Trinidad and Tobago's public health care system works to expand services while coping with labour shortages

Many of the health indicators for Trinidad & Tobago are similar to those of developed countries. Well over 90% of the population has access to clean drinking water and proper sanitation. Regarding childbirth – one of the key health benchmarks for emerging markets – nearly all expectant mothers make at least four doctor visits before giving birth, and virtually all births in the country are attended by health professionals. The percentage of infants who are immunised against poliomyelitis and other diseases like diphtheria, pertussis and tetanus, are roughly the same as those in the US.

Income & Health

Nevertheless, per capita income in T&T at purchasing power parity – often used as a proxy for gauging potential health spending – was about half of that in the US in 2013. Some health indicators, moreover, reveal that T&T has more in common with the rest of Latin America and the Caribbean, where income figures are generally much lower – though it still usually ranks above the regional averages. In 2011 T&T had about 18 doctors, 35 nurses and three dentists per 100,000 people, compared to regional figures of 17, 14 and four. The incidence of tuberculosis in 2012 in T&T was about seven times that of the US, compared with about 10 times the US figure for the region as a whole.

The average citizen of T&T has an overall life expectancy at birth of 70 years, and a “healthy” life expectancy of 61 years. For men, the probability of dying between 15 and 60 is around 23%; for women, 13% – figures that compare unfavourably to those of the Americas region, which includes the US, Canada and Mexico. Although infant mortality improved markedly in T&T over the 1990-2012 period, the rest of the region improved more. Interestingly, the prevalence of HIV in T&T is about three times that of the rest of North and Latin America, but the incidence of AIDS is about half that of the US or Latin America and the Caribbean. Women are far likelier to have AIDS in T&T than in the US and Latin America.

As one might expect in one of the region’s wealthier countries, years of life lost through communicable diseases in T&T are relatively low. Loss of years through non-communicable diseases (NCDs), however, are high for the region – a significant fact given that the rest of the region includes the US, where NCDs like diabetes and obesity have a high prevalence. There are elevated risk factors in T&T for blood glucose and obesity among females, as well as for blood pressure among men. T&T may well have the highest incidence of diabetes in the Western hemisphere, as Samuel Ramsewak, dean of the Faculty of Medical Sciences at the University of the West Indies (UWI), told OBG – partly because of the genetic predisposition of the Indo-Trinidadian community, who account for about 35% of the population. Other contributing factors are obesity and unhealthy diets. In all, some 130,000 of T&T’s population of about 1.34m – about 9% – have diabetes. Of these, 11% have compromised vision. The latest evidence suggests that the incidence of NCDs has been getting worse rather than better. In November 2014 the minister of health, Dr Fuad Khan, noted that the number of obese primary school children in T&T increased from around 11% in 1999 to 23% in 2009.

Medical System

T&T’s public health system is free of charge at point of delivery. In recent years, press reports have indicated an impetus among officials to move towards a National Health Insurance System, in which the costs are funded in large part by a levy on the working population. Such a system would also likely require payment at point of delivery from foreign nationals, who currently benefit from free public health care in T&T.

As of early 2015, at least, the system is funded by a “pay as you earn” income tax surcharge from the state coffers. In his budget statement of September 8, 2014, the minister of finance and the economy, Larry Howai, said that the allocation for public health spending would amount to TT$5.5bn ($848m), out of total spending of TT$67.2bn ($10.4bn). Through the Chronic Disease Assistance Programme (CDAP), approximately 47 drugs are distributed for free to patients with certain conditions, including diabetes, asthma, cardiac diseases, arthritis, glaucoma, depression, high blood pressure, an enlarged prostate, epilepsy, hypercholesterolemia, Parkinson’s disease and thyroid diseases.

Regional Health Authorities

The public health system is overseen by the Ministry of Health (MoH). Since the introduction of the Regional Health Authorities Act in 1994, however, the day-to-day business of providing health care has been delegated to the five Regional Health Authorities (RHAs). The MoH’s current role is therefore to determine policies, allocate resources to the RHAs and ensure that they are performing in a satisfactory manner.

The largest of these by population is the North West RHA, which serves around half a million people in Port of Spain and the surrounding areas, overseeing three hospitals, including Port of Spain General, and health centres in 16 locations. The South West RHA based in San Fernando, which is nearly the same size by population though much larger by geographic area, runs two hospitals, including San Fernando General and the Point Fortin Area Hospital, two District Health Facilities (in Couva and Princes Town) and 32 health centres. The North Central RHA is third-largest by population served, at 220,000 people, and with its base at the Eric Williams Medical Complex at Champ Fleurs is responsible for the Mount Hope Women’s Hospital, the Caura Hospital at El Dorado, and the district health facilities at Arima and Chaguanas, the two largest towns in its area, along with 13 health centres. The Eastern RHA, which serves just 120,000 people though its territory covers the entire eastern third of Trinidad, is based in Sangre Grande, the location of its only hospital, and is responsible for the Mayaro District Health Facility and health centres in 15 locations, from Toco in the island’s far north-east to Guayaguayare in its far south-east. Last, the Tobago RHA serves the 60,000 residents of that island from its base in Scarborough, overseeing the Scarborough General Hospital and health centres in 19 locations.

