Trinidad and Tobago invests in health infrastructure

The health sector of Trinidad and Tobago is founded on the principle of a free, universal coverage funded by the government and taxpayers. The FY 2019/20 budget assigned health care the third-highest allocation after education and national security. In addition to providing health care to a population of over 1.3m, much of this budget will go towards the construction of new hospitals and clinics. While the ageing population and chronic diseases becoming more prevalent pose challenges to health care provision, national campaigns are seeking to encourage Trinbagonians to adopt healthier lifestyles. Implementing a preventive care approach has been highlighted as the most effective way forward.

Structure

The management of the health care system is divided into two tiers, the Regional Health Authorities (RHAs) and the Ministry of Health (MoH), per the Regional Health Authorities Act No. 5 of 1994. The MoH manages the financing, regulation and governance of national health care, as well as the implementation of government legislation. RHAs work at the regional level, managing hospitals and health service providers by region. There are four RHAs in Trinidad and one in Tobago. Together, they oversee nine hospitals, 96 health centres and nine district health facilities.

General Indicators

Life expectancy at birth in 2018 was estimated at 73.4 years by the UN Development Programme (UNDP) in its “Human Development Report 2019,” an increase of 5.4 years since 1990. The UNDP also gave T&T a human development index value of 0.799 in 2018, ranking it 63rd out of 189 countries measured, in the high human development category.

As life expectancy increases, maternal mortality continues to decrease. A 2018 report from the Pan American Health Organisation (PAHO) and the World Health Organisation (WHO) stated that four direct maternal deaths were reported in 2015 and two in 2016, while there were no reports of direct maternal deaths in 2018. Furthermore, child mortality rates had stagnated at around 32 deaths for every 1000 live births from 1990 to 2007, but they subsequently dropped from 32.8 deaths in 2007 to 26.1 in 2017.

According to the latest data from the World Bank, health care expenditure stood at $1064 per capita in 2016, a drop from 2015 spending levels, which were at $1116, but a significant increase since the 2000 figure of $227. Meanwhile, in FY 2019/20 the MoH was allocated TT$6.08bn ($898.9m), the third-highest budget allocation that year at around 3.7% of the country’s GDP.

Hospitals & Facilities

A significant portion of the new budget allocation is being used to construct new hospitals and upgrade services around the country. Such projects include the Arima Hospital in northern T&T, which should be operational by March 2020, providing 150 beds and serving a population of 250,000, at a cost of TT$1.5bn ($221.6m).

The Port of Spain General Hospital’s new central block is expected to be completed by January 2022, providing 540 beds and serving 400,000 people. The update to existing facilities will provide biomedical, radiology, pharmacy and laboratory facilities.

The Point Fortin Hospital, in the south-west of Trinidad, is also scheduled for completion by March 2020. It will have 100 beds, providing medical care for 75,000 people across the region, with a budget allocation of TT$1.2bn ($177.3m). Meanwhile, the new Sangre Grande Hospital will replace the existing outdated medical centre in the poorer eastern region of Trinidad. A carbon copy of the Point Fortin Hospital, the project is expected to be completed by 2021-22 at a cost of TT$1.2bn ($177.3m). Sangre Grande is expected to improve access for rural populations, as well as the speed at which people are treated. Funding for both Point Fortin and Sangre Grande will be provided by an Austrian bank under a government-to-government arrangement and construction will be managed by Austrian firm Vamed Engineering.

Smaller projects include the Roxborough Hospital in north-eastern Tobago, expected to cost TT$60m ($8.8m) and scheduled for completion in 2021; the St James Medical Complex upgrade, a new cancer centre in Port of Spain, costing TT$45m ($6.6m); and the Diego Martin Health Centre in the north-west of Trinidad, estimated at TT$8.6m ($1.3m).

The government is also channelling funding towards the improvement of medical training facilities, such as the Couva Medical and Multi-Training Facility (CMMF), a 230-bed hospital. Owned by both the government and the University of the West Indies, the CMMF has the latest technologies and equipment for medical training, advanced diagnostics and follow-up care. It is also expected to provide a greater opportunity for medical tourism thanks to the purchase of 30 dialysis chairs, two vitreo-retinal machines for eye surgery and a catheterisation laboratory for angiograms and angioplasty, expected to be installed in the first half of 2020.

