Locums, agency staff and volunteers are the face of public hospital health care in the NSW Northern Rivers region in 2023-2024

 

Clarence Valley independent, 13 December 2023:

Staff shortages amongst doctors, nurses, and specialists on the north coast has seen the Northern NSW Local Health District spend $148 million in the 2022-2023 financial year on agency staff.....

In July 2023, The Sydney Morning Herald revealed that NSW Health was spending about $1 billion annually on temporary health workers, with $148 million spent on locum doctors who are paid up to $4000 a day, while working in under resourced regional hospitals.

Northern NSW Local Health District NNSWLHD Chief Executive, Tracey Maisey said the past few years have been challenging, navigating the COVID-19 pandemic, floods and bushfire emergencies.

“Despite these challenges our staff have succeeded in delivering high quality and positive outcomes of care,” she said.

“When vacancies exist, NNSWLHD engages agency medical and nursing staff to supplement the permanent workforce across the District.

“The 2022 floods had a significant impact on local communities and our local workforce, and agency staff played an important role in supporting our services throughout this period.

“In the 2022-23 financial year, the costs associated with our agency workforce totalled $148 million.”

The $148 million spent in the 2022-23 financial year on locum staff equates to about 13 per-cent of the Northern NSW Local Health District NNSWLHD annual budget, with more than $68 million paid in wages and $16 million spent on accommodation for these staff.....

Recruitment of staff is ongoing.

“An overseas nursing recruitment program conducted earlier in 2023 is bolstering local nurse numbers, with the first of 60 new nurses already settling into their roles at hospitals across the District,” Ms Maisey said.

“In partnership with our staff and expert external support we have developed a comprehensive recruitment campaign, and there are recruitment and retention incentives for critical roles.

“We are supporting the retention of existing staff by assisting eligible staff on temporary contracts to transition to permanent employment and are working with our facilities to support them to improve internal recruitment processes and timeframes.

“We have also increased our new graduate nursing numbers, as well as offering permanent positions rather than traditional fixed term contracts.”

The Northern NSW Local Health District board has also looked at the issue of creating a volunteer arm in its service provision and in November 2023 issued a media release which stated in part:

Northern NSW Local Health District (NNSWLHD) is calling for community members to join the Healthcare Helpers volunteer program, with a range of roles available in health facilities for 2024.

Applications are now open for volunteer roles supporting patients, visitors and healthcare staff in facilities in Tweed, Nimbin, Ballina, Lismore, Maclean, Grafton, Bonalbo, Urbenville and Kyogle.

NNSWLHD Volunteering and Fundraising Manager, Claire Quince said the volunteers support health staff and improve the experiences of patients and visitors.

“After welcoming 30 new Healthcare Helpers to Lismore, Grafton and Maclean Hospitals in June this year, we are now expanding the program to the District’s other health facilities,” Ms Quince said.

“In addition to meet and greet roles in hospital public areas, we are introducing companion volunteers to provide social support to patients undergoing surgical procedures, cancer treatment and dialysis rehabilitation, as well as new mothers in the maternity ward.

“Our residential aged care facilities at our Multi-Purpose Services are also recruiting companion volunteers to provide social support and assist with outings for aged care residents.”

NSW Upper House report on health & hospital services in regional, rural and remote areas of the state documents instances of lack of access to specialist services, understaffing, poor treatment outcomes, inadequate ambulance presence, long wait times, high out-of-pocket expenses and discrimination

 

It is hardly a secret that the NSW public health & hospital system has been under stress for much of the last two years and remains under stress in 2022.

Nor is it a secret that the ongoing global Covid-19 pandemic and seasonal respiratory disease have played a big part in this organizational stress.

However, they are not the only contributing factors and in rural, regional and remote areas health services stress has been building for decades.

There is a reported absence of a GP or chronic shortage of health professionals in: Bonalbo, Eurobodalla, Gunnedah, Deniliquin, Edward River, Manning Valley, Port Stephens, Temora, Glen Innes, Gulgong, Wee Waa, Wollondilly, Mid-Western Regional Council, Coleambally, Warren Shire Council, Broken Hill, Wentworth, Merriwa, Tenterfield, Parkes, Coonamble, Gwydir, Bourke, Hay and Leeton, with another 41 Western and Far West NSW towns identified as being at risk of not having a practicing General Practitioner within the next 10 years.

Often there is only one doctor on duty at smaller regional, rural or remote hospitals and 27 per cent of all adverse events (clinical incidents or mishaps) occurred in rural and remote health services.

