The new government of Trinidad and Tobago is set to roll out a new national insurance system

A push for comprehensive health care reform in Trinidad and Tobago (T&T) could see the country’s health care sector undergo significant changes in the medium term. Elected in September 2015, the People’s National Movement (PNM) government, led by Keith Rowley, has pledged to lead the country’s transition to a comprehensive national insurance system by 2018. The move comes at a time when T&T’s leadership is adjusting to a reduction in government revenues, following the sharp decline in oil and gas prices since mid-2014. Energy revenues, which have traditionally accounted for 40% of the country’s GDP, were down by 75% in April 2016. In addition to lower public revenues, structural inefficiencies and rising health care costs are some of the challenges T&T authorities will be tackling in the coming years.

Two-Tier

T&T has a two-tier health care system, with a decentralised and free-of-charge public system coexisting alongside private facilities. It is not uncommon for people to access services in both systems, depending on waiting times, expertise and equipment availability. The public health care system offers primary, secondary and tertiary level care through its network of nine hospitals, 97 health centres and nine district health facilities, according to the Ministry of Health (MoH).

In addition to its regulatory function, the MoH oversees policy development, planning, monitoring and evaluation, and is also responsible for allocating resources to the country’s five Regional Health Authorities (RHAs), the local agencies in charge of service provision oversight since the introduction of the Regional Authorities Act in 1994. Serving approximately 500,000 people, the South West RHA (SWRHA), based in San Fernando, is the largest by geographic area, covering more than one-third of Trinidad’s land surface and extending from Couva in the north to Icacos in the south-west. The SWRHA oversees the San Fernando General Hospital and Area Hospital Point Fortin, as well as two health facilities and 33 health centres. The North West RHA also serves 500,000 residents in densely populated Port of Spain and surrounding areas, and manages three hospitals, including Port of Spain General in Trinidad’s capital and 17 health centres. The Eastern RHA, based in Sangre Grande, serves another 120,000 residents, managing two hospital and 15 health centres, while the North Central RHA, based around Arima and Chaguanas, oversees six hospitals, 12 health centres and one outreach centre. The smallest, the Tobago RHA, serves the island’s roughly 60,000 residents from its base in Scarborough, overseeing the Scarborough General Hospital and 19 health centres.

Epidemiological Transition

With the public primary health care system providing a large portion of the population with access to health care services – including maternal and child health, preventative and chronic disease programmes – T&T has been able to make significant progress in a number of health indicators. Births attended by skilled staff had reached 100% by 2012, while infant immunisation rates exceeded 90% in 2014, according to the Pan-American Health Organisation (PAHO). Moreover, infant mortality and under-five mortality rates – at 12 and 14.5, respectively, per 1000 live births in 2012 – remain below the Latin America and Caribbean averages of 15.5 and 18.9, respectively. The country’s life expectancy stood at 70.1 years in 2015 – 66.6 and 73.9 years for men and women, respectively – compared to an average of 75.1 years for the Latin America and Caribbean region. As health care access expanded, authorities were able to bring the spread of communicable diseases (CDs) under control, with CDs and maternal, prenatal and nutrition conditions representing a relatively small share (9%) of total deaths by 2012, according to World Bank data. However, the country’s epidemiological profile is now characterised by the prevalence of non-communicable diseases (NCDs), in particular chronic degenerative and lifestyle-related conditions, raising new challenges for health authorities. NCDs, which include cancer, diabetes, cardiovascular, digestive, skin and musculoskeletal diseases, and congenital anomalies, accounted for 80% of deaths on the islands in 2012.

Chronic Conditions

A rise in obesity rates has played a key role in driving up the incidence of diabetes and heart disease, which, along with cancer, cerebrovascular disease and injuries, make up the leading causes of death in the country. In a 2013 report by the UN Food and Agriculture Organisation, T&T emerged as the country with the highest obesity rates in the Caribbean, with 30% of the adult population considered obese. Mexico topped the overall chart with 32.8%, ahead of the US at 31.8%. At 13.1% of the population aged 20 to 79, the prevalence of diabetes in T&T also surpasses that of the US, with 9.4%. The government’s Chronic Disease Assistance Programme (CDAP), established in 2003, has been instrumental in addressing the prevalence of NCDs. Through the CDAP, patients can access free prescription drugs and other pharmaceuticals for a significant number of chronic conditions, in particular diabetes, asthma, cardiac diseases, arthritis, glaucoma, depression, high blood pressure, thyroid disease, epilepsy, enlarged prostate, Parkinson’s disease and high cholesterol.

