Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697799279900.pdf (Dominica)
FOREWORD HONOURABLE JULIUS TIMOTHY MINISTER FOR HEALTH Quality health care has been an important factor in the socio economic development of our people.

Our epidemiological profile is now similar to that of developed countries.

This Strategic Plan for Health charts the course for the health system to address the challenges we currently face.
It is the result of a collaborative effort of stakeholders both within and beyond the public sector who contributed significantly to the thinking manifested in the Strategic Plan and will continue to contribute to the management of the changes they sought.

It seeks to build on the milestones achieved and also presents strategies for tackling outstanding challenges.

We pledge to develop a healthier and more productive society by embarking on a program of prevention and healthy lifestyle choices.
Health promotion will be at the core of the approach that will seek to strengthen the role of the people, both individually and collectively in the delivery of health services.

We will surmount the challenges identified through hard work, enthusiasm and the support of NGOs, the private sector and other Ministries.

This National Strategic Plan for Health is a living document.
It will be modified regularly to adapt to changes in the population’s health status, demography, technology and the economy, and action plans will be fine-tuned in response to regular evaluation of outcomes.

I am grateful to all persons who contributed to the development of this Plan and will do everything possible in support of its implementation.
HONOURABLE JULIUS TIMOTHY MINISTER FOR HEALTH ACKNOWLEDGEMENTS The Ministry of Health gratefully acknowledges the contribution of all persons who made the development and publication of this National Strategic Health Plan possible.

• The Core Planning Committee for overseeing the process • The chairpersons of the various sub- committees for giving leadership and guidance on the development of their assigned areas.
• The members of the four sub committees who collected the data and ensured that the views of their organizations were considered.

• The Permanent Secretary in the Ministry of Health for his unwavering support and commitment to the process.

• Our collaboration of partners including the private sector, NGO’s and other line Ministries.
• The Pan-American Health Organization, particularly the Country Program Officer for Dominica, who coordinated the entire process and all others who contributed to making this National Strategic Health Plan a reality.

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TABLE OF CONTENTS FOREWORD MESSAGE ACKNOWLEDGEMENTS CHAPTER 1: OVERVIEW ……………………………………………….. 1 FOUNDATIONAL STATEMENTS …………………………………………….

1 PROCESS OF PLAN FORMULATION ………………………………………….

2 CHAPTER 2: STRATEGIC CHALLENGES ………………...………….


7 Summary Situation Analysis ………………………………………………………… 7 • Health status of the population ………………………………………………… 7 • Management of health services and response capacity …………………….

8 • Influence of social determinants on the health of the population ………….. 9 • Sustainability of health services…………………………………..................... 9 • Organization and management of the health system………………………... 10 Summary of Challenges ……………………………………………………………….
11 CHAPTER 3: ACHIEVING HEALTH & WELLNESS …..……………… 14 Plan addressing: • Health status of the Population ……………………………………………….. 16 • Social Determinants of Health ………………………………………………… 24 • Management of Health Services……………………………………………….
26 • Organization & Management of the Health System ………………………… 28 • Resources for Health …………………………………………………………… 31 Implementation strategies …………………………………………………………… 33 ANNEX 1: Scope of Work of Sub Committees ……………………………………… 34 2: Composition and Terms of Reference of Strategic Planning Committee 37 3: Work Plan Proposal ……………………………………………………….

39 4: List of Participating Organizations/Individuals ………………………….

41 LIST OF ABBREVIATIONS …………………………………………………………… 43 REFERENCES ………………………………………………………………………….
44 If we do not swim together We will all drown one by one Hon Roosevelt Skerrit Prime Minister 2008 CHAPTER 1 PRINCIPLES FOUNDATIONAL STATEMENTS VISION Partnering for optimum health MISSION To enhance the ability of persons living in Dominica, to better manage their own health, improve their productivity and quality of life and reduce their risk for disease and injury in the most cost-effective way.
Global & Regional Mandates Caribbean Cooperation in Health III Millennium Development Goals Caribbean Commission on Health & Development Port of Spain Declaration Renewing Primary Health Care Initiative International Health Regulations Global Framework Convention St Georges Declaration MARPOL Convention on Tobacco The following principles will be used to guide Dominica’s health services and system into the future: • People-centred - the health system regards the interests of people as the central priority when making decisions.
The needs of individuals, families, and identified and communities in they participate addressed and decision-making their improve to health and well-being; are • Accessibility - health services are reasonably located and user-friendly so that all people in the community including the youth can obtain the services they need in a timely fashion.

• Accountability - the outcomes of health are measured, assessed, and publicly reported to achieve maximum effectiveness.
services • Affordability - services provided must be at a cost which does not act as a barrier to access.
• Equity - every person has a fair opportunity to attain his/her full health potential regardless of factors such as socio-economic status, gender, age, ability, and culture; • Quality - health services are delivered within acceptable clinical standards, service providers, and in an environment of teamwork, creativity, and commitment; qualified by • Sustainability - the public health system is structured and supported in a way that ensures stability of human resources, efficient use of financial resources, and long-term affordability.
1 Process of Plan Formulation Following the end of the planning cycle for the Dominica NSPH in December 2006, the Ministry of Health decided to embark on a strategic planning process that would allow the country to design the improvements and charter the direction in health.

The process involved wide national participation, consultation, and support to ensure that the resulting NSPH reflected the interest of the people.
To guide and facilitate the process, the MoH selected a Strategic Planning Committee (SPC) with wide participation of stakeholders and other sectors with direct responsibility for safeguarding the health and well being of the population.
To aid the completion of the work assignments, the SPC was divided into the following sub-Committees; • Health Profile & Systems: - responsible for gathering information and conducting the analysis of the demographic and epidemiological profile including the physical environment; analysis of the policy, legal and regulatory framework, EPHF and Public Health, steering role and institutional capacity of the MOH.
• Social Determinants of Health: - analysis of the social, economic and political environments utilizing the determinants of health approach, with particular emphasis on education, housing, labour, social participation and support networks, gender and social justice.
• Health Financing which was later amended to Resources for Health:- provides analysis of the current and projected financial framework to ensure universal access and equity in health; physical infrastructure, health information; human resources for health; health technology and equipment • Health Services: - analysis of the organization of health Services, both public and private, and its management and response capacity.
In February 2007, Cabinet approved the composition and terms of reference of the Strategic Planning Committee, the four Sub-Committees and a Core Committee consisting of chairpersons of the subcommittees and the Health Plan Coordinator.

(See annex 1) The Core Committee ensured the definition of the NSPH 2008 – 2017 within a framework of broad participation with reference to the national priorities of Dominica.
Members were also responsible for chairing the sub-committees and ensuring the development of a communication strategy for the consultative process with stakeholders which would allow them to participate and ensure national “buy- in” for the approval of the NSPH.

They achieved consensus on the priority health problems, directions and operational volumes of the NSPH.
The SPC led, coordinated the drafting, discussion and consultation processes, ensuring intersectoral participation, wide stakeholder consultation and feed back.

Deliverables for the SPC were: 1.

A Concept paper for the strategic planning process 2.

An updated Health Situation Analysis 3.

A draft NSPH 2008- 2017 2 4.

A draft Cabinet Paper 5.


A Social Communication Plan for the dissemination of the NSPH The reports presented by the subcommittees informed the health situation analysis and guided the decision making process for the establishment of strategic directions, priorities, goals, indicators and strategies for achieving these.

Each sub- committee constituted not less than five persons.
Technical support was provided by the Pan American Health Organization’s Office of Eastern Caribbean Coordination (PAHO/ECC), under the coordination of the Health Systems Development Advisor.

They provided capacity - building, technical guidance and support throughout the process.

(Workplan proposal is detailed in Annex 2).

Methods of data collection varied by sub committee and depended on type of information needed.

This included focus group meetings, questionnaires, research among others.
Two consultations were held at the end of 2007.

The first was to present the draft situation analysis and the other to present main challenges, objectives and strategies for improvement.

Feedback received was incorporated into the document.

The draft situation analysis was presented to heads of department for comments.

Each Chairperson made presentation on behalf of their sub committee.

The document was sent to the PAHO ECC office for comments before final printing and dissemination.
The methodology for compilation for volume two (2) was similar to that for volume one.

A stakeholders meeting was held to present the draft Plan, and provide instructions for development of Volume 3. inadequate Progress was commitment to the process by key stakeholders.

It was agreed that the NSPH below.

would resource constraints and impeded by human operational volumes outlined contain four as Operational Volumes of the National Strategic Plan for Health Volume 1: Health Situation Analysis.
This volume contains an overview of the health sector in Dominica.

It also describes the health problems and the response of the Ministry of health to date.

