TRINIDAD AND TOBAGO
1. TRENDS IN POLICY DEVELOPMENT.
Over the last ten years, Trinidad and Tobago has undergone significant changes in its political organisation. Policies of trade, currency liberalisation and for strengthening the social safety net have been implemented. Strong support was given to the plan for the reform of the health sector which includes the reorganisation of the Ministry of Health, the introduction of a national health insurance system and the commissioning of the Eric Williams Medical Sciences Complex (EWMSC). Other changes include activities related to public sector reform, consumer protection, environmental protection and tax reform. Many of the political decisions taken to implement these policies were relatively unpopular. The move to more independent >safety net= measures (National Health Insurance and tax reforms) were not generally accepted by the public.
There are 8 ministries delivering programs related to the >safety net system= many times with duplicate programs and there is no overall policy framework and no lead agency to provide strategic direction and to prioritise and rationalise its various components. In order to address these constraints, the government has convened an Inter-ministerial Committee under the leadership of the Ministry of Social Development (MoSD). The MoSD is also working with the National Insurance System in the strengthening of this contributory social security system.
The system of local government has been improved through the revision of the Municipal Corporations Act of 1981 which had established 13 municipalities, each with its Chief Executive Officer and management team, including a Chief Public Health Inspector and Medical Officer of Health. The objective is to create self governing corporations, with elected local government officials who will be accountable to their constituencies and responsible for their geographical area. The main role for the corporations in health will be in providing food safety and sanitation services while health care services, including vertical health programmes would remain the responsibility of the Ministry of Health and the new Regional Health Authorities (RHA).
2. TRENDS IN SOCIOECONOMIC DEVELOPMENT.
2.1. ECONOMIC TRENDS:
Since the early 1960's the economy has depended on the production and export of petroleum and gas. Oil windfalls between 1973 to 1982 increased income, investments in physical infrastructure and improved living conditions. Per capita Gross Domestic Product (GDP) rose to US$6,600 per annum in 1982. As oil prices declined during the 1980s, the economy experienced a sharp contraction with an average annual decline of 4.5% between 1982 to 1989. Per capita GNP dropped to US$3,160 in 1989 and unemployment rose sharply. The GNP showed a reversal and some growth in 1990 to 1991, in part attributable to currency devaluation as well as stringent spending restrictions to control the recession. Due to the slow recovery of oil prices, and the continued decline in drilling and oil production, the GDP decreased again in 1991-1993. From1994 to 1996 (projections), the GDP shows steady improvement primarily due to measures of trade and currency liberalisation; diversification strategies in agriculture, manufacturing (non-oil) and tourism; restructuring, divestment and liquidation of state enterprises; introduction of tax reform, including a 15% value added tax (VAT) and reduction of personal and corporate taxes; tighter control of public expenditure and reduction of the fiscal deficit; and increases in public utilities tariffs. The TT dollar had a devaluation against the US dollar of about 5% in late 1996 that will have some impact on the health sector, heavily dependent on imports for supplies and equipment.
Inflation rates have declined to about 3.2% for the period January to September 1996 due to the removal of VAT on some basic food items at the beginning of the year but is expected to show a small reversal given the currency slippage at the end of 1996. Reversal of the unemployment trends are also being seen since this recovery
Over the period of economic recession (1982-1989), there was an increase in the levels of poverty. Absolute poverty increased from 3.5% of households in 1981 to 14.8% in 1988. Overall poverty is estimated as 21% of the total population. Almost one half of the total poor live in St George County. In urban areas, the economic pressures of the poor coupled with high youth unemployment, has contributed to growing problems of crime and drug use.
There has been a significant reduction in public sector health expenditure over the period 1981-1992. In the period 1981-1986, the annual real expenditure per capita, in constant 1985 dollars, was TT$528 as compared with TT$279 in 1987-1992. The reduction in expenditure was caused primarily by the economic recession, reduction in public sector compensation packages, increased number of vacancies within the MoH, particularly nursing. Capital expenditure declined significantly during the period 1988-1992, with most of the expenditure being directed to the construction of EWMSC (84%) and less than 1% directed at Community Health Services.The bulk of recurrent expenditure is accounted for personnel (73%) and goods and services (19%). Most of the expenditure on Personnel was in Hospitals and Laboratories (75%) with only 9% channeled to Community or Local Health Services. The National Health Insurance System (NHIS) estimates that spending on health care services in Trinidad and Tobago as a percentage of GDP is approximately 4.7% - 2.4% from the Government Sector, and 2.3% from private spending. Four medical insurance plans have been launched since 1992 and are available on an individual or family basis (previously health insurance was only available through group policies.) There is also evidence of an increasing number of health care facilities and procedures being made available in the private sector.
