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BERMUDAHEALTHSTRATEGY2022 - 2027BERMUDA HEALTH STRATEGY 0
BermudaHealth Strategy2022-2027Contact us:We’d love to hear from you! If you have any queryor concern, reach out for a helping hand.Please find our contact details below, if you wouldlike any further information about the BermudaHealth Strategy 2022-2027.Mailing Address:PO Box HM 380Hamilton HM PXBermudaStreet Address:Email:Continental Building25 Church StreetHamilton HM 12BermudaMinistry Headquarters: moh@gov.bmPhone: (441) 278-4900Website: https://www.gov.bm/ministry/healthDepartment of Health Child Health childhealth@gov.bm Dental Health dentalclinics2@gov.bm Environmental Health envhealth@gov.bm Nutrition nutrition@gov.bmSocial Media:Health Insurance Department hip@gov.bmFacebook: @healthbermudaOffice of the Chief Medical Officer officeofcmo@gov.bmTwitter: @HealthBermudaInstagram: health BermudaEpidemiology & Surveillance epidemiology@gov.bmPublished by:Reference as:Ministry of Health (January 2022)Copyright 2022 Ministry of HealthMinistry of Health (2022) Bermuda Health Strategy 20222027. Government of Bermuda.BERMUDA HEALTH STRATEGY 1
Table ofContents040305Welcome fromthe Minister ofHealthOur vision,mission andprinciplesState of healthin Bermuda0715Our 5-yearhealth strategyRoadmap fordelivery16ReferencesBERMUDA HEALTH STRATEGY 2
Our vision, missionand principles“Our Core Vision:Our mission is to makeBermuda healthier:“Ensuring that all peoplehave equitable access toneeded informative,preventive, curative,rehabilitative and palliativeessential health services, ofsufficient quality to beeffective, while alsoensuring that people do notsuffer financial hardshipwhen paying for theseservices and criticalmedicines.”Healthy people in healthy communities”Our strategic principles guide all our work:Care Promoting healthy living andpreventative care Understanding our population'shealth needs Providing access to healthcarecoverage Strengthening our healthcareworkforce Harnessing healthcare technologyDelivery Focusing on person-centred care Partnership and collaborativeworking Preventing wasteful care andpromoting efficiencyBERMUDA HEALTH STRATEGY 3
Welcome fromthe Minister of HealthI am proud to introduce theMinistry of Health’s new strategic plan for 2022 – 2027.This Government remains committed to putting our peopleat the center of a healthcare system that supports healthierand more productive communities for Bermuda.While our health system is already well-developed and wellsupported by dedicated professionals, challenges inproviding equitable and affordable physical and mentalhealthcare have been growing for several decades.The reasons are complex, requiring collaboration betweenall stakeholders to deliver the person-centered, multi-yearchange required for a more sustainable, healthier future.While there is much to be proud of in our health system, it isimportant that all residents can access affordable andessential services, delivered effectively and efficiently.Yet, as I write this, we currently find ourselves in a difficultperiod of transition brought on by the pandemic.We must continue this positive collaboration to developa health system fit for the future. The Ministry will leadthe necessary changes and deliver the stronger andmore efficient health system that we need.As our island and people recover from the pandemic,our work to reignite and refresh our ambition of universalhealth coverage (UHC) will help set a new path forstrengthening healthcare for all. A healthy nationbenefits all citizens as well as our wider economy.With this strategy we aim to provide Bermuda with aclear vision for health with the refreshed priorities for ourhealth system.We look forward to taking these bold next steps togetherand welcome your contributions.COVID-19 has shone a bright light on healthcare - inparticular, the strength and resilience of our healthcareworkforce - and I want to acknowledge the island’s gratitudeto them in helping us through this difficult period.But the pandemic has also highlighted the importance of anaccessible healthcare system. It has shown that access toaffordable, high-quality, essential healthcare is a basic right,and one that this Government is committed to seeingintroduced for all.While this new strategy builds upon our previous work, thepandemic has changed our healthcare landscape. This haslimited our ability to pursue our ambitions as originally setout and at the pace we intended.At the same time, it has helped build a more united coalitionof stakeholders, working together shoulder-to-shoulder tomeet the immense challenges we have all been facing.The Hon. Kim N. Wilson, JP, MPMinster of HealthBERMUDA HEALTH STRATEGY 4
