is part, of course, obviously of the development and implementation of the package of services. And what is unique about this PBF is that it's going to encroach or impinge on all of what that we need to do for universal healthcare. So it's like a pilot, it's a pilot universal healthcare, so to speak. So it looks at the development of the package of services and of course it's this time we're focusing on diabetes and hypertension, but you could have other services or the chronic diseases based on your analysis and what you see is looking in terms of efficiencies, it's looking in terms of data collection, it's looking in terms of analysis, it's looking in terms of accountability and governance and all of those other issues that ministries of health have been grappling with in terms of not only providing universal healthcare, but also in terms of providing a much more efficient service for people. Okay, let's get into the essential package of health services. What is being taken into consideration for the design of it and what will it constitute? Clearly, one of the things that have to come into consideration is what we call the epidemiological profile. So how does it affect the country? What's the burden of disease? How many people get sick? How many people die from it and so on? How many people are incapacitated from it? Another, of course, would be the cost. We cannot not also include the cost. So you would want to ensure that, yes, you're delivering these services. It has to be quality services as well. You have to take into consideration the cost. You also have to take into consideration your capacity to implement that. And so you would have to do a lot of reform of your services. A lot of the things that we're doing now in the absence of universal healthcare, common universal healthcare, the health sector will have to be a lot more efficient in terms of its data, in terms of its use of data, in terms of how it governs things, in terms of how it procures and how it provides services. So in a nutshell, that is what universal healthcare and what the PBF program pilot is trying to do. Okay, so for the pilot, you'll be focusing on the two non-communicable diseases as you mentioned, diabetes and hypertension. Exactly. Getting to what prompted this decision. Okay, so first is the epidemiological profile. So diabetes and hypertension has been consistently among the top 10 causes of death in St. Lucia for many years, as I could remember. And in addition to that, they account for about, if you really do the analysis, they account for about 75% of the mortality burden in St. Lucia. And so even in the absence of any analysis, we knew at the Ministry of Health that diabetes and hypertension has to make that list. And so even if we don't have a finalized list, we know that diabetes and hypertension is going to be on that list. And then with the advice from the World Bank and some of the other experts that work with them, they have decided, well, okay, we're going to be focusing, we're going to focus the pilot on diabetes and hypertension. The pilot is very, very important in terms of introducing us to these reforms, but also letting us get wet our feet, so to speak, in terms of when we have to come around to do the universal health care. So these were some of the things that had gone. And of course, we always have the issues of the provision of services. We're always talking about quality, quality of services, the coverage, how many people are we reaching, are we reaching the correct people? So that is what we are currently working on to try to put those reforms in place so that when we begin to implement, we still will not be perfect, but at least we would have taken into consideration some of the existing circumstances that we have and then trying to move forward with the assistance from the bank and some of the other experts that's working with us right now. Okay, let's get into some of the activities to be financed under the improvement of service delivery through performance-based financing. Right. Okay, so there are four main activities, well, two main activities. So screening, definitely screening for diabetes and hypertension and treatment for diabetes and hypertension. But we're also going to be looking at reforming or improving the existing data collection. We have to be working with the health management information unit to calibrate whatever systems that they have in place that will enable us to do the performance-based financing. We have to also work with some of the quality of care issues in terms of the delivery and the diabetes and hypertension. So over the last couple of months, we've been looking at all of the guidelines, all of the protocols, all of the different strategies that has been used in the Caribbean and internationally and to see how we could come up with, calibrate some of the procedures and some of the guidelines and protocols that will enable us to begin to implement performance-based financing. We are talking performance-based financing under the St. Lucia Health System Strengthening Project. Are we going to stick a pin in that, Mr. Jabati? So when we come back, we get into funding, a critical aspect of that. Stay with us. Pamela, I noticed that you built your retaining wall on my property. You will have to give me my land back or compensate me for that. My contractor isn't dumb. I trust that he will not build anything on your property. Where is your proof? Let's go to court. This situation does not require you to go to court. Looks like we have to go through mediation here. Mediation is a way people resolve conflicts like this. Someone, a third party, comes to speak to both parties. This person is called the mediator. The mediator is impartial. He or she makes sure that communication between both parties is effective