2.2. DEMOGRAPHIC TRENDS:
The 1990 census reported a population of 1,238,800. The average annual growth rate was 1.1% over the period 1990-1995 and is projected to remain relatively unchanged between 1995 and 2000. The slowing of the population growth is partly due to declines in birthrate combined with a stable crude death rate, but also to substantial out-migration between 1984 and 1989.
The age-sex structure has been moving from a broad based developing country population pyramid of 1960 to a more transitional constrictive shaped population pyramid, with 30% of the population still under 15 years of age and 6% over 65. By 2010, the over 65 population will increase to 7.5% of the total population. The biggest growth, however will be in the 40-64 age group.
Despite significant movements of population between urban and rural areas over the past decade, the urban/rural ratio has not changed substantially. Urban areas incorporate the two largest cities, Port of Spain and San Fernando as well as St. George County around Port of Spain.
2.3. SOCIAL TRENDS:
There has been a steady and significant improvement in the level of educational attainment. In 1970, approximately 8% of the population had no level of educational attainment and by 1990, this had been reduced to about 3%. There was a continuous decline of the percentage of persons who had primary education as their highest level of attainment and a steady increase in the percentage of men and women achieving secondary and tertiary education levels. The Government continues to provide education at primary and secondary levels with no additional education taxes or fees. The education sector receives the largest share of the public budget which has been fairly constant over the last decade at about 12%. The University of the West Indies has been restructured into a more proactive, sustainable institution responsive to the changing needs of the economy.
2.4. FOOD SUPPLY AND NUTRITIONAL STATUS:
The food available to the population is sufficient to meet its basic needs with an excess of energy (30%), protein (60%) and fat (50%). There are a number of problems, however, which translate into uneven consumption and pockets of malnutrition around the country. Agriculture contributes 2.2% of the GDP. Food imports continue to increase and in 1994 amounted to TT $1100 million. Markets are in poor condition, temperature and storage facilities are inadequate and transportation is left to the producer. This has caused the growth of roadside vendors who sells from poorly constructed shelters, foods such as fish, shellfish, poultry and fresh vegetables. Food prices have increased faster than wages. Between 1985 and 1994 the index of retail prices increased from 140.5 to 297.6 whereas the minimum wages rose from 446.3 to 504.0. The cost of the basic food items for a single person represents 27% of a minimum wage earner.
Weight at birth is not systematically recorded. A survey in 1990 recorded a prevalence of 18% of low birth weight (< 2500g). In 1989-1990, a survey done on primary school entrants found that 7.1% were wasted and 2.7% were stunted. Only 2% were found to be overweight.
The only population based data on Anaemia comes from the a study of 1993 where 25% of women of reproductive age had Haemoglobins <10G. In 1995, 2115 (17.6%) mothers attending Government clinics had Hb < 10G. Haemoglobins are not done routinely in child health clinics. A 1992 survey done in government child health clinics in children 6-24 months found a prevalence of Hb<10G in 48% of the children assessed. In 1989 a survey among primary school children 5-7 years found a prevalence of 61%.
A study in 1990 has indicated that Tobacco, Alcohol, Exercise and Nutrition are the factors that need most attention.
The National Health Survey of 1995 shows that 13% of males 15-24, and 30% of all males over 15 report that they have smoked 100 or more cigarettes in their lifetime. Prevalence was highest (37.6%) in the 35-44 age group and declined in older age groups. Smoking in females is much lower , 5.1% in all age groups over 15 and maximal (7.1%) in the 45-54 year old age group. Smoking prevalence was significantly higher in households reporting low per capita incomes and among less well educated respondents. The Ministry of Health now has a no-smoking policy aimed at making all publicly funded health institutions smoke-free, discouraging its organizations from using funds obtained from Tobacco companies for sponsoring health events and informing new employees that the Ministry of Health and its associates have a no-smoking policy. The Ministry of Health has also taken the initiative for the development of a national no-smoking policy.
Eighty percent of males and 54% of females reported that they had drunk 12 drinks or more in their lifetime. Heavy drinking (>=21 units per week) was reported by 10.5% of males. This rose to 13% in the Central Region where the sugar industry is based.
