 The panel, the discussion, an objective and impartial view of the issues of interest to you. The nation beat is on now. Good morning. Welcome to the nation beat. Today, I am here, Andrew Charles, head of standards development in the Sanusha Bureau of Standards. And within the standards of activities, we felt it was necessary to look at and have a panel discussion on healthcare as it relates to the theme, a shared vision for a better world. With a focus on the third United Nations Sustainable Development Goals, ensuring healthy lives and promoting well-being for all ages. Health and crime are two major issues of national importance. And the high levels of noncommunicable diseases in our space results in a significant reliance on the national healthcare sector. In any field, standards are necessary to achieve the highest consistency and quality of outcomes. So the topics for discussion today are the upcoming healthcare projects, which include standards development and the overall need and importance of standards in the public and private sector. So with me, I have today a group of panelists, experts in the field basically. Immediately to my right, I have Ms. Ira Isaacs, who serves as the chair of our Health Products and Services Technical Committee. Then I have Ms. Heidi Kodra, who also serves as the vice chair of our Healthcare Committee. And finally, we have Mr. Neym Jebaptis, who is the performance-based financing controller or coordinator. First, I'll hand it over to Ira to give a brief biography of herself and basically see it something about herself, then I'll ask her the questions. So go ahead, Ira. Okay, so good morning, everyone. Happy to be here. So a brief biography of myself. Well, that's always interesting. As a public healthcare professional, I have a philosophy of quality as a love language for excellence. So that is really the motto by which I work. I'm a registered nurse. I would say I love people. And having the highest standard of quality of life is the aim by which I do everything when it comes for the people, for the people, by the people. So that really is just my philosophy and who I am as a whole as a being. Okay. Thank you, Ms. Isaacs. Okay, so I'll move on to Heidi Kodra, Jagna. So Heidi, can you give us an introduction of yourself and a brief biography of who you are? Okay, as you said, my name is Heidi Kodra Jagna. I am also a nurse by profession. So you see the passion that we share equally in terms of improving the quality of care for all. I also am a quality assurance officer at the Ministry of Health within the quality assurance unit. And also, again, as vice chair, I serve on your committee, your health standards committee. What can I say about myself? That's perfect. Thank you very much, Heidi. Like Ira, I am passionate about improving the quality of care that persons receive within the health sector, whether it is public or private. We know that the role that standards play in ensuring consistency, safe, and an environment that will, I should say, facilitate a better patient outcome. All right, thanks a lot, Heidi. Thanks a lot for that. So, okay, finally, Niam, Mr. Jabatis. Thank you very much. So my name is Niam Jabatis. I am a trained medical demographer, and that's my qualification. But I also have wide experience working in the Ministry of Health, epidemiology, and also biostatistics and was director of the HIV and AIDS program. I am retired, but was given another opportunity to serve under the government's trust towards universal health care. I am currently the performance-based financing coordinator under that project, which looks at delivering quality treatment and screening services for hypertension patients in the primary care sector. So I hope I can provide some kind of information that will be consistent with what we are trying to achieve here today. Thanks a lot for that, Niam. Thanks a lot for that panel. So I'll move on to the questions. So to Ira, can you give me some history of the development of the Code of Practice for Healthcare Facilities, General, and any upcoming standards development that you may know of? Okay. So when you look at the healthcare system within St. Lucia, one of the things we had realized, and this started quite a number of years ago under the health sector reform. And this is about, let's say 2006, I will put this date, yeah? And what we had realized about the health care sector is that we were seeing a set of issues. And no matter what we were doing, we could not resolve those issues. And some of them were, same as what we have today, noncommunicable diseases under rise. You had our lives both. We were seeing that there was an issue with that. Just the overall health of people, but also the dissatisfaction of the public with our healthcare service. And it wasn't just from the public. We were seeing it from our nurses and doctors, from the administration itself. And so what the stewards of that time and the structure did is that they sat down and they asked, what can we do? And they came about with the strategic plan, the national healthcare strategic plan of 2006 to 2011. Beautiful, beautiful plan that laid out a road map for journeying towards quality of healthcare for all, which is the motto of the Ministry of Health. Quality healthcare for all. And they asked themselves, what is quality? What are the dimensions? What is this thing that we always speak about called quality? What does it mean? How do we get there? What resources do we need? And who are the persons who should be driving this? And it is based on those questions that the framework, the national healthcare quality framework was developed within the departments, within the Ministry of Health, the corporate planning unit. And through that, we further continue to develop the national healthcare quality policy. Through that policy, we laid out the guidelines of some of the strategies and the activities that we wanted to do to get not just our healthcare services, but our healthcare professionals and our environment to a point where everyone felt comfortable, safe, receiving reliable care, and that is the love language that we're talking about. It's almost as