Public Sector

Investment in new hospital projects is expected to greatly improve the country’s public health sector. Greater training and development for staff, as well as improved access for patients, aim to fix some of the current challenges the public sector faces. For instance, while T&T provides free universal health care, there are often complaints about access and wait times in hospitals. In 2015 a public survey found that 65% of the population was discontent with the health care system’s management. Overcrowding, wait times and negligence were cited among the main issues, with poor facility maintenance also highlighted. This sentiment partly explains why those who can afford it have begun to turn to private alternatives for medical care.

Out-of-pocket spending for secondary services, such as medicine, continues to be an issue. In 2016 it accounted for 40.08% of health care expenditure. While this number dropped from 49.32% in 2006, it remains significantly above the global average of 18.56%. Moreover, annual out-of-pocket per capita spending on care increased from $292 in 2006 to $426 in 2016. As an individual’s level of access to services and medicines that require out-of-pocket spending is dependent on income, the government has been looking to public-private partnerships (PPPs) to reduce the stress on lower-income populations. An example of this is the TT$1.1bn ($162.5m) contract for the Port of Spain General Hospital’s new central block signed in May 2019 with Chinese firm Shanghai Construction. By encouraging PPPs, the government aims to shift funding towards patient care and medicine that would have preciously required out-of-pocket spending.

The construction and upgrade of several hospitals and health care facilities seeks to fix some of the main challenges in the sector. In addition, in 2018 the government put TT$34m ($5m) into the Medical Equipment Upgrade Programme to update equipment across hospitals and health care facilities, while TT$25m ($3.7m) was spent under the Hospital Refurbishment Programme on infrastructure upgrades managed by RHAs. While both of these programmes may offer cheaper alternatives to private health care, the country would also benefit from up-to-date public studies on access and spending to reduce the access limitations and out-of-pocket expenses that are often quoted as the main difficulties in the sector.

The modernisation of medical centres through digitisation will also help to reduce inefficiencies. To this end, the MoH contributed TT$5m ($739,000) to the development of an electronic medical record system in the Arima and Point Fortin hospitals, according to Lawrence Jaisingh, director of health policy, research and planning at the MoH. The system will create a paperless patient registry, reducing the duplication of medical records across different medical departments. If successful, this programme could be rolled out across other hospitals as well.

Private Sector & Insurance

Private health care expenditure in 2016 was at $501 per capita. In 2017 the private sector accounted for 11 hospitals, more than 100 nursing homes, several general practitioners’ offices, over 300 pharmacies, and laboratories and diagnostic centres. The MoH outsources several treatments to private facilities through the External Patient Programme established in 2014 in partnership with the RHAs. This often concerns patients who need dialysis, cancer treatment or cataract surgeries, “when the demand is greater than supply and on urgent cases where the essential services are not available in the public health sector,” Jaisingh told OBG.

While general health care in T&T is free, dental care is almost entirely privatised. The state provides certain services to children aged two to 12 free of charge, including fillings, cleaning, fluoride treatment and dental health education. For adults, however, only pain relief, typically for tooth extractions, is covered. Therefore, dental treatment requires either private health insurance or costly out-of-pocket spending for anything other than emergency oral care.

While the use of one-off private services is common, private health insurance penetration remains low due to high package costs. A 2015 MoH report found that donor, NGO and employer contributions – via insurance companies – accounted for less than 1% of health spending. Expatriate workers who self-fund or receive insurance coverage from their companies are some of the less common examples of full private insurance coverage. Health insurance contributions to public services are generally very difficult due to the lack of an adequate billing system.

Medical Tourism Potential

Medical tourism has not been a priority so far in T&T, yet close regional examples such as Barbados, which has attracted patients thanks to new fertility and dialysis facilities, could provide the framework for an effective strategy. Moreover, revenue from medical tourism could give a much-needed boost to the overall health care budget.

