Health-care in TT going back into the future

The question was once asked, “Why do we pay so many taxes?” The true, and only, Father of our Nation, the late Dr Eric Williams, replied that there is free health-care, subsidised basic food items, free education including university, subsidised public transport, subsidised public utilities, etc. Today, public utilities are no longer subsidised, public transport is close to being privatised, tertiary education is no longer free, basic food items are no longer subsidised. The present Minister of Health now wants us to believe that he is introducing free health-care.

FREE HEALTH-CARE

Public health-care in Trinidad and Tobago has always been free, until the Regional Health Authority (RHA) Act of 1994 and the attempt to implement the Health Sector Reform Plan (HSRP). HSRP proposes that the RHAs introduce fees for services at their various institutions. John Eckstein will recall the numerous objections of the medical profession. Medication is still free at the various dispensaries of public health facilities. It is free if you are prepared to wait in line for hours. It is free if you are aware that there is a shortage of pharmacists and if one calls in ill, the wait gets longer. It is free if you are aware that the dispensary gets only a portion of its demand. It is free but you will only get a portion of your prescription, hence you may have to return two and three times per month for that one month’s supply, adding to the long line. It is free if you wait whole day, only to be told that the medication is not available and then to return another day. Medication has always been free but is now free following the introduction of free medication by Mr Imbert in 2003.

Laboratory investigations are also free. And the Public Health Laboratory is the only recognised laboratory for certain blood investigations. It is free provided that you are willing to sleep on a bench in the corridor for one week and more, awaiting the results of your dengue titre, for example or pay privately, to obtain the results quicker. It is free, provided that you wait months for HIV and Hepatitis results. It is free, provided that wait over six months to obtain histology results for your cancer diagnosis, results that are obtained within days privately. Radiology services are free, if you are willing to wait months for a date of appointment. Machines are over 20 years old and recently (2003), three machines at SFGH were non-functional at the same time. So it is free if you are willing to wait for months or pay to have it done privately ASAP. Your Government MP may however, change that appointment. In 2001, Minister Fuad Khan promised new machines for the Radiotherapy Centre within months, never happened. In 2002, Minister Imbert outshone all by promising a new Oncology Centre to offer free services for poor people. In 2004, nothing has been done. The only machine bought is a machine that is highly NOT recommended. This machine only creates problems for the patients. And now, silence.

In April 2002, new state of the art radiology equipment was promised within months. This was eventually delivered in 2004. And the CT scan at SFGH, I am told, is technologically inadequate. Better yet, it operates ONLY during the daytime from Monday to Friday. During the nights and on weekends, you still have to obtain private scans. But I have not heard any patient and the public complain. But health-care is never free. All taxpayers pay it for. But taxpayers never demand the services for which they have paid. They will however blame the workers, never the administrators for deficiency.
Present Problems.

Public health-care is faced by many problems and deficiencies. The chief ones are:
* Management
* Lack of planning and RHAs
* Human resources
* Financial resources
The public health services were never managed properly. In fact, to this date, there is no management structure. All decisions are made at the ministry of health. With respect to the RHAs, all decisions are made by the Minister of Health, as de facto, micro-manager. In previous years, Hospital Administrators were senior public servants, who usually had little or no experience in hospital and health matters. Hospital administrators were never given the fullest authority to ensure proper running of the hospitals. However, they had to accept all blame for all failures.

Now that present administrators are trained in this function, they are subordinates to RHA Managers who know little, earn bigger salaries (usually not approved) and produce poor results. The introduction of the RHAs has shown the lack of management structure within the health services. However, the RHAs went overboard in the hiring of managers. SWRHA, for example, has close to 40 managers within its structure. It is now known that some of these appointments were never approved and in some cases, were not transparent. Some senior persons were known to have their employment terminated by one RHA, only to be re-hired by another RHA, “virtually” the next day. And despite these overburdened managerial structures of the RHAs, little or no results were forthcoming. Impropriety, however, has occurred in all forms and fashion. In 2002, the Auditor General had not been satisfied with the accounts of the SWRHA for 1997. What about 1998, 1999, 2000 and 2001?

