Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698926459715.pdf (Trinidad and Tobago)
Committee to Review the Levels of Health Care Delivery by the Regional Health Authorities and to Rationalise the System of Public Sector Doctors in Private Practice August 29, 2016 Report 1 Review of the Levels of Health Care Delivery by the Regional Health Authorities Disclaimer Several individuals and organizations are acknowledged for their responses to our requests, their attendance and assistance.
This is not meant to suggest that they are in any way responsible for the findings of the Committee or the recommendations made.

Indeed some of the respondents clearly expressed concerns and disapproval.

The Committee accepts responsibility for the findings and recommendations made.
Contents ACKNOWLEDGEMENTS .................................................................................................................................. i SIGNATURE PAGE .......................................................................................................................................... ii ABBREVIATIONS ........................................................................................................................................... iii EXECUTIVE SUMMARY ................................................................................................................................. vi 1.0 INTRODUCTION ....................................................................................................................................... 1 1.1 Overview of the Health System .......................................................................................................... 2 2.0 PILLAR 1: PUBLIC SECTOR DELIVERY OF HEALTH CARE ......................................................................... 11 2.1 PRIMARY HEALTH CARE .................................................................................................................... 11 3.0 PILLAR 2: PUBLIC SECTOR DELIVERY OF HEALTH CARE ......................................................................... 15 3.1 SECONDARY AND TERTIARY INSTITUTIONS/SERVICES ...................................................................... 15 3.2 (A) SERVICE DELIVERY ....................................................................................................................... 15 3.2.1 Accident and Emergency/Triage (Screening) ............................................................................. 15 3.2.2 Ward Management .................................................................................................................... 17 3.2.3 Laboratory .................................................................................................................................. 18 3.2.4 Radiology
18 3.2.4 Radiology .................................................................................................................................... 18 3.2.5 Pharmaceuticals/Ward .............................................................................................................. 19 3.2.6 Bed Management ....................................................................................................................... 19 3.2.7 Surgery ....................................................................................................................................... 20 3.2.8 Operating Theatre ...................................................................................................................... 20 3.2.9 Obstetric Services....................................................................................................................... 21 3.2.10 Senior Medical Officers ............................................................................................................ 21 3.2.11 Clinics ....................................................................................................................................... 23 3.3 (B) INFRASTRUCTURE ........................................................................................................................ 24 3.3.1 Port of Spain General Hospital ................................................................................................... 24 3.3.2 St James Medical Complex ......................................................................................................... 24 3.3.3 St Ann’s Hospital ........................................................................................................................ 24 3.3.4 Eric Williams Medical Sciences Complex ................................................................................... 24 3.3.5 San Fernando General Hospital ................................................................................................. 25 3.3.6 Sangre Grande
 Hospital ............................................................................................................. 25 3.3.7 Scarborough General Hospital ................................................................................................... 26 4.0 PILLAR 3: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE ................................................................. 27 4.1 VERTICAL SERVICES ........................................................................................................................... 27 4.1.1 Chemistry, Food and Drugs Division .......................................................................................... 28 4.1.2 The National Blood Transfusion Service (NBTS) - Blood Bank ................................................... 28 4.1.3 The Child Development and Behaviour Unit ............................................................................. 29 4.1.4 Thoracic Medical Unit (Pulmonary/Chest Clinic) ....................................................................... 29 4.1.5 Arima Rehabilitation Centre ...................................................................................................... 29 4.1.6 Dental Services ........................................................................................................................... 29 4.1.7 The Trinidad and Tobago Public Health Laboratory .................................................................. 29 4.1.8 Queen’s Park Counselling Centre ............................................................................................... 30 4.1.9 Nutrition and Metabolism Division ............................................................................................ 30 4.1.10 Population Programme (Family Planning Services) ................................................................. 30 4.1.11 Insect Vector Control/Public Health Division (Admin) ............................................................. 30 4.1.12 Health Education Division
 ........................................................................................................ 30 5.0 PILLAR 4: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE ................................................................. 32 5.1 RHA EXECUTIVE/ADMINISTRATION .................................................................................................. 32 6.0 PILLAR 5: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE ................................................................. 34 6.1 CHIEF MEDICAL OFFICER ................................................................................................................... 34 7.0 PILLAR 6: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE ................................................................. 36 7.1 MINISTRY OF HEALTH ADMINISTRATION ......................................................................................... 36 8.0 OTHER AREAS OF HEALTH CARE DELIVERY ........................................................................................... 39 8.1 MAJOR PROJECTS .............................................................................................................................. 39 8.2 PHARMACEUTICALS/ACQUISITION ................................................................................................... 40 8.3 C40- REPORT ..................................................................................................................................... 42 8.4 EXTERNAL PATIENT PROGRAMME (EPP) .......................................................................................... 44 8.5 CARDIAC SERVICES ............................................................................................................................ 45 8.6 EWMSC- SECONDARY OR TERTIARY INSTITUTION ............................................................................ 46 8.7 HOSPITAL RATIONALIZATION ............................................................................................................ 47
47 8.8 ONCOLOGY ........................................................................................................................................ 49 8.9 MENTAL HEALTH/PSYCHIATRY .......................................................................................................... 51 8.10 UWI FACILITY ................................................................................................................................... 52 8.11 UWI PERSONNEL ............................................................................................................................. 53 8.12 WHITHER RHA: DO WE RETAIN THE RHA STRUCTURE ................................................................... 53 8.13 WHITHER RHA: IF YES DO WE ALTER/REDUCE THE NUMBER OF RHAs .......................................... 54 8.14 HEALTH NEWS/EDUCATION ............................................................................................................ 55 8.15 NURSING ......................................................................................................................................... 56 8.16 TRANSFERABILITY OF PERSONNEL ................................................................................................ 57 8.17 TRANSFER OF SERVICES .................................................................................................................. 58 8.18 AMBULANCE SERVICES ................................................................................................................... 58 8.19 STAFF RECRUITMENT (SPECIAL AREAS) .......................................................................................... 59 8.20 SPECIALIST MEDICAL OFFICER/CONSULTANT APPOINTMENTS ...................................................... 59 8.21 DENTAL SERVICES ............................................................................................................................ 61 8.22 INDIVIDUAL RESPONSIBILITY
 .......................................................................................................... 61 8.23 ACCESS/FINANCING MODEL ........................................................................................................... 62 8.24 ALLIED PROFESSIONALS .................................................................................................................. 62 8.25 PROFESSIONAL BODIES ................................................................................................................... 63 8.26 REPRESENTATIVE BODIES ............................................................................................................... 63 8.27 NGOs ............................................................................................................................................... 63 8.28 INTERESTED PERSONS ..................................................................................................................... 64 8.29 COUVA HOSPITAL ............................................................................................................................ 64 8.30 BUDGETARY ALLOCATION ............................................................................................................... 67 8.31 DATA ............................................................................................................................................... 68 8.32 REGULATING HEALTH CARE QUALITY ............................................................................................. 69 8.33 HUMAN RESOURCES ....................................................................................................................... 70 8.34 AUDIT .............................................................................................................................................. 72 8.35 LEGISLATIVE CHANGE...................................................................................................................... 72 9.0
72 9.0 SUMMARY OF RECOMMENDATIONS .................................................................................................... 74 10.0 MATTERS FOR FURTHER DELIBERATION/EXAMINATION ................................................................... 76 11.0 CONCLUSION ....................................................................................................................................... 77 12.0 PRIVATE PRACTICE .............................................................................................................................. 79 Appendix ..................................................................................................................................................... 80 ACKNOWLEDGEMENTS The Committee could not have accomplished its work thus far without the important contributions of: - The Honourable Dr. Keith Rowley, Prime Minister of the Republic of Trinidad and Tobago for the confidence reposed and the continued support.
- The Transition Team.

- Permanent Secretary/Staff of the Office of the Prime Minister.

- The Members of the Secretariat.

- The Honourable Mr. Terrence Deyalsingh, Minister of Health - Permanent Secretary, Deputy Permanent Secretary and Executive staff of the Ministry of Health Interested bodies, Individuals.

Institutions: C40, NIPDEC, Chairman of NIPDEC - Boards, Executives, Several staff members- RHA, Institutional staff.

- - Professional, Representative Bodies, Unions.

- - NGOs.
- - NGOs.

- Other ministries- staff- Local Government.

- Consulted Individuals.

- Well-wishers.

- The NCRHA and the Centre for Health Economics.

UWI provided accommodation on several occasions.


Particular commendations are offered to the members of the Secretariat for dedicated quality support, namely: -Mrs. Antonia Popplewell, former Permanent Secretary, Ministry of Health -Ms. Kerry-Ann Burris, Senior Monitoring and Evaluation Officer, Office of the Prime Minister -Ms. Tiffany Bethel, Researcher, Office of the Prime Minister.

To all those contributors and many others yet unmentioned, we express our profound gratitude.
i SIGNATURE PAGE Mr Winston Welch (Chairman) ______________________________________ Dr Wayne Frederick ___________________________________ Professor Karl Theodore ___________________________________ Mr. Martin De Gannes ___________________________________ Dr. Adesh Sirjusingh ___________________________________ Mrs Valerie Alleyne-Rawlins ___________________________________ Dr Albert Persaud ___________________________________ ii ABBREVIATIONS A&E ASA Accident and Emergency Annual Services Agreement CARPHA Caribbean Public Health Agency CCHD Caribbean Commission on Health and Development CDAP Chronic Disease Assistance Programme CMO Chief Medical Officer CNO Chief Nursing Officer COSTAATT College of Science, Technology and Applied Arts of Trinidad and Tobago CPO Chief Personnel Officer CQI Continuous Quality Improvement CTU Central Training Unit CMOH County Medical Officer of Health DHF District Health Facility DHV District Health Visitor DP Dual Practice DPA Director of Personnel Administration EAP EHS EPP Employee Assistance Programme Emergency Health Services (Ambulance) External Patient Programme ERHA Eastern Regional Health Authority EWMSC Eric Williams Medical Sciences Complex iii HR ICU IR Human Resources Intensive Care Unit Industrial Relations GMRTT Global Medical Response of Trinidad and Tobago MBTT Medical Board of Trinidad and Tobago M&E Monitoring and Evaluation MoH Ministry of Health MSW Medical Social Worker NBTS National Blood Transfusion Service NCRHA North-Central Regional Health Authority NGO
 Non-Governmental Organisations NHMC National Hospital Management Company NWRHA North-West Regional Health Authority NIPDEC National Insurance Property Development Company Limited OECD Organisation for Economic Co-operation and Development PAHO Pan American Health Organization PHI Public Health Inspector PMO Principal Medical Officer POSGH Port-of-Spain General Hospital PS Permanent Secretary QPCC Queen’s Park Counselling Centre RHA Regional Health Authority iv SFGH San Fernando General Hospital SMO Specialist Medical Officer SOP Standard Operating Procedures THA Tobago House of Assembly TRHA Tobago Regional Health Authority USC UTT University of the Southern Caribbean University of Trinidad and Tobago UWI The University of the West Indies UDECOTT Urban Development Company of Trinidad and Tobago WHO World Health Organization v EXECUTIVE SUMMARY By letters dated November 15, 2015, Cabinet of the Republic of Trinidad and Tobago established a Committee to: 1. Review the levels of health care delivery by the RHAs 2.
Rationalize the system of public sector doctors in private practice.

The Committee consisted of seven (7) members supported by a secretariat.

In making its assessment the Committee had several visits and meetings with personnel in the health sector, reviewed written submissions, noted comments of members of the public expressed in the print and electronic media, and took its own counsel based on the knowledge, experience and skill set of its members.
In setting out its response to the mandate the Committee at first offers a brief overview/perspective on the health portfolio in general.

It then addresses the factors that influence or are influenced by the RHAs and finally a response on the grant of private practice.

In the overview, the report very briefly seeks to locate the Trinidad and Tobago health system in the international arena.
Information is provided on the prevalence of Non Communicable Diseases (NCDs), the increasing expenditure trend and the challenge of managing such expenditure profile efficiently while securing accessibility to the population.

There is supportive argument with endorsement of the call for continued and expanded attention to primary health care with its undoubted impact on longevity, healthy lifestyle and productive capacity.
The RHA perspective, at the outset identifies the major pillars in the delivery of health care in the State sector.

These are primary care, secondary and tertiary care, vertical services, RHA Administration, Office of the CMO and MoH Administration.

The perspective is predominantly a hands-on, operational, executive management type; admixed with policy, with an eye on immediate implementation, but not omitting the longer term view.
vi The findings and recommendations are presented thus: Individual presentations of several other important areas of health care delivery.

 An analysis of the major components of the current RHA delivery structure   Recommendation is proffered on the retention of the RHAs  A note of advice is presented on the Couva Hospital Finally: the second part of the mandate: retention or not of private practice for government employed doctors.
The Major Components (Pillars) Pillar 1- Primary Health Care The existing components of primary care are analysed.

Despite the repeated representations on the need for emphasis on primary health care and the recognition of the immense progress made, questions remain on what further needs to be done: Improvement of the primary care facilities.

  Guaranteed presence of services, expanded in some instances.
 Disentangling the quagmire that has emerged with the transition to the RHAs- important personnel distributed across the administrative landscape with subsequent compromise of administrative and legal functions.

 Detailed recommendations on the enhancement of the actual service delivered.

 A simple but sustained, vigorous and effective education program is pivotal.

Pillar 2-Secondary and Tertiary Institutions The secondary and tertiary services are provided by the hospitals.
Here the Committee adopts a hands-on approach in offering direct administrative and operational advice (itemized) on managing the services that impact the patient directly, e.g.

A&E, Radiology, Laboratory and Pharmacy.

On the infrastructure side: some important, urgent infrastructural works for the national hospitals are identified.
Pillar 3- Vertical Services There are several areas of service delivery which are national in scope and not necessarily regional and which in the transition to the RHA appear to have been left rudderless since the MoH (Head Office) is no longer in the business of service delivery.

vii Several vital and important services are trapped within these arrangements e.g.

National Blood Transfusion Service (NBTS); Chemistry, Food and Drugs Division and Insect Vector Control.
Advice is proffered on the need for an ‘advocate’ for these services and certain recommendations are made for improving their efficiency.

Pillar 4- RHA Executive Each of the 5 RHAs is managed by a separate executive created following the enactment of the RHA Act No.5 of 1994.

Is this another layer of constricting bureaucracy and does it meet the managerial and executive objectives?

Some of the challenges are identified and recommendations made.
Pillar 5- Office of the CMO The transition to the RHA has left the Chief Medical Officer without adequate professional and technical support so crucial to the functioning of that important office which has many statutory obligations.

Pillar 6- The MoH The MoH (Head Office) has been impacted and left challenged in exercising its supervisory function (policy and regulatory) and in properly advising the Minister.
Having identified the major pillars in the health care delivery, all of which impact the RHAs and are pivotal to the eventual success or failure of the RHAs, we then address individually some additional areas of detailed consideration.

These include: Major projects involving existing hospitals and proposed new hospitals The EPP- a programme geared towards sourcing private services for those not adequately represented in the public sector.
Review ought to address expanding costs and institutional arrangements for cost containment and managing output.

viii Mental Health/Psychiatry Support is offered for the continued provision of a mental hospital at St Ann’s with revised attempts at re-establishing the community mental health outreach and mental health promotion in general.

Pharmaceuticals Several of the hindrances in the availability of pharmaceuticals are presented under the headings of Pharmaceutical Supplies and C40 Report.
The UWI The University and the potential for its expanding costs to the State is a matter of concern as indeed are the likely costs for funding more students.

Additionally the roles of some university staff are also addressed.

Oncology The costly Oncology Centre is addressed in the context of oncology services in general.

Cardiac Services Cardiac services are impacted in a substantial way and suggestions are made on the way forward.
Several Other Areas are examined even if briefly: Retention of RHAs (Whither RHA) A position is taken on the retention of the RHAs notwithstanding the existing challenges; as well as the retention of five (5) RHAs in the first instance but with certain synergies being initiated as we carry the discourse on further rationalization.

The Couva Hospital The rationale for the Couva Hospital remains unclear, but the facility is to be utilized.
Several of the proposals which have been advanced are recorded, some having greater merit than others.

The Couva Hospital should not dominate the health agenda, there are no compelling reasons so to do.

A deliberate and rational evaluation of its merit relative to the merits of other institutions and the proposed options is to be undertaken.

ix In concluding the segment, reference is made to a number of incomplete or proposed encounters with professional bodies, representative bodies and NGOs.
Mention is made of some of the issues initiated and the need for further attention.

The report on Part B remains outstanding.

Acknowledgements are in order for the numerous, dedicated and influential contributors to this exercise.

This represents the first report of this Committee in offering an option for early intervention and within the limited time.

A second report should offer the opportunity to address unaccomplished matters and to review/ audit matters addressed in the first report.
x 1.0 INTRODUCTION By letters dated November 15th 2015, the Cabinet of the Republic of Trinidad and Tobago established a Committee to: 1. Review the levels of health care delivery by the RHAs 2.

Rationalize the system of public sector doctors in private practice.