if we talk everything and holistically look at it and ask the questions, okay, what are the requirements? Because that's what standards are. Standards are basic requirements of getting the best outcome, fit for purpose. So if we say we are going to do X, Y, and Z, we do X, Y, and Z, and the outcome is this, because we have set the mark. And so we did that through the standards. Now the Code of Practice, the healthcare facility Code of Practice, for instance, was driven by our need where we realized that we were, and as Neham said he's a demographer, so he can probably speak to this, we realized that we are moving towards a demographic of people who are aging. And so when you look at the layout of our healthcare facilities, when we give care, is it safe for you to come to us? And is there a way for us to come to you? And we put those sorts of things, what you call accessible healthcare, ramps, an environment that is free of violence and discrimination, an environment that is friendly, an environment where when you come to us, we ensure as best as possible that you are not just comfortable with what we're giving you here, but that you are involved in the care. And that's people-centered care, we call it people-centered approach to healthcare. And based on those, we sat down and we said, we took things like PAHO Smart Health Facilities. We look at standards from the British Institutes. We looked at standards from Canada, Australia, but we asked ourselves, are these standards appropriate for St. Lucia because big countries, big money, but we know that as a small island there is a constraint of resources and even some of the resources are time and people. So we sat down as a committee and this is how we came together as a committee. And we looked at the standards and we asked ourselves, how can we adopt this to St. Lucia for the cultural environment, for the people with the resources that we have and with the time frame that we needed it. And that was the journey towards us creating the code of practice for the healthcare facilities, but also the code of conduct for our healthcare professionals. Now, within this, best practice is that standards 16 to 24 months of development, but again, because our resources in what you call export is quite limited, we had to seek outside help. Now, this is where we did a collaboration with the blur of standards, who also connected us to accreditation Canada and persons such as the Caribbean regional quality of standards, who have been helping us in that journey of creating the standards. That standard process is when we came together as a committee, healthcare export, we have the nursing council, we have the solution medical and dental council, we have persons from various doctors and nurses as Heidi herself, but when we sit at the table, it is not us creating the requirements and just handing it to you. We send it out for public comments to all healthcare professionals and we ask for comments and when you give us the comments, we go back to the table, we look at it and we address those comments accordingly. That is the process in us developing these standards. These are what we call pilot standards for now, because they are the two and let me say, which is one of the very first countries in the OECS regional Caribbean, islands that have created such a quality management system that have created such standards. So we are leading what I would say a pathway towards leading the other islands, towards quality healthcare for all. And so many other islands have adopted this approach. So we foresee in the future when we continue with these standards development and other standards development such as medical tourism. There is something that has been on our table. Also, clinical guidelines, how do we give care in a manner which what is happening in the public sector is also happening in the private sector? It's not that when you come to us and you go somewhere else, you get different care. No, we want everything to be standardized. So that's really the vision by which we are having and going. Okay, thanks a lot for that Ira. So what I'm getting from your discourse is that it's a holistic view and it's also a very consultative process, not just consultation of technical experts, but consultation of the nation on the whole, the public, to give their thoughts, give their feedback on the standards development of the healthcare sector. So thanks a lot for that Ira. Excellent. I'll move on to Heidi. Heidi, the question for you is, what do you think of the development of the national healthcare quality policy and what is its applicability to the United Nations Sustainable Development Rule 3? Okay, thank you, Andre. The Ministry of Health has made significant strides since the development of the national healthcare quality policy and this policy created an avenue to improve the overall health system within the country by providing guidance to the national strategic health planning. As such, the quality assurance unit was developed to support the core goals and principles of the national healthcare policy and ultimately aiming to provide accessible, affordable and high quality care to all solutions. And the policy is closely linked and it does support the UN SDG3 goals, such as focusing on ensuring health and well-being for all and for all ages. So if we have to break down the SDG3, we see different components, SDG1, 2, 3, 4. And when we look at the national healthcare quality policy, it basically encapsulates everything, all areas such as accessibility to healthcare. So the national healthcare policy actually prioritizes and outlines to ensure equitable access to healthcare services. And this aligns with the SDG3, aiming to achieve universal health coverage, which includes accessing the essential services for all. And I must say that if you look at most of the districts or the regions, we have healthcare facilities. We have about 33 healthcare facilities that persons can access within their communities. So making it accessible for those persons who cannot necessarily go to the private sector, to a private doctor or cannot afford to go to the hospital to see a doctor, the Ministry