and efficient. So, the mediator is a judge? No, the mediator is not a judge. Mediators, unlike judges, do not decide cases or impose settlements. Let me get a mediator to handle this retaining wall and that kitchen. Kitchen? Yes, your kitchen also falls on my land. Let me call the mediator. Thank you so much for staying with us. This is an edition of Issues and Answers on NTN. We're talking about performance-based financing as part of the St. Lucia Health System Strengthening Project. We're speaking to the Performance-Based Financing Coordinator, Mr. Nahum Shibatist. And we came off of the break speaking on the essential package of health services for the pilot program and the focus on diabetes and hypertension. Tell us how will this package be funded? Okay, so the entire project is $20 million, $20 million U.S. dollars, but for the diabetes, for the performance-based- Can I just see Lucia Health System Strengthening Project? The entire project is about $20 million, but for the diabetes and hypertension component, the PBF component, is $4 million U.S. dollars. And it's over, so we have about 30 months, so to speak, to use that money and to implement performance-based financing. Okay, so PBF, put this into context for us in terms of other countries that would have already implemented this program. Right, so there are a few countries who have been in the Caribbean. We don't have much data in terms of for the Caribbean region, but definitely for Latin America. In fact, the external consultants are from Latin America. But the difference between them and ours is that most of their PBF approaches has been with maternal and child health. So this is kind of the first in the few that's going to be looking at chronic diseases and specifically diabetes and hypertension. So again, we see Saint Lucia being used as a pilot. Some people like to say guinea pig, but I prefer to say pilot, you know, and it's because I think that the international thing, the international agency, see something peculiar about Saint Lucia. One of the things that's going for us is that we do have a health information system already in place, and that was coming from another project from the World Bank. And so what was done was to build on what exists. So in terms of the information system, in terms of what's happening even right now in the primary care setting, that's the other thing. It's all going to be happening in the primary care setting. And so rather than focus, because most of, when people talk about health, most people focus on hospitals, but in the case of the PBF, it's on prevention. So in other words, if you can get the prevention right, then you'll have a less burden and a much more complex issues to deal with at the hospital. So that is the whole approach. And then if you ever have to achieve universal health care, which if you want to see as the ultimate goal of this PBF, then now what WHO has recommended is that you start in the primary care. And so in terms of all what is recommended, this is the approach that the bank and the expose had advised the country to take. And so for me it's very exciting, and because this is the first time that we do have diabetes and hypertensive services, yes we do, but I can say here that we do not really know how whether or not we're making progress, so to speak. We know, I mean we can see, but we still have a lot of amputations for a lot of amputations. We still have, we don't know for example, if you take a particular community or a particular population in the country, what is the prevalence of diabetes and hypertension there? So hopefully over the next, when we start to implement this, this is the information we have on our fingertips, and so we'll be able to plan a lot better for the strategically, for the health of the country, at least from the perspective of diabetes and hypertension, but of course we could always extend those lessons and learn to some of the other things that will be in the package. Okay, I want to segue a little bit. The project itself is in full swing. So tell us what are you guys learning in terms of where you started from at the beginning of the project, but now you're beginning to assess what's happening on the ground. Right, so we are not there yet. We are not yet in full swing. It has taken us about nine months to think about. But the project is fully fledged. Fully fledged, so we're going to be starting, we're going to be actually starting in July. We are launching in June, so next month we're going to be launching and we are trying to get all of the deliverables that we need to have in place for launching right now. Let me just say that the support that I've received from the nurses has been tremendous. The support from some of the key staff that's going to be implementing that PBF has been tremendous and even the support from the bank and the external consultants has really been tremendous. They have given us a lot of flexibility in defining this, although PBF is relatively new, we had to learn about PBF and had to be consistent with some of the recommendations of the bank, but it's a very important, I think, and a crucial learning process for us. And so hopefully we would be able to answer your question a lot more in terms of the figures tell you what's the prevalence in this community or in that community. And so with that type of information, I believe we can have, we can do a lot better for the persons living with diabetes. More effective execution. A lot more effective execution. And I'm looking forward to reducing the number of amputees. A lot of, we're going to be have, we'll have, if you want a frame for doing a lot more research and evaluation. And so not only informing the non-communicable disease, but some of the other programs that we may have where we can take some of the