Given the rate of NCDs in T&T, one would expect cardiovascular mortality to be higher than it is, and preliminary studies have shown that this has to do in large part with the existence of the CDAP, which ensures access to essential medication for people living with chronic conditions.

Structural Inefficiences

Despite the progress observed in other indicators, relatively large fluctuations in maternal and perinatal mortality rates remain a concern for the T&T health care sector. In 1990 the maternity-to-mortality ratio was around 50 per 1000 live births. A 2014 estimate by T&T’s public health authorities placed the ratio between 52 and 54 for that year, showing very little change from 1990 and falling short of the Millennium Development Goals, which called for a 70% reduction.

A look at the variability over time shows peak years in which the ratio increases as high as 140, followed by years in which it falls as low as 53, according to data from the PAHO. The fluctuation appears to be indicative of the non-sustainability of certain measure as well as the more reactive character of T&T’s health system. In response to this situation, the MoH has engaged PAHO in technical cooperation that will address the problem, including a systems review of maternal and child health services, integration and capacity building on the perinatal information system that provides analytics for policy-making, programme development and clinical decision-making and training on post-partum haemorrhage, which is a common cause of maternal deaths. The impact of these interventions have already started to be demonstrated with a life of a mother with severe post-partum bleeding being saved using a low-cost technique learnt from one of PAHO’s training workshops.

Though in theory T&T’s subsidised health care system is available to all, a number of structural inefficiencies have restricted effective access to services. At 2.7 per 1000 people, the number of hospital beds in the country is only slightly lower than the US’s 2.9, and above that of the Latin America and Caribbean region’s two, according to the World Bank. Meanwhile, in 2013 the country had 18.1 doctors and 35.1 nurses per 10,000 people, according to PAHO, above Latin America’s averages of 17.6 and 13.8, respectively. A combination of ageing infrastructure and ongoing labour shortages leading to increasing waiting times for patients, even for relatively simple medical procedures, has contributed to the widespread perception of chronic shortage and deteriorating standards in the public system.

Labour Shortages

Despite producing a significant number of medical graduates each year, T&T continues to suffer from a shortage of health professionals, in particular nursing staff, a trend associated to a large extent with the significant brain drain the country continues to experience. T&T is home to the Faculty of Medical Sciences of the regional University of the West Indies (UWI) St Augustine Campus, with a total of 2748 students in the 2014/15 academic year. The institution is a long-established and internationally recognised centre for medical training, offering training in medicine, dentistry, veterinary science, pharmacy, nursing and optometry. Other medical training institutions in the country include the School of Nursing, Health and Environmental Sciences at the College of Science, Technology and Applied Arts of T&T and the MoH’s School of Nursing.

The introduction in 2004 of the Government Assistance for Tuition Expenses (GATE) programme has also effectively expanded access to tertiary education, and medical training in particular. GATE is available to nationals pursuing approved programmes at local and regional, public and private tertiary institutions, and covers 100% of tuition fees at the undergraduate level and up to 50% at the postgraduate level. While students who benefit from GATE are expected to work in T&T for a period of time after graduation, depending on the value of the grant, enforcement is not always strict and a significant portion of health professionals continue to leave the country for more profitable health care markets in North America and the UK. UWI medical graduates are automatically qualified to work in any CARICOM country and often meet the requirements for the US Medical Licensing Examination, a prerequisite for residency in hospitals in the US. At times, T&T health care authorities have had to resort to importing foreign labour to supply the local market, with an estimated 70% of nursing staff in the country being outsourced from Cuba, the Philippines and India, according to the T&T Coalition of Services Industries (TTCSI). In recent years, a series of labour disputes, in some cases leading to protests and work stoppages, have further exacerbated staffing challenges.

Meanwhile, it is common for specialist doctors, known locally as consultants, to have a private practice and work in the public system simultaneously, raising concerns regarding the duplication of efforts and conflicts of interest. “This duality leads to a duplication of costs. This is one of the biggest challenges we need to overcome in order to maintain health care costs under control,” Anton Cumberbatch, technical advisor at the Centre for Health Economics at UWI’s St Augustine Campus, told OBG. “For this, we need to formalise contracts with doctors operating in both systems in a more efficient manner that prevents conflicts of interest.”