The National Health Survey of 1995 has indicated that a majority of adults know that regular physical activity is good for their health but less than 20% meet the criteria of 30 minutes of regular exercise 3 times weekly. Most communities and employers do not have public facilities for physical activity. There is no official health policy on physical activity. The Ministry of Sports supports mainly competitive activity. In 1997, this Ministry has been working on a plan for training persons in the community to promote physical activity. There has also been an increase in the number of both commercial and NGO sponsored physical activity events.
Three surveys have shown that close to 40% of adult females and 20% of males have Body Mass Index greater than 30. The National Health Survey of 1995 shows that the poor tend to choose full cream milk, fewer green vegetables and white flour. A national nutrition policy is being formulated with a focus on the prevention of the non-communicable diseases. Guidelines on healthy eating have been issued by the Association of Dietitians and Nutritionists.
Domestic violence has been difficult to quantify. Fourteen percent of males and 7% of females 15 years and over reported sustaining an injury in the past year. Mortality rates indicate an increase in intentional injury and a decline in accidents. There is a seat belt law and the use of breathalysers is now being tested. The Ministry of Health has stated that the prevention of injury is one of its priorities. The Government has placed crime reduction as one of its main priorities.
There is no reliable data available on Psychoactive substance abuse although there are clear indications that drug related crimes are increasing, which may serve as a proxy indicator of increasing abuse of illegal drugs, in particular, marijuana and cocaine.
3. HEALTH AND ENVIRONMENT.
3.1. GENERAL PROTECTION OF THE ENVIRONMENT:
There have been efforts to develop national environmental health strategies but they have been constrained by the fact that responsibility for the myriad of different factors is spread across many different Government Ministries and Agencies, with no lead agency empowered to manage. In 1995 was created the Environmental Management Agency (EMA), to develop and strengthen sectoral linkages. Some work has been developed on establishing air quality standards and in the reduction of road traffic emissions, particularly those relate to lead.
The MoH has begun to play a more active role in surveillance and in advocacy related to environmental issues. It is monitoring health hazards more, explaining the risks to health of environmentally unsound development to the other sectors. It is also performing risk assessment and providing the government and communities with the information for policy formulation and for appropriate environmental and health legislation. Work is also ongoing in other Ministries and agencies on the establishment of environmental monitoring systems e.g. Institute of Marine Affairs for coastal pollution, MoPD and Solid Waste Management Agency for hazardous and oily waste, Ministry of Health and the Pesticides and Toxic Chemicals Act..
3.2. WATER SUPPLY AND SANITATION:
According to the Central Statistical Office 97% of the population have access to water; 71.2% of the population have connections to a pipe-borne water supply and 15.8% have access to standpipes. All of the pipe-borne water supply is chlorinated, and meets international standards.A Cholera alert has been in effect since 1992. A 1992 survey found 78.5% of households with running water. However 70.6% of these reported having water from the mains in the last week and 78.3% reported storing water. There were marked regional differences. Public health measures have been implemented advising the population on how to manage their supply.
Ninety-nine percent (99%) of the population have adequate excreta disposal: Urban - 30% through house connections to a municipal sewerage system and 70% through privies: Rural areas - 97% through privies. Regular collection and disposal services for domestic garbage are provided free of charge by local authorities. Approximately seventy-seven percent (77%) of respondents in the 1992 survey reported that their solid waste was collected, 17.8% had a designated collection site and 8.5% burned their garbage on site.
Many of the problems related to inconsistent water supply and inadequate sewerage management are related to poor state of the infrastructure which was put in place in the 1960s. The loss of water through the distribution system is estimated to be as high as 50%. As many as 9 agencies, all public sector, are involved in water and sanitation management with no formal framework for their collaboration and coordination. Despite these problems the gains achieved in terms of control of diarrhoeal diseases are still evident in that Trinidad and Tobago remained cholera free through the peak of the epidemic in South America during 1990 to 1992.
4. HEALTH RESOURCES.
4.1. HUMAN RESOURCES:
The information on human resources is limited because the centralized personnel function of the MoH maintains data primarily for payroll and budgetary functions and no reliable data is available for health professionals in the private sector. Plans are ongoing through the HSRP to to establish a Human Resource Management information system. For the private sector the sources of information are primarily the Registering bodies like the Medical Board and the Nursing and Dental Councils. Efforts to improve manpower projections and planning will also include the institutional strengthening of the professional registering bodies. No data are available on traditional medicine or non medical providers.