of Health has made it available to them, accessible. And like Ira said, again partnering with PAHO and SMART, make it accessible, wheelchair access as well, so you find most of the facilities, we have included ramps. And we have been working on the toilets for disabled persons. So we are working, and again, as Ira said, looking at standards. And we know now that the role that standards plays in achieving overall health for all, in terms of when we were looking at the health, the standards for the healthcare facilities, we understand now that any new facility that is being built has to follow particular standards. Okay? And simple things that persons may not look into, such as the size of a door. The size of a door cannot be the same as when you enter in your bedroom. Because we're looking to service all persons, whether it be on a wheelchair, whether it be on a trolley, a gully, whatever it is, that person should be able to enter that room freely. And moving forward, we look at the SDG32, where the reduction of preventable deaths. And the policy also highlights the importance of the development of standards and guidelines to reduce preventable deaths from improving quality of care, such as early diagnosis and infective treatment. And looking at that, we see that we have made strides and, thankfully, for the World Bank, who has been funding our initiatives, the Ministry's initiatives. And Mr. Neham will continue along with that when we get there in terms of the progress that we have made. Also, we look at the universal health coverage, SDG 3.8, which Mr. Neham also will expand on. And we see that we started out in phases, and one of those phases was the maternal and child health, which is the first phase. Because of that, we're doing a lot of testing and ultrasounds throughout the duration of the pregnancy. So, basically, we have that monitoring in place to capture whether there's anything going on and that effective treatment can be given to reduce the incidence of deaths of steel bonds and so on. So, we have been making strides, and this is just the first phase. And we have a lot going on right now at the Ministry of Health. We are presently looking into the prevention and management of CKD, that is renal failure, chronic renal disease. We're looking into preventing that. And this is where the screening comes in and also Mr. Neham's department. That's where they're coming in, the prevention aspect of it. And we're also progressing slowly to cancer screening as well. So, basically, we, as a Ministry, we have been proactive, rather than reactive. And in terms of patient safety, the SDG-36, we have been working tediously. And this is where our partnership has basically grown with the St. Lucia Bureau of Standards in understanding that where standards, the rule that standards play, such as the risk management. And you know that we have partnered, we have been working together to actually execute that training within our Ministry. And by extension, our autistic health holders, the St. Jude's Hospital, the OKU Hospital and other facilities. Okay, so thanks a lot for that, Heidi. Again, the general idea I'm getting here is the quality of healthcare is extremely important and access to healthcare for all is extremely important. Thanks a lot. I'll move on to Mr. Joabtees. Neham, we know that money is important, an important resource to make anything happen. So, again, what is performance based for? Okay, so performance. Okay. So a break right now. Okay. I actually thought it was going on today. That's actually why I stopped you. Sorry about that. Suicidal thoughts like other mental health challenges can affect anyone. It can be you, your colleague, family member or neighbor. Everyone has a role to play in preventing suicide. Know the warning signs. Two or someone you know is in crisis or emotional distress. Call the suicide hotline at 203. Remember, help is available. This is a message from the Employee Assistance Program, Department of the Public Service. Contact us at 468-2269 or 468-2260. Welcome back to Nation Beat. And thank you very much. We're moving on to Mr. Neham Jabaptis. The question again, because finance is extremely important in any endeavor, we're going to look at finance and healthcare. So the question I have for you is, what is performance-based financing and how does it aid the application of a more successful health regime? Right. Thank you very much for this question. Performance-based financing really is a mechanism, or you could call it a methodology that is used to strengthen health systems. The difference between performance-based financing and traditionally what we're doing is input financing. So we finance staff, we finance equipment, we finance the things that we need to deliver our outcomes and our outputs. Performance-based financing actually finances the outputs. At this stage, and when it's with outputs, we're talking about those things that we do, we use the equipment, we use the staff, we use the activities to get out of our programs. So in our case, for example, the main outputs for our performance-based financing program is to have, for example, persons treated according to the guidelines and protocols. We'd pay for that. To have persons screened according to the guidelines and protocols, we'd pay for that. To have persons registered, we'd pay for that. So we are very specific, we have indicators to indicate the outcomes that we're looking for and then we pay for it as opposed to paying for staff and paying for equipment, what we're doing traditionally. Essentially, that is the difference. So it's a difference moving from input-based financing to output-based financing. How we hope to mature in the future is to move from output-based financing now to outcome-based financing. So here you will now finance P for a person to get better. P for a person to live longer. But that is future for us. We're doing everything in steps. You cannot just jump into an outcome. You first have to have certain outputs there. So we're starting there, financing that. When we have developed the culture and the information that we need to, then we can go and mature further and advance in our