The members of the Committee so appointed are: 1.

Mr. Winston Welch (Chairman), former Medical Director, Port of Spain General Hospital 2.

Dr. Wayne Frederick, President, Howard University, Washington, USA 3.
Professor Karl Theodore, Director, HEU, Centre for Health Economics, UWI 4.

Mr. Martin De Gannes, former General Manager, Human Resources, Scotiabank 5.

Dr. Adesh Sirjusingh, Administrator, Clinical Services, Sangre Grande Hospital, Eastern RHA 6.

Mrs. Valerie Alleyne-Rawlins, former President, Trinidad and Tobago Registered Nurses Association 7.
Dr. Albert Persaud, former Executive Medical Director of Health, South West RHA In meeting its mandate, the Committee;  Visited several health institutions  Convened meetings of staff, management, employees, interested parties and representative bodies  Took note of comments of members of the public via print and electronic media  Took its own counsel based on knowledge and experience in various disciplines including the health sector  Reviewed some written submissions before it.
It has been necessary to examine several areas that either impacted or are impacted by the RHAs in the delivery of health care.

At the same time all areas could not be examined in finite detail at first instance.

Additionally, greater attention is paid to conclusions arrived at, more so in areas of significant overall impact.

The Report opens with an Overview of the Health System and some of the problems it faces.
It then deals with the RHAs and other aspects of health care delivery in part A and on the Private//Public Practice engagement in Part B.

1 1.1 Overview of the Health System This section will include a brief overview of the health care delivery system.

We begin with the WHO Health Systems Framework which has become the standard for countries like Trinidad and Tobago.

Figure1.
Figure1.

The WHO Health Systems Framework As indicated in the diagram, a health system comprises six building blocks aimed at delivering four distinct outcomes and mediated by four key vehicles- access, coverage, quality and safety.

The Committee has not been unmindful of these and similar matters in this exercise.

The Trinidad and Tobago Health Situation With the above picture of the appropriate health system in mind, what do we find in Trinidad and Tobago?

The WHO report on NCDs is informative.


2 Figure 2.

The Morbidity Picture Trinidad and Tobago, 2013 This diagram speaks volumes.

Almost half (46%) of deaths in the country are due to heart disease or diabetes and a similar number holds for deaths from heart disease or cancer.

Also nearly 80% of all deaths are due to non-communicable diseases.

This is the health situation facing the country and should continue to serve as a major focal point in our health service delivery.
Additionally, infant and maternal mortality have reportedly not yet been reduced to expected levels.

There is also the desire for improved life expectancy.

3 What about the government’s expenditure on health?

Figure 3.
Figure 3.

Government Health Expenditure (GHE) Government Health Expenditure (GHE) in Trinidad and Tobago, Nominal and Real (TT$ Billions) - 2005-2014 5.07 4.94 4.63 4.24 4.10 3.88 3.68 3.15 2.62 2.55 1.97 1.89 2.07 1.95 2.84 2.66 2.38 2.60 2.75 2.72 ) s n o i l l i B $ T T ( E H G 6 5 4 3 2 1 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 GHE (Real Terms) - TT$ Billions GHE (Nominal Terms) - TT$ Billions Year From the government’s point of view, the question that arises is one of value for money.
The diagram portrays the trend in public health spending over the period 2005 to 2014.

Given the levels of spending, there are two main questions that must concern us: the adequacy of health financing and the efficiency (technical) of this financing.

On the face of it, in Trinidad and Tobago the adequacy of finances to provide for the health of the nation is not in question.
From a level of public health spending of $1.97 billion in 2005, spending reached (in real terms) a level of $2.7 billion in 2014, almost a 40% increase.1 In nominal terms the change has been, of course, much more dramatic, with the increase reaching 93% (TT$5.07 billion).

The graph above illustrates that the increase has been on a steady upward trend for the decade indicated.
Since national income over the same period rose by 24% the increase in health spending was remarkable, clearly greater than the increase in the nation’s income.

Moreover, in terms of per 1 Source: CBTT and World Bank 4 capita health spending, in the Caribbean only the Bahamas, with a level of health spending of close to $2,000, has had a higher level than Trinidad and Tobago.

Looked at from another angle we get a different picture.
For when we consider the share of government health spending in GDP we see that while PAHO suggests that 6% of GDP is the target for countries committed to Universal Health Coverage, government health spending in Trinidad and Tobago has been averaging just under 3% for the past decade.
However, before any recommendation can be made for an increase in government spending on health, the matter of the efficiency of spending needs to be addressed and other influential factors need to be taken into consideration.

Do we know if the country is getting value for money from the expenditure incurred?

While a full efficiency analysis was not the remit of this report, the sense we had was that there is immense room for improvement on this front.
We are informed, for example, that the unit cost of primary care services varies widely across the RHAs.2 This points to a need to examine how these services are delivered in the different RHAs.

It should also be noted that since Trinidad and Tobago is one of the countries that have adopted the WHO call to Universal Health Coverage (UHC), efficiency has now become an imperative.
In sum, what we seem to have in Trinidad and Tobago is a situation where in spite of the high and increasing level of expenditure on health, including a very high level of out of pocket (OOP) expenditure, almost 40%, when we recall the health statistics provided, there is a strong sense that the health system is not performing to the best level that it could.

What should be the strategy at this time?


This report suggests that, given the strained resources of the country we will need to find a balance in taking the steps necessary to strengthen the primary care system, those needed to improve the quality of care at the nation’s hospitals, and the administrative structures required so to do.
Based on our findings from a review of the health system, we will therefore present recommendations for upgrading primary care, for improving the hospital experience, service delivery in general as well as the administrative structures.
2 Costing Health Services in Trinidad and Tobago, a study done for the Ministry of Health, HEU, Centre for Health Economics, 2014 5 Health Services Delivery If we are to offer recommendations for improving the quality of health care in the country it would be useful to begin by clarifying the picture of the health system we have in mind.

This picture can be painted with the help of three sources.

The first source is the 1994 Health Sector Reform Report, Towards a Health Nation.
The main theme of that Report was the need to transform the health system of Trinidad and Tobago into one that is anchored on Primary Health Care.

As if foreseeing the burgeoning of the non-communicable diseases (NCDs), the Report warned that only a biasing of the health system toward primary care services would meet the health needs of the population.
Referring to the NCDs, the Report tells us that if these diseases are not arrested and appropriately managed by the providers of primary care, they result in admissions to hospitals followed by expensive episodes of illness often leading to permanent disability or death.

The second source is the 2005 Report of the Caribbean Commission on Health and Development (CCHD).

In this Report attention was drawn to two interesting facts.
The first was that the epidemiological profile of the countries of the Caribbean and that of the richer Organisation for Economic Co-operation and Development (OECD) countries was almost identical, with Cardiovascular disease, Diabetes, Cancers and Stroke among the top causes of death in both jurisdictions.
The second bit of evidence advanced by the CCHD was that the level of per capita spending on health in the OECD countries was many times higher than what prevailed in the Caribbean, and in some cases exceeded the per capita income of some countries of the region.

The suggestion emerging from these two facts was that it would be a mistake for the Caribbean to attempt to deal with its health problems in the same way that the OECD countries were dealing with theirs.
We would be facing levels of morbidity which the economies of the Caribbean simply could not afford.

The recommendation of the CCHD therefore was that the countries of the Caribbean needed to convert their health systems into prevention-oriented systems.

This, of course, was a clarion call for a much greater emphasis on Primary Health Care and Public Health.
The third motivating source of our picture comes from the more recent call by WHO for all member countries to configure their health systems to provide what was labelled Universal Health Coverage (UHC).

This was a call for countries to provide quality health care for every citizen or resident in a way that no one is exposed to financial distress because of health.
Since everyone knows that secondary and tertiary health care are very expensive, the call to UHC could not possibly be to provide this kind of care for every single citizen or resident with health systems structured as they are at present.

In other words, the call to UHC is really a call for making Primary Health Care readily accessible to everyone in the country.
6 It must be acknowledged that a call for the advancement of Primary Health Care (PHC) does not mean that the health system will not provide the secondary and tertiary care that becomes necessary.

What it means is that the health system will be one that seeks to minimize the incidence and the levels of morbidity so as to make the demand for hospital care a demand that the country can readily afford.

In this sense a high quality of secondary/tertiary care will be available to all who need it.
In other words, only with a properly functioning primary care system will countries be in a position to provide the scale and the quality of secondary and tertiary care demanded by the population.

The welfare and the economic implications here are tremendous.
For one thing, seeing that the country is now faced with an increasing number of non-communicable diseases, which are in some respects preventable and manageable, we will need to be concerned about the nature and extent of our investment in our hospitals.

Certainly we have to maintain and, in some cases, upgrade our hospitals but at the present time particular emphasis has to be placed on upgrading our primary care personnel and our primary care infrastructure.
7 8 The Regional Health Authorities were established by Act No.

5 of 1994.

They were established as a direct result of the health sector reform programme which had among its principal objectives: 1.

Rationalising public and private services including strengthening of primary care.

2.

Decentralisation of services to five (5) RHAs.

3.

Reform of the Ministry of Health into a sponsoring and regulatory body.

4.

Development of new management systems.

5.

Studies on the financing of the sector.


Prior to the establishment of the RHA, the public sector health care was administered by the Ministry of Health (MoH) and conducted mainly through primary, secondary and tertiary care facilities.

It remains to be determined whether the emergence of the RHAs and the intended separation of the delivery arm (RHA) from the policy and regulatory arm (MoH) have accomplished the desired results as presently observed.
In the assessment of the current status of the public sector delivery of health care, it is convenient to identify major pillars that have emerged/evolved and now support the health care delivery objective.

These major pillars may be conveniently referred to as follows: 1.

2.

3.

4.

5.

6.
2.

3.

4.

5.

6.

Primary Health Care Service Delivery/Infrastructure Vertical Services RHA Executive/Administrative Chief Medical Officer Ministry of Health Administration Any evaluation of these pillars should permit some reasonable conclusions on the successes or inadequacies of the RHAs.

In the conduct of this exercise, the aim has been to avoid the recording of a litany of woes with a tiresome repetition of detailed shortcomings.
Instead there is the desire for brevity in presentation with a solutions/implementation based approach being of paramount importance.

More importantly, the focus is on the patient’s perspective amplified in primary health care and under secondary and tertiary care.

The patient encounters in the secondary and tertiary services are conveniently captured as the patient walk through.
9 This emphasis on the patient in no way diminishes the major importance of staff charged with the onerous responsibility of delivering quality health care nor indeed the facilities and equipment committed to such pursuit.

Additionally, it is perhaps also useful to assert at the outset that the tale of the health sector is not one of purely bad news.

A considerable body of work is conducted on a daily basis with tremendous outcomes.
What is perhaps more important though, is whether we are delivering the best outcome to the majority in a most cost effective and timely manner as well as in a considerate and customer friendly manner.

We now visit the major pillars, six in all, as outlined.

10 2.0 PILLAR 1: PUBLIC SECTOR DELIVERY OF HEALTH CARE 2.1 PRIMARY HEALTH CARE The precise definition of primary health care can be somewhat elusive.
Simply put though, primary health care refers to the basic health care delivered in the community largely, but not solely, via Health Centres.

This level of care in the public sector has become dismembered over time, partly at first into Local Government and later to the RHAs; but with a significant portion remaining with the Ministry of Health.

In our assessment of primary health it is appropriate to look at some essential elements.
The major constituents of the primary health care sector have been Primary Health Care Proper and Public Health.

Primary Health Care Proper Primary health care proper is conducted mainly through Health Centres providing: walk-in services, chronic disease clinics, antenatal and postnatal clinics, child welfare/immunization clinics, allied health-domiciliary, health promotion/education.

These have been transferred to the RHAs and are now headed by primary care managers.
Public Health The public health component is administered simultaneously by both the Ministry of Health under the Chief Medical Officer and the Local Government under their Chief Executive Officer (CEO).

The complexity does not end there as the Public Health Inspectors, the main operatives of the public health delivery are either employed within the Ministry of Health or the Ministry of Rural Development and Local Government, with both bodies discharging similar functions.
The public health component includes the following main areas of function:  Public Health Department- with responsibilities in the areas of food safety, vector control, environmental health/occupational safety, drainage, overgrown premises, building inspectorate, port health, public health engineering, all administered largely by public health inspectors  Disease surveillance  Medico legal duties 11 Dental services which are also delivered under the primary care services are conducted partially within the Ministry of Health and partly within the RHAs.
The attempted separation of service delivery from the Ministry of Health has been partially derailed by the fact that the relevant legislative authority for District Medical Officers has not been transferred.

Since the Ministry of Health is reportedly no longer in the business of hiring doctors, there has been a sustained depletion of CMOsH despite recent resuscitative attempts.
In effect there are two (2) streams of medical officers in the primary health care sector, some RHA, some public service (MOH) employees with different reporting relations, different service areas and complexity in the opportunities for professional advancement.
Some of the same can be said for the Public Health Inspectors (PHI): the Ministry of Health group, capable of promotional advancement to Chief PHI, operating on 8am-4pm work schedules, with nationwide scope of operations while their Local Government counterparts operate with extended hours, are answerable to the Statutory Service Commission and function within the realm of a Regional Corporation.

The story of the Public Health Nurse/ District Health Visitor (DHV) is not entirely dissimilar.
The shortage of DHVs must be addressed as a priority.

Such is the story of the complexities that have emerged in the interrupted transitions that are associated with the RHAs.

In summary, the issues are:  Disparate territorial areas of responsibility.

 Different terms of engagement.

 Peculiar and in some instances dual reporting relationships.

 Dissimilar compensation packages.

 Different legislative authority.

 Varied reporting relationships and bodies of control.
 Limited or frustrated opportunities for professional advancement.

Recommendations Accordingly, what is clearly needed at this time are:  Regularization of the working arrangements of the various groups delivering primary health care.

It is hardly likely that clearly delineated territories, roles and responsibilities, and reporting relationships will be accomplished in the short term and therefore facilitative arrangements should be put in place.
12  Promotion of an enhanced symbiotic relationship between the local government bodies and the RHAs and of course the Ministry of Health e.g.

CMOH collaboration with RHA, CEO.

Standing executive meetings of CMOH, PHI, RHA managers and CEOs of regions.

 An effective and enhanced vigorous education and health promotion programme.

 A regularization of the Dental Programme.


At the Health Centre level steps should be taken for:  The urgent development of clinics for the follow up of discharged hospital patients.

 Improvements to the physical facilities of Health Centres in several and certain strategic Health Centres.

 Extended hours in strategically selected Health Centres.

 Suitably located and resourced District Health Facilities (DHFs)  Rejuvenation of the impact of the DHV on the household.
 Reliable availability of support services and staff- Pharmacists, Nurses, Social Workers, educators, pharmaceuticals  Reliable scheduling of medical services  Guaranteed and adequate medical presence  Sufficient medical staff to manage follow-up clinics  Improved arrangements for the movement of patients to and from secondary institutions  Updated record keeping with attendant clerical support.
Aggressive steps should be taken in the pursuit of electronic record keeping which should enhance easy retrievability.

 Supportive guidance on recuperation and rehabilitation  Vigorous education programme.

Apart from the structural and organisational challenges in general, the challenge of the public health inspectors are numerous and it is convenient and useful to list several of them:  Technical staff is employed by the Ministry of Health, while manpower is provided by  Local Government.
Inspectors in Local Government bodies are employed by the Statutory Service Commission and perform similar functions with different hours of work and different jurisdictions to the inspectors in the Ministry of Health who are employed by the Public Service Commission with island-wide jurisdiction and county assignments that overlap the boundaries of the Regional Corporation.
 The explosion of food handlers, the increase in the number of special events, and the several public holidays added to the increase in night vending and varied cultural habits in food preparation create a demand which is unmatched by the availability of public health inspectors and the hours of work.

13  There is difficulty in accessing premises for vector control activities due to the mismatch of hours of work of both inspectors and households.
 Limited attention to Veterinary Public Health, Chemistry Food and Drugs and Public  Health Laboratories.

In the transition, insufficient attention was given to regularizing affairs of Public Health Inspectors.

 Data of the Regional Corporations may not necessarily be harmonized with data of the Ministry of Health.

 Incineration of medical waste presents an on-going challenge.

 Health committees no longer enjoy the full support of the CMOH.

 Previously joint visits were undertaken with DHVs.
These are now hardly conducted.

 There was one health educator in each county; now in short supply.

14 3.0 PILLAR 2: PUBLIC SECTOR DELIVERY OF HEALTH CARE 3.1 SECONDARY AND TERTIARY INSTITUTIONS/SERVICES The secondary and tertiary services are provided in our hospitals.

Some of the services are basic in nature or secondary while more elaborate specialized services are tertiary.
In addressing the secondary and tertiary institutions we may conveniently look at (a) their service delivery (as encountered by the patient in his/her proverbial walk through and (b) the physical facilities (infrastructure).