It was quite obvious that health-care standards were falling rapidly and dramatically in the 80s. The then administrators were clueless. Today, administrators are still clueless. No one thought that it was necessary to first consult the workers within the system. Instead, foreign planners and financiers were consulted. And by themselves, without surprise, hatched a foreign plan, with a promise of a foreign loan of US$120 million. And the government of the day accepted immediately. Even the legislation was placed in Parliament, three days before documents were released to the public for discussion. At the Egg Nog inquiry of 1992, one recalls the shock of Dr Elizabeth Quamina when she was informed of the conditions at St Ann’s Hospital. Dr Quamina had just retired as Chief Medical Officer. Participating at the inquiry were Dr Rawle Edwards and Dr Rampersad Parasam. In 2002, during a political tour by the new Minister of Health, Dr Edwards also expressed shock at the conditions of St Ann’s Hospital.

Incidentally, Dr Rampersad Parasam is now the Chief Medical Officer. So ten years and more later, the ministry of health officials are still clueless. The HSRP was a carbon copy of the English model, imposed upon us by the English experts. This model was a failure and was thus abandoned totally in 1996 in England. Despite an increasing population, the plan recommended decreased personnel including doctors, nurses, etc.

Despite an increasing and aging population, the HSRP further recommended decreased numbers of hospital beds, despite overcrowding. Despite an indigent population of over 26 percent, the HSRP recommends the introduction of a National Health Insurance Scheme (NHIS). These were all recipes for failure and the system did fail. In July 1998, the Joint Working Party of the Royal Colleges and the British Medical Association made recommendations as follows for a hospital catering to a population of 500,000 at the level of Consultant/Specialist Medical Officer:

Whilst the Joint Working Party recommends 95 Consultants in the above-mentioned specialties, HSRP recommends only 38 for the year 2000 but in 2003, there are only 20 presently employed. And there are no vacancies presently, except for Cuban and United Nations doctors only. Presently, our service has only 40 percent of the number of nurses, compared to the 80s. Attempts to re-start the operating theatres at both PoSGH and EWMSC have failed due to shortage of nurses and other reasons. The continued functioning of the operating theatres at the much-criticised SFGH is due to the goodwill of the nursing staff, who many times give-up lunch and snack breaks. However, that camel may soon break its own back.

Nurses, soon after graduation, undertake foreign examinations and migrate to greener pastures with lots of enticements. Over 86 percent of UWI graduates from the Faculty of Medical Sciences have left the public health service and have also migrated. They were all successful at their English Language and Medical Examinations. Despite a requirement of UWI that undergraduate students of most faculties must complete a Language, Logic and Composition/ Use of English Course, only Minister Imbert believes that it is discriminatory for the Cuban and United Nations Volunteer doctors to demonstrate fluency in English.

It must be noted that foreign doctors were always registered in Trinidad and Tobago. All doctors, including locals, trained in Foreign Medical Schools were granted a Temporary Licence for a period of three years, during which time their performance is monitored and supervised. The creation of a panel to bypass these very high standards will not only jeopardise the safety of the public but will also destroy the future careers of these panel registered doctors. Persons applying for the scholarships to Grenada must note that they will only be granted a Temporary Licence, after successful completion of their Internship.

In 1994, the RHAs were established. In 1996, they were to employ the first set of employees, Medical Doctors. The situation was chaotic. And to this date, 2004, the situation remains chaotic. In January 2003, doctors refused to work without an employment contract. Apart from the three lawyers who collected close to $1M for the unsuccessful injunction compelling medical doctors to work without employment contracts, many were amazed at the actions and utterances of the RHAs and their Minister of Health. The SWRHA presently has no procedures and protocols regarding human resource matters. A previous Human Resource Officer was made General Manager. Jobs are created and persons are appointed with the swipe of a magic wand.