universal health care thrust. So that's basically the difference between performance-based financing and some of the other traditional financing that we have been doing. Okay. And again, so looking at the application to a successful regime, what I'm getting... Oh yes, yes. The second part of the question. So it is very... Because it calls for reforms. I spoke a lot about reforms. The thing about where we are here today, we did a lot of work in the past. And let me say here, it was not a waste of time. We did not achieve what we had to achieve maybe in the past. First of all, I think a lot of people thought universal health care is just like a cross-sectional thing. You just come and you just do it and you get universal health care. But we have done visits towards the countries who have been implementing universal health care 25 years, 15 years, and they are still learning and they are still reforming. So the decision to move to universal health care in steps is critical and it's the best decision that we could have. So we started, we started with what we have and then we work on what we have but we have a goal for what universal health care, what we want to achieve in universal health care. We all know essentially universal health care is a package of services. You cannot deliver everything. You need to have those services that you need to deliver to your population based on needs, epidemiological demographic, and other needs. You need to have those services and you also need the financing mechanism. Financing is always important. What the PBF is doing now is trying to provide lessons on how we could end up with something that we could afford. You know, something where our people is participating. Something that is not just at the national level. Something starting from the level of the community because it's starting from the catchment areas. So we're going to reform the way that we do. We deliver care. One other thing, when the first design we got of that program it didn't have a quality component. We had to put in a quality component to make it a part of it. And we are working with all of the quality teams in the country including the Bureau of Standards that is going to look at that program, count to verify the data, look and see if indeed there is quality. And of course it's going to be based on the CAFA guidelines. The same thing, all of the guidelines in the past that we had used. So now we have to update the guidelines. We have to monitor the guidelines. It is not easy work. People cannot just say you would see it's easy work. It's not easy work. We have to do the reforms. We need to do the reforms. We need to create the environment within which we could successfully operate universal health care delivering quality care to our patients but also knowing what's going on. Knowing what's going on in terms of having the data, having the right staff mix having all of the different components of the health system in place. The financing, governance, getting the supplies and everything across to ensure that all of that, you arrive at the outputs and the outcomes that you really have planned for. So it's a work in progress. It will always be a work in progress. Countries, I mean, Korea is doing that for about 25 years. Colombia is in 15 and there are kind of leaders in the world at this stage and they're still learning. You know, so it's a long journey. It's not, it's a step by step by step and the approach the ministry has, why diabetes and hypertension? Because these are the two greatest killers in the country. Hypertension is often under estimated as a cause of death but it is a significant precursor for things like heart disease, strokes. So we have to control it. We have to control it if we have to reduce the premature mortality that we're supposed to be doing under the SDGs. So I am very honored at this time that I could still use my skills to to serve my country. It's a very honorable thing and anytime I talk about the P, the performance I'm very passionate because I spent a lot of years in data and diabetes and hypertension was where we always had a lack of because it's a lot. It's a huge undertaking. A lot of people, 19% I think 19% of our population is suffering from diabetes for example. I mean we thought it was like 10% but it's as high as 17 to 19%. So if we don't do something now, now we will be probably aiming for a quarter of our population with diabetes. So that's prevention in the primary care setting. If we do prevention well then the hospital will have less burden. So that is the focus now, at least for the next year and a half. It took us almost two years to get the structure in place. That's the other thing. We cannot do quality if we don't have a structure. We cannot do quality if we don't have quality police or quality inspectors. We need to put all of those things in. We can talk about quality and then we have not yet defined it. I mean we have to put in the structure, we have to know about it and we have to practice it. You know, small steps and I think once we can do it that way we probably would be in a much better way to deliver quality care. When we say quality care we want to be able to define it. We want to be able to monitor it. We will be able to measure and say alright we have achieved quality, we have achieved quarter quality, half quality or whatever. So these are the things that's where we aim in. That's how we have to go for it. And it will take us time. That's the thing we have to understand. It will take us time to do it alone in the ministry. We have to involve the community, involve the people. Let them understand it and then even give us solutions as well. You know, but so for now and again the World Bank is very big on this and really trying to get us to change our culture and to understand and I'm talking about organizational culture, not our culture. Change our culture towards moving towards more information, towards more doing things objectively, looking at effectiveness, looking at efficiency. All of those define in these in terms of very simple terms and terms of data so that we can see actually see progress and measure progress. So that is in