Both dimensions are worthy of consideration at this juncture.
3.2 (A) SERVICE DELIVERY The patient in his/her proverbial walkthrough encounters several areas/aspects of service delivery, namely:  Accident and Emergency/Triage (Screening)  Ward Management  Laboratory  Radiology  Pharmaceuticals/Ward  Bed Management  Operating Theatre  Obstetric Services  Senior Medical Officers  Clinics Here we look at services that have a direct and immediate impact on the patient’s experience and from where a significant number of complaints emerge.
Among these complaints are: inadequate customer relations, long waiting times/periods, deficiencies and inefficiencies of staff management, bed shortages; inadequate medical and other supplies, insufficient and inconsistent pharmaceutical supplies, delays in obtaining radiological and laboratory investigations.

It would therefore be appropriate to proceed with the recommendations and solutions for immediate implementation in addressing these shortcomings.
3.2.1 Accident and Emergency/Triage (Screening) The Accident and Emergency Department accepts patients with accident and emergency problems.

These patients are sorted according to the gravity of their illnesses by a process referred to as triaging or screening.

15 The functioning of the A&E Department  There must be early commencement of the new day’s clinical activities (probably 7am- 7:30am).

 Preparatory and cleaning exercises must be completed well in advance of commencement of clinical activities.
 The triage/screening- medical personnel should be the immediate first contact for the patient.

 Triaging should be conducted by an officer of appropriate qualification and experience.

 The triaging process should not be preceded or delayed by non-urgent demographic data collection or prolonged history taking.

 Resuscitation must be commenced with required haste.

 The expeditious movement of patients should not be retarded by unnecessary, non-urgent and time consuming investigations and procedures.
 Non urgent investigations and procedures would be better provided elsewhere.

 The movement of patients through A&E should be expedited.

 The questionable application of foreign models where patients are triaged to then be regrouped for treatment is to be critically reviewed.

 Transfer of patients from the ambulance must be expeditious and trolleys/gurneys released promptly.

 The A&E Department must be a priority area for staff allocation and must be well staffed at all times.
 Departmental layout and management stations must facilitate an effective patient throughput.

 The detention of patients in A&E is to be discouraged to only short-stay reviewable conditions with the intention of discharge.

 Likely, long-stay patients are better served at their specialist care destinations, allowing the A&E staff to be relieved of the responsibility of managing admitted patients, holding themselves on alert for emergency patients.
 The A&E staff should have the responsibility for assessment and admission of patients.

 Small observation areas/ward for short-stay patients less than 12 hours is the preferred approach.

 All staff should have customer relations training moreso those in direct contact with patients and members of the public.

 All staff responsible for patient service delivery should have a direct reporting relationship to the medical director and medical administration in general.
 Appropriate information, both disease specific and general education, should be provided to the patient.

16  Continual and enhanced education on use of primary health facilities (health centres) and efficient use of the A&E Department should be provided.

 Continued and enhanced education on primary health care- health promotion, disease reduction, trauma reduction should be provided.
3.2.2 Ward Management There should be:  Customer relations training and crisis management for ward staff including Nurses.

 Training of supervisors in ward management.

 Adequate arrangements for communicating information to limited specified relatives.

 Information on visiting hours must be clearly communicated to the public with due consideration of flexibility for critically ill patients.

 Adequate Nursing staff with due regard to satisfactory nurse/patient ratio.
 Nursing students must be involved in the ward management exercise as a critical part of their training and service introduction.

Trainee Nurses should also be required to attend shifts after normal hours and on weekends, to get them accustomed to these working hours.

 Due attention given to the availability of allied professionals namely, Physiotherapists, Dietitians and Medical Social Workers.

These officers are crucial to the effective management of beds.
 The effective support of hospitality services: sanitation, laundry, attendants and maintenance.

 Timely and adequate supplies delivery.

 Safety and security provisions.

 Effective supervision by the senior officers of all the respective services.

This includes department heads, service managers and the senior nursing staff/ personnel.

 Active consideration to enhancing the hospital management at nights and weekends is advised.
 Adequate discharge arrangements including summaries and directions on clinic and primary care follow up.

 Where appropriate, pharmaceutical counselling, guidance on lifestyle adjustments, convalescence, recuperation, management of disabilities, care of the elderly, available social support services.

 A review of the arrangements with the National Blood Transfusion Service and the availability of emergency blood supplies is strongly advised.
 All of these provisions must be subject to daily independent review.

Seniors must walk the floor.

17  Ward clerks must have a direct reporting relationship to the Head Nurse, apart from the responsibility to the Medical Records Officer or other Supervisor.

 Similarly, where staff perform duties in a particular area or for a particular service, they must have a reporting relationship to the supervisor of that particular area.
 Ward Clerks must secure the patient records, update these records, appropriately file reports and ensure records are made available for patients repeat visits.

 Ward Clerks must also be prepared to perform duties on other wards as the exigencies demand.

 Ward Clerks must be subject to similar customer relations and courtesy requirements as the nursing staff.

3.2.3 Laboratory In the use of laboratory facilities, there must be:  Avoidance of excessive and unnecessary, non-urgent investigations.
 Selectivity in ordering repetitive tests.

 Effective arrangements for the early collection and transport of specimens and retrieval of reports.

 Pre-emptive ordering of reagents and other laboratory supplies.

 Adequate recording and filing of investigation reports.

 Regular servicing of equipment.

 Adequate provision of Medical lab technicians.

 Review of major equipment needs including crucial back up equipment.
3.2.4 Radiology With respect to radiology services, there is need for:  Medical staff improvement in the selective use of expensive and time consuming investigations.

Improved attempts to expedite procedures.

 Senior oversight in the selection of such investigations.

  Measures in place for timely reporting.

 Measures for monitoring and depleting backlog.

 All radiological departments to review bookings beyond reasonable time and take steps to  eliminate such bookings.
Immediate steps to review all outstanding requests over 3 months and determine the status including discard where appropriate.

 Procurement hurdles for parts and ancillaries to be overcome.

18  Effective monitoring of equipment.

 Prompt maintenance including purchase of parts and supplies.

Follow the proper procurement process.

 Reduction in equipment down time facilitated by pre-emptive action.

 Review of the complement of radiological staff and equipment.
3.2.5 Pharmaceuticals/Ward In the provision of pharmaceuticals on wards and in clinics:  Medical staff must familiarise themselves with the government formulary, particularly the use of alternatives within groups of commonly prescribed drugs.

 There must be regular/daily communication by the pharmacy of unavailable pharmaceuticals.

 Within wards there must also be communication between nurses and doctors on the unavailability of medication.
 Appropriate attention should be paid to prescribing habits and availability of pharmaceuticals for weekends and public holidays.

 Cheaper, simpler medication is not necessarily poorer in quality.

 Pharmacists are to be increasingly engaged in the counselling of patients with prescriptions.

 Prescribing habits in relation to clinics visits are to be reviewed.

 In the event of mixed prescriptions- CDAP/Hospital/Health Centre, creative arrangements should be made.
3.2.6 Bed Management With respect to bed management:  Senior doctors and nurses need to be actively involved in the management of beds.

This is not purely a role for the bed bureau.

 There must be early and decisive intervention in care of admitted patients.

 Regular ward rounds must be conducted, including arrangements for weekends and public holidays.

Investigations must be expedited.

  Surgical and other procedures for mandatory in-patients must be expedited.
 Patient discharge should not be delayed by non-urgent investigations and procedures.

 There should be timely advice to relatives of anticipated patients discharge.

 The SMO and senior persons need to be effectively involved in the daily management of their patients with timely discharges.

19 The bed management devices/strategy must be functional 24/7.

Bed management bureau for restricted hours is certainly not the answer.
Alternatively, heavily staffed bed bureau functioning 24/7 may not necessarily be cost-effective.

Serious consideration should be given to establishing or maintaining wards allocated to disciplines so that:  Doctors need not travel to several wards to identify their patients.

 Nursing staff develop greater familiarity and expertise in managing patients grouped according to disciplines.

This is not to suggest that overflow patients cannot be accommodated where space is available.
Public education in use of hospital beds is highly desirable.

3.2.7 Surgery  Surgery lists should be supervised and managed by senior medical staff.

 Appropriate attention should be given to emergency cases, including prolonged lying-in patients.

 Cancellations must be appropriately explained to patients.

 Cancelled patients ought not to be placed at the tail end of the waiting list.

 Patients in critical need must have priority both for clinic appointments (first visit) and surgery appointments.
 Regular and effective review of surgery waiting lists must also be conducted.

 Adequate follow-up arrangements must be in place for post-surgical patients.

 Each institution must have a distinct quality mechanism to treat with complaints of patients with urgent or unsettling matters.

3.2.8 Operating Theatre  Operating Theatre schedules may be developed or refined so that there is predictability and certainty in the availability of surgical lists.
This would allow patients to establish more definitive booking arrangements.

 Adequate recovery/resuscitation room spaces should be made available.

 All staff categories must be sensitized to and responsible for the prompt turnover of patients.

 Review of the acquisition and provision of hardware, instruments, implants and other equipment and supplies is mandatory.

 Strategies must be advanced for the maximum utilisation of the operating theatres.
20 3.2.9 Obstetric Services  Accelerated attempts must be made in the provision of midwives.

 In the interim, support nursing staff may be provided to conduct non-obstetric nursing duties but not midwives’ duties.

 Strict protocols should be established for the monitoring and management of the pregnant patient.

 Twice daily rounds must be conducted in the labour ward by senior officers with the appropriate assessments made and careful instructions established.
 There must be effective doctor to doctor handover of labour ward patients at the end of each on call period.

 The operating theatre and staff must be available on a continuous basis.

 The responsibility of the patients of the labour ward is that of the on duty Consultant Obstetrician.

However, arrangements may be put in place to allow the involvement of additional Consultants.
 The monitoring of post-delivery patients particularly post caesarean section patients is to be afforded meticulous attention.

3.2.10 Senior Medical Officers The SMO staff ought to lead the clinical management team and must hold themselves responsible for/to:  The early commencement of clinics.

 The management of new clinic patients.

 Effective review and discharge of long stay clinic patients.

 Conduct of large clinics.

 Management of surgical waiting lists with prioritization of urgent matters.
 Expeditious management of patients through A&E or otherwise.

 Evaluation of admitted patients by next morning/ within the 24hour on call period.

 Be available within reasonable proximity to respond promptly to on call duty.

 Available for ready input on emergency/on-call duty.

 Guide juniors in the selective and cost effective use of diagnostic radiological, laboratory and other procedures.

 Manage the supervision, training and discipline of junior staff.
 Wherever necessary, clearly delegated instructions with requirement for feedback reporting.

 Commence ward rounds on time.

 Regular ward rounds with junior staff and nurse teaching.

 Teaching, instruction, demonstration to junior staff and nursing staff.

21  Corrective and educational guidance of junior staff.

 Bed management- senior doctors must be actively involved in the management of bed occupancy.

 Effective turnover of patients with appropriate discharge schedules.
 Proper discharge summaries.

 Commence operating lists on time.

 Conduct major surgical procedures.

 Guide and direct junior officials in the selection and conduct of surgical cases or conduct of procedures.

 Manage surgical lists.

 Effective and supportive communication with patients who have had surgeries postponed.

 Adequate, timely rescheduling of patients with cancelled surgeries (not at the end of the queue).
 Review and report all adverse events; contribute to morbidity and mortality conference.

 Engage in the reporting and remedying of faulty or defective equipment.

 Management of the health care team.

 Timely and effective communication with selective relatives of patients.

 Facilitating visiting rights in urgent circumstances.

 Timely reports on patients.

 Prompt staff reports.

 Cultivate meaningful professional working communication with nursing and other categories of staff.
 Early intervention and communication to senior staff in potentially contentious matters.

 Attend departmental and staff meetings as required.

 Management and supervision of other staff.

 Familiarize with the terms and conditions of employment of junior staff and implementation of RHA rules, procedures and protocols.

 Provide timely reports to Head of Department and Medical Director on matters in need of early attention.

 Contribute to the departmental budgetary process.
 Serve on institutional or ministerial committees where necessary.

 Conduct medical evaluations.

 Provide opinion/advice as required.

 Measurable output with targets in the non-clinical areas e.g.

Pathology, Radiology, Laboratory.

22 3.2.11 Clinics In the management of clinics:  There must be advance arrival of clinic staff.

 Patient’s records/reports (laboratory/radiology/pathology) must be sourced and made available in advance.
 Adequate clerks should be available to meet and treat with patients’ needs.

 Clerks should not be required to leave their patients’ station to source records.

 Medical and nursing staff are expected to function as a team in the completion of clinic activities.

 Clinic appointments should be staggered.

 The intervals of repeat visits should be managed with regard to prescribing habits.

 Suitable candidates should be referred and encouraged to visit the health centres.
 Avoidance of simultaneous clinics in the same place is advisable.

 Monitoring and supervision on a daily basis.

 Urgent conditions must be appropriately accommodated in the waiting list.

Attention should also be paid to:  Non adherence to clinic schedules.

 Patient circumstances in their desire to be first in line, transport availability, availability of accompanying relatives, job or family commitments, reluctance to leave the clinics.

Public education is a necessity.


 Many clinics are conducted in cramped, crowded and congested areas.

Where necessary, suitable accommodation is to be addressed.

 Visits by an external inspectorate and service audit (quality) team are strongly encouraged/advocated.

 Effective summaries must be prepared for discharged patient.

 Senior officers must be involved in the review of the management of long stay patients.
 Effective communication must be made to patients on major clinic adjustments/schedules.

 All individuals meeting these clinic obligations must be directly accountable to the medical director in the discharge of their duties.

The CEO must facilitate this administrative reporting structure.
23 3.3 (B) INFRASTRUCTURE 3.3.1 Port of Spain General Hospital  There have been reports of seismic instability of the central block of this institution for several years with the need for more aggressive intervention.

The central block housing the majority of the wards, ICU, step down unit and corridor to the operating theatre needs to be replaced.

We have not been privy to the details for construction and relocation of services.
 The clinic spaces are very small and overcrowded, pharmacy cramped and A&E also very limited in space.

 There is need for the installation of a MRI machine.

 The medical records department remains a congested one with storage challenges.
3.3.2 St James Medical Complex  Serious consideration should be given to the installation of a Linear accelerator, noting the repeated delays in the development of the Oncology Centre at EWMSC and a lingering need for a facility at the St James Complex, a likely win-win situation.

 Some of the wards are without piped oxygen.

 Adequate equipment for the physiotherapy department is needed.

3.3.3 St Ann’s Hospital  Refurbishing/renovating of admission wards.
 Refurbishing of Forensic Wards (with appropriate levels of security and review of the conditions under which patients are detained therein).

 Provision of steam generating plant for meal preparation.

3.3.4 Eric Williams Medical Sciences Complex The Complex accommodates the Adult Hospital, Children’s Hospital, Women’s Hospital, Dental Hospital, Veterinary Hospital, Medical School, Laboratories, lecture rooms, Dental School, Veterinary School, School of Nursing, and School of Pharmacy.
 There are reports that these schools are becoming overcrowded with the corresponding requests for expansion.

 As it stands, expansion of the dental hospital is being conducted; a new additional maternity building is very near completion and an expansive Oncology centre without beds is in the relatively early stage of construction.
 This compound presents challenges in streamlining its functionality; there are evident maintenance issues; the University speaks to its buildings being in disrepair; and the complex may become a cumbersome management encounter.

24  It is strongly advised that serious consideration be given to limiting further major construction and expansion on this site.
While the Complex is expansive, the adult hospital is of moderate size and there is an evident mismatch of the relatively large medical staff/numerous specialist services to the limited bed space.

 There is also a requirement for adequate patient accommodation for the Cardiac Service, especially given its national scope.
 The adult hospital challenges may be partly addressed by the Arima Hospital, although one wonders whether a better option could have been a new Sangre Grande Hospital and a scaled down Arima facility not far removed from the EWMSC and with the priority bus route intervening.

3.3.5 San Fernando General Hospital  The new facility is totally outfitted with generous allocation of space.

Was the occupation of the new office complex the best decision?
Concerns exist about the generous allocation of two (2) floors for a University expansion while the Maternity department is in need of accommodation.

 The slow elevators may be counter-productive to a medical service over several floors.

 We would need to be assured of our national fire-fighting capability to service this facility, as well as our ability to evacuate patients in time of need.
 The maternity department is housed in dilapidated conditions in the oldest of the three hospital buildings and needs to be rehoused.

It is doubtful whether a new maternity structure should be a priority.

  A Cardiac Facility, not necessarily of the same magnitude as EWMSC is of merit.

 A possible limited Oncology department/ improved service.

 What remains to be done with the old hospital building?
3.3.6 Sangre Grande Hospital  Simply put, Sangre Grande is in dire need of a new facility; a simple, compact and fit for purpose institution with scope for logistically smooth expansion as years and funds permit.

 The small existing hospital is a hodgepodge of old structures and refurbished cargo containers.
The physical structure doesn’t say much for our use of resources, but it speaks volumes on the tolerance, forbearance, commitment and application of staff who labour under such challenging conditions to provide a relatively good level of service to the population of the eastern border of Trinidad.