State of healthin BermudaOur community’s health and well-being, pre-pandemic:Infrastructure hestincidence rate ofdiabetes in the OECDwith over 13% ofresidents diagnosed50% of residentshave at least onechronic condition suchas diabetes, heart orkidney disease1 in 3residents havehigh bloodpressure and/orhigh cholesterol 29mis spent every year ondialysis and demandfor this service growsby 10% each year83.5 yearsis our projectedlife expectancy by20301 in 3 peoplewill be aged over65 by 2039(2019: 1 in 5)There are 3.9 people in the workforcefor every over-65 dependent. By 2039,this will drop to 1.7 which could resultto a reduction of funding into ourhealthcare system12% of residentsare uninsured11.6% of GDPis spent on health,the third-highest inthe OECDHealth expendituregrew by 92% between2006 and 2017There are 7.9 nursesper 1,000 in Bermuda,lower than the OECDaverage of 8.8Bermuda Hospitals Board isharnessing digital health anddata to enhance care byimplementing electronicmedical recordsBermuda HospitalsBoard is accredited atAccreditation Canada’shighest levelBERMUDA HEALTH STRATEGY 5
Bermuda has a complex system of healthcare components:There are many sources of There are several entitiesfunds and collectingfor purchasing servicesagencies for healthcareusing private, public andrevenue.charity funds.Service provision isdelivered both by private,public and charitableproviders.There is a high utilisation ofoverseas care, sometimesbased on preference ratherthan clinical needs.One Year of Health System Funding, Pre-COVID-19Health financing refers to the “function of a health system concerned with the mobilisation, accumulation andallocation of money to cover the health needs of the people, individually and collectively, in the health system.”- World Health Organization, 2000 93M 58MOverseas careDoctors 46M 31MPharmacyDentistry 37M 80.5MGovt. facilitiesOther 307MBermudaHospitalsBoardCare deliveryPrivate insurersFund pool andpurchasing of services(Cost of 652.5 million)(Administration cost 83.5 m) 110M 166MCo-pays orOut-of-pocketTaxesGovernment 453M 7MPremiumsCharityCharitiesRevenue collection(Funding of 736.0 million)BERMUDA HEALTH STRATEGY 6Source: National Health Accounts 2019; World Health Organisation, 2000; numbers may not total exactly due to rounding
CARE1. Promotinghealthy living andpreventative careWe want toempower thecommunity tolead healthylifestyles byenabling peopleto increasecontrol over, andto improve, theirhealth.The health needHow will we do this?Health promotion and prevention iswidely recognized as being anessential requirements for building astronger health system. Increase public awareness of healthdeterminants such as diet and exercise, andencourage adoption of healthier lifestyles topromote well-being through strengthenedand collaborative health promotion activities Prevent, reduce or modify the course ofcommunicable and non-communicablediseases, including mental health Identify at-risk individuals in order to initiateearly intervention Maintain a healthy environment by identifyingactual or potential environmental healthhazards and applying effective controls Ensure health aspects are considered aspart of all future policy developmentIncreasing rates of preventable chronicnon-communicable diseases, such asdiabetes and heart disease, place aburden on our limited healthcareresources and threaten the wellbeingof Bermuda’s individuals and widereconomy. Many of these diseases arestrongly related to lifestyle factors suchas poor diet, physical inactivity andsmoking.Similarly, the equal importance ofpromoting mental health is recognized,as is the need to challenge historicalstigma and preconceptions.There is a role for everyone to play insupporting good physical and mentalhealth, and we are committed toenhancing our efforts to promotewellness and healthier living.How will we measure success?Making it easier for people to shift theirmindsets and behaviours to make healthychoices is key to success. Promotion: Assess the five core dimensionsof all health promotion programmes weundertake: reach, efficacy, adoption,implementation and maintenance Prevention: Number of interventions toprevent and manage illness throughhealthcare coverage, clinical guidelines, thetreatment paths which people experienceand surveillance of persons with or at risk ofdiseaseQuestions to consider How can we collaborate with healthcareproviders to promote healthy living? How can employers and communitiesencourage behaviors to support healthierlifestyles? What will it take for individuals to embraceproactive responsibility for their own healthoutcomes?BERMUDA HEALTH STRATEGY 7
