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The Role of the Regional Health Authority Boards - A Board Member's Perspective Geoffrey B. Frankson MBBS, MA (Oxon) A Member of the Board of Directors of a Regional Health Authority can usually be described as a capable, concerned and committed citizen who is used to a high level of responsibility for decision-making. It will be obvious to such an individual who takes the time to read a few of the documents from the early 1990s that the establishment of the Regional Health Authorities was an important step in the implementation of the Health Sector Reform Programme in Trinidad & Tobago. With a little more research, he or she will come to understand the basic premise of the reform programme; namely, that a shift in emphasis from tertiary to primary care is urgently needed in order to improve the efficiency and cost-effectiveness of health care delivery in this country. What will be less obvious to members of the Board is the overall objective of the Reform Programme, which is to achieve an improvement in the general standard of health and well-being of the people - ALL the people - in the region served by the RHA. It will take a pretty perspicacious member, coming to the Board without any prior exposure to the history and philosophy of medicine, to appreciate the fundamental shift in the nature of the nation's health problems that has taken place over the last fifty years. But it is this shift in the main causes of ill-health - from infectious, communicable diseases to so-called lifestyle diseases - that has led ultimately to a need for health sector reform. Even doctors, who have been trained as healers, have to step back and look objectively at what they do in order to appreciate that the main challenge is no longer to provide more and better healing for the sick, but to induce changes in the health-related behaviour of the whole population. Members of th4e Board, however, are not really asked to reflect on the raison d'etre of reform. What they are faced with on assuming office is a plethora of challenges arising out of the exercise of reform. To wit: the circumstances in which thousands of people work are being changed. Health sector employees are being asked to do what they have always done and know how to do under new systems of accountability and control. Old priorities are mixed up with new ones as those with vested interests in, for example, tertiary care struggle to maintain their status and influence in the face of challenges from those who are pushing the shift to primary care. So difficult is the exercise of reform that the Board of Directors is inevitably inundated with problems "needing urgent attention". In meeting after meeting, the business of the day is a list of decisions that must be made in order that the organisation - or rather, the many organisations operating within the Region - continue to function smoothly. No time can be devoted to discussions on policies that will serve the broader objective of improving the health of the population. It may be - in fact, it ought to be - that those policies are already enshrined in a strategic plan for the region, but certainly in case of the NWRHA, the strategic plan is little more than a wish list of improvements that need to be made in the delivery of clinical care. And, we should note, in the delivery of clinical care, even with the best of intentions, tertiary care is always more demanding of time and resources than is primary care, thus defeating the purpose of the whole exercise. The NWRHA serves a population of around 700,000 people, and has about $5,000,000 a month in expenses. This is a huge organisation; indeed, under its aegis are several institutions, each of which is arguably big enough to require its own Board of Directors in order to ensure good performance. The biggest institutions - with the longest lists of problems - are the major hospitals, and hospitals are primarily and inescapably tertiary care institutions. And so it is that the Board of Directors of the of the NWRHA finds itself at grave risk of becoming a part of the problem rather than a source of solutions. At the same time, the Ministry of Health, mainly via the PAU, has been busily making broad infrastructural changes that are supposed to further the shift in emphasis towards primary care. This has sometimes led to conflicts between the Ministry and the RHAs that are important, not so much as conflicts but as indicators of the role that the RHAs find themselves playing in the overall scheme of things. The way things have evolved, the MOH makes the decisions that are intended to engender health sector reform and directs the RHAs to act accordingly. The RHAs, facing the harsh realities of implementing those decisions, ineluctably become little more than administrator who can only choose what instructions to follow and which funds to use, and who eventually come to see themselves as 'rubber stamps' with insufficient ink. With this denouement the RHA Board members understandably become preoccupied with money. One of the realities of health care the world over is that there will never be enough money. it is in the nature of medical interventions that success with the easier, simpler and cheaper ones leads to increasing demands for more complex and expensive ones. Heal sore with plasters and people will then want plastic surgery for the scars; save babies from dying from neonatal tetanus and parent will want cures for those born with holes in their hearts. A shortage of money concentrates the mind wonderfully. For Board members with a background in business, in particular, it is easy to shift from a focus on health care reform to a focus on health care delivery. Efficiency becomes their main concern and outcome matters less - especially when the desired outcome is something as nebulous as a shift in emphasis from tertiary to primary care. "What do you mean by 'emphasis'?" they might well ask. Regrettably, there are few signs that any of this is going to change in the foreseeable future. If more money is made available to the RHAs there will undoubtedly be improvements in the delivery of health care; indeed, there are strong arguments for doubling the proportion of the national budget devoted to health care simply to raise the standard of existing are. But standard of care is not the only issue; indeed, it is not even the main issue. The Health Sector Reform Programme is intended to change the way in which the health of the people is managed. Change is the top priority, not improvement, and so far the Board members have not been appointed to be change managers but administrative managers. Perhaps it is time to rethink the role of the RHA boards. Perhaps there should be, on the one hand, Boards of Directors for the large institutions such as the hospitals, with specific responsibilities for improving the services provided by those institutions, and on the other hand, a separate bureaucracy specifically designed to serve the health needs of the entire population of the regions. What we really need in our hospitals is not a shift in emphasis from tertiary to primary care, but better care at all levels. Yes, it would be nice to have community-oriented hospitals with outreach programmes and continuity of care between specialists and family practitioners. But the top priority in clinical care is to improve what the hospitals and polyclinics are structured to do, and that is to provide care for sick and