a nutshell what I hope in saying all that I answered, but I'm always very passionate on it. So again what I'm getting from that and there's a lot of commonality of what you guys are saying. It's really that again from your discourse a while ago, the performance base and the PBF performance base financing is looking at not just the money but looking at a projectized approach. Inputs, processes, outputs, outcomes. And then looking at that and again being realistic up with it not looking at it where okay this is going to happen tomorrow but seeing tomorrow will come then it's next week, then it's next month two years down the line. Again being very realistic to what are the outputs and what are the outcomes and then when we look at it like that when we follow that model that projectized approach again I heard the quality resonating with Heidi resonating with yourself Neil that when we look at that approach of incorporating quality having that repeatability in the care looking at access to the care looking at the standards to the care and a long term basis of not just starting yesterday but information from quite yes yes yes utilizing those metrics and getting to an end point. I'm saying end point almost in quotation marks because that end point is a continuously learning end point so it's always moving further and further constantly progressing continuous quality improvement that's the deal I was going to bring it's we actually use the term continuous quality improvement CQI and continuous quality improvement says and I'm going to add to the wisdom of Neyham and Heidi continuous quality improvement has what you call a methodology to it. Let's just say it's a roadmap. Plan do check you plan what you have done your plan what you're doing and sometimes in the planning things change as you're doing it so you need to check it and when you're checking it and you realize this is not working I need to go back and fix or change or add or take out then you act on it and that's a continuous cycle continuous cycle it's like you never finish going we do not believe in perfection we believe in fit for purpose meaning to say what we plan for and the outcome that we desire we are getting it and then when we get that outcome we grow we call it we don't hang our hats where we cannot reach it we make it very realistic to our environment to our people to our resources to what we can do so we're not putting shoes that we cannot wear I like that we do not put shoes that we cannot wear and so in the wisdom of Neham when we looked at the outcome we asked ourselves so where is the value for money evaluation and that value for money where it's our evaluation which is our monitoring value because when we're planning we're checking as the monitoring side of it but when we go to the evaluation side on our outcome with our value for money we get there then is when we're going to say yes we have accomplished and here's how we accomplish this now in quality before quality was used in products and people are in products but we are a product of our society and there's no such thing as poor people or sick people it's really poor opportunities and poor resources and so when we looked at it we said we're going to give them the best that we can now the outcome of where we want to go and see them going because healthy people is a healthy economy and a healthy economy is a healthy nation so it isn't we didn't just sit at the table and decide that we want it to be like the big countries meeting international standards no we care for our people we care for our people because we are the people and we are the very standards that we set we use the system we live in this system we no longer breed people we brand people meaning to say this is who the vision we have for you we are going to help you to get there that's the loving us we don't make sacrifices we do sacred duty that's what we nurses say this is not a sacrifice it's our sacred duty to the nation and the people so when you look at the sustainable development gold and you look at the performance based financing we are moving towards a healthy nation what does it require for us to be a healthy nation these are the inputs this is the input that we need based on the input before we were doing input but it wasn't working so what's the output that we need this is the output so where are we going that's the outcome we have a vision we know where we are going we are just taking it step by step plan we are doing it we are checking to see what we are doing as we go that's our passion it's for our people look at the age of Neham Neham have retired but he's back here with us that's the four steps that we are following the young people like ourselves so it isn't that we are putting things in place and sometimes we ask we know we ask our patients how was the service today and you say nurse I don't like the waiting time believe it we go back and we ask ourselves we cut down on this waiting time right we don't think that you out there sitting and drying and we think that it's okay no we feel it too we feel it too because we are the same like you and that is where again the Ministry of Health we have understood the importance of where quality stems from and because of that we have taken a patient centered approach and we have a committed team at the Ministry of Health we have the Minister who is passionate about health care we have our PS our DPS the CMO we have the other units that make up our Ministry Corporate Planning the Quality Assurance Unit and we recently have it's been about two or three years now we've had the non-communicable diseases unit so we have understood how we cannot just deal with illness and diseases on the whole but sometimes we have to break it down and we have to focus and taking that approach the Quality Assurance Unit we have embarked on doing patient satisfaction surveys and the purpose for these surveys is to understand what is really going on the ground so we can understand what is really affecting whether it is the delivery of care or patient outcome and for that we focus closely on the primary care setting because we recognize that we have to start care we recognize