DELIVERY2. Focusing onperson-centeredcareWhen deliveringperson-centredcare, individualsare included inthe decisionmaking process,and care focuseson theirindividual healthneeds. Peopleare treated notonly from aclinicalperspective, buttheir values andwants are alsoconsidered.The health needHow will we do this?Person-centred care and services canimprove the individuals’ and familyexperiences, and health outcomes. Encourage people to take an active rolein their care and promote wellness Encourage healthcare providers to berespectful of an individual and theirfamily’s preferences Include individuals and, whereappropriate, family representatives aspart of decision-making Improve information accessibility andcommunication to individuals receivingcare and their familiesPeople who have a positive health careexperience are more likely to return forhealth promotion and preventativeservices (such as routine check-ups).A person-centred approach ensurescontinuity of care across serviceproviders, contributing to improvedoutcomes and reduced duplication ofcostly services.Engaging people to co-participate instrengthening our health system, fromintegrated essential care pathwaydesign to system stewardship andgovernance, is key to our futureapproach.How will we measuresuccess? Feedback from individuals, alongsidetheir families and carers Inclusion of representatives of thegeneral public at forums (whereappropriate) Monitor use of overseas specialists andlocal service provision Measurement and monitoring ofpopulation health outcomesQuestions to consider What are people’s experiences of theircare journey and care? How can we include people moreactively in their care? What information is available for peopleand how can we make it moreaccessible?BERMUDA HEALTH STRATEGY 8
CARE3. Understandingour population'shealth needs“Promoting andprotecting healthis essential tohuman welfareand sustainedeconomic andsocialdevelopment.”World Health OrganizationThe health needHow will we do this?In order to manage the island's limitedfinancial means, we need tounderstand what our priority healthneeds are, including both physical andmental health. Undertake a comprehensivenational health needs assessmentto better understand currentpopulation health challenges Use international benchmarking tounderstand gaps and solutions inhealth service delivery Develop processes and metrics totransparently measure and regularlyreport markers of care and needThe growth in chronic preventable noncommunicable diseases like heartdisease, kidney disease, cancer anddiabetes has placed strain onBermuda’s health system capacity,particularly as our population ages.Urgent change is needed to addressthis pressing challenge. We mustestablish a clear and accurate pictureof what these health needs are andimplement ways to monitor andmanage them.How will we measuresuccess?System-level metrics to measure,monitor and manage population healthneeds will be put in place, includingmetrics such as: People’s experience of care Adopting use of internationallyrecognized health metrics, such as:1. Deaths within the hospital,adjusted to account forpopulations which are more- orless-likely to die (the ‘hospitalstandardized mortality ratio’)2. Deaths from preventable ortreatable conditions, adjusted forage (the ‘age-standardizedmortality of potentially avoidabledeaths’ metric)Questions to consider What are the high-priority careneeds for our population? What gaps are there in our currentstandard health benefit and howcan we address these gaps? What do people want to seeenhanced, introduced or removed?BERMUDA HEALTH STRATEGY 9