injured people. Some of that improvement will come with more and better equipment, but most of it will be realised by improving the relationships between people; that is, between doctors and patients, between medical professionals and administrators, and between administrators and maintenance engineers. We need to examine our systems of delivery of services (especially interpersonal relationships) in order to improve, not change, those systems - except, of course, where change is clearly indicated, such as the modernisation of communications, record keeping and inventory control. The requirements in the communities served by the hospitals are an entirely different kettle of fish. it is here that the Health Sector Reform really has to bee seen and felt. It is here that real change has to be instituted in the way in which all players play the game, professionals and patients alike. People in the communities have to literally learn to live differently if their health is to improve. Quality of care is not the issue; it is quality of life, and "Authorities" cannot force a better quality of life on a people. The later have to achieve that for themselves - or bear the consequences in the hospitals. If we are to bring Health Sector Reform into our communities then the four Regional Health Authorities should probably be displaced by (or subserved by) about fourteen District Health Authorities, which, in turn, supervise the activities of dozens of Community Wellness Councils. These should consist, not of high-powered decision-makers, but of community leaders, teachers, family practitioners, social scientists, role models and other change agents who can really bring about the shift in emphasis we so sorely need. As was acknowledged in the original Reform proposals, it is at the community level that we must really make an impact on people's daily lives. It is only when people accept that things must change in the ordinary course of their lives and not just when they are sick that we will succeed in reforming the health sector. And, furthermore, it is only when people accept personal responsibility for making these changes that the process will truly begin. These observations are summarised in the following diagrams. As we see in figure 1, representing the prevailing health care system, the population is broadly divided into two groups: those who have been "diagnosed" by the doctor (gatekeeper) with a condition that needs medical intervention, and those who are assumed, in the absence of any clinical symptoms and signs, to be "healthy". Primary interventions either restore their previous state of health or lead to referral further into the secondary and tertiary care sector. Ninety-five percent of the health care budget is allocated to "care" on the right side of the diagram. What the Health Sector Reform programme is expected to accomplish is a shift in emphasis from tertiary to primary care thus reducing overall costs - a stitch in time saves nine and that sort of thing. This is a necessary and commendable goal, but note that those in the "healthy" populations approach the gatekeeper only when they suspect they are ill and not on the basis of any objective measure of health. With all of the lifestyle diseases, this approach generally takes place only after many years of accumulating risks and declining standards of health. Even "primary" care is therefore often too little and too late, coronary artery disease being the classical example. Preventative measures consume about four percent of the budget and are generally more protective than preventative in that they seek to keep people from exposure to disease-causing agents found in the environment, other people, insect vectors, food and water. Such "health protection" does little to reduce the risk of succumbing to lifestyle diseases. Less than one percent of the health care budget is actually spent on improving the standard of health of those on the left of the diagram. And yet it is only in so doing that lifestyle diseases can be realistically prevented. In other words, health promotion or wellness, long before primary care is accessed, is the most effective way to "shift the emphasis" from tertiary care where the lifestyle diseases are concerned. In figure 2, representing what is essentially a more elaborate model for the Health Sector Reform Programme, the so-called shift in emphasis is taken a step further. Beyond simply promoting more and better primary care for those in need, the whole population is encouraged to participate in programmes that will improve overall standards of health and well being, thus reducing the risk of becoming ill. "Care" at every level will always be needed for there will always be sick people. Indeed, health promotion or wellness more often postpones than prevents morbidity from lifestyle diseases, but such postponement means more years of productive life. Increased productivity, in turn, creates the wealth needed to raise the standards of care in hospitals and other institutions, so wellness and better care go hand in hand. In this perspective, Health Sector Reform goes far beyond the increase in the efficiency of delivery of services with which the RHA boards have inevitably become preoccupied. Reform will not be accomplished by trying to overcome the problems of delivery that have arisen over the last ten years of structural reform, but by rethinking the whole process. This is truly a "paradigm shift" in the way we must think about health that is summarised in figure 3 below. Figure 3: A Paradigm Shift - from the old model to the new:
These are the changes that it will be incumbent on a District Health Authority and its Community Wellness Councils to implement. In order to succeed they will need autonomy, funds, facilities and policy guidelines from the Ministry of Health; the same opportunities and resources, in other words, that were to be afforded the RHAs. But far more than the large and cumbersome RHAs are able to do, the Councils will bring the reforms into the communities. They will foster decision-making by the people, for the people in circumstances that allow quick implementation, evaluation and feedback. Even if mistakes are made (and mistakes will be made), the cost to the health sector as a whole will be manageable, given the small scale of each of the operations. The overriding objective of the Health Sector Reform Programme is a healthier, happier, more productive society in which citizens take more responsibility for the quality of life and the standard of health that they enjoy. A lot of good work has already been done on improving and diversifying the infrastructure that is essential for better health care, and we must, of course, prepare ourselves to take advantage of the many improvements in care that modern medical research promises to make available in the years to come. The reform programme however, must be broader in vision than that which is implied by the phrase "health care". It must move the society 'towards wellness', and wellness is a holistic concept in which all aspects of life are equally important. We must think wellness, and we must live it. We must "walk the talk", as they say, in order to understand what Health Sector Reform is really intended to accomplish. That may mean that we need, not only a different kind of "Board of Directors" for the Regional Health Authorities, but perhaps a different kind of board member as well.
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