25 3.3.7 Scarborough General Hospital  The Scarborough Hospital is inviting and pleasantly laid out.
Shelter from the elements in the waiting areas for outpatients may have been an oversight in the desire for open spaces and ventilation.

 The ward space may become inadequate in due course, particularly surgery.

Fortunately the layout of the institution should not make an additional ward or two an imposing venture.

Other major/new infrastructure are considered under the heading, New Projects.

We now turn to the third pillar of the evolved/newly emergent health care delivery structure.
26 4.0 PILLAR 3: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE 4.1 VERTICAL SERVICES There are certain service delivery units originating within the Ministry of Health and which have been responsible for particular activities of national scope e.g.

blood banking.

These units within the Ministry have been conveniently referred to as Vertical Services and continue to provide service functions despite the fact that the Ministry of Health is reputedly no longer in the business of service delivery.
Whatever the original intent, several uncertainties prevail: In essence, with the establishment of the RHAs, several of these services appeared to be managerially placed in an “on-hold” folder, (a by-product of the unfinished health sector reform program), awaiting determination as to where they should be properly located in the health sector.

To this time, their pre-existing issues have remained unresolved.
Other issues have also emerged and their positions in the health sector are still to be clearly identified/delineated/determined.

These bodies report variously to the RHAs in the districts where located; the Ministry of Health- Director of Health Sector Planning; the Deputy PS or to the Chief Medical Officer with his numerous burdensome portfolios.

These services as a group reveal/reflect deficiencies:  Various reporting relationships (as indicated above).

 Overlapping lines of management and funding.


 Unstable or inadequate management.

 Limited and in some instances inadequately trained staff.

 Little, inadequate or almost non-existent accommodation.

It is hardly necessary to list in finite detail all the matters that afflict these units.

However, a listing of some elements will serve to make the point.
Incidentally, the staff are very much alive to some of the issues that confront these respective authorities The body of vertical services with which the Committee interacted include:  Chemistry, Food and Drugs Division.

 National Blood Transfusion Service (NBTS) - (Blood Bank).

 Child Development and Behaviour Unit/EWMSC.

 Thoracic Medical Unit (Pulmonary/ Chest Clinic).

 Arima Rehabilitation Centre.

 Dental Services.

27  Trinidad Public Health Laboratory.

 Queen’s Park Counselling Centre.


 Nutrition and Metabolism Division.

 Population Programme (Family Planning Services).

 Insect Vector Control/Public Health Inspectorate.

 Health Education Division.

Oncology and C40 are vertical services and will be dealt with elsewhere.

While the following units have not yet been met by the Committee:  Field Clinics.

 Child Guidance Clinic-NWRHA.

 Hansen’s Disease Clinic.

 HIV Aids Counselling Unit.

 EHS (ambulance).

 Lady Hochoy Home.


 Princess Elizabeth Home.

We hereunder identify in summary most of the major issues in the respective services/units: 4.1.1 Chemistry, Food and Drugs Division  The Drug Advisory Committee is non-functional.

 The laboratory is also non-functional for want of a suitable healthy and safe work place.

 The assessors/readers to look at clinical trials are also not available.

The net result is that there is a backlog of approximately 530 tests still to be done.
Approvals for importation of certain pharmaceuticals cannot be granted.

4.1.2 The National Blood Transfusion Service (NBTS) - Blood Bank  Has not had a medical director for 5 years.

 The RHAs ought to have transfusion committees, some of which are not in place.

 There has been no re-education on the policy on blood donation.

 The CMO is to identify a secondary testing site.

 The absence of training programmes limit the availability of staff.
 The absence of trained staff curtails the long held desire to increase donor acceptance after 2pm and on weekends.

 Policy formation and adherence were last effected in 2007.

 Public relations via Ministry of Health is deficient.

 A donor recruitment officer is not in place.

28 4.1.3 The Child Development and Behaviour Unit This Unit has a staff of one, indeed a shared person.

It provides a national service and is severely under resourced while having a waiting list extending to 2017.
This service is underdeveloped due to what is claimed to be bureaucratic delay and non-recognition by the Ministry of Health.

Is reporting to be made to the Business Manager or the Head of Paediatrics NCRHA?

4.1.4 Thoracic Medical Unit (Pulmonary/Chest Clinic) This service, as significant as it is, now appears suspended between Caura and EWMSC.

There are no assigned beds at EWMSC.


The Division craves the support services and facility of EWMSC and is reluctant to embrace a return to Caura owing to the seeming antiquated and isolated state of Caura.

There are concerns about administrative support.

The national TB programme with its outreach centres is in need of redirection/reinvigoration/revitalization.

4.1.5 Arima Rehabilitation Centre This is an outreach/satellite centre of St Ann’s Hospital for rehabilitation of psychiatry patients.
The 16-18 acres of land which were a gift from the Holy Ghost Fathers for gardening/rehabilitation of the clients is underutilised.

The current occupants of the Centre are aging and unable to do gardening.

There needs to be a turnover with a new influx of patients who would benefit from the gardening/occupational therapy.

These need to be supported by a qualified teacher.

Construction/repair work at the Centre ceased over 2 years ago.
4.1.6 Dental Services The representation on dental services was that from EWMSC.

It speaks to a deficiency in primary dental care.

NCRHA Dentists are present in 4 health centres.

The significant number of health centre dentists fall under the Ministry of Health and yet others fall under other RHAs.

Therein lies the recurrent items of dual, unclear, confused, supervisory and reporting relationships.
4.1.7 The Trinidad and Tobago Public Health Laboratory The Public Health Laboratory has had its functions severely restricted since destruction of its premises by fire several months ago 29 4.1.8 Queen’s Park Counselling Centre QPCC provides service for as many as 2,400 patients per year, including 48,000 blood tests.

It meets a national as opposed to regional service.

Short term employment of its nursing staff (3 months contract) is a major impediment.
4.1.9 Nutrition and Metabolism Division This Division is limited in technical support with reliance on a number of On-the-Job Trainees (OJTs).

 Staff are engaged on very short term contracts  Questions arise as to whether these facilities should operate out of the Ministry of Health head office 4.1.10 Population Programme (Family Planning Services) Again, there is a recurring theme; no direction and limited staff capability.

Challenges include a tenuous and strained relationship with the RHAs.
Clinic Administration operates/is conducted under the Ministry of Health, and the Health Centre services under the RHAs.

4.1.11 Insect Vector Control/Public Health Division (Admin) This Division reports to the CMO but provides a myriad of services within the boundaries of the RHAs and the Regional Corporations.

Further detail is provided under Primary Health Care/Public Health.
4.1.12 Health Education Division The Health Education Division has been largely engaged with a structured school health education programme together with corporate communication but not without enormous challenges of staff and other resources.

The message is that primary and community health have not been advanced as a priority and that health education as a whole is quite inadequate.

 Surveillance data is commonly unavailable.


 The absence of a director, staff shortages and role confusion among medical staff, add to the difficulties.

 All of these functional limits persist despite avowed acceptance that more resources need to be funnelled into primary health care.

30 Conclusion: How then do we proceed?

These bodies all seem to be in need of someone to champion their cause, to make vigorous representation at the administrative and policy levels.
Given the fact that the Ministry of Health is reputedly no longer in the business of service delivery nor in hiring medical and other related staff, it would be useful to consider having the RHAs actively engaged in their management, more so with respect to the hiring.

There are already existing examples e.g.

Psychiatry services under the NWRHA and Cardiology under NCRHA.

But most importantly under whichever area, a vigorous rehabilitation of these services is required.
In the short term, a functional cooperative arrangement/relationship between these bodies, the RHAs and the Ministry, is required.

31 5.0 PILLAR 4: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE 5.1 RHA EXECUTIVE/ADMINISTRATION With the proclamation of the RHA Act, a number of regional bodies, five (5) in all were established.

These bodies, Regional Health Authorities, each consists of an RHA Executive body operating/managing primary, secondary and tertiary facilities.
The RHA executives operate the facilities in delivering services to their respective communities on behalf of the Ministry of Health.

The RHA executive was intended to provide the new impetus for service delivery in close proximity to the executing bodies in the secondary and tertiary as well as primary institutions and other bodies.

However concerns now exist whether the RHA executive represents a new tier of bureaucracy.
As a first measure, notwithstanding the strength and independence of the RHA Act, there ought to be an improved working relationship between the RHAs and the Ministry of Health administration at minimum to satisfy the requirements of the Act and more directly in improving functionality.

There is also noted the high turnover of executive managers with the corresponding loss of institutional memory.
With respect to the inner workings in the RHA executive the following are required:  The establishment of a meaningful and identifiable reporting relationship to strengthen the executive authority of the Medical Director (institution) as distinct from the Executive Medical Director.

 All individuals that have an impact on patient care must have a direct reporting relationship to the Medical Director (institution).
 Redesigning of the roles of executives in consonance with product output/delivery namely the medical care product.

 New emphasis on the utilization of more on the floor individuals monitoring, supervising, meeting and greeting patients and executing according to needs.

 Executives must become familiar with their institutions and must be expected to walk the floor.

 Executives are expected to develop their skills and knowledge in health care management, not purely business management.
 A reliable system of reporting and accountability is required.

 The imaginative use of some staff, e.g.

senior nursing persons in supervising and monitoring exercises.

32  The Executives must be at the forefront of harmonizing many of the relationships across regions and counties and ministries as well as from Ministry to RHA.
 All of these matters will not necessarily be under the exclusive purview of one body or another and will require imagination, skill and insightful/purposeful collaborative efforts.

 Review of the number of executive/senior management positions and their suitability for purpose as well as the number of organisational layers within the RHAs  Review of major HR portfolios.

 Review of the expenditure portfolios.


  Review of institutional procurement and management arrangements Improved reporting relationship with the Ministry of Health Of particular note is the administration of health in Tobago which finds itself in a strangling embrace of four different bodies: the Ministry of Health, the Central Administration Service/Ministry for Tobago Development, the House of Assembly and the Tobago Regional Health Authority.
33 6.0 PILLAR 5: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE 6.1 CHIEF MEDICAL OFFICER The Chief Medical Officer is the Chief Technical Officer of the Ministry of Health.

He/she is the Ministry’s and government’s main advisor in addition to performing various administrative and statutory functions in health care delivery.

This office is established within the Ministry of Health and remains so.
However, the office of CMO is singled for separate treatment as a major pillar in the health care edifice given the substantial and influential import.

His/hers is an onerous responsibility in which he/she is called upon to perform a multitude of tasks on a daily basis.

The multiple roles and functions include:  Exercise of responsibility and authority under several statutes.

 Operational and supervisory duties in professional bodies e.g.

Medical Board of T&T.


 Supervisory responsibility in several Vertical services e.g.

National Blood Transfusion Service (Blood Bank).

 Cross ministerial duties e.g.

Local Government, Labour- medical board, Public Health Act and National Security- Quarantine Act.

 Member/Chairman of various committees e.g.

Tenders.

 Administrative duties include reports on subordinate staff.

  Point of contact individual for liaison with international agencies e.g.

PAHO, WHO, Interview panels e.g.


Public Service Commission.

CARPHA.

 Attendance at international conferences.

 Available as Advisor to the Minister of Health.

 Attendance at multiple local meetings, press conferences.

 Attendance at meetings with Permanent Secretary.

 Approving policies, reports.

The above is by no means an exhaustive list.


Prior to the advent of RHAs, the Chief Medical Officer also had a direct oversight role over the secondary and tertiary institutions as well as the primary health care sector.

He was supported by four Principal Medical Officers, namely:  Principal Medical Officer - (Institutions), with oversight of secondary and tertiary institutions.

34  Principal Medical Officer- (Community Services) with oversight of the Primary Health Care Sector.
 Principal Medical Officer- (Epidemiology).

 Principal Medical Officer- (Insect Vector Control).

This is not to suggest that the Office of the Chief Medical Officer was adequately staffed.

Moreover with the advent of the RHAs the Chief Medical Officer was stripped of the support of the Principal Medical Officers (one remained) and so the office of the CMO has been left hopelessly exposed and dispossessed in that oversight role towards the RHAs and support role to the Minister.
It goes without saying that the CMO is in need of the establishment of a proper Secretariat, ably staffed by senior professional technical staff and other support including legal; for example, in the areas of maternity services there is need for greater coordination and monitoring of maternity services at the level of the MoH.

This must be commenced with some urgency.

The CMO cannot be seen running from press conference to press conference and meeting to meeting like a headless chicken.
Much better is desired.

While on the question of senior technical support, it should be observed with concern that the cadre of senior officers available for succession to the position of CMO is no longer available.

The CMO is a public service post while senior RHA staff are non-public servants.

Incidentally this scenario repeats itself in a number of areas including Chief Nursing Officer and to some extent Chief Public Health Inspector.
In preparation for the likely resolution of succession arrangements it would be instructive to note that parity needs to be restored to the Specialist Medical Officer of the institutions with the CMOH (range 65 in the public service).

This would rectify a classification error of several years past where separation was effected on grounds which created an anomalous seniority divide that has been capitalised upon by some to the unfair disadvantage of the institution based doctor.
In summary:  The CMO must have an appropriate secretariat where the service delivery element of the RHAs is to be reported to the Ministry of Health and indeed to the Honourable Minister.

 There is need for professional support similar to the roles of the PMO.

The RHAs may assist in the short term.

Where the service delivery element of the RHAs is to be reported to the Ministry of Health and indeed to the Minister, the CMO must be factored into the equation.
35 7.0 PILLAR 6: THE PUBLIC SECTOR DELIVERY OF HEALTH CARE 7.1 MINISTRY OF HEALTH ADMINISTRATION The Ministry of Health as expected is the State body responsible for the overall management of the health sector in the country.

Formerly this Ministry was responsible for articulating policy, exercising regulatory function as well as implementation and management of services.
However, with the emergence of the RHAs, the service delivery arm was hived off with the residual Ministry of Health body being responsible for policy and regulatory functions One would expect that with the separation of service delivery in an incomplete and uncertain fashion, the administrative area of the Ministry of Health would hardly escape unscathed.

It would be convenient at this time to indicate some of the areas of operation that remain within the Ministry of Health.
These include: Human Resources, Finance, Policy/Planning, Office of the CMO, Vertical Services, Health Education, Corporate Communications, Project Management Unit, Internal Audit, International Co-operation, Health Sector Advisors.

The following observations are made:  The Committee did not have the benefit of meeting with the Project Management Unit, and so information on many of the new projects was not readily available; maybe UDECOTT or some other agency could answer.
 The internal audit function was largely financial and was only convened when specifically requested.

 Boards of Survey are up and running again.

The onus is largely on the relevant RHA or institution.

RHAs have to initiate the process and do it correctly.

 The Ministry of Health in meeting some of its international obligations is a member of a Caribbean Public Health Agency (CARPHA) technical committee and is represented by the Permanent Secretary.
There are plans to rebuild the Public Health Laboratory.

 The areas of the CMO and Vertical Services including Health Education are addressed in further detail elsewhere in the report.

At this juncture it would also be convenient simply to identify some of the many concerns of the senior administrative staff of the Ministry.

Some of their concerns are otherwise addressed in various parts of the report but some are not.
Separate and apart from the matters treated specifically within the body of the report, it should be emphasised that the Committee is not yet sufficiently informed to offer a position/view on all of 36 the other matters listed.

Those unaddressed form part of a body of work for further deliberation/ consideration.

A listing of the concerns for further evaluation is as follows: 1.

The relationship with the RHA is a ‘mix of turbulence’.

RHAs in some instances were not seen to be taking responsibility.
Some HR practices were violated in the hiring outside of established positions and the grant of leave was at times treated in an ad hoc manner.

Approval from CPO’s office is required to pay certain workers, as well as attach allowances.

2.

The relationship with the CMO’s office is unclear and there is need for a collaborative effort.

3.

In the relationship with other bodies:  The signed MOU with COSTAATT was never enforced.
 The health visitor programme has now been transferred to COSTAATT and the programme languishes in uncertainty.

 Public Health Inspectors- some posts were transferred to the RHA – officers can’t get promoted.

4.

The Piarco Airport falls within the sphere of operations of the NCRHA and there are associated challenges.

5.

Annual Service Agreements were not honoured -there was about 30% of reporting and the indicators were off target.

6.
6.

There was the need for a handbook of policy within the RHAs as well as a need for an updated Adverse Events Policy (this policy, the Committee is informed, should already be available) 7.

On data collection, the statistical manual is dated 1986 and there are no coders.

8.

There are weaknesses in procurement across RHAs.

Requests for equipment or expensive parts costing over 1 million dollars are often lacking crucial information 9.

Succession planning within the RHAs is inadequate.

10.
10.

Subventions are provided regularly on a monthly basis to the RHAs for laboratory reagents.

There should hardly be reason for inadequate supplies.

11.

The transfer of dental services from the Ministry of Health to the RHAs should be expedited.

12.

The proposed health card is beset with many challenges.

13.

A new draft Annual Services Agreement (ASA) is being prepared and there is expectation that it will be honoured.

14.

The project manager would be able to shed light on some new project costs.
15.

The number of foreign recruits e.g.