It contains detailed situation and response analyses for the priority health areas.

Volume 2: Action Plan - Describes strategic directions, goals, objectives, proposed strategies and mechanisms to bring about improvements to health status in Dominica.

Volume 3: Operational Plans.


This Volume is a compilation of operational plans for implementation of the NSPH by health institutions, health districts and service departments Volume 4: Resources for Health- Contains estimates of resources needed for execution of the plan.
3 • Financing which includes (1) strategies for financing the health sector, (2) a compilation of the costs of plans in volume three, (3) the estimated cost of • Primary Health Care Services, (4) the cost of action plans for hospital services, (5) a consolidated cost of the NSPH with indication of sources of funding.

• Estimates of human resource needs of the sector including a training plan which outlines areas for training in preparation for the required skill mix at all levels of the health system.
• An outline of the proposed HIS structure and road map for the implementation and a compilation of monitoring and research needs.

• Proposals for physical projects, including estimated costs • Inventory of equipment needing replacement over the next 10 years, new items to be added to list, and proposed timetable for introduction of health technology.
The operational plans which make up Volume 3 were developed by the heads of departments and program areas, using the objectives, strategies and indicators developed in Volume two.

The benefits which are expected to be derived are as follows: 1.

To better monitor activities and evaluate outcomes 2.

To enable each department and program area to identify their role in implementation of the NSPH.

3.

To facilitate the yearly process of corporate planning.

4.
4.

To assist in the implementation of National Health Accounts Volume 4 is a compilation of all estimated costs and budgets for resources needed over the next ten years.

Currently, Dominica does not have a clear picture of the cost of providing health care to its citizens.

Technical assistance will be provided by PAHO to cost the different sections of the NSPH as outlined above.
The long awaited human resource plan for the health sector which is expected to be developed with technical assistance from PAHO will also be costed.

Costs include training in priority areas identified in the training plan.

Cost of implementation of the proposed Health Information System structure and strategies for financing are presented in this section.

It is expected that several physical projects will be undertaken during the lifespan of the NSPH.
These projects and estimates of costs are outlined in this volume.

The estimated cost of new equipment and technology as provided by the Procurement Committee is included in this volume.

Given the financing constraints faced by the country, it is important that all aspects of the plan be costed in order obtain a clearer understanding of the challenges faced and develop strategies for meeting them.
4 The public health approaches outlined in the Essential Public Health Functions (EPHF) is a strategy for improving overall health systems performance.

They describe the spectrum of competencies and actions that are required to reach the central objective of public health, improving the health of populations.
EPHF 1 Monitoring, Evaluation and Analysis of Health Status Essential Public Health Functions EPHF 2 EPHF 3 EPHF 4 EPHF 5 EPHF 6 EPHF 7 EPHF 8 EPHF 9 EPHF 10 EPHF 11 Public Health Surveillance, Research, and Control of Risks and Threats to Public Health Health Promotion Social Participation in Health Development of Policies and Institutional Capacity for Planning and Management in Public Health Strengthening of Institutional Capacity for Regulation and Enforcement in Public Health Evaluations and Promotion of Equitable Access to Necessary Health Services Human Resource Development and Training in Public Health Quality Assurance in Personal and Population-based Health Services Research in Public Health Reduction of the Impact of Emergencies and Disasters in Health It is recognised that health promotion and disease prevention are cornerstones of wellness.
Population health (simply the ability to look at the collective health of a group rather than that of individuals, health promotion (focusing on health rather than illness disease and injury), prevention (preventing ill health from occurring), and health protection (taking measures to safeguard health), are principles and approaches which will be integrated into the programs identified in this plan for the next ten years, in support of the shift from illness to wellness and from health systems to health.
Health Promotion Strategy 1.

Healthy public policy, 2.

Reorienting health services, 3.

Empowering communities to achieve well-being, 4.

Creating supportive environments, 5.

Developing personal health skills, 6.

Building and maintaining alliances and partnerships 5 CHAPTER 2: STRATEGIC CHALLENGES Summary Situation Analysis Dominica has made commendable progress in recent decades in terms of all the classic indicators of population health.
This is largely as a result of the government policies addressing social determinants of health, and emphasizing the importance of primary health care.

We stand justifiably proud of the gains made in spite of limitations and challenges such as setbacks by natural disasters and limited resources.
Although there remains a great deal to be done, we are confident that having understood the value of good health to the social and economic development of a nation, our leaders will continue to give health the priority it deserves so that our people will continue to live longer healthier lives.

Good health is a balance of physical mental, emotional and spiritual elements.

All four interact for a strong healthy person.


If we neglect one, we get out of balance and our health suffers in all areas.1 the extent Health to which an individual or group is able, on the one hand, to develop aspirations and satisfy needs; and on the other hand, to change or cope with the environment.

Health is for therefore seen as a resource everyday life, not the objective of living; is seen as a positive concept it personal emphasizing resources, as well as physical capacities.
social and The priority challenges facing Dominica can be combined into the following categories: 1 National Aboriginal Health Organization 2002 7 •health status of the population including demographic change; • Influence of social determinants on the health of the population •Management of health services and response capacity including quality •Organization and management of the health system.

• Sustainability of health services.


Health Status of the Population; and cancer, Dominica has high rates of circulatory diabetes.

disease, Additionally, Dominicans tend to rank high on the risk factors of obesity, alcohol consumption, and lack of physical exercise which are strongly linked to many chronic diseases.

health the by promotion Chronic diseases are now the main cause of morbidity and mortality with aggressive and education strategies being employed to combat their effects.
incidence of chronic Lessening healthy disease the onset of behaviours, preventing disease, and managing disease in an effective manner will bring significant benefits to Dominicans.
This population health approach will improve quality of life, length of life, and reduce the burden on the health system of treating chronic disease promoting and control Prevention of Communicable diseases has been very successful, although lately there has a re- emergence of certain diseases such remains as endemic recent emergence of Influenza A H1N1 has proven our vulnerability to global threats.

tuberculosis.

Dengue in Dominica.


The Over the past two years PAHO has assisted Dominica to develop National Influenza Preparedness Plans as required by WHO in accordance to the International Health Regulations 2005.

Technical cooperation provided by CAREC consisted of capacity building for influenza surveillance which included provision of laboratory supplies, training for specimen collection, submission and testing, and in compliance with IATA regulations.
in shipping training As a result of the capacity building activities, Dominica was better able to implement the enhanced surveillance required for the new variant of swine influenza virus.

Like the rest of the Caribbean region, HIV& AIDS poses a serious threat to the most productive sector of our society.

Trends point to decreasing morbidity rates which may be attributed to the availability of treatment.
Another area of serious concern is the injury which amount of preventable country occurs particularly among youth.

throughout the to continues The population size and structure in Dominica undergo significant change which has a direct impact on is necessary to anticipate and react to these changes to ensure the right health services are available and accessible to best serve the needs of the population the health system.
It present The key elements of demographic change which planning challenges are: - population decline, -urbanization, -out migration, mainly of young people, including young families, resulting in a decrease in the availability of traditional family supports for seniors 8 -Aging population: this means services and supports for seniors are becoming more important and services for children need to be based on a declining population.
•Management of Health Services and Response Capacity; The current health situation in Dominica is favourable and must be maintained.

The primary health care system was firmly established and has worked well, however it needs to be evaluated and reviewed.

There is a functional referral system in place.

Health is viewed as a basic human right, and every citizen has equal access to health care services.

Health services are provided through health teams across the island.
Priority attention is given to the health of priority groups such as children, women, the elderly.

Adolescent health and services and men’s health require some more attention.

Services at primary health care level are free at the point of delivery.

A system of user charges is in place at the hospital, but collection rates are very low.

continues The main challenge affecting the delivery of services is limited human to resources.
Dominica depend on technical assistance from Cuba, Nigeria and recently China to provide specialist services to its citizens.

Drugs are available at all public health facilities and are free of cost at community level.

Patients at the hospital fee of only pay an administrative EC$5.00 per prescription.

Secondary Care receives larger portion of the annual budget in spite of the focus being on prevention.
Services have been expanded to include an the Intensive Care unit at PMH and a Diagnostic Centre at Portsmouth.

Tertiary is neighbouring islands.


accessed care in Integration of services and promotion of wellness programmes are some of the strategies this for Plan for health implementation in •Influence of Social Determinants on Health of the Population Dominica has realized that while health and social services make a contribution to health, most of the key determinants of health lie outside the direct influence of health.
Whether people are healthy or not, go beyond the provision of health services and are largely determined by their circumstances and environment.

Virtually all major diseases are primarily determined by specific exposures to the economic and social conditions under which people live.