CARE4. Providing accessto healthcarecoverageThe long-termambition is toensure that allpeople haveequitable accessto essential,affordable, highquality physicaland mentalhealth services.The health needHow will we do this?Bermuda’s health system is challengedby unsustainably high costs and doesnot provide equitable access to qualitycare for our population. Share the future-state vision forBermuda’s health system for furtherdiscussion with all stakeholdersWhile our healthcare spending percapita is one of the highest in theworld, up to 35% of the populationremains unable to access qualityhealthcare without financial hardship.This includes those who are uninsured(about 12%); or have definedunaffordable health insurance or areunderinsured (about 23%).Bermuda’s health outcomes do notreflect the amount currently spent onhealth, publicly or privately. Thiseconomic burden must be addressed.We are committed to strengthening ourhealth system to provide affordableaccess to essential health coverage forall residents. Publish updated national health accountsdetailing the flow of resources within thehealth system, acknowledging in-kindsupport and the specific impacts ofCOVID19 Model the future value and sustainabilityof our current health system Establish the impact of strengthening ourhealth system on our economy, i.e.increasing employment opportunities,decreasing absenteeism due to ill healthHow will we measuresuccess?Recognising that health care strengtheninghas a minimum 10-15 year horizon, it isimportant that we measure our progress. Tosupport effective measurement, we will adoptthe United Nations Sustainable DevelopmentGoal (SDG) measures, including: The proportion of a population that canaccess essential quality health services The proportion of households which spendan unsustainable proportion of income onhealthcareQuestions to consider What are the priority health services thatresidents most want to improve and makeaccessible? What are the unmet health needs of ourpopulation that expanding healthcarecoverage could help address? In addition to strengthening healthcarecoverage, what other opportunities arethere to help strengthen wellness in all ourcommunities?BERMUDA HEALTH STRATEGY 10
CARE5. Strengtheningour healthcareworkforceThe combinationof governanceand the rightskillset in ourhealthcareworkforce is keyto deliveringhigh-qualitycare.The health needHow will we do this?Strengthening trust, accountability andcoordination of care across our healthworkforce is essential to delivering astronger healthcare system. Agree a set of principles ofgovernance and accountability acrossour healthcare system to overcomesiloed working and promotecollaboration with clearresponsibilities Develop and launch a new nationalhealth forum based on the abovestewardship organisational structure Complete our population health needsassessment and health workforceplan based on these needs Establish a register of studentsstudying health subjects to help shareknowledge, skills and job openingsWe must also consider how ourpopulation’s health needs are beingmet by our workforce and theimplications for health workforceplanning.To strengthen our workforce and theservices provided, it is important tobuild a holistic framework thatpromotes high-quality, coordinatedhealthcare services.How will we measuresuccess?We will engage with and listen to ourhealthcare workforce. We will: Work with professional organisationsto maintain a regular report of staffinglevels, retention, vacancies,challenges and successes Regularly measure and report theexperiences and satisfaction of ourhealthcare workforceQuestions to consider What are the challenges and barriersimpacting the healthcare workforce? How can we increase and diversifyemployment opportunities in thehealthcare sector? What are the unmet skills and trainingneeds of both our current and futurehealth sector workforce?BERMUDA HEALTH STRATEGY 11
CARE6. HarnessinghealthcaretechnologyTechnology canhelp improveaccess tophysical andmentalhealthcareservices. Thiscan also improvehow healthcareis delivered andhow outcomescan bemonitored.The health needHow will we do this?Bermuda is a leader in promotingdigital engagement across oureconomy and is in an enviable positionto use our existing digital experience inareas such as FinTech to improvecare, enhance value and drive widereconomic investment opportunities tosupport our digital economy. Establish a system-wide vision andintegrated digital healthcare strategy Develop a system-level dashboard withmetrics to measure and manage systemand population health, with periodicpublic reportingFrom improving access to care usingtelemedicine consultations, to reducingoverseas treatment and diagnosticsthrough enhanced remote monitoring,there are substantial benefits to berealised.It is critical we harness health data toimprove