In addition, the NSW Ambulance service is frequently overwhelmed by a combination of low staff numbers on a given day, vehicles tied up by being 'ramped' at over stretched hospitals and increased travel times.

A NSW Upper House inquiry was established on 16 September 2020 to inquire into and report on health outcomes and access to health and hospital services in rural, regional and remote New South Wales.

It received 720 submissions.

The following are extracts from the Inquiry report tabled in the NSW Parliament on 5 May 2022.

NSW LEGISLATIVE COUNCIL, PORTFOLIO COMMITTEE NO. 2, REPORT 57, May 2022, “Health outcomes and access to health and hospital services in rural, regional and remote New South Wales”

Committee comment

3.126 As already outlined in this report, the inquiry has heard evidence from a number of witnesses providing first-hand examples of inadequate health services and care in rural, regional and remote New South Wales. There is no doubt that doctor and clinician workforce issues are a key, if not the key to explaining many of these experiences. The committee acknowledges and appreciates the many doctors and clinicians who gave up their time and shared their expertise and personal experiences to inform the inquiry of the issues they face in rural and remote settings, including their ideas about ways to improve the current situation. These accounts provided detailed and thoughtful evidence as to both the challenges and opportunities to address them.

3.127 It is clear to the committee that the availability of doctors and clinicians in rural and remote locations is short, in some cases critically short of where it needs to be. While Chapter 2 detailed the impact this shortage is having on members of the community, the committee has also heard doctors and clinicians describe the unsustainable working conditions, particularly with respect to hours of work arising from insufficient supply of doctors and clinicians to cover the available work demands. The committee is concerned about doctor and clinician shortages and maldistribution in rural and remote settings, and the risks it poses to the health of community members, doctors and clinicians alike.

3.128 Consequently, the committee finds that rural, regional and remote medical staff are significantly under resourced when compared with their metropolitan counterparts, exacerbating health inequities…..

3.130 Indeed, there can be little doubt that the doctor workforce challenge is complicated and compounded by the division of responsibilities between Commonwealth and State. In fact, both levels of government acknowledged the Commonwealth/State divide as one of the most challenging aspects of health care delivery. But the existence of these challenges is not new. The committee is of the view that efforts to overcome them have been inadequate to date, ultimately failing to achieve the necessary structural reform. Consequently, the committee finds that the Commonwealth/State divide in terms of the provision of health funding has led to both duplication and gaps in service delivery.

3.131 The committee therefore recommends that the NSW Government urgently engage with the Australian Government to establish clear governance arrangements and a strategic plan to deliver on the reforms recommended below to improve doctor workforce issues. This should occur at the ministerial level to ensure the necessary political and policy momentum is maintained. We also believe that with a renewed commitment to work together to break down barriers and achieve health reform, progress can be made on those initiatives that both levels of government have identified as meritorious, but where progress has been slow or non-existent.

3.132 Despite the role played by the Australian Government, the committee also believes that, given the interdependency between primary health and hospital care, there is a need for the NSW Government to investigate ways to support the growth and development primary health sector in rural, regional and remote areas and support the sector’s critical role in addressing the social determinants of health and reducing avoidable hospitalisations for the citizens of New South Wales. [my yellow highlighting]

The report made 44 specific recommendations which are outlined on pages xv to xxii of the report found at:

https://www.parliament.nsw.gov.au/lcdocs/inquiries/2615/Report%20no%2057%20-%20PC%202%20-%20Health%20outcomes%20and%20access%20to%20services.pdf

Formal response from the Perrottet Government in not due until November 2022.

Northern Rivers region fronting up for local frontline COVID-19 healthcare workers, paramedics & public hospital support staff

"We will buy meals from local businesses to be delivered to staff at Byron and Lismore Base hospitals. We won’t forget wards people, cleaners, those doing the testing, those on the phones and in admin. And we won’t forget night shift. This is also a way we can support local businesses. (Sadly, home-baked meals and treats are not possible due to food safety issues.) At Lismore, which is a very big hospital, we'll begin by taking meals into the Emergency Department, ICU and the COVID wards. We are organising donations of biscuits, teas, coffee, trail mix, chocolate, smoothies and juices to be put in tearooms (and regularly topped up) in these two hospitals....Depending on the amount raised and requests that come in from frontline workers, we will look for ways to offer other support to frontline workers outside their work environment." [Sarah Armstrong, Fundraising Organizer] 

This year five members of the Mullumbimby community decided to offer practical support during this particular COVID-19 surge to as many healthcare workers in the public hospital system, support staff who keep the system running and to paramedics who transport people to hospital. 