Hospitals & Medical Centres

Although the number of hospital beds in T&T, at 2.7 per 1000 people, is not much less than in the US (2.9) and considerably more than across Latin America and the Caribbean (2.0), the perception of chronic shortage among authorities has prompted the government to build new health care infrastructure.

The Administrative Complex in San Fernando has been converted into a 216-bed teaching hospital, connected to San Fernando General Hospital by a skywalk. The Children’s Hospital and Multi-Training Facility in Couva will provide another 230 beds (including 80 for children), plus centres for training 300 students from UWI’s School of Medicine, Nursing and Pharmacy. The new National Oncology Centre is due to be commissioned in 2015. New hospitals being built include those at Penal, Sangre Grande, Point Fortin and Arima. The government is also currently upgrading medical centres at six locations and has converted others into 24/7 facilities.

Operational Issues

While many hospitals and health centres are being built and opened, official moves to improve operational efficiency at medical facilities remain a work in progress.

In early 2013, health minister Khan highlighted some of the chief issues in this regard at a conference in Port of Spain, after receiving complaints about patients’ wait times at hospitals and the length of time that patients were occupying beds. Simple processes such as movement of blood samples between emergency rooms and laboratories, he found, were unnecessarily complex. Patients have had to wait for weeks, sometimes even months, to receive results from a CT scan, MRI scan or pathology report.

In a major step in December 2013, Khan made an announcement stating that responsibility for the CDAP programme would be transferred to the RHAs, which will now be responsible for purchasing their own drugs. Previously, CDAP had been run by the National Insurance Property Development Company (NIPDEC), a subsidiary of the National Insurance Board of T&T – the central organisation in the country’s social welfare system, which is also involved in property development and management.

NIPDEC, however, has also acted as a procurement agent for some government agencies, and at the announcement of the transfer, Khan noted that NIPDEC and CDAP “do not seem to be working in the best interest of the health institutions”.

Staff Management

A related issue has been consistency in the services provided to patients by front-line non-medical staff. At the early-2013 conference, for example, Khan highlighted how non-medical staff are central to the efficient operation of hospitals and clinics but are partly shielded by the unions. “[Patient] escorts are supposed to transport patients about the hospital,” he said, “and when they decide not to be found or decide not to go to work although they do get paid for it, and you try to discipline them, the union comes after you.”

In August 2014, Khan noted that he had held several meetings to discuss such problems in T&T’s health care sector with government ministers, including Vasant Bharath (Trade, Industry, Investment and Communications), Marlene Coudray (Local Government) and Roodal Moonilal (Housing and Urban Development). The proposed solution was to train and deploy around 460 customer service representatives at Port of Spain General Hospital over the subsequent two months, followed by an additional 770 people to be given training and employed across the country’s health care system.

Staff Shortage

Another fundamental issue has been a shortage of skilled staff. At the time of the opening of the new San Fernando Teaching Hospital, for example, the government had to import some 120 nurses from Cuba and 60 from St Vincent. Indeed, Ramsewak told OBG that the shortage of nurses and of specialists in a variety of areas, including pathology and neurosurgery, are two of the biggest challenges facing T&T’s health care sector aside from the prevalence of NCDs. In both cases, part of the problem is that the pay and conditions offered by the RHAs are seen as inadequate by medical professionals who are T&T nationals. This perception steers potential candidates away from medical professionals, exacerbating the shortage of qualified personnel and increasing reliance on foreign labour.

For nationals already in the profession, the unions lobby for higher pay and benefits. While this may make the medical field more attractive to locals, it also raises costs for hospitals, making it harder for them to hire more staff and boosting the competitiveness of foreign hires. As of early 2015, the Medical Professionals Association of T&T (MPATT), was still in negotiations with the South West RHA in relation to pay and allowances for fiscal years 2009/10 and 2014/15. Among its demands are a 4% rise in its members’ pay for each year from 2011/12 to 2013/14 (implying backpay), a 5% rise for 2014/15, and a 20% hike in allowances.

As the officially recognised majority union for doctors working in the South West RHA, the MPATT holds full rights and authority for collective bargaining with the South West RHA. In addition to this, it is also the de facto trade union for doctors in the other four RHAs, and as a result it possesses the ability to negotiate on behalf of an individual member.

Medical Training

Such staff shortages exist despite the quality of T&T’s education system. The Faculty of Medical Sciences at the St Augustine Campus of UWI, a long-established and internationally recognised centre for medical training, is divided into six schools: medicine, dentistry (the only one in CARICOM until another opened in Jamaica in 2012), veterinary science (the only one in CARICOM), pharmacy, nursing and optometry. With about 2000 students in all, the annual enrolment intake is around 450, including 250 medical students, and graduates are automatically qualified to work anywhere in CARICOM countries. The medical school also runs around 20 graduate programmes, including in obstetrics, gynaecology, family medicine, emergency medicine, psychiatry and anaesthetics. Other institutions in the country train medical staff as well: the College of Science Technology and Applied Arts of T&T, for example, runs an Academy of Nursing and Allied Health at its campus in El Dorado.

