Dominica’s Health Systems Transformation

The term “building back better” is a common phrase on the island of Dominica. Unfortunately, like many of its Eastern Caribbean neighbors, the island has felt the wrath of one too many hurricanes, with Hurricane ‘Maria’ in 2017 practically devastating the island leaving its people and environment in shambles. This lush and beautiful island - just 290 square miles with a population of under 74,000 - has managed to always “build back better.

The Commonwealth of Dominica is revered not only for its eco-tourism but also for the warm and friendly disposition of its people. Historically its primary health care system, grounded strongly in the primary health care approach, was known as one of the best in the Caribbean; however continuous hurricane damage coupled with an economic decline presented major challenges for the health system to respond to the growing needs of the population. With the support of the Pan American Health Organization (PAHO), Dominica successfully pivoted, transforming these challenges into tools and opportunities for growth and development, paving the way for a Health Systems Transformation towards achieving Universal Health.

Dr Lynora Fevrier Drigo, Dominica’s Acting Chief Medical Officer- gives a status update on the island’s primary health care system.

Despite the constant threat of natural disasters, Dr Drigo suggests that it created a pathway to a first in resiliency.

“We acknowledge all the hurricanes, storms, and hydro metric events that we’ve had to encounter throughout the years. We have decided as a nation led by our government that we are going to become the first resilient country in the world and so our new health facilities are built with that in mind structurally. More people are being trained: our new and incoming staff into the health systems are being trained a lot in emergency response. We also have the smarting of facilities and that’s being done in conjunction with PAHO along with the World Bank. We have our new National Emergency plan that’s coming on stream. So overall we have not remained stagnant in the list; what we have done is augmented what we started with and so we now have a more robust system going forward.”

One of the essentials of the Health Systems Transformation was the implementation of a Hospital Authority, a Board of Directors and a Chief Executive Officer.

Dr Ruby Blanc, Hospital Medical Director at the Dominica China Friendship hospital, speaks to the current transition and its effectiveness.

“Previously the hospital which was then known as the Princess Margaret Hospital was governed by the Ministry of Health. We reported directly to persons in the Ministry, for example, the Medical Director to the Chief Medical Officer, the Hospital Services Coordinator to the Permanent Secretary and the Matron to the Nursing Head at the Ministry. As you can well imagine, in terms of running a hospital, making urgent decisions on a day-to-day basis, you really need that kind of control on site. We had some visionaries, there are some people who worked very hard on this, and the decision was made that we should fall under the Authority, a Board which would have direct control and more importantly there would be one person who would have overall responsibility and that person would be the Chief Executive Officer. With that, just over two years ago with the necessary legislation and laws passed and the Hospital Authority came into place and we’ve since moved into this new governing structure.”

Now, how does this new Authority gel with care delivered in other settings and at other levels?

Dr Blanc says the key is “focus and communication” which will ultimately yield the benefits.

“Previously, you had the Ministry of Health focusing on all the different areas of health, you now have one individual and a team focusing primarily on the running of the hospital. Obviously, the hospital does not function in isolation, we have to relay to primary health care and all of the other support areas. So within this new governing system we’ve had to find ways in which to keep the communication lines open, as well as when we introduce new things into the system or new systems. We note that it does not exist in isolation and that we have to involve primary health care and the other support services into those discussions as we plan and as we roll out.”

Leading the charge of the Dominica Hospital Authority Team is Nancy Francis - Chief Executive Officer. She believes the most important activity for the hospital currently is the customer-focused element; this is first on her agenda.

“Understanding why we are here, the people we serve and how to ensure we deliver quality service to the population is of utmost priority and also to make sure that our internal customers have the tools that they need to be effective.”

The CEO believes the development of the strategic plan with the assistance of the PAHO has driven the people focused module.

“We really spent time with the consultants to understand what it means to be people focused, the activities involved and how we fit in the process. Now we have to spread the message to our team members to make sure that they understand what is required of them and to also get feedback from our customers in order to improve our services. We have to take time to listen to people and we have to think about how people factor in the whole equation of health care.”

Any transformation process, be it health or otherwise, is laced with its benefits and challenges. When addressing the hospital services Dr Drigo brought to the fore that the shift from the Princess Margaret Hospital (PMH) to the Dominica China Friendship Hospital created a bed capacity four times that of the PMH which was much more needed space. Although the Acting CMO is excited about the number of young Dominicans going off to study both nursing and medicine- the flip side she laments is a major hiccup.

Not having enough staff to adequately complement the size of the hospital facility will always be a major challenge, an issue all administrations in the region are currently facing. Even with attrition lurking in the background, the benefits of the Transformation of the Health Systems in Dominica are motivating. Dr Blanc shares one of those benefits.

“Being under the authority of the board gives you a bit more room to maneuver. Things that probably may not have been necessarily attainable under the Ministry but now with a board, with new laws and regulations to govern the running of the hospital, there might be some more flexibility, some more areas, more room to be creative in terms of funding and as well as the other areas that will be necessary to run here better.”

The Digital element is leading the Transformation, resulting in a paperless system.

Sheri Shillingford is an Epidemiologist and Hospital Information Research Analyst. She simplifies the Health Management Information System transition.

Digital literacy and its timeline is another key component in the overall transformation.

Dr Germaine Jean Pierre, Project Manager - Caribbean Digital Transformation Project

Dr Germaine Jean Pierre is the Project Manager - Caribbean Digital Transformation Project.

She anticipates there may be some teething issues with the transition to digital literacy with respect to training and it may take a year or two to get everyone on the same slate. Nonetheless the team is prepared and there is a plan.

“We have created sixteen innovation hubs right across Dominica and we are now trying to do that assessment of where is a nurse in terms of digital literacy? Is that person able to enter information into a system; can they use Microsoft Word? So we are working with the supervisors to get that data and then we are going to offer training. Because we have sixteen innovation hubs it means that someone does not have to leave Marigot and come into Roseau: there is a hub within the vicinity. So we are going to offer digital literacy training for those who need it.”

While there are many factors in the overall transformation process to ensure an effective changeover and guaranteed success, Dr Blanc shares her thoughts on one factor which she believes is necessary.

Dominica

Barbados and the Eastern Caribbean Countries

Primary Health Care

Health Services