Rising Costs

Health care costs have risen over the past decade, associated not only with structural inefficiencies but also with the prevalence of chronic diseases and an ageing population. Total health expenditure represented 6% of GDP in 2014, according to the World Health Organisation (WHO), up from 4% in 2000, with the public sector accounting for 52% of total expenditure. The private sector accounts for the remaining 48%, with the majority of expenditure – 82% – being out-of-pocket. The economic downturn is likely to pose additional challenges for the public health sector in the near-term. According to the Central Bank of T&T, the GDP contracted 2% in 2015 and is set to contract by another 2.3% in 2016, on the back of lower oil and gas revenues. Budgetary constraints have already led the government to introduce a cost-cutting programme to reduce operational expenditure by 7% in each of the government’s ministries. The sector received an initial total allocation of TT$6.1bn ($939.4m) for the 2016 fiscal year, the third-largest after national security and education and training, though that total was later reduced by TT$6m ($924,000), following the mid-year budget review of April 2016. The amount was nonetheless an increase from TT$5.5bn ($847m) the previous year.

Universal Health

Despite the strain on government coffers, the newly elected Rowley administration has indicated its commitment to making the Universal Health Insurance Programme a reality, with authorities looking to transition to a comprehensive national insurance system. “The Universal Health Insurance Programme has been an elusive goal. We will place universal health insurance high on our agenda and ensure that by December 31, 2018, a national health insurance system will be in place and operational, thus bringing much relief to all our citizens,” Colm Imbert, the minister of finance, told Parliament in late 2015.

The proposed insurance system would provide citizens with access to health care at a facility of their choice, public or private, the minister of health, Terrence Deyalsingh, told local media. The new system would also require partnerships with insurance companies and private health care providers to establish suitable costs, accountability, quality assurance and standards of care for medical procedures, according to local media reports. As of April 2016 it remained unclear whether authorities would move to adopt specific mechanisms to finance the new system.

The new government is also set to review the National Health Card, launched in July 2015 by the previous People’s Partnership coalition government, under the leadership of Kamla Persad-Bissessar. The card, which was designed to provide citizens with access to public health care and prescription medication free of charge or at a reduced cost, was set to be implemented by the National Insurance Property Development Corporation (NIPDEC) in phases. The first phase of the rollout, which entailed registration of patients under the CDAP programme, was completed in September 2015. In addition to facilitating access to health services and medication, the card was also expected to introduce portability and streamline medical record keeping.

Added Capacity

Given the country’s new macroeconomic context, the newly elected government is also reviewing the existing hospital strategy and is expected to deliver a hospital construction and refurbishment plan. In FY 2016 the health care sector will benefit from an allocation of TT$644.1m ($99.2m), under the country’s Public Sector Investment Programme (PSIP), for the modernisation of health facilities and the purchase of critical medical equipment.

The sum of TT$200m ($30.8m) is also being allocated for the National Oncology Centre, a new cancer care facility located at the Eric Williams Medical Sciences Complex, that will offer diagnostic imaging and radiation therapy services.

In addition, the PSIP for FY 2016 includes the construction of two new hospitals at Arima and Point Fortin. The 150-bed Arima Hospital, for which a sum of TT$120m ($18.5m) was allocated, will be located on the compound of the existing district health facility. According to media reports, the hospital will cost between TT$1.5bn ($231m) and TT$1.8bn ($277.2m) to build, with construction expected to reach completion within three years. Work on the new 100-bed Point Fortin Hospital is set to commence in FY 2016 with an allocation of TT$85m ($13.1m). The two new hospitals come after completion in 2015 of a new Children’s Hospital in Couva, by the former government. The hospital, which began construction in 2012 by Shanghai Construction Group International ( Caribbean), a regional subsidiary of the Shanghai Construction Group, reached completion in August 2015 at an estimated cost of TT$1bn ($154m).