At the UWI’s Faculty of Medical Sciences, the student body is dominated by T&T nationals for three reasons. First, T&T students in their final year of school tend to outperform their peers in the Caribbean Advanced Proficiency Examination (CAPE). Administered by the Caribbean Examinations Council, the CAPE is the rough equivalent of A-Level exams in the UK. Each year, there are around 500 applicants for the faculty’s medical programme with suitable results from CAPE (or, in some cases, first degrees from a university). Students are selected not only on the basis of their grades, but also on their involvement in co-curricular activities.

Those who have not been accepted to the programme therefore have three options: apply again the following year; try to enter UWI’s medical schools in Jamaica or Barbados, where the academic entry requirements are somewhat lower; or seek entry to a private medical school such as St George’s University in Grenada or Ross University in Dominica.

The second reason why T&T nationals dominate the studentry at UWI’s Faculty of Medical Sciences is that they benefit from the Government Assistance for Tuition Expenses (GATE) programme. Together with other subsidies, this means that their medical education is effectively free.

The third reason is that the UK’s General Medical Council stopped certifying the faculty in 2004 – not from any deficiency of the faculty so much as due to a change in EU rules. Since then the faculty has been certified by the Caribbean Accreditation Authority for Education in Medicine and other Health Professions, yet the resulting reduced access to the UK has tainted the programme’s appeal to foreign students. Normally, UWI charges foreign medical students around $25,000 a year in tuition fees.

In theory, recipients of the Financial Assistance Studies Programme – which includes many T&T nationals enrolled in the medical programme of the Faculty of Medical Sciences – are required to work in the country for a certain period, or else the grant will convert into a loan. In practice, however, this rule is not rigorously enforced. Graduates of the faculty are usually able to meet the requirements of the US Medical Licensing Examination, which is a pre-requisite for residency in a hospital in that country. The result is that T&T suffers from something of a “brain drain” of trained medical professionals.

Medical Tourism

The government is exploring the notion of developing T&T into a destination for medical tourism. In early 2014, for instance, Khan mooted the possibility of importing retired doctors from the UK to help the country promote itself as a market for medical and educational tourism. There are concerns, however, about the feasibility of the undertaking. In practice, as Dr Sree Venu Potluri, managing director of West Shore Medical Private Hospital at Cocorite told OBG, T&T would face stiff competition from providers in Panama and Colombia. Potluri noted, however, that West Shore Hospital – one of about 10 in the country – does receive patients from Guyana and some of the islands in the anglophone Caribbean that are closest to Trinidad.

Incentives for private health care businesses also appear to be less than those for companies in other sectors wishing to set up operations in T&T, such as financial institutions seeking to take advantage of concessions offered by the T&T International Financial Centre. Operators of private hospitals can import drugs duty free – a helpful factor for health centres like West Shore Hospital that rely almost entirely on imported pharmaceuticals – yet duties must be paid on other imports of consumables and equipment, which can be costly.

Insurance

Private health insurance is available from insurers such as Guardian Life of the Caribbean, a subsidiary of the Guardian Holdings Group, and Sagicor Life, a part of Sagicor Financial Corporation. These providers generally cover about 90% of medical expenses. However, medical insurance is still seen as a luxury, as Potluri told OBG, hindering uptake. All the same, those who understand the benefits of health insurance and can afford it generally place a high value on it – especially in a country where incidence of NCDs remains relatively high.

Specialist Treatment

Despite the shortage of specialists noted by Ramsewak, West Shore Hospital has generally been able to provide around 90% of the specialist treatments and procedures that would be available in a large developed country, including neurosurgery, angioplasty and open-heart surgery, and generally does not have to fly specialists in from other countries, as Potluri told OBG. The hospital also typically has access to the foreign exchange that it needs to buy imported equipment.

More problematic still is the shortage of nursing staff, who account for a large portion of its 300 staff. Even though the hospital offers far better pay and conditions than the RHAs, Potluri said, some 70% of its nurses come from outside T&T. The main countries of origin are poorer CARICOM countries, India, the Philippines and Cuba, while older staff often come from the UK and other EU countries.

Outlook

The three major challenges for T&T’s health care sector – the rising prevalence of NCDs, a shortage of specialists and a shortage of nurses – will not be resolved quickly. Progress towards improving the efficiency of the CDAP programme and the smooth running of the RHAs’ hospitals and clinics is also likely to be measured.

A move to a National Health Insurance System, in which health care is largely funded by a levy on the working population, is possible but unlikely in 2015 given elections being held in September. That said, as wealthier people become more concerned about deficiencies in the public system, health insurers could see a range of new opportunities. The industrial relations climate within the RHAs is likely to remain problematic, while development of the medical tourism industry will depend on the availability of well-trained professionals and nursing staff.