The context of people’s lives determines their health.

for This is particularly II cardiovascular disease and diabetes.
the case type this plan the priority for During stakeholder consultations development un- of employment and job security ranked the highest among issues, affecting Dominican youth and women in particular.

Unemployment leads to health problems such as mental stress, poor nutrition and diet, violence and crime, teenage pregnancy and other sexual health problems, illegal drug abuse and trafficking.
reproductive and Other social determinants of health affecting the Dominican population include the erosion of social support networks, social environment, personal life practices and coping skills.

This is particularly evident among the the 9 youth and evidenced by deviant behavior.

The government had has made significant strides in improving the housing conditions of many through its housing revolution.

Most households have access to safe drinking water and good sanitation.
Dominicans have universal access to primary and secondary school education; however, with the emphasis on the academics, there is need for alternatives such as technical vocational training for those who are unable to meet the standards.

face adequate • Sustainability of Health Services.

increased The health services costs during a time of fiscal restraint.

The funding of health is a strategic concern.


Without and sustainable funding the system cannot provide quality care and will suffer from instability.

The main drivers of increased health costs are new technology, new pharmaceuticals and treating chronic diseases in an aging population.

Dominica has no system of social insurance.

The small number of persons in creates a challenge for the viability of such a scheme.

Health insurance is provided by private insurance companies.
formal employment is unknown, Although the cost of delivering health there are certain care inefficiencies which must be tackled, such as reducing lengths of stay in hospital, and delivering more services on an out-patient basis.

Many of the facilities built following the introduction of primary health care in the grossly are early underutilized and costly to maintain.
challenge These the government’s ability to sustain pressures 1980’s now system unless continued efficiencies and new models of service delivery can be achieved.

The Ministry of Health with technical from PAHO completed a vulnerability assessment of all its health facilities at the end of 2008. assistance the resource management, Human retention of health particularly workers continues to be a priority issue for the government.

The area of largest attrition has been among trained nurses.
The Dominica State College with technical the government of Cuba continues to train different categories of nurses to fill the gaps.

The government of Cuba also assists in training of medical doctors.

assistance from Currently, health technology is limited, but is expected to play an expanded role during the life of this plan.

Procurement and maintenance of equipment requires strengthening.

Health Information for decision making is of growing importance.
There is need for physical space to house the current Health Information Unit.

A National Surveillance Committee meets weekly to review any reports of communicable diseases on the island.

Human resource for that department is also critical.

•Organization and Management of the Health System to improve is need the There institutional capacity to manage and develop the health system to meet demands of changing epidemiology, technologies and resource emerging constraints.
Health care delivery in Dominica is channeled into primary and secondary care.

The clinics are the first point of contact with the health services and serve to minimize demand pressure on the heath centres and the hospital.

10 This system has worked well for the two plus decades; however, past government cannot continue to be the main provider of health care.

Private health services are limited and out patient care usually provided by individual practitioners, who work on a part time basis.
There is need to provide incentives encouraging investment in health provision.

Health services need to be reorganized to meet changing trends in health care delivery.

Dominica has no health sector reform agenda in place to effect that change.

Quality management continues to be an area of weakness; however, with the identification of a focal point, strategies are being implemented to strengthen that area at national level.

Health Planning is an area of identified weakness urgent strengthening.
The Ministry has no position of Health Planner.

needs which The Health Promotion Resource Centre provides education to the public on matters of health, with a focus on empowering communities.

Some of their initiatives have been viewed by PAHO as best practices in the Caribbean.

The medical model is still very dominant and there is need for re-organization of the system to reflect the changing needs of the population and keep abreast with current trends in health management.
is very well The Dominican public this informed about health increased knowledge is being translated into a greater interest in and greater demand for improvements in our health services.

issues The Strategic Plan for Health in Dominica describes the challenges currently faced by the health system and sets out new directions for the system over the next ten years.
A clear understanding of the scale and dimensions of these challenges will demonstrate how the plan is effectively targeted on the best solutions.
A summary of the challenges is outlined in Table 1.1 below: Table 1.1 CHALLENGES Priority Areas Challenges Priority Area 1 - Health Status of the Population 1.1 Chronic Non- Communicable Diseases 1.2 Selected Cancers 1.3 Nutrition and Physical Exercise 1.4 Mental Health & Drug Abuse Prevention 1.5 Family & Community Health Rising morbidity and mortality related to CNCD’s High levels of risk factors for cardiovascular diseases among population.
Lack of standardized approach to management of CNCD’s Increasing rates of cancer Nutritional deficiency diseases Insufficient attention to the causes of persistent anaemia among the 0-5 age group and pregnant women Obesity and lack of physical exercise Limited information for decision making.
Food Security Lack of a comprehensive program for monitoring food security High cost of nutritionally appropriate foods Persistent stigmatization and discrimination of persons with mental health disorders Lack of mental health policies and plans (including substance abuse) Lack of Quality assurance in provision of care to the mentally ill Antiquated mental health legislation Inadequate programs for early detection, prevention and intervention of mental health issues Inadequate referral among sectors Inadequate clinical services for children, adolescents, forensic cases and substance abusers Limited information on mental health issues Child Health Inadequate breast feeding programmes High perinatal mortality rates The number of children with developmental and other disabilities Limited progress in the management of common childhood disease Child abuse Adolescent health Lack of comprehensive approach to adolescent health(ADH) services for in and out of school youth Initiation of unhealthy behaviours including early sexual activity, drug abuse and poor dietary habits (GSHS) Reproductive health Inadequate quality and coverage of reproductive health care services especially for adolescents and men Late bookings at ante natal clinics 11 1.6 Oral health 1.7 Accidents & Injuries Improve the health of the Indigenous people Elderly Limited information on the health issues and needs of the elderly Inadequate preparation by individuals for growing old Inadequate preparation of health care workers, community and family to meet the needs of the elderly Persons with disabilities Limited physical access to health facilities Services for persons with special needs Inadequate information systems for national surveillance of oral health situation Inadequate oral health coverage Lack of guidelines regarding oral health Accidents in the home, particularly among children.
Accidents at the workplace Incidence of road traffic accidents (RTAs)particularly among youth New and re-emerging diseases Food water and vector borne diseases Weak STI and TB programmes HIV and AIDS Priority Area 2 - Social Determinants of Health 2.1 Personal health Practices 2.2 Social Support Lifestyle behaviors • Smoking • Substance abuse including alcohol • Poor eating habits • Lack of exercise • Poor stress management Limited social support Increased number of school drop - outs Lack interest and low performance by males in school Unemployment/ underemployment particularly among single women High incidence of alcohol and other substance abuse including alcohol Gender-based inequities related to income, age, and social status Sexual and physical abuse of women and children Priority Area 3 - Management of Health Services 3.1 Primary Health Care 3.2 Secondary Health Care 3.3 Private Health Services Outdated structure Quality of service High levels of risk factors for CNCD’s Weak information system Lack of trust by the public Ineffective management system Increased demand for patient care services Limited human and material resources Weakness in plant Weak information system Limited collaboration with private services 12 3.4 Environmental Health Food security Control of communicable diseases Limited Port Health Surveillance Priority Area 4 – Organization and Management of the Health System 4.1 Health management, planning and policy 4.2 Health care delivery system 4.3 National Health Accounts 4.4 Quality 4.5 Legislative Framework 4.6 Disaster Management Limited monitoring, evaluation, and analysis of health status of services Weak planning capability Outdated management structure Lack of regulatory and enforcement policies for public health practice.
Absence of reform agenda Limited interface of the health delivery systems with other sectors Insufficient interface of departments within the health sector Insufficient data collection on health expenditure Unknown cost of providing health services Lack of quality assurance in personal and population-based health services Outdated public health laws Absence of comprehensive disaster/emergency management plan Priority Area 5 – Resources for Health 5.1 Health Care Financing 5.2 Human Resources for Health 5.3 Health Infrastructure 5.4 Health Information 5.5 Health Technology and Equipment Under-financing of health sector resulting from government being the main financier of health services Disparity in allocation of resources within the Ministry of Health Ability to provide advanced technology Inappropriate use of existing resources Inadequate supply of health professionals with the appropriate skills Inadequate attention given to design of health facilities Weak facilities maintenance systems Limited information for decision making Inadequate utilization of available information Timely replacement of equipment Acquisition of new technology Prolonging the life span of medical equipment 13 CHAPTER 3: ACHIEVING HEALTH &WELLNESS A wellness strategy has been developed to improve the health of the nation.
Wellness is a state of emotional, mental, physical, social and spiritual wellbeing which enables people to reach and maintain their personal potential within their communities.