However, the facilities had yet to become operational as of April 2016, with difficulties in mobilising the necessary funds and staff (an estimated 2500 staff are required) to operate the new facilities preventing the launch of operations. Given the constraints, in April 2016 the minister of health told local media that the new government would be seeking a private sector partnership to fund, staff and operate the facility as the project goes forward.

An additional TT$31m ($4.8m) was allocated in FY 2016 for the upgrade of health institutions managed by RHAs under the Hospital Refurbishment Plan and another TT$30m ($4.6m) under the Medical Equipment Upgrade Programme.

The government has also indicated that it will be acting immediately to address the shortage of medical personnel. Imbert told Parliament during the presentation of the 2016 budget that the government would work to ensure that all medical students at the Mona and Cave Hill campuses of UWI, in Jamaica and Barbados, respectively, would receive GATE funding. “We will expend substantial resources on training opportunities in all areas of health care, including support staff in professions allied to medicine, particularly nursing,” he said.

In a bid to further improve efficiency, in late 2015 the government appointed a special committee to perform a comprehensive review of the public health system. The committee will be looking in particular at the performance of the RHAs, and also at the critical issue of specialist doctors practising in both the public and private systems.

Private Sector

The private sector had yet to feel the impact of the economic downturn in the first quarter of 2016. Local hospitals have reported that 2015 was a mixed year for the private sector. Even though growth was nearly flat, some segments, such as dialysis services and radiology, have shown consistent growth in recent years. A trend that carried in to 2015, and is expected to continue in the future.

Comprising 10 medical institutions with the capacity to accommodate 39,000 patients, the private sector has been benefitting from increasing demand for private services in recent years, in part fuelled by the ongoing capacity constraints affecting the public sector. The growth in dialysis services is due to the fact that, given the capacity constraints within the public system, dialysis services are increasingly being subcontracted to private providers in T&T. For some time the public sector has subcontracted a limited range of services to private health care providers under specific programmes such as the External Patient Programme. In the period from 2010-15 the range of services saw a small increase, with the public sector subcontracting cardiac surgery for the first time. According to media reports, the current government is also looking to engage the private sector in the provision of oncology services, in a bid to contain the rising incidence of cancer, making for a stable outlook for the private sector in the near term.

A rise in health insurance penetration rates is another factor contributing to the increase in demand. The number of patients with health insurance has risen dramatically in the past 20 years. Health care providers attribute the growth in insured citizens to the fact that more employers are providing health care than in the past.

According to the WHO, in 2014 private insurance at 14% represented a modest percentage of total private health expenditure, suggesting substantial room for organic growth. As of the first quarter of 2016 there was no indication of downsizing in the government’s labour force, effectively the country’s largest employer providing health insurance to its employees. Therefore, significant fluctuations in demand for private services are unlikely. Nonetheless, as insurance companies attempt to control costs in the new recessionary environment, processing of claims could become more cumbersome. Increasingly hospitals are beginning to see insurance companies request more documentation and become a bit tighter in the way they process claims.

Pharmaceutical Stock-Outs

In early 2016 the public and private sectors were both feeling the strain from a series of pharmaceutical stock-outs, with Pharmacy Board president Andrew Rahaman expressing concern over the shortage of H1N1 vaccines in particular in January. According to Rahaman’s statements to local media, the shortage of drugs at health centres and hospitals reaches an estimated 30-40%. Administrative changes seem to be at the root of the shortages.

According to Delaysingh, the previous government had ended the annual contracts it had with NIPDEC to procure pharmaceuticals, while working to establish the National Health Services Company (NHSC) to replace NIPDEC as the official public pharmaceutical procurement agency. However, according to health authorities, the NHSC failed to get off the ground and in the meantime NIPDEC has been on a month-to-month contract, affecting the procurement cycle. “We are going to revert to the old system of putting NIPDEC on a yearly contract, so it will be the procurement agency for drugs in T&T,” Deyalsingh told local media in January 2016. T&T relies primarily on imports to meet its pharmaceutical needs, with drug costs accounting for roughly one-fifth – around TT$800m ($123.2m) – of the annual budget allocated to health, according to former chief medical officer Colin Furlonge. With businesses in general feeling the strain from the limited availability of foreign exchange, in particular US dollars, some fear this could exacerbate the occurrence of pharmaceutical stock-outs, increasing the risk of development of microbial resistance and making conditions more difficult and more expensive to treat.