The Commonwealth Secretariat and the T&T Coalition of Service Industries drafted the National Strategy for Medical Tourism in 2012, presenting the country’s potential as a medical tourism destination. T&T has strong joint replacement, cardiac surgery and dentistry segments, three of the main attractors of medical tourism. The report found that each medical tourist could contribute around $10,000 to the country, based on a 14-day trip and treatment. By targeting both tourists and the diaspora population, many of whom live in the US, around four hours away by plane, the state could significantly develop the medical tourism segment.

The government has demonstrated interest in building facilities to support medical tourism. For example, the Couva Hospital facility for diagnostic care, which includes specialist equipment, is already open. However, more centres are needed for the country to attract this type of activity, Jaisingh told OBG.

Medical Staff

According to preliminary data from a study from PAHO and the WHO about core indicators on health trends in the Americas, in 2018 there were 12.4 physicians, 3.4 dentists and 37.2 professional nurses for every 10,000 people in T&T. Further MoH research suggests there are on average 25-40 patients per doctor in outpatient clinics. The MoH is currently working with stakeholders to compile a comprehensive review of health care professionals, in partnership with the WHO’s National Health Workforce Accounts platform.

Many health care specialists from T&T seek employment in foreign markets, contributing to a shortage of health care professionals in the country. The private sector bridges this gap to an extent, with private doctors accounting for 54% of curative primary care in Trinidad in 2018. However, the shortage has also led the MoH to seek foreign medical specialists to work in the sector. In 2015 then-minister of health, Fuad Khan, turned to Cuba, India and Uganda for health care professionals who could support T&T’s system. According to local media, a large number of specialist health care providers were hired from Cuba in 2019 to address the staffing shortages in public health care.

Previously, in a 2012-16 strategic plan, the MoH had announced the 10-Year Manpower Plan to ensure the future of national health care employment and encourage the employment of the growing number of Trinbagonian medical professionals. Most health care professionals graduate from one of three tertiary institutions: the University of the Southern Caribbean; the Faculty of Medical Sciences of the University of the West Indies; and the College of Science, Technology and Applied Arts of T&T, with the latter two being public.

NCDs

Despite progress in some areas, challenges remain for the health care system in T&T, including the high level of non-communicable diseases (NCDs), many of which are chronic, in an ageing population. According to 2016 estimates from the WHO, NCDs accounted for 81% of all deaths in the country. Heart disease caused 25% of all deaths in 2015, followed by diabetes, at around 14%. In addition, premature NCD deaths in 2016 were estimated at 9800. Obesity has been highlighted as a major cause of NCDs in T&T, with over half of the country’s population between the ages of 15 and 64 was registered as obese in 2017. According to the authorities, childhood obesity levels concerning ages five-18 are particularly worrying, having increased from 2.4% in 1999 to 55% in 2017.

The National Strategic Plan for the Prevention and Control of NCDs 2017-21 aims to address these issues. The MoH has already initiated several policies and programmes to curb tobacco use and alcohol consumption, and promote healthier lifestyles. These include the long-established National Alcohol and Drug Abuse Prevention Programme, the introduction of the Tobacco Control Act of 2009 and the establishment of the School Nutrition Programme in 2017. The latter has allowed notable advances to be made regarding the lifestyle of schoolchildren, providing 40,000 of them with balanced breakfasts and 100,000 with lunches from pre-primary to the secondary level.

However, the MoH will have to build on this momentum to achieve its 2025 goal of reducing by 25% the burden of preventable mortality – that is, before the age of 70 – due to heart disease, diabetes, cancer and stroke. The MoH aims reach this target through a multi-sector approach, promoting healthier lifestyles and shifting the health care focus from responsive to preventive.

There have also been talks about the introduction of a sugar tax, following a Parliament committee meeting in January 2019. As in the UK, a sugar tax could encourage people to choose healthier food and drink options. A 2015 study by UK- and US-based researchers that assessed 2010 beverage intake from adults over the age of 20 in 187 countries found that T&T was the highest daily consumer of sugar-sweetened beverages, with an average of 590 ml per day. However, there has been no announcement of a sugar tax to date, and the cost of introducing the reform could continue to be an off-putting factor in the medium term.