There is need to promote and coordinate those activities which focus on health and wellness to obtain maximum impact on the population.

The health system is still focused on the illness model and with the full support of our partners we plan to move to one which achieves wellness.
The wellness strategy is built on the parameters of promotion, prevention, protection and early intervention.

Health Promotion Health promotion is the process of helping people take control of and improve their health.

The concerns with the extent of CNCD’s among the Dominican population needs to be addressed.

The key contributory factors such as diet, physical inactivity, smoking and alcohol misuse need to be tackled.
The Health Promotion Resource Centre (HRPC) will- • Assist individuals, families and communities to make healthy choices with particular focus on healthy eating, active living, smoking prevention and moderate alcohol consumption.

• Continue to promote the Health Community Initiative in collaboration with other sectors.
• Make health promotion an integral part of the Primary Health Care System Disease Prevention Many diseases and injuries are preventable through immunization, early detection and change in behaviour.

Prevention is one of the key functions of the Primary Health Care system.

Health Protection The Ministry of Health has the responsibility for protecting the health of the public in areas such as communicable diseases and food safety.
The Environmental Health Department in conjunction with other departments such as the Dominica Solid Waste Corporation and the Dominica Water and Sewerage Company, are people.

mandated protect health the the to of Child & Youth Development Early childhood development is the foundation for lifelong competence and coping skills that have a positive impact on health, behaviour and learning.
Along with investing in early childhood initiatives, the wellness strategy will also focus on supporting the health and well-being of youth.

This will be done in partnership with the Ministry of Education Youth Affairs & Sports, NGO’s, Youth Division, Welfare Division among others.

The following five strategic directions provide the overarching framework for action on health.
They also provide a framework for all partners in the health system to 14 link their policy decisions and investments to health outcomes.

1.

Population Health 2.

Determinants of Health 3.

Health Systems 4.

Health Services 5.

Resources for Health The terms used throughout the plan are operationally defined as follows: Priority issues: Areas of main concern Goal: summarises the ultimate direction or desired achievement.
Strategic objectives: A statement of change that will contribute to the overall goal Objectives: speak to specific desired achievements.

Indicator: The statistics or measures that are used to measure progress in implementing the Strategic Plan for Health.

Unless otherwise indicated, 2009 forms the base year for all indicators.

The following goals are long term in nature with a five to ten year horizon.

1.

Improve the health status of the people of the Commonwealth of Dominica 2.
Strengthen the capacity of communities to support health and well being 3.

Provide quality health services that respond to the needs of the population 4.

Develop a reformed health system which provides equitable, sustainable and high quality services 5.

Advocate for adequate resources for health.

Within each goal, medium term objectives have been identified.
15 GOAL: Improve the health status of the people of the Commonwealth of Dominica Priority Area 1 - Health Status of the Population 1.1 Chronic Non- Communicable Diseases Strategic Objective: To increase healthy behaviours and supports among the population Challenges Rising morbidity and mortality related to CNCD’s Objectives To reduce morbidity and mortality related to CNCD’s Strategy Health Promotion – focus on prevention Indicators Mortality rates from Diabetes, hypertension and selected cancers reduced by at least 10% by 2019 Healthy Public policy Reduced rates of complications of CNCD by end 2018:  amputations by 20%  CVA’s by 10%.
To determine the economic impact of specific CNCD’s.

Research and surveillance Economic costs of management of diabetes and hypertension established by 2017 High levels of risk factors for cardiovascular diseases among the population.

To reduce risk factors of cardiovascular disease.
Empowering communities Research Wellness Centre piloted in one Type 3 health centre by 2012 Re-orientation of health services Wellness Centre established in all seven health district by end 2018 Promote wellness culture Public awareness (IEC) Building Alliances At least two (2) NGO’s offer wellness programs by 2015 At least 10% decrease in the number of newly diagnosed individuals with cardiovascular diseases by the end of 2018 Lack of standardized approach to management of CNCD’s To standardize care and treatment for specific CNCD’s Healthy Public policy Diabetic and hypertensive manual completed, disseminated and in use by end 2012 • Diabetes • Hypertension • Asthma 16 Guidelines for asthma management available and utilized in all health care facilities by end 2014.
1.2 Selected Cancers Strategic Objective: To reduce the incidence of breast, prostate and cervical cancer among the general population.

Challenges Increasing rates of cancer Strategy Healthy public policy Objectives To decrease morbidity and mortality related to Prostate, cervical and breast cancers.
Indicators Guidelines for screening and management of specific cancers developed and in use by 2014 To Improve health seeking behaviours Cancer registry developed by 2013 Public awareness(IEC) 20% increase in number of men 45 years and over screened for prostate cancer by 2018 20% increase number of women aged 15-49 screened for cervical cancer by 2018 20% increase number of women aged 15-49 screened for breast cancer by 2018 To promote smoke free environments Policy enacted to prohibit smoking in public places by end of 2012.
1.3 Nutrition and Physical Exercise Strategic Objective: To promote health living through proper nutrition and physical exercise.
Challenges Nutritional deficiency diseases Insufficient attention to the causes of persistent anaemia among the 0-5 age group and pregnant women To decrease the prevalence of anaemia among the identified groups Strategy Objectives Healthy public policy: Creating supportive environments Re-orientation of services To improve nutritional quality and safety of foods particularly among the poor.
Developing personal health skills Building alliances Indicators National infant and young child feeding policies established by 2015 Revised growth chart incorporating WHO growth reference utilized in all public health facilities by 2011 Nutrition surveillance system for young children 0- 5 yrs established and integrated into national HIS by 2015 Empowering communities Research 20% decrease in anaemia in pregnancy among primigravida by 2017 17 Obesity and lack of physical exercise To promote healthy diet and physical activity among the general population Healthy Public Policy: National Dietary guidelines Baseline data on prevalence of obesity in the general population established by end 2012 Empowering communities Healthy food options available at schools offering School Feeding Programmes for students by 2012.
Physical activity mandatory at all levels of education by end 2011 ≥10 % decrease in prevalence of obesity among selected population groups by 2018 Limited information for decision making.
To obtain data for programme planning Surveillance systems Information on nutritional status of population available at HIU by 2016 Food Security Lack of a comprehensive program for monitoring food security To strengthen national capacity for monitoring food security Healthy Public Policy: Role and responsibilities of National Food & Nutrition Council expanded by 2011 Public Awareness Building alliances Ratified Food & Nutrition Policy and Plan implemented by 2011 Empowering communities Food Safety Act implemented by 2016 Laboratory capacity to detect food borne diseases increased by 2015 High cost of nutritionally appropriate foods To improve access to acceptable food quality Health Public Policy Public Awareness Taxes on selected basic food items decreased by 2014 1.4 Mental Health & Drug Abuse Prevention Strategic Objective: Improve health outcomes and reduce negative impact of mental illness.
Strategy Challenges Information, Education and Persistent stigmatization and Communication (IEC) discrimination of persons with mental Create supportive health disorders.
environments Research Objectives To reduce stigma and discrimination among general population Indicators Data on level of stigma and discrimination among the general population available by 2012 18 Lack of mental health policies and plans (including substance abuse) To provide guidelines for mental health programmes Healthy Public policy Consultations Mental health policy approved by 2011.
Mental health Plan developed and implemented by end 2012 Lack of Quality assurance in provision of care to the mentally ill To improve the quality of mental health care Reorienting Health services Standards of quality to enable periodic evaluation of mental health care delivery established by 2013 Antiquated mental health legislation To modernize mental health legislation to address needs.
Legislative Reform Revised mental health legislation approved by 2015 Inadequate programs for early detection, prevention and intervention of mental health issues To strengthen efforts aimed at prevention of mental health disorders Building and maintaining alliances and partnerships Incidence of mental illness decreased by 15% by end 2019 Inadequate referral among sectors To develop guidelines and protocols for standards of care for the treatment of mental disorders Public awareness Healthy public policy Re-orienting health services Mental health services fully integrated into Primary Health Care Services by 2014 Number of admissions/re-admissions to the Acute Psychiatric Unit decreased by 20% by 2018.
100% health care workers receive competence based training in mental Health by 2015 Inadequate clinical services for children, adolescents, forensic cases and substance abusers Limited information mental health issues Mental health services that address the needs of the entire population To make information available for decision making.
Integrated services Build Alliances Appropriate mental health facilities and services available by 2019 Re-orienting health services Surveillance Mental health information system established and integrated into the national health information system by 2014 1.5 Family & Community Health Strategic Objective: Health and the quality of life of selected vulnerable groups in the population improved Challenges Child Health Inadequate breast feeding programmes Strategy Objectives To consolidate gains made in child health Healthy public policy High perinatal mortality rates Creating supportive environments 19 Indicators 30% increase in number of infants exclusively breastfed up to four (4) months by 2018 Perinatal mortality rate reduced to 10% per 1000 live births by end of 2019.
The number of children with developmental and other disabilities Reorientation of services Incidence of low birth weight babies decreased by 2017 Developing personal health skills Building alliances At least 80% of children entering primary school screened for developmental disabilities by 2017 in accordance with national guidelines Limited progress in the management of common childhood diseases To strengthen capacity to address new issues Empowering communities Child abuse Immunization policy developed and implemented by end 2011 Protocols for management of common childhood diseases established by end 2014 Comprehensive systems for prevention and management of child abuse established by 2017 Adolescent health Lack of comprehensive approach to adolescent health(ADH) services for in and out of school youth To develop comprehensive, client oriented services for adolescents Initiation of unhealthy behaviours including early sexual activity, substance abuse and poor dietary habits (GSHS) Strengthen ability to implement Adolescent health services.
Healthy public policy: Creating supportive environments Reorientation of services Developing personal health skills: Guidelines for provision of adolescent health services established by 2013 Repeat GSHS (2018) reveals increase in the proportion of adolescents with healthy behaviours: - Delayed initiation of the use of tobacco, alcohol and illegal drugs: - Postponement of the onset of sexual activity Building alliances 20% decrease in teen parenting by 2018 Empowering communities Reproductive health Inadequate quality and coverage of reproductive health care services especially for adolescents and men To improve the quality, availability, accessibility and appropriate use of reproductive health services Healthy public policy: Creating supportive environments Reorientation of services Comprehensive reproductive health program established by 2016.
Number of men accessing reproductive health services at public health facilities increased by 30% by 2018 20 Maternal Health Late bookings at ante natal clinics To strengthen maternal health services Developing personal health skills: Early bookings (12 weeks)at public health facilities increased by 40% by 2018 Improve the health of the Indigenous people To provide culturally sensitive health services of the Kalinago people Building alliances Empowering communities Empowering communities Developing personal health skills Public health approach 0% maternal mortality maintained.
At least 30% reduction in rate of hospitalization during antenatal period by 2017 Systems for greater community involvement in planning and implementation of health care programmes implemented by 2015 Specific budgetary allocations for health care of the indigenous people established by 2017 To promote and protect the health and well being of older persons Healthy public policy: Creating supportive environments Elderly Limited information on the health issues and needs of the elderly Inadequate preparation by individuals for growing old Inadequate preparation of health care workers, community and family to meet the needs of the elderly Persons with disabilities Limited physical access to health facilities Improved access to health care for persons with disabilities Services for persons with special needs 21 Guidelines for delivery of services to the elderly established by 2015 Data on health issues and needs of the elderly available by 2017 Specialist geriatric services available by end 2014 Training programmes for health care workers, individuals and community care givers instituted at the Dominica State College by end 2016.
All public health facilities made wheel chair accessible by end 2015 Public health services expanded to include: Speech therapy, Physical therapy and Occupational therapy by 2019 Guidelines for provision of services for persons with special needs established by 2019 Reorientation of services Developing personal health skills Building alliances Empowering communities Healthy public policy: -Creating supportive environments Reorientation of services Developing personal health skills: Building alliances Empowering communities 1.6 Oral health Strategic Objective: To provide quality oral health services for the general population Challenges Objectives Strategy Inadequate information systems for national surveillance of oral health situation To increase availability of information on oral health Information Systems Surveillance Indicators Oral health information integrated into national health information system by end 2012 Inadequate oral health coverage To strengthen national oral health programme particularly among children Human resource development Public Awareness Re-orienting of services Physical access to services for children improved by 2011.
Improved access to dental services : • Hours of operation • Services offered Linkages between dental and oro-pharyngeal services increased Guidelines for provision of oral health services established by 2011 Lack of guidelines regarding oral health To provide guidelines for oral Public policy health practice.