To that end a GoFundMe page was set up and in a matter of the first 16 days and 397 donations had raised $29,610 of a target of $50,000 to provide free hot and cold drinks, healthy snacks, biscuits and meals in the tearooms of Mullumbimby's local hospital Byron Central Hospital and Lismore Base Hospital the dedicated COVID-19 public hospital in the Northern NSW Local Health District. 

The Echo reports that organisers have provided their first delivery of meals to Byron Hospital, handing over dozens of pre-cooked dishes prepared by local vegan caterer, Yummify. Lismore Hospital will also receive their first shipment soon, with local business Mayfield Kitchen providing the meals.

Plans are underway to also allow paramedics on duty to access free coffee and snacks at selected cafes under this grassroots community scheme. 

Many local businesses and residents from across the region are throwing their weight behind this organised gesture of appreciation. 

If you would like to join in by making a small donation to "Front up for the frontline" this is the the link: www.bit.ly/3rrJo70. 

The organisers have stated "We’d love to do this for every hospital in our region but it’s a task too big for the six people working on this. We’re happy to offer guidance to anyone wanting to do the same for their local frontline workers."

 

Frontline medical staff not happy with Morrison Government's lack of thought or preparation behind the national plan to re-open Australia

 

Nurses union the ANMF calls on Australian Prime Minister Morrison to address critical concerns before triggering national plan to re-open Australia

ANMF Australian Nursing and Midwifery Federation Journal, 1 September 2021:

The Australian Nursing and Midwifery Federation (ANMF) has written to Prime Minister Scott Morrison to outline its significant concerns regarding the government’s national plan to re-open Australia and transition the country’s pandemic response based on the Doherty Institute’s COVID-19 modelling and the Commonwealth Department of Treasury’s economic analysis.

In the letter, the union requests that more detailed modelling and analysis be undertaken and considered by National Cabinet before it takes any further steps to re-open the country.

“As you are aware, the nursing and midwifery workforces, as the largest and best distributed components of the health workforce, are fundamental to ensuring that the Australian community remains safe and healthy both during COVID outbreaks and as we seek to gradually move the nation beyond the current ‘suppression phase’ of the COVID-19 response,” ANMF Federal Secretary Annie Butler wrote.

“This means that the impacts of re-opening and transitioning the country’s national COVID-19 response prematurely without adequate planning or sufficient resourcing will disproportionately affect nurses and midwives and their capacity for ongoing delivery of quality care.”

Ms Butler argued the Doherty modelling, which currently underpins the government’s proposed re-opening plan, fails to take into account all the factors affecting this capacity.

Specifically, the ANMF has called on the government to consider the following factors before re-opening:

1. Current health system demand capacity, including expansion capacity, both critical care and general, and management of non COVID health demand

2. Assessment of safe vaccination targets, which include the entire population, not just those currently eligible

3. Vaccination rates needed for vulnerable populations, including those aged over 70 and other high-risk groups

4. Management of anticipated vaccination rollout channels for boosters, once recommended

5. The impact of the Delta and future variants, including on children, particularly in the context of uncontrolled community transmission, as is currently occurring in NSW

6. How the test-trace-isolate-quarantine TTIQ workforce will be fully resourced and maintained without impacting the nursing and midwifery workforces

7. How to ensure all communities across Australia will have equal access to safe healthcare as we progress through the pandemic

Like all Australians, Ms Butler said the ANMF was keen to transition the country’s COVID-19 response from one of strict virus suppression to more relaxed restrictions. However, it cannot happen without first addressing critical concerns, she warned.

“We cannot overstate the importance of ensuring that we do not make this transition until we can guarantee that vaccination rates and appropriate public health measures are sufficient to allow the health and aged care systems and their workforces to be able to continue to deliver best practice care to all those requiring it.”

AMA calls for stronger quarantine model – a need to move away from temporary measures and introduce permanent quarantine solutions

Australian Medical Association, 2 September 2021:

The AMA has called for an urgent stocktake of potential quarantine sites around Australia in a submission to the Chair of National Review of Hotel Quarantine, Ms Jane Halton AO PSM. Ms Halton invited the AMA to provide this submission as part of her further review into Australia’s quarantine arrangements.