There are currently about 1 physician to 1,200 population in Trinidad and Tobago There are still problems with respect to the number of junior staff, House Officers and Interns, in the hospital services, which is remedied by contracting non-nationals to these posts. It was estimated that in 1993, approximately 150 foreign doctors were working in the Government Sector. The newly opened Medical School of the University of the West Indies graduated the first class of 64 doctors in 1994, increasing to between 90 and 95 from 1995 onwards. The HSRP addresses the issues of physician supply and restructuring physician services in the Government hospitals, recommending the strengthening of primary care by reallocating resources, and adaptation to international trends as they relate to physician manpower planning. The plan will also make recommendations with respect to Specialist Training and continuing medical education programs. One of the priorities for Post Graduate Training is the establishment of a Family Medicine/General Practice Program. A similar situation exists for dentists as with physicians. Current dentist to population ratios are satisfactory by International Standards, and the first class of 20 graduated from the Dental School in 1994, increasing to 25 from 1995.
Trinidad and Tobago has a shortage of nurses. There was some recent improvement, following the recommencement of Nursing training in 1989, and new nurses entering the system from 1992. There are many vacancies for nurses in the Community Services - but this is related not only to training but recruitment and qualification issues. Critical shortage areas have been identified in other health related professional areas like dietetics and nutrition, radiology, physiotherapy, occupational therapy, pharmacy.
4.2. PHYSICAL INFRASTRUCTURE:
The deteriorating state of physical infrastructure, including equipment, is attributed to the lack of ongoing preventive and routine maintenance systems, skills and budgets and is of particular concern to the Minister of Health and the new Regional Health Authorities. A National Health Services Plan (NHSP) was developed as one on the major outputs of the HSRP design phase to address the issue of sustainability of investment in physical infrastructure. The NHSP will guide investment in infrastructure, and in human resource development required to achieve the shift in resources to primary and preventive care.
According to plan the network of public health care facilities will be rationalised in the following ways: Primary Care Services - reinforcing the network of existing facilities by upgrading selected health centres; constructing new ambulatory health care facilities and enhanced health centres; converting the remaining health centres to outreach centres with once or twice a week preventive services. Hospital Services - reduction in the number of acute hospitals (from 13 to 5) and hospital bed capacity while increasing the capacity in the remaining hospitals for ambulatory and diagnostic services; improving the inpatient facilities; Community Care - shifting inpatient care of the elderly and disabled to the private or NGO community based setting. National Emergency Ambulance Service - introduction of an emergency transport system to improve access and integration of the rationalised network of health facilities.
The hospitals have deficiencies in both physical condition and functional content, in building area and in equipment. Substantial investment will be required to modernise the existing hospital infrastructure to provide hospital based services which are part of an integrated and expanding health care delivery system. To guide this investment within the context of the NHSP, 10 year Development Control Plans (DCPs) have been completed for the 5 hospitals. The DCP sets out a programme of construction and a mechanism for monitoring and control. The DCPs are also tools to ensure balance and a method of distributing resources nationally.
The Annual Services Agreement will define managerial and service objectives for the year for the RHAs. It will also outline the agreed structural investment programme and set up the criteria for monitoring performance of the RHAs. No system of capital charging has been determined and at least for the short term, capital investment will be managed centrally.
4.3. ESSENTIAL DRUGS AND OTHER SUPPLIES:
The MoH has developed national drug policies. The Pharmacy Division of the MoH, launched an initiative in 1990 to introduce concepts of rational drug prescribing in the public sector. Methods of estimating drug requirements have also been developed, but there has been limited success in the acceptance of the use of standardised treatment protocols for even the more common diseases and conditions. Computerised inventory management and drug dispensing systems have been introduced in all major hospitals, and the system will be linked to Central Supply in the near future. In 1994, a National Drug Formulary was produced for use in the public sector which will contribute in increasing the awareness of the range of options available, costs of treatments and the need for better rational drug prescribing practices.
Blood transfusion services are centralised and a national unit is responsible for setting the standards for collection and distribution of blood products. All blood donation is done on a voluntary basis and 100% of blood collected is screened for hepatitis, HTLV I and HTLV III.
4.4. INTERNATIONAL PARTNERSHIP FOR HEALTH:
As a middle income country. T&T does not qualify for major donor assistance. The major inputs are from PAHO, UNDP and in 1993-1995 from the IDB for the financing of the design studies for the HSRP totalling about US$5.2 million. Although, the percentage of assistance is small ( about 1-2%), the impact is significant because it is usually provided in a priority area identified by the Government and in the form of technical cooperation or consultancy services which otherwise the government would be unable to source because of the inflexible national tendering and financial regulations. In the future some of this inflexibility will be removed by the HSRP, and it will be important for the MoH and the RHAs to develop new systems of identifying, allocating and utilising technical cooperation funds. International agencies are also beginning to explore ways to work with other institutions like NGOs, MoSD.