1.7 Accidents & Injuries Strategic Objective: To reduce preventable accidents and injuries among the general population.
Objectives Challenges To promote safer home Accidents in the home, particularly environment among children.

Strategy Information education communication(IEC) Indicators Number of cases reporting to public health facilities decreased by 30% by 2019.
Accidents at the workplace To promote safer working environments Public Policy Healthy Public Policy Advocacy Legislation Legislation on safe workplaces updated by 2016 Occupational health and safety programmes established by 2012 Incidence of road traffic accidents (RTAs)particularly among youth To decrease the incidence of road traffic accidents.
Policy Screening guidelines for personal and vehicle licensing established by 2011 Public Awareness Safety measures enforced by 2011: • Wearing of seatbelts & helmets Appropriate signage displayed by 2014 22 1.8 Communicable Diseases Strategic Objective: Reduce morbidity and mortality through early detection and prevention.

Challenges New and re-emerging diseases Objectives Provide early detection and treatment of communicable diseases.
Strategy Surveillance Healthy public policy Indicators Protocols established for early detection and management of new and emerging diseases by 2011 Food, water and vector borne diseases To strengthen surveillance systems for food vector and water borne diseases.
Surveillance Health Public Policy Weak STI and TB programmes HIV and AIDS To strengthen STI and TB programmes To reduce the incidence of HIV in the Commonwealth of Dominica; and To alleviate the negative impacts of HIV and AIDS on persons infected and affected.
IEC/BCC Policy IEC/BCC Networking Multi sectoral approach Policy and legislation reform Multi sectoral approach Scale up of services Capacity to manage new and emerging diseases increased by 2017: • Identification of resources both human and financial and material Incidence of the following diseases decreased by 2017   Water borne – 20%  vector borne - 15% food-borne - 25% Integrated programme for STI’s including HIV and TB by 2012 Incidence of HIV reduced by 50% by 2018 23 Priority Area 2 - Social Determinants of Health GOAL: Improve the capacity of non health stakeholders to actively contribute to health and well being.
2.1 Personal health Practices Strategic Objective: To empower individuals to take responsibility for their health Objectives Challenges Lifestyle behaviors Smoking Substance abuse including alcohol To promote healthy lifestyle practices among the general population Strategy Healthy public policy Increasing personal health skills Poor eating habits Lack of exercise Poor stress management Indicators of Success Framework Convention for Tobacco control implemented by 2011 Strategies for the prevention and management of substance abuse developed by 2018 Appropriate support systems established by 2018 2.2 Social Support Strategic Objective: To increase social support networks leading to greater social cohesiveness and better standards of health Challenges Limited social support Strategy Healthy public policy Objectives To reduce social and economic inequalities Indicators of Success Social networks established in the schools, workplace and community by 2019 Information, education communication (IEC) Employment insurance available to workers in precarious jobs by 2018: • construction, linesmen, health care providers, garbage collectors Increased number of school drop - outs To improve health and well- being of the total school community.
Protect universal access to a high quality education system 25% decrease in number of drop outs by 2018 Lack interest and low performance by in school males To improve overall performance of males in school Supportive environments Building alliances Systems established by 2016, to equip parents to provide support for children 25% increase in number of males completing higher education at DSC by 2019 Secondary schools’ curriculum reviewed by 2013, to include more vocational training 24 Unemployment/ underemployment particularly among single women To improve health of individuals through increased employment opportunities.
Healthy public policy Equip people for the work available, e.g.

retraining Government allocation of budgetary resources for skills training programmes increased by 10% by 2013.