Australia’s current hotel quarantine has resulted in over 30 breaches, one of which has led to the third wave of infections. Australia needs to move away from this temporary measure and introduce permanent quarantine solutions.

The AMA has welcomed the announcement of the three quarantine facilities announced in recent weeks, however the facilities will take months to complete. The AMA is also concerned about the lack of engagement with the local medical communities in the vicinity of these facilities.

The submission also calls for further examination of the options for expanding home quarantine for fully vaccinated people arriving from lower risk locations. This would alleviate some of the burden on quarantine facilities.

AMA President Dr Omar Khorshid will meet with Ms Halton in the coming weeks to further detail the AMA’s priorities in ensuring Australia has a robust quarantine regime. Underpinning the AMA’s position are two goals: To prevent COVID-19 originating overseas from spreading through Australia, and to ensure that Australians can continue to return here from overseas, ideally in increased numbers.

National Cabinet needs to look at the whole Australian hospital system, not just ICU beds

Doorstop interview, 2 September 2021:

DR OMAR KHORSHID: The AMA is today calling on National Cabinet to look at the capacity of our hospital system, not just ICU beds, but our whole hospital system, to make sure that once we open up, we don’t see a disastrous reduction in the care available to Australians who are sick simply as a result of increase in the risk of COVID in the community from opening up. And of the hospitals having to pivot towards treating COVID without treating all those other conditions that people currently present with.

The reality in public hospitals in Australia right now is that they are full, they are always full, and there are ambulances parked outside, too many of them as we speak, simply because the hospitals don't have the capacity to look after the healthcare needs of Australians. That's before COVID. And we know that as soon as COVID comes into the community, hospitals will have to stop doing elective surgery. They will have to turn their ICUs into COVID ICUs. And that means people not being able to access lifesaving cancer surgery, lifesaving heart surgery, because the ICUs will have very sick COVID patients to look after, patients who stay in the ICUs for weeks and weeks.

Now, we are not worried that our system will fail to look after COVID patients. We think the planning has been done, but we are worried about Australians who get heart attacks, who need surgery, who have a sore hip, who are going to miss out on care if we don't get the planning right. Our hospitals are starting from a position of being completely overloaded, and adding more to that load is only going to make things worse. So we're asking National Cabinet to take that into account with their planning. Is it right to open up at 70 or 80 percent if the hospitals are going to predictably fail within weeks? Which will, of course, send us straight back into lockdowns, which would be extremely disappointing for all Australians or is there a better way to plan to use our system, to make sure that the resources that we do have, limited as they are, can be best pointed towards the most efficient care possible?

Now, we're asking for planning not just around ICU beds, but around all the processes, the staffing, how we deal with COVID in hospitals, how we run our primary healthcare sector, so that we've got the best chance that when Australia does open up to the rest of the world, when we do open up our interstate borders, that we have a healthcare system available to everybody who needs it. It’s a pretty simple ask, but it's a complex task. And we believe that we must use the available weeks and months that we have, to get that planning done so that the healthcare system doesn't become the handbrake on Australia's economy and our ability to open up…...

A NSW Legislative Council "Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales" has been underway since August 2020, but curiously its terms of reference do not mention gender bias

 

Gender bias takes many forms and the media perhaps more frequently reports on gendered income bias. Such as the longstanding pay gap between the average weekly full-time earnings of males and females, which predominately favours men. Currently Australia's national gender pay gap stands at 13.4 per cent. Or the end of working life disparity between the superannuation outcomes of men and women.

However, it has been apparent for many years now that the health professions, hospitals and governments carry a general societal bias against women into the healthcare sector and that bias barely rates a mention when governments establish terms of reference for parliamentary inquiries into aspects of health service delivery and outcomes.

The NSW Legislative Council Portfolio Committee No.2 - Health’s Terms of Reference for its current Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales is no exception to this lack of consideration of gender bias.

A bias which has the potential to disproportionally affect the health outcomes for females from low income families, those women who identify as Aboriginal or Torres Strait Islander and women living in regional, rural and remote areas.

So these articles below are a timely reminder that the existence of gender bias is indicated in Australia and also of the global scale of such bias.

Australian Institute of Health and Welfare, “Cardiovascular disease in women”, report excerpt, July 2019:

1.1 A focus on women

Much of our knowledge of heart disease is based on research conducted primarily among men (McDonnell et al. 2018), which shapes our view of how cardiovascular disease impacts the Australian population. However, it is known that there are important differences between women and men in risk factors for CVD, in symptoms, and in treatment and outcomes.