lessons learned from the PBF and bring it across and apply it to some of the other conditions that we're looking at under health. Okay, so not yet in full swing, but fully fledged. Fledged. Flaming to get into the swing of things in July. In July. Just give us a status update, a progress report of sorts for this period. Okay, so up to now, so when I first came, we, yes, as I said, we did have, we knew the health, so we knew the health centers that we were going to focus on. Those were selected at the design phase. So now we had to work with all of the health center. We did a quick assessment of the health centers to try and find out what's their capacity. And I could report that in 16 of the 17, because we're going to be implementing in 16 facilities during the two and a half years. But a goal, of course, would be to get everybody because when you start to see progress, and normally PBF, wherever PBF has been implemented, there has been progress. So we're going to be implementing, we're going to be starting with eight facilities in the first six months. And then we're going to be bringing on the other nine, the other nine from January of 2022. That would be phase two. That would be phase two. Currently, what we are doing, we are developing with the assistance of the, we are hiring some staff. We're going to be hiring some staff to do some supportive supervision with the health centers. You will appreciate it's going to be a few, some new procedures. And so that staff itself hiring will be trained by the external consultants. And so they will be working with the facilities to ensure throughout the implementation of the pilot. And then we also will be hiring some IT, some IT staff as well, to work with the health management information unit. So my job really is to coordinate all of those units. There's about four or five units within the Ministry of Health. So that by the end of the pilot, we would have had build capacity in those units to allow the bank to phase out, so to speak, and then us to continue. But also will be at the end of the day, we want to have capacity also to be able to implement the universal healthcare. So just have always in the back of your mind that these are two, four services, really is diabetes screening, hypertension screening, diabetes treatment, hypertension treatment. But there will be a lot, there will be a few more services to be added on in the package of services. But we would have gotten lessons learned from the PBF so that by the time we're ready to implement the universal healthcare, we would be in a much better place than if we're starting from scratch. Wonderful. We argue for our final break when we come back, we're talking projected outcomes, key deliverables under this project. Stay with us. Everyone say counseling, counseling, counseling. How do you know about each other? They feel my fate, PS1, but I show my counseling. Maniglasia, just yesterday, you asked me advice about your husband and we spent over an hour on the cell. So say counseling, what does that mean? Just think about it, Maniglasia. When you have a difficulty with someone, you ask your friends for advice to help you to deal with your problems. But wouldn't you prefer getting advice from a professional counselor? I hope we're not one of those who think counseling is for crazy people. Mm. When your situation can be weird, I'm going to use professional counseling, but Maniglasia, each share a condition of doctor's visit. Eh, eh. Don't you know the Ministry of the Public Service has an employee assistance program, they call it EAP, which is offering six pre-counseling sessions for government employees. Eh, Glasia, why don't you take advantage of it? Really? It's free? Let me have one, let me call the EAP unit ASAP, because I want professional, did you say free? Free counseling. Boy, Glasia, wow. Who is the counseling, sir? Call the EAP unit at 468-2269. EAP works, let it work for you. Thank you so much for staying with us, we're talking performance-based financing under the Health Assistance Strengthening Project of St. Lucia. I have in studio for the past two segments, we've been speaking to Mr. Neham Jabatist, who is the performance-based financing coordinator out of the implementation unit. We've come across the plans, the activities that are scheduled for the next few months in terms of the rollout of this project and more specifically performance-based financing aspect. Speak to us about the projected outcomes. What are the key deliverables of this project that is hoped to come out after all is said and done? Okay, so first and foremost, I would go start with the impacts. We would want to see first a reduction in mortality, then we would also want to see a reduction also in mobility. So in other words, to prevent as many people as from getting the disease and prevent those people from dying. In addition to that, there are other, if you want to call it low-hanging fruit. So for example, much better quality services, much better quality services, that also would be a significant outcome. Also the use, using the key data that we have to make decisions. So evidence-based decisions as well. We also going to have service delivery, a much, much better service delivery, quality service delivery. We are also going to be and ultimately, what we would want to do is to provide lessons as well so that when we come across to implementing universal healthcare, we also would have had these outcomes that would help us to deliver a much more effective package for universal healthcare. So this is the one that comes to mind, but obviously there are others like improving the existing services, building the capacity of the Ministry of Health, even while we are doing, the chance to evaluation, evaluation of different programs. So it's PBF, but we will, during