High prevalence of substance abuse including alcohol.
To reduce demand for illegal substances and alcohol Continuing education Empowerment of individuals Building alliances Supportive environments 10% increase in funding for small businesses by 2015 Alternative to drugs programme expanded by 2012 to include out of school youth Support for recovering addicts available by 2018 Gender-based inequities related to income, age, and social status To reduce gender based inequities Social inclusion framework Gender mainstreaming Gender issues mainstreamed into services by 2014 Creating supportive environments Mechanisms for seeking redress for gender based discrimination established by 2015 Sexual and physical abuse of women and children To significantly reduce the incidence of abuse among women and children Partnerships Developing personal health skills Creating supportive environments Legal system amended by 2015, to facilitate the prosecution of perpetrators and protect identity of minors.
Facility for housing and support of abused women and children available by 2019 Strategies for management and support of abused women and children implemented by 2019 25 Priority Area 3 – Management of Health Services GOAL: Health services that respond to the needs of the population 3.1 Primary Health Care Strategic Objective: To renew focus on Primary Health Care Services Challenges Outdated structure Objectives Upgrade PHC system to address current health needs Strategy Establish PHC as an approach cutting across all sectors Re-orienting health services Empowering communities Healthy Public Policy Quality of service Strengthen capacity to deliver public health services High levels of risk factors for CNCD’s Reduce the incidence of CNCD’s Improve Resource allocation for prevention promotion Re-orienting health services Empowering communities Building Alliances Developing Personal Health Skills ICT development Strengthen Information System Weak information system 3.2 Secondary Health Care Strategic Objective: To strengthen capacity to deliver client-centered services Challenges Lack of trust by the public Objectives To restore public confidence in public healthcare system Strategy Strengthen Quality Assurance Ineffective management system Establish effective management system Building Alliances with Media Management autonomy Increased demand for patient care services Promote more appropriate use of services at the secondary care facilities Information Education Communication (IEC) Integrated Health Service Limited human and material resources To provide adequate resources for improved patient care.
Financial management HR plan 26 Indicators Primary Health care services re-oriented by 2012.
Continuous Quality Improvement (CQI) implemented in all health districts by 2012 Diagnostic services available in at least 4 health districts by 2019 Programme for primary prevention of CNCD’s established in all health districts by 2012 5% decrease in incidence of diabetes and hypertension by 2019 Quality of information available improved by 2013 Indicators CQI programme implemented by 2011 Management structure recommended by Value for Money Study implemented by 2012 15% reduction in the number of non emergencies presenting at A&E by 2015 Repeat admissions to medical wards reduced by ≥10 percent by 2015 Stock out of essential drugs and supplies reduced by 10 percent by 2016 Adequate staff with appropriate skill mix to Weakness in plant To improve physical facility at the PMH Hospital redevelopment Strengthen inventory system Strengthen Information System Weak information system 3.3 Private Health Services Strategic Objective: Greater private sector involvement in provision of health care services Challenges Limited collaboration with private services Objectives Strengthen public/private partnership ICT development Strategy Net working and regulatory reform 3.4 Environmental Health Strategic Objective: Reduce conditions in the environment that pose public health risks Challenges Food security Objectives Strengthen food safety surveillance system Strategy Healthy public policy: Information Education Communication (IEC) Health Promotion Control of communicable diseases Strengthen monitoring capacity for
 communicable diseases Behaviour modification through public education meet available by 2019 Refurbishment of Princess Margaret Hospital completed by 2015 Quality of information available improved by 2013 Indicators Data from private sector incorporated into national health information system by 2014 Protocols for standardization of provision of healthcare implemented in private sector by 2012 Increase in number of private care services by 2019 Indicators Food surveillance integrated into National Health Information System by 2012 ≥40% percent increase in food establishments adhering to national standards for food safety by 2016 ≥25% percent reduction in outbreaks of communicable diseases by 2019 Limited Port Health surveillance Strengthen port surveillance system Healthy public policy Empowering communities Health promotion strategies integrated into environmental health programmes by 2012 Port Health Unit established by 2012 Developing personal health skills Increase in surveillance activities by 2017 International Health Regulations (IHR) National Laws amended to reflect IHR by 2011 At least 3 officers trained in port health by 2014 27 Priority Area 4 – Organization and Management of the Health System GOAL: A health system which provides equitable, sustainable and high quality services 4.1 Health management, planning and policy Strategic Objective: To strengthen the institutional structure of the health system Challenges Limited monitoring, evaluation, and
 analysis of status of health services Objectives Strengthen the capacity to assess the health services.
Strategy EPHF 5- Development of Policies and Institutional Capacity for Planning and Management in Public Health EPHF 6 - Strengthening of Institutional Capacity for Regulation and Enforcement in Public Health Weak planning capability Strengthen linkages between strategic and operational planning Human Resource development and training Outdated management structure Lack of regulatory and enforcement policies for public health practice.
Strengthen management structure Leadership Development To protect the population from unsafe public health practices Healthy public policy Absence of reform agenda To implement change in an organized way Reorientation of health services 28 Indicators Health improvement processes aimed at developing national health objectives established by 2017 System for monitoring and evaluation of policies implemented by 2019 Institutional capacity for the management of public Health Systems strengthened by 2017 Capacity to manage international cooperation in public health strengthened by 2017 Health Planning Unit established by 2011 ≥80% of heads of department of Ministry of Health trained in Health Planning by 2016 All corporate plans linked to national strategic plan for health by 2012.
Recommendations from revised “Value for Money Study” implemented by 2013 Periodic monitoring evaluation and revision of the regulatory framework implemented by 2016 Systematic processes to enforce existing laws and regulation established by 2019 Health reform Agenda developed and implemented by 2012 4.2 Health care delivery system Strategic Objective: A functional and effective system which meets the needs of the population Challenges Limited interface of the health delivery systems with other sectors Objectives Strengthen collaboration with other sectors Strategy Building and maintaining alliances and partnerships Indicators Functional system for obtaining public health data from private sector established by 2014 Social Participation in Health Social Service Unit established by 2012 Insufficient interface of departments within the health sector Strengthen communication processes within the health sector Team Building Net working Service level agreements Intersectoral Communication Implementation rate of decisions taken at meetings increased by 40% by 2017 Quarterly schedule of planned activities within MoH available to all departments by 2011 4.3 National Health Accounts Strategic Objective: Align health financing to national priorities Challenges Insufficient data collection on health expenditure Objectives To track flow of money through the system Strategy Functional Financial Systems Indicators System implemented by 2014, to track flow of funds through the health system Unknown cost of providing health
 services To determine cost of providing services Functional Financial Systems Cost analysis available to determine true cost of providing health services by 2019 4.4 Quality Strategic Objective: To provide Quality Health Services to the Population Challenges Lack of quality assurance in personal and population-based health services Objectives To improve the quality of services provided to the population Strategy Quality Assurance in personal and population based Health Services (EPHF #9) Healthy Public Policy 29 Mechanisms for updating health financing information implemented by 2017 Indicators Standards and evaluation for the quality improvement of individual and collective health services defined by 2017 User satisfaction with health services improved by 2019 System for management and assessment of health technologies implemented by 2017 Advisory services and technical support for the sub-national health entities implemented by 2015 Indicators Public health regulations reviewed and published by 2017 Indicators Improved management of emergency/disaster preparedness and response capacity by 2013 Guidelines and standards that support emergency preparedness and disaster management in health established by 2012 Partnerships with other agencies and/or institutions strengthened by 2015 Technical assistance and support provided to health districts by 2018, to reduce the impact of emergencies and disasters on health.
4.5 Legislative Framework Strategic Objective: To strengthen the legislative framework of the health system Challenges Outdated public health laws Objectives To ascertain laws are kept current Strategy EPHF 6 - Strengthening of Institutional Capacity for Regulation and Enforcement in Public Health 4.6 Disaster Management Strategic Objective: To strengthen the preparedness and response mechanism of the health sector Challenges Absence of comprehensive disaster/emergency management plan Objectives To reduce the impact of emergencies and disasters in health Strategy EPHF #11 30 Priority Area 5 – Resources for Health GOAL: To mobilize adequate resources to deliver effective and efficient health services to the population Disparity in allocation of resources within the Ministry of Health Ability to provide advanced technology 5.1 Health Care Financing Strategic Objective: Universal access to equitable, quality, health care through sustainable financing Challenges Under-financing of health sector resulting from government being the main financier of health services Objectives To distribute the burden of financing health care Strategy Health care Financing Reforms To redistribute resources according to priority needs Programme-based budgeting To provide appropriate and sustainable technological services To optimize the use of resources Medical technology policy Inventory management Strategic controls Inappropriate use of existing resources 5.2 Human Resources for Health Strategic Objective: A motivated workforce, equipped to provide quality health services Challenges Inadequate supply of health professionals with the appropriate skills Objectives To develop the appropriate HR skill mix to sustain the health system Strategy Strategic HR Planning and management 5.3 Health Infrastructure Strategic Objective: To provide safe and functional health facilities Challenges Inadequate attention given to design of health facilities Objectives To provide structurally safe and secure health facilities Strategy Safe Hospitals Initiative To ensure health facilities are functional during and immediately following an unusual occurrence 31 Indicators Mechanism for financing of health sector implemented by 2012 Private health system expanded in areas of inpatient care and diagnostics by 2019 By Financial Year 2012/2013, budget allocated to identify areas based on priority needs.
Guidelines for the provision of new technology established by 2016 System of inventory control for monitoring use of resources implemented by 2011 Indicators Guidelines for HR management and development established by 2013 Competencies for HR within the MOH strengthened by 2012 HR Information system developed and integrated into HIS by 2012 Indicators ≥ Eighty percent (80%) of buildings housing health facilities refurbished by 2016 All new buildings meet the requisite building specifications by 2018 Weak facilities maintenance systems To strengthen maintenance systems Preventive Maintenance Improved maintenance systems established by 2012 5.4 Health Information Strategic Objective: To improve the Health Services through the application of ICT Challenges Strategy Objectives Limited information for decision making To transform internal processes and procedures to significantly improve service quality Integrated delivery system Indicators Supportive protocols and structures regarding health information implemented by 2012 Inadequate utilization of available information Enabling regulations, policy, standards and guidelines 90% pertinent staff re-skilled in information technology by 2014.
Information for decision making more readily accessible by 2015 5.5 Health Technology and Equipment Strategic Objective: To improve healthcare delivery through the safe and judicious use of medical technology Challenges Timely replacement of equipment Objectives To procure equipment based on health needs Strategy Procurement policy Indicators Guidelines regarding the use of medical technology established by 2017 Acquisition of new technology To ensure the safety, efficacy and quality of medical equipment/ technology Quality Assurance programme for medical equipment/technology Biomedical engineering unit established at Princess Margaret Hospital by 2015 Prolonging the life span of medical equipment All nonfunctional equipment at public health facilities replaced by 2019 System for maintenance of equipment strengthened by 2013, placing greater focus on preventive maintenance 32 Implementation Strategy The NSPH is meant to be a working document.
The next phase as outlined above is the development of the operational plans by program and departmental heads with input from other stakeholders.