Need for greater awareness

Many women are unaware of the risk that CVD presents to their health. Their knowledge about heart attack symptoms and CVD as a cause of death is less than optimal—in 2018, for example, only one-fifth (21%) of Australian women correctly perceived heart-related causes to be the leading cause of death (Bairey Merz et al. 2017; Flink et al. 2013; Heart Foundation 2018; Hoare et al. 2017).

2 Cardiovascular disease in women

Women presenting with CVD often have different symptoms than men. These symptoms may not be recognised as CVD, thus increasing the likelihood of a missed diagnosis.

Although men with heart attack typically describe chest pain or discomfort, women are more likely to have non-chest pain symptoms such as shortness of breath, weakness, fatigue and indigestion (Mehta et al. 2016; Wenger 2013), and frequently with worse consequences (Maas et al. 2011; McDonnell et al. 2018; Pagidipati & Peterson 2016).

Women generally present with CVD later in life than do men. Older women are also more likely to have other health conditions, making their CVD more complex to diagnose and treat, which in turn can lead to worse health outcomes (Bennett et al. 2017; Saeed et al. 2017).

Physicians are more likely to underestimate CVD risk in women, and this can influence their diagnosis and treatment (Wenger 2013). Research finds that younger women aged under 55 with acute coronary syndrome are more likely to be misdiagnosed and discharged from emergency departments than men (Bairey Merz et al. 2017; Saw et al. 2014).

Differences in treatment

A number of studies have identified disparities between women and men in CVD treatment and in outcomes. Women with acute coronary syndrome tend to receive fewer medications, are less likely to have their condition treated aggressively and have fewer invasive interventions (Kuhn et al. 2014, 2015, 2017; Pagidipati & Peterson 2016; Saeed et al. 2017).

Similarly, women with ST segment elevation myocardial infarction (STEMI: a type of heart attack) are less likely to receive invasive management, revascularisation or preventive medication at discharge (Khan et al. 2018). Women with stroke are more likely to have a delay in care than men, and are less likely to receive aspirin, statins or thrombolytics (Raeisi-Giglou et al. 2017).

Healthier women

An increased recognition of gender differences in risk factors, presentation, treatment and outcomes will contribute to improving women’s cardiovascular health in Australia.

The Australian Government, the Heart Foundation, the Stroke Foundation and other key stakeholders contribute by building awareness among the public and health-care providers about the risks of CVD to women’s health.

Chronic conditions, including CVD, and preventative health are a priority for action in the National Women’s Health Strategy 2020–2030 (Department of Health 2018). The development and delivery of a national campaign to promote awareness of the different risks for and symptoms of CVD in women is a key action in the current strategy. The ongoing monitoring of the impact of CVD is an important component of policy and programme initiatives that focus on women’s health.

Australian Institute of Health and Welfare, Cardiovascular disease in Australian women — a snapshot of national statistics, June 2019:

”Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.” [THE LANCET COMMISSIONS, The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030, 16 May 2021]

 

The Lancet, 19 June 2021:

Ana Olga Mocumbi (May 2021) “Women's cardiovascular health: shifting towards equity and justice”

Cardiovascular disease in women is understudied, under-recognised, underdiagnosed, and undertreated globally, despite being the leading cause of death in women worldwide, as highlighted by a new Lancet Commission.¹ Several misperceptions contribute to this neglect, notably, the persistent view that cardiovascular disease primarily affects men or only women in high-income countries and results from poor lifestyle choices. The Lancet women and cardiovascular disease Commission¹ identifies disparities in prevalence and outcomes of cardiovascular disease in women worldwide, delineates the substantial impact of socioeconomic deprivation in determining these differences, and proposes strategies to address these inequities, increase sex-related research, and support integration of care and strengthening of health systems.¹

From 1990 to 2019 there have been large declines in cardiovascular disease age-standardised rates of death, disability-adjusted life-years, and years of life lost.² There have been declines in age-standardised prevalence of coronary heart disease and stroke mortality rates in men and women in most parts of the world, with greater age-specific reductions in coronary heart disease in men than in women.³

