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HEALTH SECTOR: REFORM OR RIPOFF? by Ken Howell

posted 3 Mar 2017, 04:02 by Gerry Kangalee   [ updated 3 Mar 2017, 04:12 ]

Image result for eric williams medical sciences complexThe state of the public health system has always been a critical political issue. The concept of Health Sector Reform first came to the fore in the Julien Commission of 1957 and was kept alive in the National Advisory Council interim Report of 1978; then came the Toby Commission Report of 1982. 

All of these reports on this question of Health Sector Reform ( HSR) led to the government approaching the Inter American Development Bank (IADB) for funding for the purpose of bringing it to reality. The IADB during 1989-1992 dispatched eight missions to this country to get a first hand understanding of the health sector and to examine the feasibility of health sector reform. .

What followed was a decision by the Manning government in 1992 to introduce Health Sector Reform. Consequent upon that decision, consultants, both foreign and local, were brought into the picture in 1993.

The consultants presented their report in 1994. That report which contained 40 Annexes outlined i) proposed models for improvements ii) human resource requirements iii) estimated costs iv) strategy for the way forward (National Health Services Plan). The stated goals of the Plan were as follows: “To improve the health status of the population by promoting and providing affordable quality health care in an efficient and equitable manner.”

The weakening of the Public Services Association (PSA) was critical to the “success” of Public Sector Reform; as it was for the initiation of the Health Sector Reform Programme. It goes without saying that the weakening of the trade union movement from within is also critical to the success of the public sector reform plan as well as the plan to hand over a substantial portion of public funds to the private sector through the sale of profitable state enterprises.

It is true that corruption is one way in which it is done, but for the purpose of this article we will deal only with health sector reform in an effort to determine whether it was an idea worth pursuing. But it is important also, to note that the reform of the health sector is but one aspect of public sector reform which engaged the attention of successive governments.

FIVE OBJECTIVES

It went on to say that; This goal was supported by five (5) specific objectives: 1) Strengthening the policy-making, planning and management capacity of the health sector; 2) Separating the provision of services from financing and regulatory responsibilities; 3) Shifting public expenditure and influencing the redirection of private expenditure to high priority problems and cost-effective solutions; 4) Establishing new administrative and employment structures which encourage accountability, increase autonomy and appropriate incentives to improve productivity and efficiency; 4) Reducing preventable morbidity and mortality through promoting lifestyle changes and other social interventions.

Image result for trinidad regional health authorities actIn 1994 the Regional Health Authorities Act was enacted. According to the Ministry of Health the strategic intent was to guide it in: achieving significant shifts in resources; reducing bed numbers; introducing specialist services; introducing new technology; introducing new management and operating systems; delivering new services based on need and effectively work with provider agencies.

However, it regarded the following as key technical requirements: i) Human Resource and Change Management strategies (Transition Plan); ii) RHA Management Systems and Protocols; iii) Quality Management; iv) Needs Assessment (National Disease Surveillance system); v) Health System Information Strategy; vi) Health Financing Strategy.

On the question of Human Resource Management, it claimed to have achieved some objectives such as the creation of six (6) core Directorates: Health Services Quality Management; Health Policy and Planning; Health Promotion and Communication; Finance and Projects; Human Resources and Information Systems.

The challenges were: dual track employment (Ministry of Health and RHA staff) and the limited capacity at the RHA and Ministry of Health to undertake new roles. Another area in which the Ministry of Health believed that it had achieved some of its objectives is in the area of RHA Management Systems. But there were challenges as well. The achievements were; the Decentralisation of decision making and the Reductions in operation cost through bulk Purchasing. The Challenges were in the area of Accountability Measures such as Business Plans, Ministry of Health Purchasing Intentions and Annual Services Agreements not being implemented.

In the area of Health Services Quality Management, it listed as Achievements, the following: the fact that the Report on Regulating Health Care Quality was finalised by Quality Management Legal experts; that the Health Services Accreditation Manual for T&T was approved and distributed to stakeholders and that the Health Services Quality Council was operational.