the implementation of the PBF, we also will be building capacity so that the Ministry can evaluate its programs on a more ongoing and regular basis. So these are some of the key outcomes and impacts that I think that we have. And of course, not forgetting all the amputations and all of the things that's happening in the hospital. And ultimately also reducing the burden of diabetes and hypertension now, but non-communicable diseases on the hospitals. These are some of the key outcomes that I envisage that we would be able to achieve from this PBF pilot. The pilot. Okay, let's speak to the overall goal. After the pilot, we know that there are plans to engage the private sector. Speak to us, give us a glimpse into what that will look like. Right, so universal healthcare, what universal healthcare really does is, there is, because right now, most of the provision of healthcare in the country is with the government. Yes. The government funds most of it. So universal healthcare would seek to engage the private sector. But what's gonna be very crucial is that both the private, the standards, the procedures of the public sector would also be applicable to the private sector. So it doesn't matter if you're a public or private provider. You would still have to, for example, go through the contracts. You would still need to generate the data that you need. And so, automatically, you would have an improvement in the delivery of service, in the public sector, as well as in the private sector. And you would have a much more standardized delivery of services with universal healthcare, you know? And of course, you are always underpinned with that in health. We always be the quality of services. So continuous quality improvement as well. So you're looking at the performance. First of all, you have to reach people, but you're also looking at quality, you know? You cannot just reach everybody. The quality of services that you, and then how you do things. So apart from the outcome, you have to look at the efficiency as well as the effectiveness. So it's gonna be very, it's not very easy. It's not very easy. We have a lot of reform to do. But at the end of the day, we will be in a much better place in terms of health in the country. And one important outcome that I didn't mention in the PBF is that we will, for example, in the PBF we will be providing free tests. So for those persons found with diabetes and hypertension, they will get free tests. One of the objectives of universal healthcare is to prevent out-of-pocket spending. And so that's why I think that this PBF is like a mini universal healthcare. Everything, almost everything that is to be offered under universal healthcare. We can see that happening in the PBF over the next couple of months. For diabetes and hypertension. For diabetes and hypertension, yes, you got it. That's right. Yeah, so just, you have your work cut out for you for the next few months. Tell us about the team that you have behind you in the rule out of this project. Yes, so my team, because my office really coordinates everything. So the team is the team of the Ministry of Health. But I can mention the key departments. So the first key department, it wouldn't happen if we do not have the primary care, the primary care services. And that's the community nursing service. They manage the primary care services. So all of the nurses in the health centers, I want to, as you say, big them up. Because if, without them, it wouldn't happen. So this would be one of the key. The other one is the health management information unit. And that's the people working the data for the primary care. They are key because the basis, all of this, the data will be automated. So we have to be building modules so that it can capture the data that we need. And so we have been working with them over the last eight or nine months, understanding the system, and then making recommendations, and then you soap it, or you soap it, I don't know what's the word, remember the word. But it was affecting their work, their day-to-day work, and they have been very, very, very helpful. I want to mention the planning unit of the Ministry of Health for conceptualizing this and for giving it priority, and for so that we now can do that. There is a focal, there is the office of the chief medical officer. There is a focal point for non-communicable diseases in there, as well, who has been very, very key because diabetes and hypertension is her focus. And so she has been very, very instrumental in moving forward, and of course, the epidemiology unit of the Ministry of Health. And one other thing that has happened, I kind of, we have formed an executive team within the Ministry of Health between these key departments and the project implementation unit that we are already starting to have oversight over this piece. So I'm not alone in this. We have been brainstorming, working with the bank and the external consultants to ensure that we could deliver a package of services for diabetes and hypertension that is cost-effective, but also very, very of a high quality and could have high impact in the relatively short time that we have to implement. Wonderful. I'd like to thank you so much for your time, Mr. Nahum Javatist, speaking to us on the performance-based financing aspect of the St. Lucia Health System Strengthening Project. Like I said, a mouthful, but definitely something that is welcomed by the people of St. Lucia. Thank you. You agree? Thank you, I agree. I totally, totally agree. Thank you, and it's been my pleasure. Wonderful. My name is Jesse Leon, signing off for now. This has been another installment of Issues and Answers, a production of the Government Information Service. Do enjoy the rest of it. Chairs, stay tuned to NTN for more programming. Goodbye. Let's go.