communication, bridge gaps,avoid duplication and reduce errors toimprove outcomes and value.With Bermuda Hospitals Boardimplementing a new electronic healthrecord to deliver safer, more efficientcare, we can seize this opportunity todeliver a better-connected andcoordinated national health system.How will we measuresuccess?While specific measurements will beidentified with the new digital healthcarestrategy, it is anticipated that the followingmeasurements will be tracked: Increased proportion of people withelectronic health records Increased use of digital health channelsto access care, both locally and withoverseas providers Efficiencies and value driven throughadoption of digital healthcare solutions Improved utilisation of healthcare data tobetter guide healthcare policy decisions,including resource allocations andprioritisationQuestions to consider What digital initiatives would residents,payors and providers most like to seebeing introduced? How can existing expertise from othermarket sectors be used to strengthendigital healthcare? What are the current obstacles to digitalhealthcare in Bermuda and how canthese be addressed?BERMUDA HEALTH STRATEGY 12
DELIVERY7. Partnerships andcollaborativeworkingWorking with ourhealthcarecommunity willhelp us achievebettercoordination ofhealth servicedelivery andimprove thehealth outcomesof our residents.The health needHow will we do this?Effectively improving the long-termhealth and wellness of our populationrequires new ways of collaborating. Initiate pilot projects with stakeholders tomap integrated essential care pathwaysfor prioritised services, to identify thecare journey and handoffs betweenservice providers Develop and document a scalableprocess to map current care pathwayvalue and benefits, to see how we canimprove our services further throughmore efficient care delivery andcollaboration between care providersComplex models of care lead to aninefficient use of health systemresources.This is particularly true for theincreasing number of people living withpreventable chronic conditions whoneed a more coordinated integration ofcare between their different healthcareproviders.Understanding and defining moreintegrated care pathways betweenproviders and individuals has beenshown to increase the quality,affordability and efficiency of careinternationally.Understanding and improving our carepathways will strengthen the healthsystem by defining standards,promoting and disseminating bestpractices and increasing resident andcare provider satisfaction.How will we measuresuccess? Improved care recipient and providersatisfaction Improved population health outcomes Identification of efficiencies throughworking collaborativelyQuestions to consider How can our health system fostercollaboration between care providersthat keeps people and health outcomesat the front of all that we do? What are the optimal approaches tocommunication and knowledge-sharingto facilitate collaboration andcoordinated care? How can we work together as a healthsystem to establish a commonhealthcare culture?BERMUDA HEALTH STRATEGY 13
DELIVERY8. Preventing wastefulcare and promotingefficiencyOur commitmentto maximisingefficiency inaddition toimproving healthoutcomes isessential tomaintain thesustainability ofour healthcaresystem.The health needHow will we do this?Our ageing population and decliningnumbers of insured residents arethreatening the future sustainability ofhealthcare in Bermuda. Identify and quantify system wideopportunities to achieve better valueIn order to provide better value, it isimportant to understand our currentand future costs.Wasteful healthcare spending, whetheradministrative, operational or clinical,must be avoided.There are significant opportunities tobetter quantify, monitor and managevalue for the benefit of residents,payors and care providers. Integrate and streamline theadministration and management ofthe Government’s health insuranceplans Ensure our procurement processesare aligned, efficient and createeconomies of scaleHow will we measuresuccess? Increase connectivity within oursystem where possible Quantify key system opportunities todeliver higher value careQuestions to consider How could greater transparency in thevalue of our health services supportresidents in making better choicesabout their own care? What are the current areas ofhealthcare that Bermuda’s residentswould like to see greater improvementeffort and focus applied to? How can improved case managementreduce waste and improve careoutcomes and resource utilisation?BERMUDA HEALTH STRATEGY 14
