Rethinking health care delivery in Jamaica (part 8)

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Rethinking health care delivery in Jamaica (part 8)

Opportunities for Jamaica in the post-COVID-19 world

Ernest Madu and Paul Edwards

Sunday, October 11, 2020

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LAST week, we looked at acute stroke care, mental health and elder care services as specific health care opportunities that will enhance the value chain in Jamaica if we make appropriate investments in those areas. We continue our series this week by highlighting health care investment opportunities in kidney disease care, oncology services and women's health. These are areas of profound need in our island but with limited options for many citizens.

Kidney (renal) care services

Chronic kidney disease is a significant public health concern. Local estimates suggest that about 300-400 people per million, or about 1,000 Jamaicans, develop the most severe form of chronic kidney disease (stage 5) every year, requiring expensive treatment options involving chronic dialysis or kidney transplantation.

At any point in time in Jamaica, more than 1,200 Jamaicans require regular dialysis. International data indicates that these local figures may be underestimated, and the actual figures may be three to four times these estimates. Additionally, it is estimated that another 150,000-200,000 Jamaicans have significant kidney disease and are at risk for death from renal and/or cardiac causes.

We know that this disease is most prevalent in persons aged 60 or older, particularly those with diabetes and hypertension, two conditions with high prevalence in Jamaica. These individuals and thousands more with milder forms of kidney disease are at increased risk for developing heart disease and other vascular complications including stroke, erectile dysfunction, and peripheral artery disease with a significant risk of limb loss.

Of the approximately 1,200 people in Jamaica who need dialysis, only 300 of this number are receiving consistently adequate care. In a Loop News article of October 31, 2019, Minister of Health Dr Christopher Tufton disclosed that individuals with severe kidney disease requiring dialysis often endure a waiting list in the public health system because of limited capacity. This is inadequate and suboptimal care, as the standard of care of dialysis patients requires several weekly sessions of dialysis consistently. To be included on a waiting list to get standard, routine care is unacceptable.

The minister further stated that those in need of dialysis who seek care in the private sector could expect to spend about $80,000 weekly. This is in addition to the funds these patients must also set aside for ongoing treatment and management of their other co-morbid illnesses. These patients are also often unemployed, or suboptimally employed, because of their chronic illness. This level of recurrent expenditure for medical care for remaining life expectancy is impossible for many and unsustainable for most Jamaicans.

A re-evaluation of the current system of kidney disease care is imperative to find ways to make these services more accessible, affordable, and economically viable for potential investors. Several private providers of dialysis services like Island Dialysis, New Wave Dialysis (Montego Bay), Latham Dialysis (Kingston) and Bellamour (Ocho Rios) have made significant investments to make these services available in several parishes. They must be encouraged and supported by authorities in Government and the population at large.

It is critically important to document the need for dialysis care in Jamaica properly, and to design a plan to meet the identified needs of the population to have dialysis care accessible to all patients in all parishes in Jamaica. This remains an attractive opportunity for a public-private sector partnership (PPP) that will provide a turn-key solution – resulting in the establishment of appropriate dialysis facilities in most parishes, maintenance of installed capacity, and the training of dialysis nurses and biomedical technicians for ongoing maintenance of systems.

Ideally, dialysis care should be available to all or at least most patients in Jamaica within one hour from their homes. An ideal programme should be affordable and sustainable but structured to ensure reasonable returns for those willing to put their capital at risk to solve this problem. It is unlikely that the public sector alone will ever be able to provide adequate capacity for dialysis care in order for Jamaica to meet the appropriate standard of care based on best medical evidence.

Oncology services

In 2015 an estimated seven out of 10 Jamaicans died from the four major noncommunicable diseases (NCDs) – cancer, cardiovascular disease, diabetes and chronic lower respiratory disease. Over the past 25 years the medical community has made significant progress in the diagnosis and treatment of various forms of cancers.

There is a need to enhance cancer care in Jamaica by supporting existing programmes and making additional rational investments to satisfy unmet needs. The Government has invested in linear accelerators for Kingston and Montego Bay for radiation therapy. On November 26, 2018 the National Cancer Treatment Centre, located on the grounds of St Joseph's Hospital, Kingston and reportedly built at an astronomical cost of US$15 million ($2.25 billion), was officially opened. This is in addition to a similar centre which opened at Cornwall Regional Hospital in Montego Bay, St James, in 2017.

