Health system unsuited for CNCD challenge

KENWYN NICHOLLS

IN TT, the major disease burden is chronic noncommunicable diseases (CNCDs): heart disease, stroke, cancer, diabetes and chronic lung disease, accounting for over 62 per cent of deaths each year, three quarters occurring in people under age 70.

Over half the country’s population has three or more of the risk factors common to those four diseases: poor nutrition, physical inactivity and harmful use of alcohol and tobacco (WHO October 20, 2021: Empowering TT Communities to Prevent and Self-Manage NCDs).

By most accepted definitions, CNCD is TT’s 21st century public health problem.

The above situation is aggravated by the fact that between 1990 and 2020, the population in the 65+ years age bracket went from 5.4 per cent to 11.5 per cent and is projected to more than double to 26.2 per cent by 2060. As people age, the likelihood of developing preventable CNCDs increases, this unfortunate situation signalling continued social and economic disaster not just for the individual and his/her household, but for TT.

Any doubts about the capacity of the current health system to provide the adequate, continuous care that patients with CNCDs need while simultaneously addressing the socioeconomic norms associated with an ageing population were put to rest by the recent pandemic.

The Ministry of Health’s daily recitations that covid19 hospitalisation and deaths were mainly aged people with CNCDs serve as grim reminders of how inadequate access to quality healthcare impacts the quality of life, as well as life expectancy itself.

If universal health coverage (UHC) was in place, TT’s pandemic hospitalisations and deaths experience would have been greatly mitigated; and that is not the whole story.

UHC, firmly endorsed by the World Health Assembly (WHA) in 2005, is defined as “access to key promotive, preventive, curative and rehabilitative health interventions for all at affordable cost.” On December 12, 2012, the United Nations General Assembly endorsed UHC as a sustainable development goal (SDG).

In 2013 TT joined some 115 countries that signed on to the UHC Partnership, a wholly funded WHO initiative, to deliver support and technical expertise to member countries in advancing UHC with a primary healthcare (PHC) approach. A US UHC success story follows.

In the biennially published Diabetes Report Card 2021, the Centers for Disease Control (CDC) in Atlanta revealed that after almost two decades of continual increases, the incidence of newly diagnosed cases of diabetes in the US decreased from 9.3 per 1,000 adults in 2009 to 5.9 per 1,000 adults in 2019.

Even more interesting was the fact that even though the prevalence of diabetes remained steady in the time frame, notification of prediabetes status nearly tripled from 6.5 per cent to 17.4 per cent. According to the CDC, with a proper diet, weight loss and exercise, only 20 of the people designated as prediabetic go on to full-blown diabetes.

Much credit for this success story should be given to the passage of the Affordable Care Act (Obamacare) in March 2010; it made healthcare affordable and thus accessible to many of the chronically disadvantaged – American Indian, Hispanic, non-Hispanic black and Asian, etc, the very groups more likely to be diagnosed with diabetes than whites.

In the American health system, research has shown that for people with diabetes, blood pressure management can reduce the risk of heart disease and stroke by 12 per cent to 27 per cent, progression of kidney disease to renal insufficiency/failure by 30 per cent to 70 per cent, and along with cholesterol management – cardiovascular complications by 20 per cent to 50 per cent.

There is no reason to disbelieve that had TT's healthcare decision-makers of the past ten years made full use of the UHC Partnership to establish UHC with a PHC approach as the nation’s healthcare delivery system, similar successes would not have occurred in TT.

The TT health system is marooned in the early 20th century hospital-centric health system and moving in directions counter-productive to the development of primary healthcare and public health.

For example, in the past decade or thereabouts, five new public hospitals have been commissioned and a myriad of private hospitals have sprung up all over TT. Construction of two more public hospitals is underway (replacement of ageing infrastructure).

Those hospital beds are dominantly occupied by patients with strokes, heart attacks, renal failure, and retinal and peripheral neuropathy (people so afflicted are at significant risk for blindness and limb amputation), all potentially preventable with development of an efficient, effective public health programme based on PHC.

As insinuated earlier, the current hospital-centric health system lacks the capabilities to effectively and efficiently address the risk factors perpetuating CNCDs as described in the opening paragraph, and to respond caringly to the socioeconomic travails that befall the ageing and aged populations.

Failure to confront and control the CNCDs already at epidemic levels in TT means excess morbidity and mortality and inevitably overburdened public hospitals.

Lengthy wait times for hospital beds, long delays in receiving critical diagnoses, results and reports, overworked health professionals, and all the constraints described in the Gafoor Report of the late 1980s, and by President Paula-Mae Weekes in her address to the UWI medical fraternity and the TT Medical Association some weeks ago, are manifestations of overburdened public hospitals.

The bottom line is those are availability, accessibility, equitability and affordability issues, and the answer is not to get into a race with the private sector to build more hospitals, contract more subspecialists, apply more wonder drugs, engage more private insurers, and so on.

Such strategies take away resources that can be better used for transformation of the health system by using health promotion, prevention, curative and rehabilitative policies and plans that will halt the relentless progression to hospitalisation and, ultimately, far-too-early death.

The main task of a healthcare system is the provision of health services demanded by the population. The system as currently constituted continues to fail in this regard; transformation to the more responsive UHC using a primary care approach is not an option.

The covid19 pandemic served as a reminder of the time bomb residents of TT are sitting on; the spate of untimely deaths of prominent members of the arts community in recent times reinforces the fact that the current health system continues to kill softly.

The Government must act with deliberate speed to implement the UHC using a public health and PHC approach. Leadership at the highest level – the lawmakers – will be required. Transformation from the current health system to UHC is a multi-sectoral challenge; all ministers must get involved.