National Consultation on Public Health Sector

Health Sector Reform Programme - The Way Forward

INTRODUCTION

The Trinidad and Tobago Chamber of Industry and Commerce in its Priorities for National Development has stated that a healthy labour force is the cornerstone of national productivity. It is therefore critical that we ensure quality, affordable health care for all our citizens, and that we reach consensus on general principles to be adopted, in any consultation on the Health Sector of Trinidad and Tobago. To this end, we must first assess the current state of affairs in order to identify the shortfalls that may exist.

The truth is that the problems being experienced in the Health Sector have existed for several decades and despite several studies over the years these problems continue to exist. We however feel over the last few months the Ministry of Health, in particular, has shown a change in focus with regard to its attitude in management. Direct phone calls are answered, E-mails are resulting in action and open dialogue - 'do it and do it now'.

While these are positive changes that should be encouraged, it is the view of the Chamber that the following also needs to be addressed:

Physicians in Government Service and Parallel Private Practice;

The recent doctors’ strike highlighted the dissatisfaction of health care professionals with remuneration levels. It is common knowledge that the salary packages paid to physicians in the Government Service cannot be construed as being a reflection of the value of their experience and reputation built over the many years, particularly in relation to their professional status. When one considers the time and high cost of university training (6 years to MD), and even more so, with specialist training of a further 5-6 years and compare this with the salary packages commanded by information technology specialty personnel or even a medical representative, the divide between professional worth is evident. Certainly their responsibilities cannot be compared.

The need for doctors to look to private practice to subsidise their Government posts is a pitfall that cannot be overlooked. The ramifications of this reality can only be detrimental to the effective functioning of the Health Sector in general and more crucial to the underprivileged citizens of Trinidad & Tobago who depend on these medical benefits the most. The cash package offered by the Regional Authorities to their physicians gives the appearance of equality with other persons employed in the Public Sector, but gives a seemingly high pay package without any perks and a limited tenure cannot be viewed as anything more than a stopgap. Alternately the package existing for public service physicians may be lower financially, but the perks and security of tenure are logically more attractive. Perhaps this is why the struggle continues and must be faced squarely with a direct attitude

The publication of the CSO with regard to the availability of doctors in practice shows an increase of 104 Doctors from 1171 in 1999 to 1275 in 2OOO. The fact that there is no exodus of doctors may perhaps, be attributed to the high cost of malpractice insurance abroad, averaging US$3,000 per month for a medical doctor to $6,000 per month for a surgeon and not in fact a reflection of contentment with the current state of affairs of these same doctors m the local Health Sector.

A close look also needs to be taken with respect to the operation of what appears to be two parallel health care management systems i.e. the Ministry of Health and the Regional Health Authorities. As a nation, we are expending precious human and financial resources in carrying these parallel systems - resources that would serve us better were we to have one properly managed and funded system.

Nursing Staff

CSO statistics show that the problem of exodus of Midwifes /Nurses/Nursing Assistants has become desperate and cannot be ignored any longer. In the last 15 years the number of nurses in the Health Sector has decreased by an alarming 50% from 3352 in 1987 to 1962 in 2001 due to their need to seek employment abroad. The foreign enticement may be attributed in part to the fact that Nurses do not require malpractice insurance abroad, and will benefit from the provision of on-going professional training and union-regulated working hours.

The seriousness of this persistent problem is heightened by the fact that the annual training of nurses cannot replace the numbers that are leaving the service. It is worth noting, however, that the training received by our local nursing staff is comparable to the training received by those graduating from foreign universities and so fortunately, our nurses are able to take up vacancies abroad. While it may not be possible to match the income being offered by the developed countries where health care is paid for, there is no question that dramatic improvements have to be made locally so as to keep locally trained professionals for the benefit of our own Health Sector. This Vital Health Care Sector deserves respect for the professional status of nursing.

While it may be felt that training is being wasted because of this exodus, one cannot ignore the fact that there exists no specialist postgraduate training offered by way of an enticement to improve the status of nursing, to increase promotional possibilities, and in that way, increase pride in the profession. When one considers the perpetual cry of lack of medical supplies and functioning equipment across the spectrum from suppliers default on delivery of consumables, lack of training of personnel on equipment procured, to the unavailability of quality supplies, international standards being the minimum, one can perhaps understand the enticement for local health care professionals to seek jobs abroad, and complain of lack of supplies or tools of their trade.

PHARMACISTS

For the past fifteen years according to CSO figures, the numbers of pharmacists in the country have remained stable at just over five hundred. Hospitals and health centres are in need of these pharmacists to fulfill vacancies, but here again, it is more lucrative for pharmacists to either work at a substantive post in the public sector and private pharmacies and companies than to rely solely on Government income. CSO figures published for the year 2000 indicate that of the approximate 500 pharmacists in service, 230 are employed in the private sector in pharmacies and private clinics as opposed to 71 pharmacists in the public sector.