Between 2010 and 2019, the age-standardised cardiovascular disease death rate increased or stagnated in many other parts of the world, including eastern Europe and countries in central, south, and east Asia.² In a Canadian setting, the 30-day acute myocardial infarction mortality rates declined similarly for women and men from 2000 to 2009, but women younger than 55 years had an excess mortality risk compared with men of the same age.⁴ Under-representation of young people in clinical studies on cardiovascular disease, as well as worse risk profile due to comorbidities, might contribute to these slow improvements. Importantly, because of women's longer life expectancy, overall deaths from cardiovascular disease are higher in women than in men, and this excess number of cardiovascular disease deaths in women is likely to increase with population ageing. Moreover, the success in declining age-standardised cardiovascular disease mortality over the past decades has been limited to countries with a high Socio-demographic Index (SDI); some countries with a low SDI had the highest cardiovascular disease mortality rate shift from men to women.²

• View related content for this article

Poverty continues to affect a considerable proportion of the world's population, determining unique patterns of non-communicable diseases, including cardiovascular disease in young women.⁵ In countries with a low SDI, where premature cardiovascular disease mortality is largely driven by poverty, poor access to care, and underuse of interventions of proven efficacy, women face the coexistence of an increased prevalence of cardiovascular disease, a rise in metabolic risk factors, and endemic infectious diseases such as tuberculosis, HIV/AIDS, and schistosomiasis. Furthermore, specific risk factors and conditions affect women in countries with a low SDI. Chronic exposure to biomass fuel is common in rural Africa and Asia and contributes to the burden of acute coronary events and stroke,⁶ affecting predominantly women; this exposure could partly explain the high occurrence of and sex differences in isolated right heart failure in non-smokers in these places.^{6, 7} Similarly, in poor countries women younger than 40 years are increasingly affected by neglected or poverty-related conditions, such as rheumatic heart disease and endomyocardial fibrosis.⁸,⁹ Moreover, maternal mortality remains unacceptably high. About 295 000 women died during and after pregnancy and childbirth in 2017.10 94% of these deaths occurred in low-resource settings, where the maternal mortality ratio was 462 per 100 000 livebirths versus 11 per 100 000 livebirths in high-income countries.¹⁰ Since cardiovascular disease is the leading non-obstetric cause of maternal mortality worldwide,¹¹ one should consider the role of disparity in fertility rates, incidence of peripartum cardiomyopathy, and pre-existing uncontrolled arterial hypertension8 as potential determinants of maternal mortality. Indeed, there are a considerable number of maternal deaths due to cardiovascular disease in low-income and middle-income countries.¹² Unfortunately, even in the USA, where the maternal mortality ratio was 17·4 maternal deaths per 100 000 livebirths in 2018, the maternal mortality ratio was more than double among non-Hispanic Black women (37·1 per 100 000 livebirths), with more than half of these deaths and near deaths being preventable, and cardiovascular disease being the leading cause.¹³ Inadequate access to quality and affordable health care along with long-standing health disparities plays a role in this disparity; additionally, social determinants of health can increase the risk of gestational diabetes, peripartum cardiomyopathy, caesarean deliveries, and future cardiovascular disease in neglected communities.

To address the gaps highlighted by this Commission, current knowledge must be used to achieve health equity so that no one is disadvantaged from attaining their full health potential because of their social position or other socially determined circumstance. Reduction of disparities in clinical outcomes requires the prioritisation of high-impact solutions in under-resourced areas, involving tailored strategies for decentralised and integrated care, and support from global and regional partners to improve the availability of interventions for cardiovascular disease prevention and management. Front-line health workers with shared competences for cardio–obstetric care, digital health, and portable ultrasound should be used to deliver decentralised care, improve referral systems, and support surveillance of sex-related outcomes. Digital health provides opportunities to enhance the quality, efficiency, and safety of primary health care, as well as help address racial and ethnic disparities,¹⁴ but insufficient digital health competencies among front-line health workers are among the factors that hamper the adoption of digital tools and technologies.¹⁵ Finally, as emphasised in the Commission, peer-to-peer supporters and educators in local communities should be used to empower women in improving their ability to access, understand, appraise, and apply health information to promote good cardiovascular health.

In the midst of the COVID-19 pandemic, values of human dignity, solidarity, altruism, and social justice should guide our communities to ensure equitable share of wealth and leveraging of efforts towards the reduction of cardiovascular disease burden in women worldwide. The Commission's recommendations on additional funding for women's cardiovascular health programmes, prioritisation of integrated care programmes, including combined cardiac and obstetric care, and strengthening of the health systems accords with efforts to bridge the gap for the world's worst off.⁵ Such a shift in women's cardiovascular care would be a major step towards equity, social justice, and sustainable development.

I declare no competing interests.

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