Cuban doctors, is not adequately reported in the RHA data.

37 16.

The RHAs have the capacity to hire in areas of great need- they need to be more robust and proactive.

17.

There is a requirement for standardization in RHA policy in several areas.

18.

The transition of management to the RHA institutions is still incomplete.

Indeed, the hospital attendants and wards maids matters remain unsettled.

19.

Several policies are due for renewal.

20.


There are concerns about created positions.

21.

Should the grant of scholarships be within the province of Ministry of the Public Administration and not the Ministry of Health?

22.

The CMO has too much work to do.

Principal Medical Officers are critically needed.

The various primary health care positions are a source of disquiet.

23.

Is the Insect Vector Control Division providing value for money?

24.

There is no Chief Nursing Officer.


Recommendations The Ministry of Health executives would be expected to:  Facilitate the transition of the vertical services including arrangements for staffing in conjunction with the RHAs and service delivery.
 Maintain more than an enquiring look into the operations of the RHAs  Require reporting consistent with service agreements  Keep the Minister regularly informed  Facilitate where possible the establishment of synergies between/among RHAs 38 8.0 OTHER AREAS OF HEALTH CARE DELIVERY Having looked at the major pillars that constitute the current health care delivery edifice, it is now appropriate to give special consideration to several areas of health care delivery activity that have varying degrees of national or sectoral impact.
Understandably such matters ought to involve the RHAs for their effective discharge and the RHA performances will undoubtedly be assessed relative to their influence on those matters as well.

The list is by no means complete, nor are the items analysed in every finite detail.

This list includes: 8.1 MAJOR PROJECTS A number of major projects are in various stages of implementation/completion and are earmarked for the Ministry of Health and related bodies.
Details are not readily available for these projects and further information gathering and evaluation need to be done.

However, the following have been identified: SWRHA/SFGH  Chancery Lane Complex (Teaching Hospital) - construction, retrofitting, equipment.

 Proposed University facility.

 Couva Hospital- $1.5 billion.

 Couva Education Facility.

 Point Fortin Hospital- $1.5 billion.

 Cardiac Unit.

 Maternity Department.

 Dialysis Centre.

NCRHA/EWMSC  Maternity Hospital Outpatient Building.
 Dental Hospital expansion.

 Oncology Centre- $700 million.

 Arima Hospital- $1.5 billion.

 Dialysis Centre.

39 NWRHA  POSGH.

- New buildings- ward, clinics, A&E, pharmacy staff canteens, residential accommodation.

- MRI.

 St James Medical Complex- linear accelerator.

 St Ann’s Hospital- ward refurbishment, steam generating plant.

Some of the unconfirmed capital costs are listed above.
These projects are identified to bring to the fore: - The substantial costs to be met in their execution, construction, furnishing and maintenance, as well as staff recruitment and deployment.

- The need for a dispassionate re-evaluation of these projects.

- The necessity to prioritize bearing in mind impact assessment in the short term and early achievables.

- The need for effective integration among project management agents including UDECOTT, the Ministry of Health, Ministry of Finance and RHA bodies.
8.2 PHARMACEUTICALS/ACQUISITION The process of acquisition to the actual consumption of pharmaceuticals can be lengthy and cumbersome involving several steps/facets: We list hereunder several of the steps in the exercise not necessarily in chronological order and with a highlighting of some existing limitations.

This is an area that calls for further engagement with the intention of promoting cohesion and refinement of the processes and ultimately improving the availability of product to the patient.
The following need to be addressed: 1.

The formulary is a listing of the drugs approved for use in the country as distinct from a Ministry of Health formulary for public institutional use.

The expansive/ range of items on this formulary should be reviewed.

2.

There is a selection committee/ Ministry Drug Advisory Committee involved in the selection and discontinuance of pharmaceuticals with the influence and recommendations of prescribers at the institutions.
There are repeated reports of difficulties in convening these committees or meetings of the committee.

3.

The Tenders Committee- its composition and effectiveness need to be reassessed.

4.

Budgeting Process- the current national budgeting cycle usually results in funds being available for purchasing in the last quarter with orders for pharmaceuticals competing with Christmas orders and subject to almost inevitable delay in delivery and ensuing unavailability of the product.

40 5.
40 5.

The Chemistry, Food and Drugs Division is involved in the approval and registration of pharmaceuticals entering the national space.

It is reported that there is a listing of approved drugs which may influence this process.

This body has been in recent times without a director, a board, a pharmacist and a drug inspector overseeing narcotics and antibiotics.

6.
6.

The CMO is in various ways involved in the implementation and supervision of several of these steps to add to his already enormous and burdensome work load.

7.

Suppliers- there are the several suppliers engaged in the importation, marketing and merchandizing of pharmaceuticals.

8.

Procurement/C40- The NIPDEC is contracted to procure pharmaceuticals for the Ministry of Health.
That body is engaged in purchasing, storage/warehousing including inventory management and distribution to the various institutions.

Storage is conducted in a large warehousing facility named C40- its designation as a property owned by the Chaguaramas Development Authority.

There have been challenges:- the isolated location of the facility, the need for a satellite- facility, adequate fire protection; an inventory control system; urgent review of the terms and condition of staff (see vertical services).
9.

CDAP- The C40 facility also provides drugs to the private pharmacies under contract in the CDAP (Chronic Diseases Assistance Programme) programme.

10.

The C40 facility supplies the Hospital and Health Centre Dispensaries and Medical Stores (non-pharmaceuticals) divisions with supplies.

The inventory management on both sides is crucial to the availability of supplies.

11.

The hospitals are also engaged in individual purchasing usually on a supposedly emergency basis.
This is quite likely to incur a higher purchase price thereby negating the benefit of economies of scale through C40.

12.

The prescribing habits of medical personnel are often negatively influenced by - The notion that cheaper drugs are no good.

- That generics are not necessarily as effective.

- Simpler medication may not necessarily be effective as a first resort.

- The use or awareness of alternatives in the absence of preferred products.

13.
13.

Pharmacists are often involved in counting pills manually while devices can be utilized and the pharmacists may be able to allocate more time for patient counselling.

14.

The Pharmacy Council is engaged in the registration of pharmacists and the licensing of pharmacies.

The challenges of the Council in meeting these responsibilities may impact the overall pharmaceutical delivery/acquisition chain.

15.
15.

Patient compliance which is influenced by several factors including non-sourcing or non- use of acquired medication.

Then there is the question of abuse by patients engaging in doctor shopping, for example.

16.

A calculated education programme is required to assist patients in their use of expensive pharmaceuticals.

17.

Efficiencies must be built into all of these processes.
41 8.3 C40- REPORT The government’s storage and distribution of pharmaceuticals and non-pharmaceuticals is conducted at a warehouse facility under the umbrella of NIPDEC.

The government’s storage of pharmaceuticals and non-pharmaceuticals was moved from under dilapidated conditions at Long Circular Road to a readily available large state owned facility of the Chaguaramas Development Authority (CDA) at Chaguaramas, under the then newly established National Hospital Management Company (NHMC).
The management of the drug portfolio was subsequently transferred to NIPDEC which has provided project management facilities for the Ministry of Health in the area of bulk procurement, storage and distribution to the Ministry’s facilities.

The Ministry of Health, the client, is the major determinant in the quantum of drugs to be procured and the resources, human and financial, to be deployed in so doing.
The current facility owned by the CDA, leased and managed by NIPDEC is a large, formidably constructed facility of three floors together with an adjacent building.

The former building accommodating pharmaceuticals on the upper level (2nd) floor, lighter non pharmaceuticals on the first floor and the heavy non pharmaceuticals on the ground floor.

The adjacent building is utilized for bulk storage.

The pharmaceuticals are stored in an air conditioned environment.
The following challenges were identified: - The building is located on the north western peninsula, not ideal for distribution across the country.

- Adequate fire protection apparatus is not in place and requires capital outlay (fire suppression system).

- Pharmaceuticals are stored on the second floor (of necessity) and movement involves the use of a large elevator which is 75 years old and somewhat unreliable.

- The system for identification of items is inadequate and largely manually conducted.
- A capital budget has not been approved since 2012.

- The existing memorandum of understanding (MOU) between NIPDEC and the Ministry of Health lapsed in 2014.

- NIPDEC has been retained on a month to month basis for procurement of drugs with all the associated uncertainties.

- The budgetary cycle is completed in October at a time when the challenges of ordering and receipt of pharmaceuticals in the last quarter of the year at times result in shortages.
42 - The C40 has acquired the responsibility for distribution under the CDAP programme and is further constrained by the absence of an inventory control and warehouse management system.

- There is a cost factor for adequate shelving in the ground floor which houses heavy items.

- The capital expenditure items as identified fall within the remit of the Ministry of Health.
- There is, in addition, the matter of contract employment, lack of parity with other NIPDEC workers, no incentives, and the constraining difficulty with Ministry of Health approvals for hiring, manpower determination and capital projects.

Additionally, from C40’s prospective the client RHA’s present the following challenges: - Ordering by individual RHAs is not necessarily synchronized/ harmonized with C40 - but there is the consequent depletion of C40 budget in meeting RHA needs.
It is not unheard of for receiving units in the RHA to abruptly change their receiving schedules without informing the C40.

- C40 is concerned about the size of the national formulary of over 1,000 items.

- The CDAP formulary consists of 52 items.

Questions on CDAP delivery include: whether there is a significant counselling component, whether there is merit in 60 or 90 days prescriptions where patients are compliant and stable and whether there is a need for a review of the list of items.
- The disposal of items for 2012 to present still awaits the Board of Survey.

- Items pulled off the formulary appear not to be communicated to the respective institutions and users.

- C40 provides a “nil stock” list which may or may not be adequately circulated.

- The integration of stock at the major institutions and C40 still remains a challenge.

MATTERS MOVING FORWARD While the location of C40 is not ideal, the spacious, reasonably well maintained facility affords some degree of comfort.
In facilitating nationwide distribution San Fernando is to be encouraged and developed as a satellite centre with improvement in the communication between C40 and its clients.

It is accepted that the acquisition of the required information technology will greatly enhance service delivery.

The use of a liaison officer of NIPDEC to interact with and check supplies is to be revisited.

Capital outlay with respect to firefighting facility, Information Technology and elevators need to be revisited.
43 Consideration should be given to NIPDEC being re installed in its annual contract.

The staff issues and morale need to be addressed by a joint effort, the Ministry of Health and NIPDEC.
Other matters for consideration: - Review of the national formulary - Review of the CDAP formulary - Review of the efficacy of CDAP - Meetings with NIPDEC and Pharmacy regional coordinators should continue/resume - NIPDEC needs to install a public relations officer with a clear and specific mandate on delivering timely and specific information to the user on items unavailable, in short supply or underutilized.
Information bulletins should be produced regularly - - Progression to a scientific approach/data driven system which provides results and timely information: - On numbers to be procured - Assists in forecasting - Provides feedback on gaps and hoarding - Estimates of waste and unexplained loss (5 million dollars’ worth returned with short expiry dates) - Who is influencing quality?

- Who monitors access of vendors to RHA?

- What about efficacy of drugs?


8.4 EXTERNAL PATIENT PROGRAMME (EPP) The EPP, we understand, is geared to providing relief to patients for services that are unavailable, in short supply or overwhelmed in the public sector.

The latter category apparently includes patients who are on a waiting list for greater than three (3) months.
The range of services include: cataract surgery, vitreo-retinal surgery, joint replacements, angiograms, dialysis, CT scans, MRI scans, echocardiography, cardiac surgery and oncology.

While in principle there may be merit in the establishment of the programme, the necessary checks may not have been clearly instituted.

One would be cautious about abrupt cessation of a programme in the absence of a clearly established alternative and the potential risk of undue hardship to members of the public.
It is worthy of mention that: - The institutions seemed unaware of the outcomes of patients.

44 - The costs were not readily available.

- Importantly there seemed to be no built-in feedback mechanism to challenge the institutions in an organized response to the growing service demands.

In other words there is scope for unchecked and costly expansion of the programme.

A review and refinement are required of: - The patient groups involved.

- The criteria for selection.


- The body/ies entrusted with selecting such patients.

- Regular review with the RHA executives in the management of these numbers.

- Corrective action within the institutions where applicable.

8.5 CARDIAC SERVICES Cardiac (Heart) services are conducted on a relatively large scale at the EWMSC.

Indeed EWMSC is the premier public health institution for such services.
We concur with the forthright representation on these services made before the Committee, which is encapsulated here: - There is a massive demand/burden on the health sector where cardiovascular disease is concerned.

- 20-25 acute coronary syndrome patients are seen every day at the EWMSC.

- Whereas in 1995 the cardiac clinic accommodated 4,000 patients, it now sees 25,000 annually.
- 80% of the cardiac patients are driven by extremely poor primary care related to diabetes, hypertension, diet and exercise.

The cardiovascular services proposed in 2014 are as follows:- 1.

Non-invasive laboratory, providing: echocardiography (waiting time 2019), stress testing, transoesophageal echocardiogram, halter monitoring.

2.

Cardiac catheterization (Invasive) Laboratory providing services: pacemakers, coiling, endovascular stenting, ROM catheter, peripheral stenting.

3.
3.

Coronary Care unit- non-functional.

4.

Cardiac Clinics- with huge workload: 150 patients a day.

5.

Cardiac Wards- attempts are being made to establish such wards.

6.

Cardiac Surgery- there is a need to develop an in house capacity, in addition to the external capacity.

The recommendations are: 45 1.

EWMSC continue to be the major cardiology centre.

2.
2.

Support-Cardiology centres/capacity should be developed at San Fernando and Port of Spain (San Fernando would no doubt require a more advanced facility than Port of Spain).

3.

Accelerate the establishment /functionality of the coronary care unit.

4.
4.

Establish clearly designated cardiac wards - this could also mean de-emphasizing certain specialist services at EWMSC, which would simultaneously relieve the immense and unacceptable burden on the A&E department for monitoring acutely ill cardiac patients.

5.

Aggressive special staff recruitments in enhancing the functionality of the respective services including echocardiography.

6.

The facilitation of a strategy and programme for the development of an in house cardiac surgery programme.
8.6 EWMSC- SECONDARY OR TERTIARY INSTITUTION The EWMSC hospital currently operates as a secondary and tertiary public hospital having commenced activity as a University-based, semi-private hospital.

Much debate preceded its conversion.

Whatever the original intention, there has been discussion over the years whether the hospital(s) at EWMSC should be both secondary (general) and tertiary (specialists) or tertiary (specialists) alone.
The decision to open the facility to both secondary and tertiary is the correct decision given the population density, the service demand, as well as the strategic location of the institutions.

Additionally the question has arisen whether the hospital should remain a public hospital or be the exclusive domain of the University.
For twenty years prior to the existence of the EWMSC, the University produced a decent product graduate out of the Port of Spain General Hospital, operating as a joint-occupant of a public hospital.

There is hardly any reason why it cannot continue to produce a quality product as a joint occupant of a public hospital.

Indeed there is much to commend the joint occupancy where students get a taste of the real world.
Additionally, though less importantly, the several schools on the premises are likely to be better served by a general hospital.

Moreover there is much to commend the medical training experience across more than one hospital as is common practice in several places across the world.

Further, one is unsure whether the country can afford a strictly exclusive university hospital at the expense of the State.

The answer: EWMSC must remain a public hospital.


46 What is of some concern where utilization of the EWMSC hospital is concerned, that is the adult hospital, is the fact that the adult hospital is a moderately sized hospital with approximately 470 beds (POS- 547 beds, San Fernando- 750 beds).

As a result it can hardly be all things to all men and while it may be contended that it is services that matter and not beds, it can hardly be disputed that the EWMSC faces challenges.
There is an undisputed mismatch between the several specialists and services with the bed availability at the institution.

The solution is not the creation of an exclusive specialist hospital but one clear solution is the de- emphasising of certain specialities at the institution.

A rudimentary service is retained while its emphasis of certain specialties at certain institutions is endorsed.
In summary,  The EWMSC should remain a public hospital accommodating both secondary and tertiary services with a rationalization of specialists across the public institutions.

 The efficiency of operations and the establishment of a healthy through-put is in the court of the senior medical staff of the institution as well as the administration.

There is need for all hands to be on deck.


In the meantime, the hoarding/ retention of the multiple patients in the A&E for several days in cramped and difficult conditions is a troubling occurrence.

This is a matter that calls for immediate and decisive action.

 Staff of all the medical disciplines and all of the medical and executive management must share in the responsibility of rectifying this situation promptly.
 Further, on the matter of the EWMSC, due consideration must be given to the likely accommodation of other institutions of learning in the public health sector facilities where necessary and appropriate: for the moment this includes UTT, USC and COSTAATT.

This is without diminishing in anyway the tremendous contribution that UWI has been making in the sphere of education of health care professionals and health education in general.
8.7 HOSPITAL RATIONALIZATION The current location of hospitals is largely a fait accompli.

Still, some attention needs to be given to the location or development of hospitals, even in hind-sight.

Firstly, the Committee is unclear of the rationale for a paediatric hospital at Couva in the face of the following: - A paediatric hospital at EWMSC (Mt Hope), 20 minutes away and which in its underutilization is partly occupied by the adult hospital.