5. DEVELOPMENT OF THE HEALTH SYSTEM.
5.1. HEALTH POLICIES AND STRATEGIES:
The major inhibitions to faster formulation and implementation of national health policies and strategies over the past 3 decades have been the centralized nature of decision making in the Ministry of Health (MoH); the rigid financial and personnel regulations within the Public Health Sector; and the absence of the organisational capacity in the central MoH for this role. Progress has been made towards removing those constraints in recent years. In 1992, the Ministry of Health presented a policy document in Parliament for the Administrative Decentralization of the Ministry of Health and in 1993 embarked on the design phase of a Health Sector Reform Program (HSRP). The Regional Health Authorities (RHA) Act was aproved in 1994.
The RHA Act established 5 Regional Health Authorities - 4 in Trinidad and 1 in Tobago - as independent statutory bodies accountable to the Minister of Health. The RHAs are responsible for providing health services to a defined geographical population within national policy guidelines. The RHAs will be the employers of staff and will own and manage the land, buildings and equipment of the Region. They will operate according to negotiated annual contracts or agreements with the Ministry.The RHA population sizes vary between 100 to 390 thousand in Trinidad, and 50,000 for Tobago. Operational and financial responsibility in being tranferred to the RHAs. The Ministry of Health retains responsibility for setting the national framework and priorities through policy and strategy formulation; establishing standards and monitoring achievement of defined goals and targets by the RHAs and the budgets are being negotiated on the basis of agreed targets as determined by health needs of the population.
The Reform and regionalisation proposals entail an extensive rationalisation of the Public Health Sector in order to achieve improved efficiencies in the current system. While the proposed National Health Insurance System (NHIS) will address funding alternatives for Health in the interest of sustainability of the Health Services, it is important that rationalisation of the system occurs to some extent before adding new money to the existing system.
Since the country has a transitional epidemiological and demographic profile, with leading causes of morbidity and mortality being lifestyle-related non-communicable diseases, the Ministry will focus its strategy on promoting wellness as the most cost effective intervention for health gain. There is full endorsement of the Caribbean Charter of Health Promotion, and in its new role, the MoH will take the leadership to ensure the implementation of the strategies.
5.2. INTERSECTORAL COOPERATION:
The formal linkages between the Ministry of Health and other Government Ministries consist primarily of Inter-ministerial committees dealing with matters of health, programme and project management and of late policy formulation. Ministries and Agencies involved in the collaborative efforts include Ministry of Planning and Development (MOPD); Ministry of Local Government; Ministry of Public Utilities (to include Water and Sewerage Authority); Ministry of Education (MOE); Ministry of Social Development (MOSD); Ministry of Community Development, Culture and Women's Affairs (MOCD); and the Environmental Management Agency (EMA). The Health Sector Reform initiatives will have significant positive impact on improving the progress towards intersectoral collaboration, at both national and regional levels. There are strong links between the Health Sector Reform and Public Sector Reform Programmes, and the Ministry of Health is participating in a Cabinet appointed committee set up to monitor the reorganization of the Ministry of Social Development.
5.3. ORGANISATION OF THE HEALTH SYSTEM:
The Government has been supportive of PHC, and the MoH has continually worked on the strengthening of the institutional capacity for delivering primary care. A major constraint has been that the system of allocation of resources has been based on historical expenditure. At the beginning of the 1980s, 4 times as much was spent on hospital services as community services; in 1992, 10 times. The organization of the health system makes it very difficult to shift resources as necessary and create the appropriate referral linkages.
The main purpose of the proposed Reforms, based on the framework of regionalisation, is in keeping with the concept of District Health System. The RHA is a District Health System based on primary health care for a more or less self-contained segment of the national health system. The RHA boundaries are coterminous with the local government or administrative areas as collaboration will be essential for the rational use of support services across sectors. A key element of the Reform proposals is better primary care. In order to accomplish some of the shift of resources between hospitals and primary care, a plan for the rationalisation of hospital services has been prepared, with the overall intention to decrease the bed stock hospital sector by 800 beds by the year 2000, while at the same time increasing throughput significantly. The success of this rationalisation plan hinges on improving the primary care services and the introduction of a National Emergency Ambulance Service, since much of the inappropriate use of hospital services is due to weaknesses in these two areas.