injecting all those monies in treatment will not solve the problem because we'll continue to have a sick nation where our focus is right now is a preventative approach management and for that to happen we need the standards we need the guidelines that not only the public sector will follow but the private as well the Ministry of Health has been engaging the private sector also because we need the input as well we provide service but at the end of the day it has to be seamless because the care has to be continuous like Ira rightfully said when a patient is seen in the primary care setting and they referred to secondary care whether it be surgery whatever it may be and they go back home they go back into the community for continuum of care at the primary care setting so this is where we have noticed the collaboration with not just the primary care setting but the collaboration has to be with public, private primary, secondary and tertiary we need an interdisciplinary approach to treating whether it is illness or disease so we can have better patient outcomes thank you very much Heidi thanks a lot for that Ira also again so we'll go to a break right now and we'll be back very shortly thank you I don't know I feel like a friend is placing heavy emphasis on the concept of food security it's our prosperity our future the enhancement of the efficiency of production distribution supply chain in the fruit and vegetable sector project more commonly known as the seven crops project is intended to increase local production of all selected crops and decrease our food import bill through the diversification of the agricultural sector and increased production of the targeted crops among the provisions are subsidized input sales, seedling distribution introduction of new varieties introduction to new technology erection of weather stations and capacity building for more on the seven crops project contact the project coordinator at 468-8122 welcome back to nation beat again St. Lucia Bureau standards and our healthcare professionals right here we're going to wrap up now with our discussion and quite an engaging discussion also on our healthcare standards in the healthcare performance based financing quality and what those things truly mean to our healthcare so what I would do after that very engaging discussion from Ira and Heidi very engaging I'll now hand it on to to name to you name to sort of wrap up and give us an idea of moving forward how we see this healthcare system and what do you envision for the future for the future I have one small acronym USAID universal health coverage is our future we've been grappling with it for 20 years I think over the last two to three years three years and with the involvement of the World Bank and now imagine we have involvement of the Bureau standards more intimate I think if we give it the chance if we give it if we continue with it we should have this policy that no matter which government comes in we have a universal healthcare health coverage goal that we work into it if not it means that we're going to start from scratch every time so I think now that we are learning about it we are learning from other countries we are starting some of the reforms through the PBF and through and now strengthening our quality and with inputs of course from the Bureau I think we in a much better have a much better way what I would think the future let us develop because one of the things that we noted in those countries that the data the data was key to everything because it's the data that you need to to I have a bias for data but I really saw that at work in that in every one of those countries there was one particular organization or institution responsible for the data the data burden from your heads of department you took it from even the ministry and you have somewhere that gives you the requisite data that you need to do the information because you need the data for the quality you need the data for the financing you need the data for bringing in your products you need the data for the staffing you need the data for everything and I think we have to seriously seriously think about giving us the information that we need for us to progress and for us to be able to measure and to know when we have achieved universal healthcare or any other outcome that we want in that regard that's what I would want to leave with us thanks a lot for that Nehemi, excellent so again we're seeing the importance of again a quality approach where we're utilizing the metrics the measurement is extremely important very very very important objectively know where we are to know where we're going to again utilize the measurements so again thank you guys very much for being here I think I could say in conclusion that the commonalities that we're seeing from all of this discourse here again the importance of standards the longevity of the information that you've sourced from previously the quality based approach and the importance of the quality based approach and the accessibility to all and then the performance based financing money is very important to make anything happen so how do you get the resources how do you mobilize these things and what is the realistic viewpoint of getting to those areas so almost in summary this is how I could see what you guys have said today and the passion I clearly see the passion in each of you all of health care why it's there why we want to improve it and why do we want to continue improving on it and with that I'd like to say thank you very much for being here today thank you very much for sharing your mind sharing your passion sharing your thoughts on this very important subject and I'd like to again thank you very much additionally because again this is not a one person or set of people speaking to this is a collaborative consensus based approach this is all about not just the experts who are here today sharing their idea but the public also giving back and saying this is what we want to see as an improvement this is what we think about the service or the facility that we're using thank you very much and again signing out of niche and beats thank you very much thank you