Even then it is still not fully occupied.


47 - A paediatric department at San Fernando General Hospital, 15 minutes away.

This has been replaced by a brand new department.

- The Port of Spain General Hospital, in the capital city, does not have a paediatric department far more a paediatric hospital.

With respect to the adult hospital at Couva the following should be noted: - Adult hospital at SFGH with emergency department is 15 minutes away.
- Adult hospital at Mt Hope with emergency department is 20 minutes away.

- Couva District Health Facility with emergency facility located in Couva proper and of which only 10% of patients attending the District Health Facility belong to the A&E facility.

- Emergency Facility at Chaguanas.

- The recent expansion of the SFGH.

Facilities already built including the Couva Hospital will have to be utilized.

It is to what use, the extent and the urgency that fall to be determined.
All this is in the face of competing and even more pressing need within the spectrum of new projects for consideration.

In the overall scheme of things the geography and population distribution appear to support a small facility at Point Fortin which would also relieve San Fernando to some extent and perhaps further diluting the need for a Couva facility.

The nature of a facility at Arima The borough of Arima clearly needs an adequate emergency facility.
The nature and extent of the hospital facility ought to be influenced by: - EWMSC (Mt Hope) being 15 minutes away via the Priority Bus Route.

- Bed availability at EWMSC, this being the smallest in bed capacity of the three major hospitals and with doubtful room for expansion.

Sangre Grande Sangre Grande is expected to meet the needs of the entire eastern geographic half of the country across the area of St. Andrews/St.

David and Nariva/Ortoire/Mayaro.


Accessibility across geography supports the need for an emergency facility and indeed at minimum a basic hospital.

 The utilization of existing secondary and tertiary services speaks volumes for their continued existence.

48  Moreover, it is to be observed that Sangre Grande still has to source certain services  from the major hospitals and this is likely to continue.
It should be observed that a review of the availability of emergency facilities is complementary to the hospital review.

 Sangre Grande appears to be a priority item for rehabilitative work if a fit for purpose new facility cannot be afforded at this time.

Scarborough General Hospital The Scarborough General Hospital appears quite adequate apart from a likely impending challenge for surgical (and obs/gyn beds).
Adequate support emergency facilities on the eastern end and on the north side of Tobago are advisable.

In summary the following need early attention:  A new central block for POS with consideration for clinics, A&E and Pharmacy.

 A MRI for POSGH.

 A linear accelerator for St James Medical Complex.

 SFGH: to look at adjusting present occupancy to urgently re-house the maternity department.

 The steam generating facility at St Ann’s should be completed urgently.
 A suitable facility at Sangre Grande.

8.8 ONCOLOGY The treatment of cancer (oncology services) is provided across the country in varying degrees including surgical interventions.

However certain special services are limited in their availability to special institutions or departments.

Oncology services have been provided over several years at the St James Medical Complex.
The facility provides radiotherapy equipment, radiological equipment, chemotherapy, wards for short- stay and chemotherapy administration and pharmacy.

There are satellite units with varying capacities at Mt Hope, San Fernando, Sangre Grande and Tobago.

The radiotherapy equipment (cobalt machine) has been deemed obsolete for several years and for some unclear reasons the replacement with a linear accelerator has been stalled despite multiple exhortations.
In the meantime there is heavy reliance on the private sector in both north and south Trinidad for therapeutic support.

After a previous stillborn (failed) attempt an oncology centre is under 49 construction at the EWMSC.

This facility is in its early stage of construction and is likely to cost about 700 million dollars.

This is without beds and with a likely reliance on the EWMSC which is already limited in bed space.
It is our understanding that two, to be acquired, State owned linear accelerators for radiation therapy are to be installed at this facility.

We are concerned about the wisdom of directing large numbers of patients across country into a single facility at EWMSC, notwithstanding its seeming favourable location at the Mt Hope intersection of the east and west major highways.
We have alluded elsewhere to the numerous facilities now bundled into the EWMSC with related challenges to access for patients across the country.

The question is why not install a linear accelerator at St James Medical Complex to complete a facility which has provided yeoman services and can serve a substantial population in the northern and western part of the country.

And this is even more advisable given the challenges that confront the completion of the facility at EWMSC.
Additionally, the nature and extent of the facility in south Trinidad would be assessed in that context.

The satellite facilities at Sangre Grande and Tobago are to be supported and enhanced in the continuing contribution to the service.

One area that remains to be considered is the emergence of breast and gynaecology units at St James Medical Complex.
The conduct of a surgical service in isolation from other patient disciplines at this facility should be re-evaluated, not omitting the administrative challenges and interpersonal conflicts that bedevil that service.

It is instructive that the current oncology service is one element of the vertical services which has been largely administered by the NWRHA with the appropriate contributions of the other regions.
This is an example where the service delivery of the vertical service can be effectively conducted by the RHAs and provides an opportunity when one looks at other vertical services and the resolution of their respective issues.

Or is it that one contemplates a delivery arm at the Ministry of Health for all vertical services.

That may indeed be the greater challenge.


What remains an issue is the harmonization in the EPP at the Ministry of Health with the RHAs in the implementation of the oncology programme.

Notwithstanding all of the above the oncology centre promises to be a state of the art high quality facility which can enhance oncology care by major leaps.

Its realization is the challenge.


50 8.9 MENTAL HEALTH/PSYCHIATRY The public institutional mental health service is anchored in the St Ann’s Psychiatry Hospital and satellite support institutions and community services.

The psychiatry hospital at St Ann’s is accommodated on a fairly expansive estate and comprises large buildings of apparently formidable construction.

On the face of it these buildings appear to have many more years of function in them.
Refurbishment appears to be on-going, if a bit sluggish at times, and it may be reasonable to say that much physical improvement of the facility has taken place and should continue.

Additionally the expanse of land and the location ought to provide a favourable outdoor environment for several of these long-stay patients.
While much has been said about the decanting of St Ann’s, it is to be observed that there remains a large population of (850) in-patients at the St Ann’s hospital and this is likely to be so for some considerable time.

Efforts therefore should be geared towards the enhancement of the facility incrementally.

This is not to suggest that decanting and community relocation of patients must not be an on-going process but there will be new patients coming on board.
As such the contributions in the various regions in the decanting process should be reignited.

The Arima Rehabilitation Centre as well as satellite units needs to be given due consideration.

Here again we see a vertical service, psychiatry, being predominantly administered by a region, the NWRHA on behalf of the Ministry of Health with a significant measure of success.
A matter of some disquiet is the recent allocation of one of the completely refurbished wards at the EWMSC for psychiatry patients where there is an overwhelming need for acute beds at that institution.

A bit of history will help.

Previously an acute psychiatry care facility, a model facility, existed at the Port of Spain General Hospital.
This facility provided appropriate wards, and specialist staff including psychiatrists, psychiatry social worker, occupational therapist, psychiatry nurses and all the supports of the adjacent hospital.

That unit was abandoned and subsequent attempts at re- establishing a unit at Port of Spain have been unproductive.
The question is if an inpatient acute care facility is to be re-established why not at the Port of Spain General and in synchrony with the St Ann’s Hospital already in POS and in proximity and with compatible administration (a further consideration in the allocation of specialities).

Moreover even if a psychiatry ward is needed at NCRHA, why not at the Caura Hospital which may not be as challenged for accommodation?
We need to be careful about possible selective specialist service installation against the logic of methodical service development and location.

In summary, 51  The psychiatry hospital needs to be retained  Satellite services properly established or is it re-established and the number of psychiatry beds at Mt Hope needs to be reviewed.
The community rehabilitation and community mental health programme is supported and needs to be further emphasised with the relevant psychiatric social workers and other facilities and staff.

8.10 UWI FACILITY The UWI has been in the business of producing medical graduates and allied professionals.

This has been conducted in a joint operation with the government wherein the University occupies State facilities in meeting its teaching and research programme.
In this regard, the University occupies premises at Mt Hope in the medical school, school of nursing, school of pharmacy, dental school, vet school, administrative block and enjoys simultaneous accommodation at the various hospitals, adult, paediatrics and maternity as well as Port of Spain and San Fernando.

It is not known that the University meets a cost for accommodation.
Correspondingly the cost for expansion of such accommodation is to be met by the RHAs and by extension the State irrespective of whatever the procurement process.

And it is understood, the University staff must provide service in return for the generous use of the facility for conducting teaching and research in what one hopes is a continued mutually beneficial arrangement.

It is debatable whether the service provided is equivalent to the level of facilities provided.
Whether that is so or not it has been agreed that the RHAs (the State) will meet the obligations of providing facilities.
It is in this context that the provision of two floors at San Fernando General Hospital for the expansion and/or duplication of the medical faculty needs to be given careful consideration not forgetting the unclear need for increased production of medical graduates locally and the further costs for students given the extent to which the State meets the cost for tertiary education in general.
Included in these considerations would be the direction of development of the Couva Hospital and the large teaching facility that forms part of that complex.

Additionally, in considering the expansion of the University, regard must be had for the anticipated accommodation of other institutions of learning including, but not limited to UTT, USC, COSTAATT which may bring added benefit to the health portfolio.
52 8.11 UWI PERSONNEL In the engagement of UWI personnel at the health institutions, the following are re-emphasized (stated or restated): - The RHAs are required to provide the physical and human resources to complement UWI staff.

In support, the physical premises are to be kept in good repair by the RHAs.

- - The University staff in the clinical arena are expected to provide services similar to the RHA staff.
- University staff must have prior approval of the RHAs before UWI staff are engaged at the respective hospitals.

- The RHA must be satisfied that it can provide support staff, clinic space, bed space, operating time and other resources to accommodate such officers and staff; that there is a compelling need for such service being given priority at that institution; and that the member is adequately equipped to meet the service needs in the institution.
- The level of appointment must be consistent/ compatible with the conditions applicable to the RHA staff.

8.12 WHITHER RHA: DO WE RETAIN THE RHA STRUCTURE The question that confronts us is having identified some of the major manifest shortcomings of the RHAs, how do we proceed.

The options: 1.

Disband the RHAs and revert to the previous Ministry of Health arrangements.

2.

Proceed to rectify some of these major shortcomings.

3.

Fund another body/mechanism to manage State sector health care.
The transition from Ministry of Health to RHA after 22 years (1994-2016) has not been an easy ride and would certainly make anyone loathe to want to embark on an entirely new journey- thus discouraging the approach in 3.

With respect to item 1, we have already set well out to sea, more than half way across the journey as it were.

Do we reverse direction and head back to base, already recognizing that there were problems we sought to escape when we set sail?
Additionally, the likely absorption of officers into the public service, age limit and all, plus seniority considerations among others would be an un- ending nightmare.

It would appear that having identified the major problems which are by no means insurmountable, we may proceed to treat with them decisively, thereby regarding option 2 advisable at this time.
53 It should also be admitted that the RHA system has permitted some measure of administrative proximity and intensity to delivery sites and some degree of flexibility in managing affairs which would otherwise not obtain in the previous ministerial arrangements.

The task therefore of streamlining, enhancing the efficiency and effectiveness of the current RHAs is the matter before us and would appear to be the preferred option.
8.13 WHITHER RHA: IF YES DO WE ALTER/REDUCE THE NUMBER OF RHAs The geographical separation of Tobago supports the need for a separate RHA.

The following factors militate against the short term merger/condensation of the 4 RHAs in Trinidad: - The present/external pressing need for streamlining of functions within existing RHAs including the administrative arm.
- The wide expanse of territorial cover, as in the case of Eastern RHA covering almost the entire eastern half of Trinidad including the counties of St. Andrew/St.

David and Ortoire/ Mayaro.

- Population densities of the North West including St. George West and Central and North Central including St. George East and Caroni North.

- The mixture of geography and population density in the instance of the SWRHA- covering St. Patrick, Nariva, and Caroni South.
- The expanding role of some of these authorities: o SWRHA- expanded SFGH, Point Fortin and possibly Couva, o NCRHA- Arima Hospital, Oncology Centre, Dialysis, Maternity Outpatients Department o NWRHA- new POSGH Block, St James Medical Complex continued rationalization of St Ann’s and psychiatry services.

o Sangre Grande- the development of a new facility, the integration of far flung services in remote areas.
This does not preclude the need for concurrent assessment/determination of areas where there may be mergers, synergies or application of economies of scale and does not discredit the need to re- visit the matter in the future.

Areas for consideration may include training requirements and industrial relations.

A dramatic merger of some of these regions is more likely to precipitate chaos.
We already have at least one previous example of a failed merger of the North West and North Central regions to remind us of the pitfalls.

54 8.14 HEALTH NEWS/EDUCATION Is there adequate health education or information?

: The health story has been communicated to a limited extent, informally by the providers at first contact and more formally by the administrative arms including the Health Education Division of the Ministry of Health considered under the vertical services.
The Health Education Division has been involved in the area of school health and in the area of corporate communications both with enormous challenges.

What is abundantly clear is the need for a robust revelation of the health story.

Conveniently, the good health story may be confronted on several fronts - School health.

- Corporate communications as above, as well as - Health information.

- Health promotion.

- Health news.

- Customer relations.

- First-line providers/counsellors: e.g.


Dietitians, Pharmacists, Social Workers, Nurses, Doctors.

All these areas of proposed activity are highlighted even to the extent that they overlap and there must be a collaborative effort in informing and educating the public.
One recommendation which is needed for immediate implementation and which the Committee is confident can have a substantial impact is the institution of a 15 minute (or less) daily programme on national radio or television or both, as well as other media avenues e.g.

social media in which bullet information is delivered.

1.

The health news segment informing, for example, on services which may not be available e.g.
clinic cancellations, unavailable pharmaceuticals, operating theatre cancellations, radiological equipment failure 2.

Health information segment- on medical conditions and their prevention/management 3.

Health promotion segment- including lifestyle, safety habits at occupation sites and on the roadways.
Add to the above the enhanced effort in the promotion of health information and education at the level of the first contact, including customer relations affairs, Dietitians, Pharmacists, Social Workers, Doctors, Nurses.

Of course all staff are included in the health promotion/education campaign.
55 Several of the issues that are ripe for exposure in the health education programme are: Health News- immunization, health centre schedules, clinic changes, service interruptions, (un)availability of pharmaceuticals, prolonged waiting times.
Health Education: vectors- mosquitoes, rodents, influenza, hygiene including waste disposal, water courses, matters affecting the elderly, physically challenged, accidents, ingestion of sharp objects, fire, lifting of heavy objects, abuse of medicine, personal responsibility, alcohol, smoking, sugars, life style diseases, first aid, ambulances, returns to institutions, RHA contact, HIV, STD, bed availability, Customer Relations Desk.
Patients need to be educated on the use and abuse of very expensive medications and medical appliances.

8.15 NURSING Do we have adequate numbers of nurses and are they delivering to the expected standards?

We have to look at some of the challenges that nurses undergo in the workplace: - As a group they are subject to a level of discipline that prevents them from departing their stations until replacements arrive.

This at time results in nurses doing continuous shifts in trying circumstances.
- The sometimes overwhelming deficient nurse patient ratios.

- Unavailability of hostel rooms and canteen.

- The safety and security risks associated with evening and late night shifts.

- Difficulties of obtaining allowances on time.

 At the same time our nurses need now collectively to confront the growing reputation for disrespect to members of the public.

 Customer relations programmes are mandatory.


 Nursing supervisors, customer relations and quality officers need to walk the floor including at visiting hours.

Staff discourtesy must be dealt with decisively.

In the case of nursing students sitting at desks rather than being actively involved in patient management, they need to be reminded that the ward is meant for practicum not a classroom.
There is need to revisit the areas of specialist training for nurses, including: Midwifery, ICU, Neonatology and District Health Visitors (DHVs).

The acute shortage of DHVs must be a priority due to its likely major negative impact on the primary care sector.

This shortage is compounded by the retirement age profile of incumbents.
56 We also have to look at: - The proliferation of categories of nurses, including nurse interns, with a rationalization of the functionality of each group and the relationship of one to the other.

- Promotion to the position of Chief Nursing Officer (CNO), a public service post now stymied by the stream of RHA appointees.

There has been no CNO for over a year and a half.


- The training programmes, the responsible training agents and the nature of devolution to COSTAAT, UWI School, Ministry of Health programmes.

- Promotional Opportunities under the RHAs.

- Appropriate attire for the work place.

- Managed but considerate visiting hours for relatives.

- In respect of ward activities, the senior nurses need to lead the effort in restoring well- coordinated teaching ward rounds in collaboration with the medical staff.
- Travelling Officer Facility for DHVs needs to be reconsidered with a view to reinstatement.

These officers need to travel on a daily basis in the performance of their duties.

8.16 TRANSFERABILITY OF PERSONNEL Under the Ministry of Health within the public service, members of staff could be transferred from one institution to another to meet service obligations.

The compartmentalized RHAs now limit such action.


