The Republic of Trinidad and Tobago lies at the southernmost end of the Caribbean chain of islands. The estimated population in 1998 was 1.28 million, of whom 27 percent were under 15 years of age and 6.3 percent were 65 or older. The population consists of a rainbow of persons of diverse cultural and ethnic antecedents
The leading causes of mortality and morbidity are heart diseases, neoplasms, diabetes mellitus, and cerebrovascular diseases. Trinidad and Tobago supports its population through petroleum and its downstream industries and from growing manufacturing and tourism sectors.
The health sector in context
The Ministry of Health (MOH) has historically been the body responsible for ensuring national health and for providing the services needed by various groups and subgroups within the population. The MOH has traditionally been required to provide leadership and also deliver health care services to the population. It sought to fulfill these roles through the development of a network of primary care facilities offering promotive, preventive, curative, and ambulatory services in close proximity to population groupings and at hospitals located in areas of major population concentration. Operations were highly centralized. Care was provided at no charge at point of contact, with all costs being borne by the Government.
The private sector mainly consisted of individual physicians and private pharmacies operating on a fee-for-service basis. Private inpatient beds were few compared with the complement in the public sector. Nongovernmental voluntary organizations partnered and supported the efforts of the Government by providing services aimed at meeting specific health needs of particular groups of persons. In some cases, these organizations received financial support from the Government to carry out their work.
Over time, both internal and external customers grew increasingly disaffected with the existing situation. Several commissions and task forces recommended that the MOH divest itself of various parts of its service delivery functions, by using boards or other such bodies to act on its behalf. After a series of consultations with major stakeholders, the Government accepted these recommendation to use administrative decentralization to improve the performance of the health sector. This involved giving to five regional health authorities (RHAs) full responsibility for the day-to-day functioning of the health facilities and the delivery of services.
To ensure coherence, the MOH would focus on the important roles of policy formulation, planning, standards-setting, regulating and monitoring of the RHAs, and evaluating improvements in health status. Implementation of this decision required a clear and distinct change from the prevailing system and naturally demanded the development of a framework within which to achieve the many and complex changes required.
Through the aegis of the Inter-American Development Bank, the country was able to obtain the services of a consultant group to develop the framework for and the details of the reform. The resulting Health Sector Reform Programme (HSRP) and the National Health Services Plan (NHSP) now guide the sector as it seeks to achieve the goals articulated and the vision shared for improved health of the population. The underlying strategy is that of more fully operationalizing a "primary health care approach," which has long been accepted and pursued by successive governments, along with this approach's principles of equity, accessibility, community involvement, self-reliance, sustainability, and relevance.
The consultant team and the local counterparts used an extensive participative approach to obtain the views of both internal and external clients and customers on a variety of issues. In addition, the teams carried out formal studies and surveys to obtain information on such areas as costs, allocation of resources, and systems. The findings confirmed the general feeling that with its highly centralized mode, the MOH was unable to respond effectively and efficiently to the dynamics of the health sector and was therefore functioning reactively rather than proactively.
Present situation and experiences
The decision to decentralize brought with it the need to address many issues in a fundamental and comprehensive manner. The Regional Health Authorities Act of 1994 created five RHAs and spelled out their obligations and powers. Each RHA is governed by a nonexecutive board whose members represent specified skills and community interests. A chief executive officer and his management executive are responsible to the board for the business of the RHA. Over the past 5 years the MOH and the RHAs have been engaged in institutional development supportive of their new roles and in learning how best to become what the law mandates directly and by inference. Five of the major challenges that the RHAs have faced are discussed below.
Governance. The decision was made to have the RHAs managed by nonexecutive boards, with a chief executive officer responsible for implementing board policy and also for leading an executive team. This change has meant a completely new way of conducting business in the public health sector. Broad policies set by the MOH are to be particularized and implemented by each RHA. The law states that the RHA board chairmen respond to the minister of health. The law is silent on any other possible relationship between persons in the RHA and persons in the MOH. These relationships therefore had to be addressed administratively. Aspects of fiduciary responsibility have been addressed through guidelines provided by the minister and through requirements in the Regional Health Authorities Act with respect to audits. The area of greatest challenge is that of monitoring and evaluation. There is the need for the Ministry of Health to guide and monitor without negatively affecting the ability of the RHAs to develop and perform as envisioned. However, there is also the need to ensure the provision of quality service in a cost-effective, cost-efficient, equitable manner.
Transfer of public service staff to the RHAs. The transfer of public service staff to the RHAs has been engaging the attention of the senior management of the Ministry of Health, and an interministerial committee has been set up to achieve the transfer. Many strategic approaches have been considered, but the reality remains that the health professionals in the country constitute a small pool. Replacement is not a simple or feasible option under the circumstances. The option of severing employment ties is equally unattractive because of the large sums of money that would be required to address the severance and pensions obligations of the Government.
