July 2019 (OPS/OMS)- In Dominica, an island in the West Indies with a population of just over 70,000, change is underway to transform the health system into one that focuses increasingly on primary health care, is people- and community-centred and is better placed to achieve universal health coverage and access (or Universal Health, as it is known in the Region of the Americas).

The Pan American Health Organization, the regional office of the World Health Organization (PAHO/WHO) has been working with the Dominica Ministry of Health and Social Services to undertake a thorough assessment of the health system, and specific recommendations are now being implemented. One example of this is the cadre of 27 new community health workers (CHW) who graduated from a training programme in September 2018, and are now starting work in communities to support health services at the primary level.

Cadre of new community health workers
Cadre of new community health workers. Photo: PAHO/WHO

Building a stronger health system

In 1978, at the time of the Alma Ata declaration, the Dominica health system was a model for primary health care, but over the past several years the primary health care system grew weaker faced with resource constraints and a greater national focus on hospital care. Unfortunately, the population’s health situation in Dominica worsened following Hurricane Maria, which devastated the island in September 2017. This has had a significant impact on human resources for health and the operation of community health centres, several of which were destroyed or made non-functional.

A systematic approach to strengthening the health system and primary health care services was required. Japanese grant funding through the UHC -Partnership supported a comprehensive assessment of the Dominica health system after Hurricane Maria. The PAHO/WHO technical team was comprised of seven persons focusing on various strategic aspects of universal health coverage and access. The team conducted the assessment in association with the Dominica Ministry of Health and Social Services and the National Health Commission during 2018 and early 2019.

It culminated in a comprehensive report which argued strongly that UHC in Dominica will only be achieved through strengthening primary health care and simultaneously addressing weaknesses within the health system relating to governance, health financing, resource allocation and management, and ensuring an integrated approach to health services delivery with intersectoral and community participation. The report made several high-level recommendations to implement action during 2019-2020.

The training of the CHWs was just one of the more urgent recommendations for health system strengthening. The skills-based training of CHW in Dominica intends to address the shortage of health personnel and increase the capacity to deliver people-centered care within community settings and multidisciplinary teams. All this greatly strengthens primary health care.

“It was a pleasure working with the PAHO/WHO team of experts, the management team in the Ministry of Health and Social Services and members of the Dominica National Health Commission to conduct the comprehensive assessment and facilitate the training of the CHWs. Even though there were many challenges, as would be expected following a major hurricane, the teams worked collaboratively to overcome them and bring to fruition the project deliverables. We are looking forward to implementing the major recommendations of the assessment report during the course of the next two years, to enable the transformation of the Dominica Health System to one that is PHC-based, resilient, sustainable and capable of attaining universal health coverage and access and the UN SDGs,”
Dr. Rufus Ewing, Advisor for Health Systems and Services for Barbados and the Eastern Caribbean Countries and the Project Manager. Photo: PAHO/WHO

Training community health Workers

The Ministry of Health and Social Services in collaboration with PAHO and with the support of Japanese funding through the UHC Partnership, has trained a cadre of 27 CHWs. The CHW training was conducted by skilled and experienced Dominica-based nurses in collaboration with the Ministry of Health and Social Services and WHO  PAHO. The curriculum was developed by the course instructors and vetted and approved by PAHO.

The six-month programme took place at the University of the West Indies Open Campus in Dominica, and comprised 13 subject areas and Basic Clinical Skills. All participants passed the Basic Life Support exam and received certificates at an official graduation ceremony on 15th April 2019.

Family and friends of the graduating class, the Permanent Secretary in the Ministry of Health and Social Services, Mrs Letitia Lestrade-Wyke, Master of Ceremony, Mrs Terrillia Ravailiere the Chief Nursing officer, and other staff from the Ministry of Health and University of the West Indies open campus attended the ceremony. The Minister of Health and Social Services, Hon Dr Kenneth Darroux congratulated the graduates on the successful completion of the programme. He said that the training was conceptualized in-order to respond to the need for increased human resource capacity in the health sector.

Training community in Dominica
Permanent Secretary Mrs Letitia Lestrade-Wyke presented certificate to Mr Kireem Vigilant. Photo: PAHO/WHO

“Taking into consideration the constantly increasing demand on our health services both quantum and quality and juxtaposing this against available resources human and otherwise, you can appreciate that today’s ceremony is a step in the right direction towards narrowing this ever-widening gap.” Minister Darroux thanked PAHO for the technical support provided to the program, and commended the PAHO Country Program Specialist, Ms Anneke Wilson on the great work done since being assigned to Dominica.

Dominica trains
Hon Dr. Kenneth Darroux, Minister for Health and Social Services, presented award to the top student Ms Alphanica Robert

Ms Wilson spoke to the graduates, saying, “Always remember when you chose to become a Community Health Aid [Worker], you made one of the most important decisions of your life, you have chosen to dedicate yourselves to the care of others.”  Ms Jean Jacob, Program Coordinator for the Community Health Aide programme, provided a comprehensive report on the course including theoretical and practical components of the programme as well as the collaboration with a number of organizations within the communities.

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Ms Anneke Wilson, PAHO/WHO Country Program Specialist in Dominica. Photo: PAHO/WHO

Ms Bertisha Bertrand spoke on behalf of the graduating class. She said that on starting the course she had very little knowledge about the role of a Community Health Aide. She is pleased to also now have a more in-depth awareness of the meaning of health.

“The course was a great opportunity to achieve clarity on health, the community and what makes a community, how it functions and what can affect its functionality. Health is broad and has many areas which taught us that we have to adapt to different personalities and to different environments. The course has produced 27 qualified foot soldiers for their respective communities and by extension the primary health care service in Dominica, " said Ms Bertisha Bertrand, graduate CHW.

Reflections from the graduates

“I was introduced to the health industry by my mother who is a Community Health Nurse. Just to see her whole effort toward caring for people and taking care of the elderly, children, young or old, I felt that I wanted to play a part.” 
Mr Vigilant, graduate CHW

“One of the things that motivated me was caring for persons who are unable to care for themselves, because we all know that living a healthy lifestyle is key to any society.”
Ms Winston, graduate CHW

“The six months was intensive. Coming into the programme I honestly had no idea what I was getting myself into but I must say it has really given me a deeper appreciation for the health services and the ability to be able to reach out to the community and to assist everyone especially the elderly.”
Ms Peter, graduate CHW