In circumventing this hurdle, the following observations are made: There should be no need for the special creation of posts called teaching posts in order to facilitate transfer of persons.
The transferability of persons is advisable in meeting firstly the services (needs) obligations of the State/the RHAs but has the added benefit of providing learning opportunities for those who may avail themselves, including but not-exclusive to those engaged in post graduate study programmes.

The permanent transfer however can prove difficult where one has to contend with seniority, compensation and demand considerations.
But with sufficient administrative will and cooperation, it should be quite possible to temporarily transfer individuals within the current arrangement as has been done before.

It is important that the applicant sees this as a grant and not a right available on demand and equally there must be cooperation in meeting service needs as required.

The University post-graduate program may also be well served by these considerations/arrangements.
Accessibility to service would be better served by such transfers.

57 8.17 TRANSFER OF SERVICES Certain specialist services are available in some institutions (larger) and not necessarily in others.

Universal access requires that such services be made readily available to those requiring it.

As such, individual institutions are expected to make appropriate provision for the respective patient portfolios thereby not forcing patients by default to seek attention at alternative institutions.
This is not to deny the fact that patients are entitled to seek attention at any institution.

However, some patients must necessarily seek certain specialist services at institutions where these services are available and they must be willingly accepted and with ample provisions made.

These include, but are not exclusive to patients from Sangre Grande and Tobago, for example.

Indeed it may be a good idea for particular desks to be available for managing these services from institution to institution.
This would be a necessary arrangement moreso where specialties are emphasized in one RHA and de-emphasised in another.

8.18 AMBULANCE SERVICES The ambulance services remain crucial to the ready, rapid and safe transport of patients in need.

From time to time a public finger is aimed at this service.

The private provider, GMRTT, of the major ambulance services has not yet been met given time constraints.
Further to this, the hospital based ambulance service has not been fully explored particularly with regard to the areas of responsibility.

Despite the fact that this area remains largely unexplored by the Committee, lingering concerns, whether legitimate or not speak to the availability of ambulances and their timely intervention.
And while a meeting of the minds is still to be accomplished the following are the observations made:  Patients transported to the A&E departments must be promptly removed from the ambulance trolleys thereby allowing the ambulance to be readily released.

There is hardly any circumstance under which ambulance trolley must be detained.

 Members of the public need to be educated on the proper use of ambulances which should not be engaged as common transit vehicles.
 Concerns which staff have about their safety and protection while travelling in ambulances should be pursued.

58 8.19 STAFF RECRUITMENT (SPECIAL AREAS) Almost from time immemorial claims of inadequate staff are made at the various health institutions.

A dispassionate look would suggest that there is often much variability in the quantum and quality needed versus demanded.

The reconciliation is a work in progress.


However, among the areas of staff recruitment that need to be addressed, the following call for urgent special attention:  Physiotherapists  Medical Social Workers/Psychiatric Social Workers  Biomedical technicians  Occupational therapists  Speech therapists  Psychologists  Audiologists  Specialist Nurses including Midwives, neonatal and ICU  Medical specialists- Pathologists, Microbiologists, Neurosurgeons, Neurologists, Nephrologists, Haematologists.
The second group we understand is being lured by more lucrative/beneficial offers in other ministries and the third group by the private sector.

Understandably accelerated training and active recruitment including short term is necessary.
8.20 SPECIALIST MEDICAL OFFICER/CONSULTANT APPOINTMENTS Specialist Medical Officers (SMO) otherwise referred to as Consultants are the leading Medical officers charged with the responsibility of managing specialist services, conducting certain procedures and managing delicate patient interventions.
Previously within the Ministry of Health, one became eligible for appointment as Specialist Medical officer (SMO)/Consultant with a recognized post graduate qualification, 5 years in the specialty and 8 years qualified, subject of course to available vacancies.

This is a promotional post and it is at the determination of the employer; no one else.

It is not to be confused with a Specialist Certificate, (recognised post-graduate qualification) which is determined by the Medical Board.
To repeat, a recognised post graduate qualification (specialist qualification), is determined by the Medical Board of Trinidad and Tobago (MBTT), not the appointment of Consultant/Specialist.

59 It is the Ministry of Health as employer and custodian of the public interest that determines what level of qualification and experience it requires for its services, subject to necessary licensing requirements.
After all, it is not a matter strictly of certification; it is also a matter of experience and managing large patient loads, a body of staff and meeting several managerial institutional and infrastructural requirements.

Similarly, the position of Registrar required 5 years post graduate experience, 3 in the specialty and a relevant post-graduate qualification (certificate) or corresponding period of experience and training; again, subject to the availability of posts.
With the evolution of the RHAs, there appears to have been a dilution and indeed a profound misunderstanding of requirements, with individuals being appointed as SMO with less experience.

In fact there has been inconsistency across RHAs with the position of SMO being used as a bargaining chip to attract employees and such positions offered in violation of the pre-existing standards and even at the whim of officials within the RHAs.
Indeed we now have the situation of individuals demanding SMO/Consultant appointments on passing their post-graduate examinations.

The reduction in the requirements for SMO is not supported.

Further, the availability of vacancies should be emphasised.
The employment or promotion of a SMO to a newly established position implies the expansion or establishment of a specialist service which requires support staff, clinic and sometimes office space, bed space, operating theatre time, logistical and operational fit and more.

Added to which is the likely existing patient demand.

It is not unheard of that because of inability of the RHAs to deliver these supports some Specialists are frustrated in not having the wherewithal to perform their duties.
It is also a source of contention among the very Specialists that there are some who have little to do, obtain similar salaries and are free to trudge off to their private practices.

Accordingly it cannot be under emphasised.

 There must be standardization of appointment of SMO across regions  The qualifications for such positions, at the discretion of the employers and subject to vacancies must be at minimum: 8 years qualified, 5 years in the speciality, recognized post graduate qualifications.
One does not go to the MBTT to determine whether an officer should be employed as SMO/Consultant; that is for the determination of the employer.
One goes to the MBTT to establish whether an officer has a registrable basic or specialist- qualification (certificate)  There must be adequate justification for such service, especially if new or expanded 60  Adequate provision of accommodation, support facilities and services, without necessarily duplicating all support staff in each instance  Clear arrangements for continuity of service e.g.

24 hour coverage, without an associated  ballooning of support staff.
In all this the RHA needs to be alive to first constructing a service rather than the predominant advance of an individual.

 What needs to be done now is a review of all SMO positions and their effectiveness in service delivery.
8.21 DENTAL SERVICES Dental Services are currently provided both by the Ministry of Health and RHA staff with some lack of clarity in roles, responsibilities and reporting relationships With respect to the dental services, the following matters are advanced for further consideration:  The regularization of the employment of dentists who now straddle RHA and MOH as has been seen in other situations.

 The supervision of such officers.

 The terms and conditions of engagement.


 The effects on promotional advancement to the senior dental surgeon position.

 The territorial and operational challenges that confront University and RHA staff at EWMSC.

 A proposal of the University for development of a primary dental health programme.

The latter would need the consultation with the RHAs, the Ministry of Health and the dental and nursing council among others.
8.22 INDIVIDUAL RESPONSIBILITY Much of this exercise of review of the health sector would come to little unless individuals take responsibility for themselves, their families and communities, supported where necessary by public education programs - Expectant mothers need to present themselves early and repeatedly to their ante-natal - - - clinics and pay heed to advice; they also need to attend post-natal clinics after.
Individuals need to attend their chronic diseases clinics, comply with their prescribed medication.

Individuals should familiarize themselves with the locations of Health Centres and other facilities in their areas.

Individuals should also familiarize themselves with the schedule of services in their respective Health Centres.

61 Individual responsibility extends to managed consumption of alcohol and cigarettes.

- - Avoidance of speeding on the roads.


- Dietary management in the selection and quantity of consumption.

- Avoidance of over eating and weight control.

- Management of the environment -Upkeep and maintenance of surroundings.

-Waste disposal.

-Avoidance of contamination or disruption of water courses.

-Noise pollution control.

- At construction sites -Control vectors- flies, mosquitoes, rodents, other pests.
- Honour clinic appointments including at Carnival, Easter and Christmas time - Observe safety rules in -Places of work and study.

-Food preparation.

A non-examinable hygiene/health science segment in primary schools perhaps weekly, fortnightly or monthly is worthy of consideration.

Make reasonable use of health care institutions.

Consistent use of institutions- rather than attending several.

Unnecessarily hoarding or discarding medication.


Unfortunately the matter of individual responsibility for self and family is one which we seem reluctant to broach.

8.23 ACCESS/FINANCING MODEL The discourse on availability of affordable health care together with the selection of a suitable financing model has been prolonged and protracted.

The respective roles of the private and public sectors in such delivery are also matters for continuous, vigorous debate and analysis.
We have not yet engaged the private sector in these deliberations neither has this Committee been tasked with those matters which are involved and require vigorous, analytical attention.

Nor does the Committee, as a whole claim the wherewithal to resolve these matters.

Suffice it to say at this time, let the dialogue continue.
8.24 ALLIED PROFESSIONALS The Allied Professionals belong to several groups including Pharmacists, Radiologists, Physiotherapists, Dieticians, Social Workers, Occupational Therapists.

62 - The allied professionals need to be encouraged to step forward and be more actively engaged in the management process at their respective institutions.

- Attention is to be given to areas of severe shortage of staff including physiotherapists and medical social workers.
- The management reporting relationships need to be established with greater certainty including a clear link to the Medical Director (not Executive Medical Director) in the discharge of the health care product.

8.25 PROFESSIONAL BODIES In our encounters, almost all of the professional bodies speak to legislative amendments to improve their respective functions whether in the area of registration, licensing, and disciplinary process or in advancing areas of activity and population outreach.
The legislative agenda clearly is a long term projection and has to be adequately analysed and ventilated.

In this respect the bodies should be expected to play major roles in engaging and convincing their memberships in initiating the process and bringing meaningful and clearly articulated and harmonious positions before the political directorate.
That notwithstanding, the professional bodies in the absence of all the necessary apparent legislative clout can still influence the sector by making polite but vigorous enquiries of their members and calling on them to account.

8.26 REPRESENTATIVE BODIES The representative bodies with whom the Committee interacted, including trade unions were very informative and constructive in their presentations before the Committee.
Major contributions were made in the area of service delivery, manpower planning and development, terms and conditions of engagement, including compensation and appointment and promotion as well as the crucial areas of supplies management including procurement deficiencies.

The substance of many of their contributions is dovetailed into the relevant section of the report.

The continued engagement of these bodies is to be recommended.
8.27 NGOs There are several non-government organisations (NGOs) that operate within the health sector.

Engagement of the NGOs has not been as productive as initially anticipated.

This is not to deny the enormous contributions of several of those bodies in the past nor the rich potential for enhancing the growth and development of the health sector.

63 What is apparent, at this time, is the NGOs have established relationships with the Ministry of Health from which some derive subvention benefits.
However, there has not been a corresponding evolution of the relationship with the RHAs.

Simply put, there is need for the enhancement of relationship between the RHAs and the NGOs, the latter being very much eyes and ears, strong support networks and major liaison bodies with the general public and, most definitely, very important and largely cost-effective tools in health care delivery.
8.28 INTERESTED PERSONS A number of individuals made informative, impressive and noteworthy contributions before the Committee in areas of health care delivery, institution management, nursing, primary health, industry, supplies dentistry, sexually management, oncology and optometry.

transmitted diseases (STDs), the pharmaceutical Their highly appreciated contributions have recommendations made.
influenced the body of conclusions and 8.29 COUVA HOSPITAL The Committee is very much aware of the fact that there is a newly built facility at Couva- The Couva Hospital includes a children’s hospital, an adult hospital and a very large teaching facility.

It is unclear what the rationale for this facility is or to what use it was expected to be put.

At various times it has been proposed/ proffered; either during or since construction:  As a facility for health tourism.
 A facility for a foreign medical school.

 A private/public hospital partnership.

 An expansion of the public health facilities under SWRHA.

 A facility in part or whole for the UWI.

 A burns facility.

 A teaching facility for allied sciences.

 Private hospital.

Some positions: It is a new spacious facility.

  There are two large A&E departments both for paediatrics and adults.

 Significant pieces of radiological equipment are on site.
Some challenges: 64  The facility is not fully equipped and may need another 70-100 million dollars to do so.

 There are entry and exit challenges to the highway with entry now via Gran Couva along a serpentine roadway, poorly lit and very sparsely populated thereby posing likely transportation and security problems.

 Unevenness on the ground floor with potential for accidental injury/fall of occupants.

In determining a way forward the following are to be considered.
We are unaware of the justification for a hospital facility of that nature at that location and wait to be guided in that respect.

That being said, it is the unpleasant task to seek to rationalize the subsequent use.

But the facility is a fact of life and has to be utilized in some way.

The following issues will impact the decision:  New projects are discussed collectively in this exercise with priority concerns mentioned elsewhere in the report.
 Rationalization of services, including paediatrics is also discussed in this report.

 The University and the limits in its expansion are also discussed.

 The likely occupants of a foreign medical school and the absorption of its graduates.

 Managing the potential social divide in either a health tourism facility or a public/private partnership.

 The even further expansion of the UWI in addition to San Fernando.
 A burns facility in Trinidad and Tobago has been extensively discussed previously and can only be of limited extent; is not necessarily housed next to Point Lisas Industrial estate and should preferably be located in an institution with a wide range of support services and facilities.

 Whether the teaching facility can function as a standalone facility for allied services and within whose remit.

 The SFGH is already at 750 beds and has a new facility, its third.
Whether a further expansion of that facility is desirable, cost effective or a priority for that matter.

 Whether a partial utilization of the facility will be tied to a large scale implementation of certain services and supports e.g.

electricity generation, air conditioning, waste water disposal, laundry, kitchens and the cost effectiveness of such.

 Other suggestions including the private lease to interested bodies for various health projects- e.g.
rehabilitation centre, adjunct to foreign institution, specialist hospital.

 The clientele of the Couva District Health Facility includes only about 10% of A&E patients.

This hardly supports the need for a new A&E department, if anything an adjacent expansion to meet health centre needs is what is required.

Utilization of an emergency facility for non-emergency patients is questionable.
65  A phased introduction of services starting with radiology followed by certain clinics, and Accident and Emergency.

This should assist in clearing the long backlog for radiology services.

 The transfer of some services including women’s health from San Fernando  The transfer of Paediatrics and some other services from San Fernando with a reclaiming of the Chancery Lane Facility.
The building is not entirely fit for hospital purpose, elevators are inadequate in size, slow in transit, and evacuation may prove a major challenge in an emergency.

This may be counterbalanced by the likely prohibitive costs in such a reversion.

 A strongly expressed view by a member of the Committee is seen below.

The member has suggested that this facility be commissioned in the following manner: - Phase One That the CAT Scan/MRI/Ultrasound equipment be commissioned as the first phase.
The waiting times at the various institutions are unacceptable, such waiting times to be shared between the inpatients and the outpatients.

The imaging services can be made available to the outpatients throughout the country thereby leaving the hospital facilities for the inpatients, which will allow for earlier discharge.

- Phase Two The second phase should be the opening of the Outpatients Department.
In particular, certain 'special' clinics can be offered vis-à-vis: Adolescent (paediatric) clinics, Child Psychology, 'Holistic' Diabetes services etc.

These clinics are not offered elsewhere and would add immeasurably to the upliftment of the health services of Trinidad and Tobago.

- Phase Three The institution of ‘Same Day Surgery' for the less complicated surgical procedures.
Registrars with about 3 years’ experience should be well suited to undertake this function - Phase Four (final) The opening of the In-patient Services.

Consideration to be given to the transfer of the San Fernando Paediatric service and the Maternity service.

These services are those that require the least dependency/support on other specialties.

It will also allow for a modern day Neonatal Unit and the opportunity to provide a Maternity Service that would be reflective of international standards.
The Couva Hospital should be viewed as an extension of the SFGH rather than an independent hospital.

The management services from SFGH can be utilized in an organized manner rather than the separate wholesale recruitment for the institution.

Conclusion: 66 The Committee is not as yet seized of all the facts, nor has been in a position to analyse all of the suggestions made in the actual utilization of this facility.
This comment will, it is hoped, help to advance the discourse and the eventual determination.

What is fervently hoped is that the nationwide priority items are not submerged in the anxiety and pressure to institute a facility with clear limits to its fitness for purpose.
8.30 BUDGETARY ALLOCATION The MoH budget amounts to $6.475B (this excludes the TRHA) The estimated 2015-2016 budgets for the regions are: SWRHA: approximately $936M - San Fernando General Hospital - Point Fortin District Hospital - 34 Health Centres NCRHA: approximately $926M - Eric Williams Medical Sciences Complex - 16 Health Centres NWRHA: approximately $907M - Port of Spain General Hospital - St Ann’s Hospital - St James Medical Complex - 17 Health Centres ERHA: approximately $420M - Sangre Grande Hospital - 15 Health Centres TRHA: approximately $500M - Scarborough General Hospital - 17 Health Centres In 2015-2016, there was a significant increase in expenditure for personnel emoluments as a result of implementation of new remuneration for certain staff following the recent completion of wage negotiations.
Over 75% of the Allocations go to Personnel emoluments and "Goods and Services".