These plans will form the basis for the annual corporate plans which are submitted to the Ministry of Finance for allocation of funds in the annual estimates.

The plan outlines: - major activities for meeting strategic objectives - - - cost budget estimates.
responsible persons/agencies targets and The NSPH will be costed and sources of finance identified since it is not possible for government to fund all activities.

It is anticipated that PAHO will provide most of the technical assistance and some financial assistance.

In addition the health system will continue expanding joint public /private partnerships.

The success of the implementation of the NSPH is based on a number of factors including robust monitoring and evaluation (M&E).
One of the recommendations adopted during the national consultations was that an M and E team which includes non – health partners actively monitor the implementation of the Plan.

• Putting health on the agenda by recognizing the mutual dependence of health and development and the need to translate their recognition into action • Promoting and understanding of “determinants of health” and how they must work together to contribute towards national development.
• Recognising the integral role of stakeholders by involving them through consultation, working groups, alliances, and other relevant methods that facilitate participation.

The plan sets out the major long-term goals for the health system and identifies the objectives, actions, and targets which will be pursued over the next ten years.
It is a plan for the whole system, and each of the organizations within the system will be asked to develop or modify their strategic and operational plans to ensure they are supporting the same basic goals and directions.

This plan is consistent with the broader social policy directions of the government expressed in the medium term Growth and Social Protection Strategy (GSPS) This Strategic Plan for Health is a living document.
It will be modified regularly to adapt to changes in population health status, demography, technology, and the economy, and to fine tune the action plans in response to regular evaluations of outcomes.
33 SCOPE OF WORK OF SUB-COMMITTEES: ANNEX 1 To facilitate completion of work assignments in the thematic areas, the SPC will subdivide into four sub- committees namely: • Health profile & Systems • Social Determinants of Health • Health Services • Resources for Health The committee will : • Identify other stakeholders in selected priority area • Conduct meetings with stakeholders inviting their input • Identify other problems affecting selected priority area • Propose strategic directions, goals, and indicators for selected area over a period of ten years • Plan strategies for meeting objectives Health Profile and health systems - Responsible for gathering information and conducting the analysis of the demographic and epidemiological profile including the physical environment; analysis of the policy, legal and regulatory framework, EPHF and Public Health, steering role and institutional capacity of the MOH.
This sub-committee was to: • Analyze the demographic variables act as conditioning factors of the health situation; • Provide a descriptive summary of the state of the population’s health; • Assess the current status of the health sector in relation to the Millennium • Development Goals; Identify strategies and interventions that will contribute to the achievement of each goal; • Summarize and analyze information on the determinants external to the sector that influence its actions and results; political, economic, social and environmental; • Describe the capacity of the Ministry of Health to develop and execute National Health Policy; • Comment on the strengths, weaknesses, achievements attained and deficiencies identified by the MOH with respect to sectoral regulation; • Describe the performance of the MOH through a summary of the results of the EPHF measurement, emphasizing the highest and lowest scores, and the actions taken to improve the performances with low scores; • Assess the achievements attained and weaknesses identified with respect to assurance; 34 • Describe the strengths, weaknesses, achievements and deficiencies identified by the Ministry with respect to health financing to include sources and preparation of National Health Accounts; • Outline the capacity of the MOH with respect to the harmonization of service provision; • Describe and analyze the strengths and weaknesses of the health system’s organization and structure; • Analyze the principal characteristics of the health sector’s human resources and how they impact the systems structure and its transformations: Personnel training; Management of employment and working conditions; Labour markets and their regulations; Governance and sectoral conflict.
• Present information on the availability of essential drugs including vaccines, equipment and technology; • Quality assurance including accreditation • Analyze the degree to which health reform processes have impacted the following: Transformation in health system functions; Guiding principles of health system reforms; Scope and effects of changes in the health system, Sustainability of the changes; • Provide information for use by other sub-committees.
Social Determinants Analysis of the social, economic and political environments utilizing the determinants of health approach, with particular emphasis on Education, Housing, Labour, Social Participation and support networks, gender and social justice.
This sub-committee will: • Recommend interventions and policies to improve health and narrow health inequalities through action on social determinants; • Compile evidence on successful interventions and formulate policies that address key social determinants; • Define a medium and long-term action agenda for incorporating social determinants of health interventions/approaches into planning, policy and technical work within the health sector of Dominica.
The committee’s work should be structured around specific themes (e.g., early child development, urbanization and health systems), the health challenges faced by particular communities (e.g., informal workers, indigenous peoples, and marginalized groups) and opportunities for policy and action.

Health Services Analysis of the organization of Health Services, Management and Response Capacity.
This sub-committee is to: 35 • Present information on factors affecting the ability of the health system in Dominica to deliver the continuum of services required to meet changing health needs in Dominica; • Analyze these factors vis-à-vis the capacity of health systems in Dominica to provide the needed health services; • Present the major challenges – current and projected – in meeting the health service provision needs in an equitable and sustainable manner; • Propose recommendations in respect of, but not limited to: - mechanisms for strengthening the capacity of the health system in Dominica to deliver the continuum of services required to meet the changing health needs in Dominica; - targeted interventions aimed at strengthening the capacity.
Health Financing Analysis of the current and projected financial framework to ensure universal access and equity in health.
This sub-committee is to: • Review and highlight key macroeconomic, fiscal and sectoral developments which influence the pattern of resource flows and choice of policies in health; • Delineate the major health financing challenges - current and projected - and feasible financing options in meeting the needs of the sector in an equitable and sustainable manner; • Specify the current mix and magnitudes of health expenditure and to assess the extent expenditure levels are providing ‘value for money’; • Outline the main features of major health financing, management and purchasing • innovations being implemented or considered; Indicate what further actions may be taken for securing appropriate levels, mix and allocation of investment in health.
36 i.
Composition and Terms of Reference of the Strategic Planning Committee Annex 2 Composition:  Ministry of Health, two (2) Programme Officers from each sub committee  Ministry of Finance and Planning  Ministry of Agriculture, Fisheries and the Environment  Ministry of Education, Human Resource Development, Sports and Youth Affairs  Ministry of Foreign Affairs, Trade and Labour  Ministry of Tourism, Industry and Private Sector Relations  Ministry of Housing, Lands, Telecommunications, Energy and Ports  Ministry of Legal Affairs and Immigration  Medical Association  Nursing Association  Faculty of Health Sciences/Dominica State College  Non Government Organization and Civil Society Groups  Private Sector (Health)  Chamber of Commerce  Insurance Community (Health)  Consumer Organization  Labour Unions  Medical Schools ii.
Composition and Terms of Reference of four (4) Sub-Committees, namely: 1) Health Profile and Systems  National Epidemiologist (Chairman)  Central Statistic Office  Principal Nursing Officer  Chief Medical Officer  Representative/Legal Affairs 2) Social Determinants  Coordinator Health Promotion (Chairman)  Social Planner  Representative/Ministry of Education  Representative/Ministry of Agriculture  Representative/Ministry of Finance 37  Representative/Ministry of Foreign Affairs, Trade and Labour  Representative/Ministry of Housing  Representative/Ministry of Community Development  Representative/Non Government Organizations (NGOs)  Representative/Gender Affairs  Representative/Social Planner 3) Health Financing  Hospital Services Coordinator/Chairperson  Senior Executive Officer/Accounts  Representative/Ministry of Finance  Representative/National Health Coverage  Representative/Consumer Group  Representative/Dominica Social Security  Representative/Private Sector  Representative/Insurance Companies 4) Health Services  Chief Medical Officer/Chairman  Hospital Medical Director  Director of Primary Health Care  Chief Dental Surgeon  Matron/Princess Margaret Hospital  Senior Community Health Nurse  Representative/Medical Association  Representative/Nurses Association  Representative/Pharmaceutical Society  Representative/La Falaise Medical Laboratory  Representative/Alternate Medicine (Herbalist)  Representative of Medical Schools  Faculty of Health/Dominica State College iii.
Composition and Terms of Reference of the Core Committee.
Composition:  Health Plan Coordinator – Chairman  National Epidemiologist  Coordinator Health Promotion  Hospital Services Coordinator  Chief Medical Officer 38 STRATEGIC PLANNING COMMITTEE AND PAHO’S TECHNICAL COOPERATION TEAM WORK PLAN PROPOSAL ANNEX 3 PHASE DATES ONE Feb ACTIVITIES (Objectives and Capacity-Building) Coordination meeting with Strategic Planning Committee: • Review of Terms of Reference, • Agreement on proposed Work Plan, • Assignment of responsibilities to sub- committees • Development of sub-committees work plans and deadlines Capacity-Building: • Basic concepts for development of a National Strategic Plan for Health (NSPH).
Information for Action March WORKSHOP # 1: Review of Information for the • TWO Situation Analysis (part 1) Capacity-Building: Integrating Social Determinants of Health • • Health Promotion Approach to Planning THREE April WORKSHOP #2: Review of Information for Situation Analysis (part 2).
Discussion on the Renewal of Primary Health Care (PHC) Capacity-Building: • Health Systems: Roles and Functions • PHC based health systems PAHO TEAM MILESTONES & OUTPUTS • Specific assignments for the collection of information for the first draft of the Situation Analysis.