CHALLENGES

It lamented the fact that challenges still existed in the following key areas: Risk Management Policy Framework; Health Technology Assessment policy and guidelines; Inventory Management and Review of Medical Records Policy and Procedures. With respect to Health Needs Assessment, it highlighted the completion of the Baseline Assessment (Situation Analysis) and the fact that it was completed as an achievement, but it claimed to be challenged by the failure on its part to conduct the first nationwide Needs Assessment.

The question of Health Financing was treated within the overview. In that area, it claimed as an achievement the existence of a new technical Secretariat to spearhead alternative financing for the sector. It would appear that this Secretariat was established because of challenges it faced following numerous aborted attempts at new financing strategies and because of alleged stakeholders’ scepticism.

In conclusion: the overview posited the following: 1) that the HSR objectives were on target; 2) that the HSRP design for achieving health system improvement was sound; 3) that the soft components (technical knowhow) to effect the sector's full transformation lagged because among other things: 1) the general Public Sector Reform process was slow and ii) There was limited absorptive capacity at the Ministry of Health and the RHAs. So what is the position with health care in Trinidad and Tobago?

Image result for trinidad cuban doctors nursesThe RHAs are challenged by the high rate of turnover of professional staff that migrates to jurisdictions where the grass is greener. That is why on June 1, 2003, the government entered into an arrangement with the UNDP for assistance in sourcing health professionals. This process of building capacity seems to be one that is on-going because, ever so often we read of the government’s decisions to source doctors and nurses from the Philippines, India, and Cuba.

INEFFICIENCY

What this means is that there is a level of inefficiency in the provision of quality health care, because the current staff levels are unable to meet the performance standards necessary to satisfy the demand for health care.

There was also the contentious issue of the staffing of the RHAs through the separation of employees, from the Ministry of Health through the process of voluntary separation, or transfer with their service to the RHAs. Those who did not wish to be employed in the RHAs had the option to be transferred to another Ministry or State Enterprise.

There was also the problem of persons who were employed with the Ministry of Health, who did not wish to take up employment with the RHAs. It is important to understand, that when the Ministry of Health implemented its plan by which the health employees were separated from their jobs, they became free agents who entered into a new employment relation with these new entities (the RHAs) through the implementation of fixed term contracts.

In the absence of UNION REPRESENTATION, individual contracts become a weapon in the hands of the employer and are used effectively, to divide and rule. Some of the other problems are the question of the shortage of beds, the overcrowding of Wards. No proper indexing systems in the Stores, and the mysterious disappearance of hospital property. There is also the problem of the chronic shortage of drugs in the Pharmacies of the Hospitals. But we are told that supplies are purchased in bulk. In addition, there is the perennial problem of breakdowns of various pieces of equipment necessary for the performance of diagnostic analysis of different types of medical problems

Patients are required to wait for months on end to be called up for surgery. This untenable situation has led to persons who can hardly afford having to resort to private institutions to have their operations. This has led to the most bold face scandal that has erupted out of the sector called the External Patients Programme which is a scheme to use the hospitals as gathering stations for private hospitals run by the very doctors who supposedly work in the public health sector. This costs the citizens of this country tens of millions of dollars and counting

The commissioning of the teaching hospital in San Fernando may/may not solve the problems of the bed shortage in the SWRHA, but other issues are yet to be resolved; such as the shortage of staff at the Eric Williams Medical Sciences Complex as well as the long delays to get a bed; the incompetence which is said to be rampant at the EWMSC and the Maternity Hospital in the area of administration, Human Resources and Industrial Relations.

As a result, many grievances affecting employees remain unresolved. These issues expose the inability of successive governments to provide an efficient and affordable health service, and because of this, there is a public outcry over what is perceived as its failure in this area, or perhaps it is, - as some people believe - a deliberate decision to run down the public health system as a means to mobilise public opinion in favour of privatization.
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