Radiation Oncology Centre of Jamaica (ROCJ) is a private, modern cancer treatment centre at which pioneering work in radiation oncology in Jamaica has been carried out. ROCJ predated the Government facilities in Kingston and Montego Bay. Perhaps, rather than reinventing the wheel in the public sector at such an enormous capital outlay, working with ROCJ to expand capacity for radiation oncology could have been explored as a PPP initiative to leverage existing skill sets within the ecosystem, reduce expenditure, improve operational efficiency and ensure the sustainability of the programmes in the long term.

While the current cancer treatment facilities emphasise radiation oncology many cancer patients will need medical oncology care, with or without radiation oncology care. However, there remains a significant deficit in medical oncology care in Jamaica and this represents a substantial and viable investment opportunity or PPP initiative worth exploring.

A medical oncology centre of excellence with a multidisciplinary team for Jamaica is long overdue. It will greatly enhance the care of the growing number of Jamaicans afflicted with cancer and in need of optimal, evidence-driven cancer care, beyond radiation therapy.

Women's health

About 51 per cent of the Jamaican population are women. Women have specific health care needs and demands that are not always met in the traditional, male-centric health care environment. According to the Women's Health Survey 2016 Jamaica published by IDB, one in four women (25.2 per cent) in Jamaica has experienced physical violence by a male partner, and 7.7 per cent have been sexually abused by their male partner. The lifetime prevalence of intimate physical and/or sexual violence was 27.8 per cent. There was no significant difference across rural and urban communities.

In Jamaica, female reproductive health ranks high among women's health concerns. For example, while 20 per cent of all women of reproductive age are thought to have fibroids globally, in women of African descent the prevalence of fibroids in women of reproductive age is over 50 per cent. In Jamaica, up to 60-80 per cent of women may have fibroids, even though many may be unaware. However, for some women, there may be significant symptoms requiring appropriate medical attention.

There is an opportunity for Jamaica to develop a centre of excellence for women's health. Investment in a centre of clinical care excellence for women's health will be an attractive offering for private sector investment if the Government will create the enabling environment to provide the necessary security for patient capital that would be needed to bring such initiative to light.

A centre of excellence for women's health will be beneficial for Jamaica. It will improve the quality of life for many women and lead to increased productivity and economic growth in a nation where women are major drivers of economic prosperity.

Need for collective action

The remarkable efforts being made by private health care operators to improve access and the quality of care for Jamaicans must be applauded and encouraged, not undermined. It is in the interest of the common good to support and promote efforts that broaden access to care and improve quality of care for all Jamaicans – whether in the private or public health care space. It is never one or the other. The public must demand greater transparency, full disclosure, and accountability in the relationship between Government officials and health care providers and operators in order to ensure that access to services and quality of care are not being willfully undermined.

The last election has given the prime minister and his party a resounding mandate and creates an opportunity to make a meaningful impact, more so in the health care sector. For effective re-imagination of health care delivery in Jamaica there needs to be a paradigm shift that recognises private health care sector investors and providers as allies in the drive for quality and access, and not as competitors to the public health care system.

Efforts to undermine progress in the private health care space whether by arduous permit processes, abuse of due process, unreasonable demands or bureaucratic bottlenecks often fuelled by implicit bias and undeclared conflicts of interest, must be eliminated for the good of society.

To avoid the suggestion that some lives are worth more than others, the tax-paying public must demand universality of standards to ensure that health officials are operating and maintaining public health care facilities under their immediate purview at the same standards that they demand of the private sector health care providers and operators. This cannot happen without a new mode of thinking. This paradigmatic shift must be led by Dr Tufton. Any efforts, under whatever guise, that impede access or quality of health care is a disservice to the nation and the Jamaican public and hurts quality of life, job creation and economic progress.

Our series continues next week by highlighting non-traditional health care investment opportunities that if properly harnessed, will improve health care for Jamaicans, build relevant and high-knowledge skills, create new jobs, and help power an economy that will be more resilient to external shocks like the COVID-19 pandemic.

Drs Ernest Madu, MD, FACC and Paul Edwards, MD, FACC are consultant cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital.

Correspondence to emadu@caribbeanheart.com or call 876-906-2107.


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