• Work plan for each sub-committee with • specific deadlines It is recommended that this phase end with a brief ceremony with the participation of the Minister, all stakeholders and most importantly, the Media.
During this ceremony, the Minister will announce to the Nation that the process has begun and invite all citizens to participate.

COUNTRY TEAM PS CMO Strategic Planning Committee (spc) Minister of Health for the launching ceremony Draft Situation Analysis, Part 1 SPC • Presentation of findings will be made on the following areas: Demographics, Education, Agriculture, Social Development, and Tourism.
• The Health Profile and Social Determinants subcommittees will present the first draft of the analysis Draft Situation Analysis, Part 2 SPC • Presentation of findings will be made on the following areas: Financing of Health Sector, Universal Access, Legal and Regulatory framework, and Provision of Health Services.
• The Health Financing, Health Services and Health Systems subcommittees will present the first draft of their analysis OUTPUT: The first version of the Situation Analysis must be put together and disseminated to all members of the Strategic Planning Committee in 39 PHASE DATES ACTIVITIES (Objectives and Capacity-Building) FOUR May WORKSHOP # 3: STEERING ROLE AND EPHF Analysis of the Steering Role of the Ministry of Health and performance of the Essential Public Health Functions FIVE July Capacity-Building: Review of the EPHF and identification of priorities WORKSHOP # 4: HEALTH PRIORITIES Consolidating the Situation Analysis and Design of the Strategic Directions, Health Priorities, Expected Outcomes and Strategies for the NSPH Capacity-Building: • Priority Setting • Logical Framework re-visited • Stakeholder Analysis SIX August NATIONAL STAKEHOLDERS CONSULTATION Futures Planning exercise Review of vision and Mission of the Health Sector and Consensus on, Strategic Directions, Priorities, and Expected Outcomes for the five-year strategic plan SEVEN October CONSOLIDATING THE NSPH Capacity-Building: Development of a Social Marketing Plan EIGHT TBD National Launch of the NSPH Dissemination and Social Marketing of the Approved NSPH 40 MILESTONES & OUTPUTS advance of the following phase.
Review of the Steering role function and the EPHF of the MOH OUTPUT: Analysis of the ministry’s capacity for performance of the EPHF and priorities for institutional development of the Ministry of Health Document prepared for inclusion in the Situation Analysis • Review of version 1 of Draft Situation Analysis.

• Each sub-committee will design proposed Priorities, Expected Outcomes and Strategies for their respective sections make presentations to the plenary for consensus.
• OUTPUT: This phase will end with a First version of the NSPH, and a list of stakeholders to be invited in the following phase.

Stakeholders will be sent the draft NSPH with sufficient time for analysis before the meeting.

At the end of this session the Planning Committee will have a wealth of recommendations made by the stakeholders and social partners.
In addition, this session will provide the MOH with a clear vision, and mission for the overall health sector (not to be confused with Vision and Mission statement of the Ministry of Health) During this phase, the committee will draft the Final version of the NSPH, a draft Cabinet Paper, and a Social Marketing Plan A Deadline for submission to the Minister must be agreed at the end of this meeting COUNTRY TEAM PAHO TEAM PS CMO SPC PS CMO SPC National Stakeholders Minister PS CMO SCP SPC Minister , PS, CMO, SPC, Stakeholders ANNEX 4 List of Participating Organizations/Individuals Departments of MOH Central MOH Dominica Solid Waste Corporation Drug Abuse Prevention Unit Environmental Health Unit Health Information HIV/AIDS Unit HRPC Laboratory/CMS MCH Nutrition PMH Primary Health Care Department Other Government Departments Adult Education Division Carib Affairs Dominica Fire & Ambulance Services Dominica Police Force Labour Division Local Government Department Ministry of Community Development Ministry of Education Ministry of Finance Office of Disaster Preparedness Social Welfare Statistical Division Women’s Bureau Youth Division 41 Cont’d
 APPENDIX IV List of Participating Organizations/Individuals Private Sectors Banks Dominica Hotel & Tourism Association Insurance Companies Pharmacies Trade Unions Utility Companies NGOs Centre Where Adolescents Learn to Love (CALLS) Christian Children’s Fund Dominica Association for Disabled Persons Dominica Cancer Society Dominica Council on Aging Dominica Diabetes Association Dominica Planned Parenthood Association Dominica Red Cross Dominica Save the Children Fund (DOMSAV) Food & Nutrition Council
 National Children’s Home Regional Organizations Caribbean Environmental Health Institute (CEHI) Caribbean Epidemiology Centre (CAREC) Pan American Health Organization (PAHO) Learning Institutions/Schools Ross University School of Medicine School for the Hearing Impaired Dominica State College – Faculty of Health Sciences 42 LIST OF ABBREVIATIONS A & E Accident and Emergency AIDS Acquired Immune Deficiency Syndrome ADH Adolescent Health BMI Body Mass Index CAREC Caribbean Epidemiology Centre CNCD Chronic Non-Communicable Diseases DMFT Decayed Missed Filled Teeth ECC Eastern Caribbean Countries EPHF Essential Public Health Functions GSHS Global School Health Survey GSPS Growth & Social Protection Strategy HIS Health Information Systems HIU Health Information Unit HRPC Health Resource Promotion Centre HIV Human Immunodeficiency Virus IATA International Air Transport Association ICT Information Communication Technology IEC Information, Education, Communication IHR International Health Regulations KAP Knowledge, Attitudes, Practices NGO Non-Government Organization NIPP National Influenza Pandemic Plan NSPH National Strategic Plan for
 Health PAHO Pan American Health Organization PHC Primary Health Care PMH Princess Margaret Hospital PPE Personal Protective Equipment RTA Road Traffic Accidents SOP Standard Operating Procedures SPC Strategic Planning Committee STI Sexually Transmitted Infections WHO World Health Organization 43 REFERENCES CARICOM: Draft CCHIII Government of Barbados.
Strategic Plan for Health 2002 – 2012 Government of Dominica.

Health Situation Analysis 2008 Government of Grenada.

National Strategic Plan for Health 2007 – 2011 Government of Newfoundland & Labrador Department of Community Services: Healthier Together: A Strategic Plan for Newfoundland and Labrador Government of St Lucia.

National Strategic Plan for Health- final draft Pan American Health Organization.
Renewing Primary Health Care in the Americas: A Position Paper of the Pan American Health Organization/World Health Organization (PAHO/WHO) Washington, D.C.2007 Pan American Health Organization & Caribbean Community Secretariat.

Caribbean Cooperation in Health: Phase II A New Vision for Caribbean Health: 1998.

Working Document for the 16th meeting of the CARICOM Caucus of Health Ministers responsible for Health—Washington, DC., USA 29-30 September 2007 44