Roadmap forDeliveryThis initial 3-year roadmap outlines the high-level steps and thetimelines needed for us to take a phased approach from highest-priorityessential services and benefits towards our ultimate future vision of astronger, sustainable healthcare system for all.YEAR 1 ACTIONSYEAR 2 ACTIONSYEAR 3 ACTIONSBUILD OUR FOUNDATIONS ANDCARE PATHWAYBROADEN ESSENTIALCARE COVERAGEDEVELOP INSUREREXPANSION & ALIGNMENT1. Develop and pilot integratedessential care pathways foressential care as an exemplar toestablishing UHC, and deliveringbetter value.2.3.4.5.1. Payor collaboration beyondGovernment Health InsurancePlans: although third-partyinsurers will be involved closelyfrom the outset, after successfullaunch of essential careInitiate new working groups2. Deliver improved value throughpathways and packages underincluding people, payors anddeveloping further integratedthe Government healthprofessionals, to build a panessential care pathways andinsurance plans, we will then besystem structure for stewardshippan-system opportunities forable to explore and considerand collaboration.improved value.options for further collaboration.Agree our starting points:3. Launch further pilot essential2. Deliver further value throughupdated national health accounts,care packages for the integrateddeveloping additional integratedidentify pan-system valuecare pathways covering essentialessential care pathways andopportunities, impact of statuscare under the consolidatedpan-system opportunities forquo, health needs assessment,Government health insuranceimproved value.and new system measures.plans.3. Launch further pilot essentialEstablish the economic case for 4. Comprehensive financialcare packages for the integratedhealthcare strengthening andmodelling of the total fundingcare pathways covering essentialUHC to support the wideravailable and costs of thecare under the consolidatedeconomic case for Bermuda.essential care packages in theGovernment health insuranceintegrated care pathways basedDevelop national digital healthplans.on pilot work undertaken to-date.strategy to align and drive wideropportunities in advance of BHB’selectronic health recordimplementation.1. Purchasing health servicesand payment mechanisms:develop options and modelledimpacts, and pilot newapproaches.6. Develop options forconsolidating the Governmenthealth plans to deliver value withinitial financial assessment andimpact modelling.Strengthen communication, actively involving stakeholder and public engagementBERMUDA HEALTH STRATEGY 15
Further readingFurther reading and references expanding on the evidence and learningreferred to in the strategy and development of the recommendations:Bermuda Health Council (2020). 2019 National Health Accounts Report: Bermuda health system financeand expenditure for fiscal year 2017 - 2018. Bermuda Health Council: BermudaBermuda Health Council (2018). Issue Brief: Dialysis. Bermuda Health Council: BermudaCaribbean Charter for Health Promotion (1993) Op. Cit.Department of Statistics (2018). Bermuda Population Projections 2016-2026. Hamilton, Bermuda:Government of Bermuda Department of StatisticsDepartment of Statistics (2016). Population and Housing Census Report. Hamilton, Bermuda: Governmentof Bermuda Department of StatisticsGlasgow, RE, Vogt, TM and Boles, SM. (1999) Evaluating the public health impact of health promotioninterventions: the RE-AIM framework. American Journal of Public Health, 89, 1322-1327.Global strategy on digital health 2020-2025. Geneva: World Health Organization; 2021. Licence: CC BYNC-SA 3.0 IGO.Ministry of Health (2019). Bermuda Health Plan – Data Assumptions 2019. Hamilton, BermudaMinistry of Health (2017). Bermuda Health Workforce. Office of the Chief Medical Officer. Hamilton,Bermuda.Nutbean, D. (1998) Health Promotion Glossary. Health Promotion International. 13(4): 349- 364World Health Organisation (2000). Health Systems Financing.BERMUDA HEALTH STRATEGY 16
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life expectancy by 2030 12% of residents are uninsured There are 7.9 nurses per 1,000 in Bermuda, lower than the OECD average of 8.8 1 in 3 people will be aged over-65 by 2039 (2019: 1 in 5) 11.6% of GDP is spent on health, the third-highest in the OECD Bermuda Hospitals Board is harnessing digital health and data to enhance care by