Lastly, there have been strides in access to vital medicine in recent years. The government’s Chronic Diseases Assistance Programme (CDAP) offers free prescription drugs to people suffering from 12 different chronic diseases. In 2019 authorities made significant improvements to the CDAP by increasing availability through the introduction of more CDAP pharmacies, including one in the Couva Hospital. The cost of setting up pharmacies has also been reduced and deliveries of medicine to pharmacies will be more frequent. There are now 47 drugs available through the CDAP in over 250 pharmacies across both islands.

Communicable Diseases

Control of communicable diseases, including HIV/AIDS, has been a key objective for T&T. The country has a strong vaccine culture: in 2018 PAHO estimated immunisation coverage at around 100% of the population for diphtheria, pertussis and tetanus, 100% for polio, and 90% for measles, mumps and rubella. The prevalence of HIV/AIDS in 2014 was around 1.65% of the population, 57% of whom were men and 43% women. Around 64% of cases were among the 15-49 age range. Testing and treatment for HIV is free across 64 sites and the availability of free antiretroviral drugs meant AIDS-related deaths declined by 47% between 2010 and 2014. The MoH has previously focused on awareness of HIV/AIDS health in big national events such as Carnival, World AIDS Day and Regional Testing Day. Meanwhile, the WHO estimated the combined prevalence of tuberculosis and HIV/AIDS at 2.9 per 100,000 people in 2015. Universal health coverage managed approximately 87% of these cases.

Elsewhere, mosquitoes continue to pose a threat, with cases of chikungunya and Zika identified in 2014 and 2016. By late 2015 there were 53 confirmed cases of chikungunya and 717 cases of Zika by the end of 2016. Dengue continues to challenge the health system as well, with 1687 probable cases in 2015. The MoH has been tackling mosquito-borne diseases by promoting the deployment of ovitraps and developing geographic information systems to manage insect populations, in addition to raising awareness through campaigns.

Pharmaceuticals

The pharmaceuticals segment in T&T is relatively small but the generics market, once judged as being low-quality and unsafe due to under-regulated imports, is now growing. This is largely in response to the higher cost of brand-name medicines. In 2015 pharmaceuticals for prescribed and over-the-counter medicines accounted for 47% of out-of-pocket health care spending. In a 2019 Trinidad and Tobago Guardian article, Dr Colin Nath from St Augustine Private Hospital expressed concern over the deterrent effect of high medicine prices on patients with chronic illnesses, adding that many medicines in T&T are between six and 30 times the comparable cost for patients without insurance in the US.

In 2018 the Ministry of Planning and Development hosted a conference on pharmaceutical counterfeiting, in which all speakers stated that managing supply chain infiltration of medicine from raw material suppliers to patients was difficult. Also highlighted was the lack of available data on pharmaceuticals and the private sector in general, making the tracking of medicine and other services difficult. T&T imported more than 90% of medicine as of 2018, making regulatory standards and checks extremely important. Official imports are checked for labelling and authorisation. However, medicine ordered over the internet still presents a problem, as much of it arrives in T&T without proper labelling.

The Chemistry, Food and Drugs Division (CFDD) of the MoH is responsible for inspecting any imported medical items. Yet due to high domestic costs, many Trinbagonians buy medicine abroad. Although the CFDD can impose heavy import duties on any medicine brought in from other countries, this can lead to an increasing number of purchases made on the under-regulated online medicine market. Since the conference, the government has been working closely with the Caribbean Industrial Research Institute to establish a strategy for monitoring and evaluating imported medicines.

Outlook

Investment in the construction of several new health care facilities across both islands of the country and the upgrade of ageing infrastructure demonstrates that the public sector is on the right path. However, challenges persist as out-of-pocket spending remains high, partly due to elevated medicine costs, and the country carries a significant disease burden. Authorities will also have to invest greater funds in the training of medical professionals if it is to fill staffing gaps. In the medium term, the country will reap the benefits of its infrastructure investment if it focuses on its medical tourism potential as a way forward.