As part of the strategy to have the workers move to the RHAs, the Government has set up a contributory RHA pension fund and has arranged matters so there will be no loss of benefits that would normally occur as a result of a change in employer. The RHA Act also provides for the continued recognition of the trade union for those public servants who transfer or temporarily move to the employ of the RHAs. This has provided the workers with a degree of comfort and a sense of security. Additional action areas relate to the verification of the employment record of each staff member before transferring that record to the relevant RHA, and the creation of suitable human resource management systems and processes in the RHAs, including an independent tribunal that will address complaints and grievances. Setting up the tribunal is critical since transfer to the RHA effectively removes the person from the purview of the Public Services Commission, which the Constitution of the Republic of Trinidad and Tobago set up to deal with disciplinary matters, including termination of employment of public officers. From the functional perspective, public service staff who work in the RHA system are and will be faced with certain skills gaps occasioned by the RHAs' use of commercial accounting systems and other management systems not usual in the public sector. The reform program plan has recognized this and has made funding provision for human resource development using several means of skills development. The expected outcome will be a cadre of staff equipped to carry out new functions, as well as existing functions in new ways.
Continued provision of national public health services. Located a short distance from the coast of South America, Trinidad and Tobago has flora and fauna similar to those of the countries on the northern coast of the continent. Mosquitoes are native to the country and are vectors of malaria and of the flaviviruses that cause sylvan and urban yellow fever and dengue fevers. Traditionally, the vector control and eradication programs and the malaria disease surveillance program have been planned and delivered in a "vertical" mode.
This permitted a clear focus on inputs and outputs and their impact. The issue now being debated is how best to maintain these desirable features without having the MOH sidetracked into program delivery. The administrative and delivery arrangements for the national programs for tuberculosis and Hansen's disease have been easier to address because of legal and other arrangements which predate the RHA Act. The medical and pub lic health staff attached to the facility responsible for the delivery of thoracic services have the mandate to manage the National Tuberculosis Programme. The decision that thoracic services will now be delivered by a particular RHA has meant delivery by that RHA of the National Tuberculosis Programme. With respect to Hansen's disease, the country has achieved the goal of elimination as promoted by the World Health Organization. Prior to decentralization it had been determined that delivery of the Hansen's disease surveillance and treatment program would be achieved cost effectively and efficiently in conjunction with the Dermatology Programme. As a result, one of the RHAs has been given the responsibility to provide this national service.
Coherence in the delivery of care throughout the country. To ensure coherence and standardization among the RHAs, the MOH has adopted a series of policy and administrative measures. In the context of decentralization, annually and on behalf of the population, the MOH "purchases" defined services from the RHAs. These purchases relate to the needs revealed in a national survey carried out in 1995 and in health services information that is routinely collected. The purchases are also based on details of the National Health Services Plan. In response to the MOH's purchasing strategy the RHAs develop their service and administrative responses. Documents providing estimated costs form the basis for discussion and negotiation with the Ministry before submission for Government funding. Once funding has been allocated to the RHAs, annual services agreements (ASAs) are finalized and then signed by the minister of health and the chairman of each RHA board. These documents support monitoring and performance evaluation. Apart from the ASAs, the minister also has authority under the Regional Health Authorities Act to give direction to the boards on important and necessary matters. Certain fora, instituted in relation to execution of the Health Sector Reform Programme, serve to develop and maintain linkages among the Ministry's executive team and the RHA teams. These relationships are valuable in sharing information and experiences and in permitting the cross-fertilization of ideas.
Financing of the health sector. As mentioned earlier, the public health sector has been financed from the tax revenues of the country. This has not changed in large measure except for one hospital, which is allied to the Medical Faculty of the University of the West Indies and was developed as a fee-for-service enterprise. This facility has been incorporated into one of the RHAs and continues to pose a challenge in terms of its continued development and realignment of role to serve a catchment population.
By law, the RHAs can consider introducing a fee-for-service model of care, but only with the concurrence of the minister of health. The Health Sector Reform Programme proposes alternative models of funding for the sector, prime among which is a National Health Insurance System (NHIS). This will be funded through employer and employee contributions and also payments from the Government on behalf of the indigent. Such a system demands many supporting and corollary policies and activities. One of the most fundamental is the articulation and agreement on a package of basic services. Trinidad and Tobago has not yet addressed this matter fully. Technical support is being accessed to complete that work and to clearly define the implementation pathway. Among the other elements that are germane to the successful implementation of an NHIS are agreed protocols and standards of care, peer review, systems to capture costs and outcomes in a manner supportive of decision-making, and a unique identifier for each person.
All of these issues are vital to the successful implementation of the Health Sector Reform Programme. Successful outcomes also require robust information systems that support management processes and that address quality. The fact that computerized systems have not been extensively used in the public health sector provides the opportunity for their introduction in a systematic and organized manner.
The Health Sector Reform Programme has already begun to bear fruits, particularly in the area of primary health care. As this reform moves forward, two factors will be critical, the human resource issue and effective communication with all stakeholders. If these concerns are not adequately addressed, it will be difficult to continue successfully implementing reform.
1 Ministry of Health, Port of Spain, Trinidad, Trinidad and Tobago.