The Chamber of Commerce fully supports the focus of the Ministry of Health towards primary health care development. We have noted substantial improvement in the physical facilities, however, in view of our statements regarding bank power we now emphasise the urgent need for moving to the next step of allocating funding to the development of primary health care personnel and their management, particularly in the remote facilities.

It is our view, that most of the clinics that are overcrowded and clogging up the hospital system should be moved to the primary facilities "zoning". These clinics can include treatment for diabetes, hypertension, heart disease, glaucoma, and asthma, once the management systems are in place. We are cognisant with the fact that certain patients will become unstable at various times and will need hospitalisation, but should this be the case our hospitals, man-power would be more readily available in such circumstances.

Of course, this cannot happen tomorrow, but we urge the Ministry of Health to develop and implement the much needed management system of personnel, goods and services at the primary health-care facilities.

Regulatory Bodies

The Food and Drug Division of the Ministry of Health whose responsibility it is to regulate the registration of new drugs, control the sale and circulation of those drugs and to ensure that any entity engaged in the private sector adheres to the laws of Trinidad & Tobago, is fulfilling its registration responsibilities adequately, in spite of the staffing inadequacies and its dependence on an annual budget the allocation from which cannot now meet the demand of policing the retail pharmaceutical trade. The cost of registration of a new drug is $750 paid directly to the Treasury, so that only a percentage of that capital is allocated to the Food & Drugs Division. This system begins a vicious circle in that Distributors, Manufacturers, Pharmacies and consumers rely upon the Food & Drugs Division to ensure that 'suitcase' traders as they have come to be known, and parallel importers are not allowed to continue to trade in illegally imported drugs for sale, since this is a loss of revenue to the Treasury and is at the detriment of consumers, who are no longer assured of a supply of quality 'registered' medicine.

The inability of inspectors from Food & Drugs to act on reports of unregistered drugs being sold by private individuals and/or pharmacies due to a lack of manpower and or transportation and/or legal power/authority to seize such illegal products has caused the existence of dangerous and unregistered drugs being available over the counter to unsuspecting consumer. Provision within the law requires registration of pharmaceutical distributors and wholesalers whose records and warehouse method of storage must be open for inspection at any time, to the pharmacy board and the various control boards such as the narcotics and antibiotics and the controlled drug divisions of the Ministry of Health. While this is also a requirement for pharmacies, owing to the lucrative trade that suitcase traders have carved out for themselves, the Pharmaceutical Committee of the Trinidad Chamber of Industry & Commerce estimates that the loss of revenue in this way is estimated to be in the millions. Inspectors are supposed to be stationed in all ports of entry but again because of staff shortages these ports are never fully covered by Food & Drugs inspectors, which has resulted in the existence of illegal imports.

Procurement of supplies

The Pharmaceutical and Medical Section of the Chamber of Commerce would readily admit that procurement through NIPDEC has improved since their assuming responsibility for the annual Pharmaceutical and Non-Pharmaceutical purchasing, both
because of its open method of tendering and availability of Comparative Bids and publication of Awards. This process has been even more improved with the launch of the official web site of NIPDEC two years ago.

It is now possible to access a history of Comparative Bids and Awards for the past three years on the Internet and transparency seems to be of paramount importance. Access to this service is available for a fee to be paid every two years and potential suppliers had to complete a Prequalification Questionnaire which included the Audited Figures for the last three years. That way, NIPDEC has a clear idea of the potential, history and evidence of ability of suppliers at all times. However, local suppliers have to produce valid NIS, VAT Clearance and Board of Inland Revenue Certificates with their bids. This is not unduly burdensome on suppliers except for the fact that foreign suppliers who wish to participate in the tendering process are not subject to these requirements. Surely we can come to some sort of level playing field. The Pharmaceutical and Medical suppliers feel that this accountability in the procurement processes of the Health Sector, however, seems to end there.

It has been the practice in recent years for the Regional Authorities to purchase hospital supplies and items of medical equipment on a "Selective Tender basis" based on a list of 'preferential suppliers'. There has never been a pre-qualification exercise for suppliers nor has there been a request for a fee to be paid so as to be included on this list. Requests for quotations are sent to Suppliers, yet no Awards are published. There needs to be clarification as to whether these Authorities are subject to the Finance Act of Trinidad & Tobago.

The ongoing Health Sector Reform Programme, funded by the Inter-American Development Bank (IDB) and administered by the Project Administration Unit, is another illustration of the problems being encountered as a result of the procurement processes being taken out of the hands of the Central Tenders Board. While tenders are published and opened publicly, the only information obtainable is the name and value of each supplier’s bid. Awards are never published other than the receipt of each company’s own Letter of Award. IDB rules stipulate that a supplier can request to see the bid and supporting documentation for each tender submitted, however the reality of the situation is that this exercise is more time-consuming than productive. In light of the above, it is therefore difficult to make a comment on the cost and quality of equipment procured, the training received or, for that matter, the value and usefulness of the equipment procured with regard to addressing the issue of lack of, and functionality of, items of Medical Equipment in the Health Sector today.