To address systemic causes of the stock-outs, the MoH has engaged PAHO in a technical cooperation initiative that aims to strengthen the pharmaceutical supply chain management system in the country. Initiatives include the development of a data-driven pharmaceutical information system that will allow for morbidity-based forecasting and evidence-based procurement of medicines. Further plans include clinical practice guidelines to help influence prescribing patterns among physicians and an update of the essential medicines list, which is the basis for procuring the country’s annual supply of medicines, to name a few of the initiatives to be undertaken.

Regional Cooperation 

In recent years, outbreaks of dengue fever, H1N1 and more recently the Zika virus, which led T&T authorities to declare a state of emergency in early 2016, have underlined the need for greater and more sophisticated regional cooperation in dealing with public health threats. “We need a health approach that ties us to the rest of the Caribbean to ensure that our borders are part of PAHO, an international protection circle that keeps track of disease control, and ensures safe travel, water, food and medicine,” Cumberbatch told OBG. “Public health threats such as Zika can have a devastating impact on service delivery systems, as we are seeing in some countries currently. One infectious disease or food or water scare can bring trade to a halt and put into question your entire tourist product.”

In a significant step in early 2016 T&T pledged support for the Regional Tourism Health Information, Monitoring and Response Systems and Standards to Enhance Sustainable Tourism, a regional initiative aimed at developing health monitoring systems and standards to enhance Caribbean tourism, and protect the health and safety of locals and visitors. Financed by the Inter-American Development Bank, the project is being implemented by the Caribbean Public Health Agency in collaboration with the Caribbean Tourism Organisation and the Caribbean Health and Tourism Association in six Caribbean countries: Barbados, the Bahamas, Belize, Guyana, Jamaica and T&T. The programme is expected to contribute to fewer and less costly outbreaks, reducing the impact of health threats on the tourism industry.

Medical Tourism

With authorities looking to accelerate diversification, medical tourism is increasingly viewed as a potentially lucrative market and a new source of foreign currency earnings.

Though medical tourism in T&T remains a nascent industry, each year a small number of patients from Guyana and other English-speaking parts of the Caribbean seek health care services in local private hospitals on the islands. As it attempts to position itself as a medical tourism hub in the region, T&T will benefit from key advantages.

A study on health and wellness services by the TTCSI noted the country’s expertise and successful track record in joint replacements, cardiac surgery and dentistry, a private sector comprising 10 institutions with a capacity to accommodate 39,000 patients per year and last, the country’s robust training base for practitioners across the medical and paramedical fields. The country also compares well to rest of its Caribbean neighbours in terms of number of specialists per capita and availability of high-technology equipment.

Nonetheless, poor service standards, labour shortages and cost of service delivery remain key challenges for T&T, which stands to face increasing competition from faster-developing medical tourism markets in the region, including Panama and Colombia. “Though T&T has the knowledge and investigative basis for the establishment of a medical industry, the service must be more customer-oriented,” Cumberbatch told OBG. “The idea of opening up an already strained health care system to medical tourists, as nationals face increasingly long waiting periods, raises further equity concerns for nationals.”

Strengthening accreditation of health care institutions will also be key to accelerate the adoption of international standards in the country. At present the St Augustine Medical Laboratory is the only internationally accredited institution in the country and in the English-speaking Caribbean. T&T made some progress in this respect in 2013, with the introduction of legislation for the establishment of the National Health Services Accreditation of T&T, which was given a mandate to review quality standards and accredit health care facilities. However, the institution had yet to become operational in the first quarter of 2016.

Outlook

Facing rising costs associated with the prevalence of NCDs and an ageing population, and exacerbated by the decline in public revenues, T&T’s public health system faces challenging times in the short to medium term.

As the authorities work to further increase efficiency and overcome capacity constraints, the private sector is likely to continue to benefit from the subcontracting of select services, and this should help propel it forward overall. With the demand for geriatric care and chronic disease management facilities similarly set to increase significantly in the coming years, these should also remain key opportunity markets for the private sector.

Over the longer term, the rollout of a national health insurance system in T&T will represent a significant step forward on the path to universal health, portability and record-keeping, although it remains to be seen whether the current strain on public revenues will affect the timing and implementation of the new health system. However, observers are optimistic that T&T is entering a new positive phase of care.