67 Only a small percentage goes towards the RHA for Developmental Projects and Medical Equipment purchase.

It follows that the effective management of those budgets will necessarily entail great attention to manpower utilization and the emoluments utilized thereby.

Similarly greater attention to the procurement and utilization of goods and services is required.
Of importance is also the delivery of services and the staff and the beds so utilized.

An important element is medical staff to beds to patient turnover in wards, clinics, surgical services, accident and emergency as well as investigative procedures so required; and the support services of laboratory, radiology, pharmaceuticals among others Unfortunately, some of the information has been slow in coming from some places.
It is our understanding that the reduced records departments of some institutions are largely responsible.

This exercise is the next for a committee of similar nature to this one.

8.31 DATA While all of the secondary institutions could provide data on annual admissions, the altered bed status over the corresponding period in at least two institutions did not allow for meaningful comparison.
Likewise the disaggregation of beds into specialties was unclear in one large institution thereby further limiting any meaningful comparison into speciality bed occupation with designated medical staff and specialists as well as designated nursing staff.

The data for clinics was just not available.

Again, meaningful comparisons of the demands and output per speciality related to staff could not be meaningfully undertaken.
The average length of bed occupancy in one large institution appeared to be well above the average length for the other institutions.

The overall numbers of admissions appear to be declining, but we cannot take comfort in that fact since there may be under-reporting in one major institution and we may in fact be witnessing a shift in patient utilization and not a real decline.

For the above reasons we hesitate to publish numbers obtained at the risk of likely misrepresentation.
We may certainly conclude that this is an area that requires early further attention.

It has been represented that several of the medical records (data collection) staff for various reasons, are no longer available at the institutions.

This also calls for early attention.

With respect to financial data, more time is required to analyse the budgets requested as against the budgets approved as against actual expenditure.
68 Additionally, the data per RHA is not necessarily disaggregated as per institution or health centre group.

The full disaggregation may not necessarily be achievable at this time given the cross utilization of some staff and some services within and across regions.

However there is still the need to look at costs to patient loads to staff numbers.
This is another area that calls for early attention and also speaks to the need for some standardization in data reporting, not only in respect of Ministry of Health budgeting but also in respect of costs for service delivery.

8.32 REGULATING HEALTH CARE QUALITY The Quality Directorate of the Ministry of Health has been dismantled.

We are unclear of the exact reasons for the decision.
The Committee saw first-hand the impact of the collapse of the organisational structures and systems for improving and maintaining quality both at Ministry and RHA levels.

We are satisfied that there is need for organisational structures and systems to address quality issues however, the Committee suggests a quick re-evaluation to determine what has been achieved and chart the way forward.
The Quality Programme as envisaged under the Health Sector Reform Programme had two parts, i) Part 1 or Continuous Quality Improvement (CQI) component included a management, sector- wide system to be driven by the leadership and involve all staff in the implementation of systems, standards and protocols to improve quality in their respective areas.
It also included a customer service strategy, and Monitoring and Evaluation (M&E) component in the form of a quality auditing system, clinical audit system and complaints review system.

ii) Part 2 or the Accountability/Regulatory component, included the development of new legislation for health services accreditation and modernisation of old legislation such as the Private Hospitals Act to create the legal framework to facilitate /support the quality improvement programme.
The Health Services Accreditation body would have become an autonomous body that would regulate health service quality for Trinidad and Tobago and beyond.

Inherent in an organisation’s ability to improve and maintain quality is its standard setting capacity and a coherent framework to support the programme’s accountability mechanisms.

During the review, the Committee saw evidence of standards and Standard Operating Procedures (SOPs) however most were due for review and update.
We were unable to ascertain the reasons for the current status.

Since the regulatory function of the Ministry of Health is part of its core responsibility in this decentralised system, the Committee agreed that the Ministry and RHAs must act swiftly to: 1.

Train/retrain staff in customer service best practices 69 2.

Strengthen the customer relations teams to once again provide real time onsite support for patients/clients 3.
Re- sensitize staff to continuous quality improvement In the medium term: 1. Review and update standards, protocols and standard operating procedures 2.

Address the need for legislation to provide the regulatory framework for quality improvement 3.

Provide the computer hardware and software to strengthen the data collection and analysis for real time decision making.

4.

Re-evaluate the policy and structures on quality to determine the way forward.
8.33 HUMAN RESOURCES Understandably, the concerns expressed by various individuals span the spectrum of the HR responsibility.

While one is unlikely to find an organization without disaffected individuals who feel aggrieved for a multitude of reasons including non-advancement, it is also true that the advancement of one necessarily leads to the non-advancement of another.

However, that being said, it is difficult to ignore the appeals of some individuals for a review of their own employment circumstances.
Previously in the Ministry of Health and the public service in general, there were bodies charged with discharging certain responsibilities-  The Office of the Director of Personnel Administration (DPA) was involved in the areas of recruitment, performance appraisal, promotion, transfers and discipline.

 The Office of the Chief Personnel Officer (CPO) through its divisions dealt with: training (CTU), classification and compensation, industrial relations.
In both the offices of the DPA and the CPO very senior officers with extensive public service and administrative experience were the accounting officers and these officers were largely constrained against the arbitrary exercise of authority since there was an overriding public service commission.

One is not suggesting a replication of some of the cumbersome elements of these public service bodies.
One certainly wants greater flexibility and responsiveness than obtained in the public service but this must be supported by the relevant checks and balances in managing human over exuberance or abuse.

In short, and without reinventing the wheel, there must be a relatively simple mechanism for addressing staff employment concerns especially at the level of the RHAs.

70 Pivotal to all of the above are: 1.

The organisational arrangements that exist to manage these portfolios.

2.
2.

The level of executive knowledge and experience available to effectively implement HR policy.

Recommendations There is need for:  Longer term HR planning.

 The effective functioning of HR committees within and across the RHAs.

 A level of consistency in application of HR policy across RHAs.

 The adjustment in the organisational charts to influence product delivery.

 Attention to performance management.

 Regular training programmes.

 The enhancement of HR/IR expertise.


  Effective employee relations strategy  Implementation of strategies to improve discipline at all levels.

Introduction of HR process- audits to ensure HR practices are properly implemented and practised by each RHA.

 Terms and conditions of employment within IR agreements should be aligned with service delivery objectives of the RHAs.

 Acute shortage of medical and nursing specialties to be addressed.

 Rationalizing the RHAs’ management structure.


71 8.34 AUDIT There has been a tradition within the MoH of conducting financial audits and boards of survey, even if not necessarily on a regular basis, but according to perceived need or upon request.

Process and service/management audits have ceased with the decommissioning of the Quality Division.

This Committee, having identified several areas in need of urgent remedial action, is of the firm view that aggressive implementation is crucial.
The resumption of the independent audit process is highly recommended.

The audit review process/follow up is necessary in the implementation of these and other recommendations.

Some of the matters to be subjected to such review and which come readily to mind are: 1.

Customer relations 2.

System for appointments 3.

Management of patient services 4.

Waiting times 5.

Procurement and supply chain management 6.

Floor supervision 7.

Roles of executives 8.

Expenditure 9.

Staff utilization 10.


Staff recruitment and promotion 8.35 LEGISLATIVE CHANGE Several of the challenges that confront the RHAs today, and indeed the MoH, have emerged in the stultified and somewhat erratic transfer of activity, personnel, and facilities from the MoH.

Several of the limitations can be addressed by cooperative arrangements and good will, or by administrative enterprise or even policy direction.
All of these approaches can be explored in the first instance in the ultimate delivery of a quality service to the population.

It is only if these attempts are unsuccessful or destined to fail that legislative clout will need to be utilized.
72 We are aware of the numerous and lengthy hurdles to be crossed in effecting legislative change, and even so, legislative or not, there are some matters that will still require cooperative and imaginative administrative goodwill, especially in areas of likely and inevitable dual reporting.

73 9.0 SUMMARY OF RECOMMENDATIONS There is need for:  Improved functional relationships of the various bodies that contribute to primary care delivery.
Resolving challenges in primary care relative to staffing, reporting, service delivery with guaranteed medical presence.

 Follow up clinics in health centres with guaranteed medical presence for hospital discharges.

This should help to reduce the burden on hospitals and support the primary care initiatives.

 Detailed attention to and monitoring of patient service delivery areas.

Details are provided in the report.


 Details of responsibilities for Senior Medical Officers, also provided  Major infrastructure needs of various hospitals/institutions   An advocate for streamlining of vertical services.

Utilization of the RHAs in staffing and Institutional Staffing: allied professionals, nursing, certain medical specialities.

other supports, Ministry of Health to determine policy.

 Review the executive structures of the RHAs- numbers and roles of executives.
Authority of the Medical Director.

Emphasis on product delivery.

 Development of synergies across RHAs.

 HR- Management.

 Financial Management.

 Data collection and utilization.

 Strengthening of the Office of the CMO: technical/medical support.

 Review of Ministry of Health to meet changed circumstances.

 Review and consolidation of pharmaceutical procurement.

 Development of cardiac services.

 Development of C40 storage and distribution.


 Oncology service- linear accelerator for St James.

 Psychiatry- continued repair of St Ann’s Hospital, revitalization of community facilities.

 Emphasis on certain specialties in certain regions.

 Proper arrangement for Sangre Grande and Tobago in accessing specialist services in other regions.

 The appointment of specialists and the development of specialist services.

 The need to facilitate transfer of patients.


 The need to facilitate staff transfers, even if temporarily.

 Listing of the major projects, likely costs and need for prioritization.

 Hospital rationalization.

 Eric Williams Medical Sciences Complex- a public service, secondary institution 74  The matter of individual responsibility.

 Simple education/health news programme.

 The university and its occupation and output.

 Other teaching facilities.

 Whither RHA.


 Specialist Medical Officer appointment.

 Dental Services adjustments.

 Ambulance Services adjustments.

 Nursing Services enhancement.

 Recording of the options for the Couva Hospital.

 Roles of representatives, professional bodies, non-government organisations, interested individuals.

75 10.0 MATTERS FOR FURTHER DELIBERATION/EXAMINATION 1.

Meeting with international and regional bodies, EHS, COSTAATT, USC, UTT.

2.
2.

Meeting with remaining vertical services.

3.

Legislative agenda of professional bodies.

4.

Prioritization of major projects.

5. Review of items raised in previous encounters.

6.

Follow up on SMO obligations.

7.

Audit functions.

8.

Data presentation.

9.

Medical and nursing staffing.

10.

The primary care agenda.

Resolving administrative complexities of staffing, reporting.

11.

RHA executive function.

Harmonizing numbers and roles, synergy with other RHAs.

12.
12.

The vertical services including National Blood Transfusion Service (NBTS) and Chemistry Food and Drugs.

13.

Education/health news programme.

14.

Couva Hospital.

15.

Detailed study of the various medical disciplines including mental health in the work place, worker health and safety, Employee Assistance Programmes (EAP).

16.

Supply Management- C40.


76 11.0 CONCLUSION This report has sought to present the major pillars of State health care delivery, identifying the issues that impact since the commencement of the RHAs.

These pillars, we recap, are primary care, secondary and tertiary services, vertical services, RHA executive, CMO, Ministry of Health.
Recommendations are made on the spot for improvement of delivery to patients within the primary and secondary institutions; and several other areas of operation and activity are given specific treatment with recommendations.

A major element would be the Health News programme which is almost guaranteed to bring substantial benefits immediately.

The topical matter of the Couva Hospital remains unresolved but with some thoughts on the way forward.
Of course, several of these matters are in need of further deliberation and evaluation.

The urgency of a first and early report could hardly permit resolution of all issues at first encounter.

In our encounters with the various bodies, wherever administrators shared the views or concerns of the Committee, they were invited, even urged to commence remedial action rather than await a report.

It was heartening to note that there were some instances of remedial action reported.
77 78 12.0 PRIVATE PRACTICE To be completed.

79 Appendix Some details of contributors: CEO, Executive Management and staff of the North Central Regional Health Authority and the Eric Williams Medical Sciences Complex, Mt.

Hope Women’s Hospital and the Wendy Fitzwilliam Paediatric Hospital.

CEO, Executive Management and staff of the South West Regional Health Authority and the San Fernando General Hospital.
CEO, Executive Management and staff of the Eastern Regional Health Authority and the Sangre Grande Hospital.

CEO, Executive Management and staff of the North West Regional Health Authority and the Port of Spain General Hospital.

CEO, Executive Management and staff of the Tobago Regional Health Authority and the Scarborough General Hospital.

Chairman of NIPDEC, Acting CEO and staff of C40, National Insurance Property Development Company Limited (NIPDEC).
CEO NWRHA, Senior Management and Staff of the St James Medical Sciences Complex.

CEO NWRHA, Senior Management and staff of the St Ann’s Hospital.

CEO SWRHA, Senior Management and Staff of the Couva District Health Facility and the Couva Hospital.
Ministry of Health Units (Vertical Services): - Adrian Mc Carthy- Acting Director, Chemistry, Food and Drugs - Adanna J.C Young- Nurse Manager, National Blood Transfusion Service - Natalie Dick- Developmental Behavioural Paediatrician, NCRHA - Candis Gomez- Pulmonologist, NCRHA - Glenda Bourne- Nurse, Arima Rehabilitation Centre/St Ann’s - Tricia Hospedales- Mental Nurse, Arima Rehabilitation Centre/St Ann’s - Michelle Sookdeo- Dentist, Dental Hospital, NCRHA - Natasha Kochhar- Head of Department, Dental Hospital, NCRHA 80 - Leslie Carrington- Acting Director, Trinidad Public Health Laboratory - Aina Jones- House Officer, Queen’s Park Counselling Centre & Clinic - Aruna Bivakaruni- Acting SMO, Queens Park Counselling Centre & Clinic - Taryn Phillip- Manager, Nutrition & Dietetics, MoH - Sheraz Ali- Administrative Assistant, Population Programme, MoH - Yvonne Lewis- Director, Health Education Division, MoH - Ohisegun Olowe- Registrar, Insect Vector Control Division Individual Presentations: - Dr. Kenwyn Nicholls, Former Director, Health Sector Reform Programme - Ms. Jean Leon, Former CEO Kings County Hospital and Senior Vice President South Brooklyn Staten Island Network, USA - Mr. Jameel Rahamand- Pharmacist - Dr. Tricia Cummings- Head Cardiologist, NCRHA - Dr. Mohammed Rahaman- President, Trinidad and Tobago Medical Association - Mr. Anthony Davis- Head Nurse, POSGH - Mr. Stewart Smith- Health Sector Advisor Representative bodies, Professional and Licensing bodies: - Mr Russell Salcedo – Treasurer, Nursing
 Council - Wilma Collins- Registrar, Council for Professions Related to Medicine - Niall Farnon- Secretary, Trinidad and Tobago Opticians Registration Council - Duane Gonzalez- Operations Manager, Friends of the Blood Bank Association - Anessa Hamilton- Assistant Secretary, Medical/Psychiatric Social Workers Board - Marsha Small- Secretary, Mental Health Association of Trinidad and Tobago - Arlene James-Euin- President, Trinidad and Tobago Association of Midwives - Jacqueline Rouse- Chairperson, Physiotherapists Board of Trinidad and Tobago - Harry Narine- Chairman, Medical Laboratory Technician’s Board of Trinidad & Tobago - Alecia Surujlal- Chairperson, Nutritionists & Dieticians Board of Trinidad and Tobago - Priya Gomes- Chairwoman, Occupational Therapy & Speech Language Therapist Board - Gwendolyn Loobie-Snaggs- President, Trinidad and Tobago Registered Nurses Association, trade union representative for TTRNA - Mr Frank Sears- President, National Workers Union - Patrick Rousseau- General Secretary, National Union of Government and Federated Workers (NUGFW) - Christopher Joefield- Vice President, PSA - Mohammed Rahman- Former President, Trinidad and Tobago Medical Association 81 Dean of Medical Sciences and senior faculty staff - The University of the West Indies: - Terrence Seemungal- Dean, Faculty of Medical Sciences - Verrol Simmons- Associate Dean - Murali Manohar- Director, SVM - Oscar Noel Ocho- Director/ Senior Lecturer - Subash Sharma- Optometry.
UWI - Sandra Reid- Deputy Dean, Clinical Services - Kenneth Charles- Deputy Dean, Graduate - McAulay Rieger- Director, Dentistry - D. Dan- Head Department, Clinical Surgical Sciences - Simone Roberts- Administrative Officer Management of Ministry of Health: - Dianne Dhanpath- Deputy Permanent Secretary - Lawrence Jaisingh- Director, Health Policy, Research and Planning - Brenda Jeffers- Health Sector Advisor - Giselle Bishop- Director, Human Resources - Geeta Maharaj- Director, Finance and Accounts - David Constant- Director, International Co-operation Desk Former Chief Medical Officers: - Dr. Anton Cumberbatch - Dr. Rohit Doon Chief Public Health Inspector: - Christopher Saith Manager of Dental Services, Ministry of Health: - Dr. Elizabeth Prayman- Manager, Dental Services, Ministry of Health 82