The cost of preparation of IDB tenders is substantial and includes 2% of the value of the bid bond and, unlike the NIPDEC procurement process, there is no record or statistics for the business community to rely on, and may in fact be one of the causes for complaints by doctors, nurses and laboratory technicians with respect to equipment purchases on these tenders. The volume of medical supplies being purchased is also of concern and signals the dire need to rethink the allocation within the health sector. If we look at the following published figures provided by the Central Statistical Office with regard to the Annual Budget of the Ministry of Health so as to procure Pharmaceutical and Non-Pharmaceutical supplies one can observe that over the last sixteen years, the money allocated for this purpose has decreased by four million US Dollars, despite the increase in cost of goods.

Pharmaceutical and Non-Pharmaceutical Procurement:

1986 TT$46 M @ $2.42 = US$19M,                        1990 TT$60 M @ $4.28—US$14.02M
1994 TT$48M @ $5.95= US$8.07M,                       1997 TT$56M @ $6.299-US$8.89M
1998 TT$66M @ $6.299= US$10.48M                     1999 TT$74M @ $6.299-US$11.75M
2000 TT$89M @ $6.299-US$14.15M                       2001 TT$95M @ $6.299=US$15.08M

The substantial differential between emoluments for all health sector employees across the board, and amounts spent on direct medical costs such as equipment, medical supplies etc, is also alarming. If we are to improve and maintain an effective health care system, this differential needs to be critically examined.

Outsourcing of services

The health service should focus on providing health care and contract out other services such as laundry and catering. The Ministry of Health must have a realistic budget for these and other services currently carried out internally. The private sector should be invited to tender for this business and if chosen carefully (proven track record in the particular industry, and not cronyism and nepotism) should relieve some of the burden of the Hospital's Chief Administrator. Laundry and catering have been listed but there are so many more services that could be provided privately. A supply chain procurement professional could ensure that stock levels are managed in a cost-effective manner and are properly monitored so as to minimise wastage and theft.

What about contracting out some health services as well? Has a feasibility study been carried out to weigh the benefits of kidney dialysis to be contracted out? Currently the kidney dialysis machines at the Port of Spain General Hospital are either booked up or not working (Sunday Express, May 26, Page 10). Is buying new machines the answer? How much would it cost to fix/maintain existing ones? There is an excellent burns unit at August Long Hospital, Pointe-a-Pierre. Could this be used by the Health Service? An extensive exercise should be conducted to compare the cost of contracting out these services with carrying them out internally.

Maintenance

Maintenance of plant and equipment is a key to successful business and should also be in the public sector, as it ensures a longer productive life of often costly capital goods. If a factory in the private sector is down for a day, money is lost and every effort is made to fix or replace the broken part. This mentality needs to be adopted in the health care sector. If a healthy population is the vision that the health service has, then broken diagnostic or treatment equipment/machinery just cannot be tolerated.

Facilities, vehicles and machinery all need maintenance schedules and these need to be strictly monitored. Here again may be an opportunity to contract out the provisions of these maintenance services. Above all however, accountability for maintenance must be assigned to the providers. If a wheelchair is broken, an ambulance door can't open or a kidney dialysis machine can't function, someone must have a clear action plan for
returning it to a working state.

Conclusion

To improve our health service, financial investment is needed. Our nearest Caribbean neighbor, Barbados currently spends nearly 8% of GDP on health, and Prime Minister Owen Arthur earlier this year alluded to the fact that he plans to increase this to 12% in his next budget. Trinidad and Tobago spends just 3% of GDP.

Development as a nation cannot be achieved without a healthy labour force. Every hour that is wasted while an employee waits at a clinic directly affects the productivity of our nation. Government needs to offer tax incentives to employers and individuals who cover their employees or themselves with individual or group health insurance coverage from private institutions. These schemes significantly reduce the burden on the public health care purse.

Companies should be lauded for the efforts they have made in encouraging healthy living, for example in the case of Scotiabank, by providing centres where mammograms can be conducted freely.

Healthy lifestyles must also be encouraged. Individuals should be properly informed as to the importance of a balanced diet, high in fiber and low in fat, of the need for daily exercise and regular checkups. Often, early detection of diseases like cancer, asthma, diabetes and heart disease saves the individual and the state a great deal of expenditure.

Some businesses proudly advertise when years have passed with no down-time due to accidents. Companies invest in education and safety equipment, among other things, to minimise accidents in the job. Financial rewards are offered as an incentive to employees as companies know the huge costs of losing time due to an accident. Just as the productivity of a company increases with a healthy workforce, the productivity of our nation will increase with a healthy population.

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