SWRHA has stated that there are no vacancies and that the system is over-staffed. Hence the reason for persons in acting positions for over three and five years respectively, who cannot be confirmed. Instead, they willingly accommodate Cuban and United Nations Volunteer doctors, who are registered by the Panel and not the Board? Trinidad and Tobago presently spends approximately two percent of GDP in public health-care. Over the decade of the 90s, an average of TT$200 million dollars annually were returned to the treasury unspent. It is recommended that developing countries spend at least four percent of GDP in public health-care. This will amount to approximately TT$2.4 billion dollars, twice that of the 2002/3 allocation. The budgetary allocation for 2003/4 was less than TT$1.5 billion. Presently, it is being publicised that wages account for too high a percentage of the budget. SWRHA claims to have a salary bill of TT$180 million. If they are allocated TT$230 million dollars, then only TT$50 million dollars is available for capital projects. If they are allocated TT$180 million dollars, then there will be no money for capital expenditure. This appears to be simple mathematics and simple logic.

Over the last ten years, the only additions have been RHA officials, managers and support staff, many of whom were appointed without attempts at transparency and approval. Hence, increased financial allocation is the only mechanism to increase capital expenditure and thus improve the health service. However, certain managerial and accounting procedures and protocols must be firmly established. The Auditor General has noted all forms of impropriety within the RHAs. Contracts awarded for TT$25,000.00 ends up costing TT$94,000.00. Another for TT$18,000.00 ends up costing TT$83,000.00.

So procedures and protocols must be established before money is allocated, for if you cannot account for one dollar, what will happen to the hundred-dollar bills? Last but not least, a comment about the lack of community services. In the early 70s, Minister Kamaluddin Mohammed built over 100 health centres. His reward was the presidency of the World Health Organisation (WHO). These health centres were nothing more than four walls. Less than 30 years later, many were condemned, demolished and re-built. One medical officer was assigned to as many as five centres. These medical officers only duties were to conduct a clinic of 30 patients. Emergency cases were referred directly to the hospitals. Hence, public announcements by administrators to utilise the services of health centres in emergencies were “smoke screens.”

It is to the credit of MPATT that doctors are now being assigned to only one health centre for a period of eight hours, Monday to Friday. This has encouraged many doctors to seek the position of Primary Care Physician 1, without the burden of night duty. To date, almost all advertised posts of PCP1 have been readily filled. Unfortunately, the RHAs have been tardy in creating these posts for each individual health centre. The problem of adequate remuneration for health-sector workers will continue an air-borne haemorrhaging of personnel, namely nurses and medical doctors.

Government entered into a contract with the United Nations Development Programme (UNDP) and the government of Cuba for medical doctors. These doctors are presently registered by a government appointed “panel,” after they failed to satisfy the high standards of the Medical Board, one of the longest standing and possibly the oldest in the world. Presently, the general public are unaware of their qualifications and the majority are from medical schools that are not internationally recognised.

The arrangements for these “panel” foreigners will result in a cost of approximately TT$19,500 per month per medical doctor. However for the doctors who have fulfilled the strict criteria of the Medical Board, they are being paid approximately TT$13,800 per month. It is thus quite clear that government in fact is prepared to pay more to lesser qualified persons, giving no regard to better qualified persons, the majority of whom are locals.

These “panel” foreigners also do not have to work at nights and weekends and must be given adequate periods of rest and relaxation. The main goal of these “panel” foreigners with unknown qualifications, as was stated in their contracts, is to treat the poor and lesser privileged of society. In other words, the government is prepared to give a poorer standard of health-care to the lesser privileged of society.

Solutions
* The present officials at the ministry of health who engineered the collapse of the public health-service cannot be the same officials who are given the responsibility to re-structure the service. Failures do not breathe success.
* The Minister of Health’s (2003) continued antagonistic and provocative manner will only result in destruction, not reconstruction. Staff are more interested in leaving, as opposed to entering, the health service.
* Protocols, procedures and guidelines must be firmly established within the RHAs to prevent the continued impropriety as noted by the Auditor General.
* Local staff should at all times be consulted with regards to the status of the service, with the aim to create local solutions.
* Improved remuneration for all categories of staff, with job security, to improve morale and to attract qualified staff. Present staff members cannot increase their level of dedication. Recognition and appreciation, not criticism, are  required.
* Increased health-care spending to at least four percent of GDP.