For the successful implementation of the PHC proposals, there will be significant review, revision and redistribution of roles and functions of health institutions and health personnel. The plan calls for an almost four-fold increase in the number of persons currently working in primary care services by the year 2000, and in the context of the national health services plan, it is proposed that most of this could be done through a shift of personnel from the hospital sector to the primary care sector. A major element of the Reform will therefore be an investment in human resource development: technical training and retraining/reskilling and management development.
5.4. MANAGERIAL PROCESS:
The main thrust of regionalisation is to devolve financial and administrative authority to a local level, the RHA. The regions will be encouraged to devolve that authority, as much as possible, to the provider unit level. The process will also serve to introduce general management principles at all the service units within the region. Each region is run by a non executive Board appointed by the President, and accountable to the Minister of Health. Local Government will be represented on the Board and individuals will be selected as representatives of the Community.
RHA performance will be monitored by the MoH according to negotiated contracts or services agreements. The MoH will be the purchaser or commissioner of health services. Its main role will be that of developing an overall health strategy for the country and ensuring that it is implemented. The main functions of the MoH include: developing National Health Policy and Strategy; allocating resources; objective setting and performance review; research and development to include introduction of new technology nationally; advocacy and regulation The MoH is developing standards for quality throughout the system, and will negotiate with RHAs against those standards. The main purpose is to make services more responsive to the client. The MoH must also develop skills in determining health needs. Additionally, it must develop mechanisms to monitor and evaluate the private sector as it relates to the delivery of health care. New management structures have been put in place in all 5 RHAs and the central MoH, and over the period 1995-1997, there has been a period of transition where many organisational issues have been tested. One of the biggest challenges was that services had to continue despite the change in managerial process. A Program Administration Unit (PAU) has also been structured so as to avoid duplication of systems and resources
5.5. HEALTH INFORMATION SYSTEM:
Both the RHAs and the MoH will require improved information systems for decision making. Data are currently collected that are not effectively utilized. The development of information systems for the decentralized system is a critical component and the priorityy areas include: Medical Records, Human Resources, Finance and Office systems.
5.6. COMMUNITY ACTION:
With the regionalisation, a more genuine partnership between the community and the health system should evolve. The regionalisation will facilitate this involvement through representation on the Board, links with local Government and the emphasis on client satisfaction and determining health needs. There has recently been more effort at strengthening the relationship with NGOs through workshops, projects and dissemination of information as well as continued support through Government subventions to selected NGOs for the provision of services. The Health Education Division has continued to support the goals of the Ministry of Health in the dissemination of information, and several initiatives in collaboration with the community are ongoing, including cholera awareness program, Breastfeeding and Healthy Communities.
5.7. EMERGENCY PREPAREDNESS:
No major natural or man-made disasters was experienced since the second evaluation. The National Emergency Management Agency (NEMA), with a full time coordinator and a committee which represents many sectors, is responsible for national emergency preparedness and relief plans. There exists a manual listing of resources which can be accessed during times of disaster. The MoH has its own Disaster coordinator for health services whose activities are to increase awareness, training, vulnerability analysis and preparation of disaster plans. Each RHA is being supported to develop its Disaster plans and this has particular significance for the Central RHA in which is located the Airport and the SWRHA which includes the Point Lisas Industrial Estate and the Petroleum Plant sites. Simulation exercises have taken place; (1) Airport simulation, 1996 (2) Disaster simulation, Point Lisas and (3) Community simulation in South Trinidad, 1990. Anticipated problems identified include (a) Transport and (b) Communication.
5.8. HEALTH RESEARCH AND TECHNOLOGY:
Under the HSRP, the MoH has undertaken a significant amount of Health System Research. The methodologies will be formalized under the new role of the MoH within the Policy, Planning and Health Promotion Department of the new MoH - which will have the responsibility for generating the information necessary for the identification of priorities and planning of services. A Research and Development function will also be developed which will include technology assessment. A National Health Status Survey was completed in 1995 in order to provide the baseline indicators at the start of the Reform. The National Institute for Higher Education, Research and Technology (NIHERST) has also been mandated to produce a policy framework for the introduction of new technology in Trinidad and Tobago. A draft policy was issued in 1996 and a final version is expected in 1997. A national level committee, the Essential National Health Research Committee (ENHRC), was also convened in 1996, to address National Health Research. One of its responsibilities is to develop a system for the coordination of health research in Trinidad and Tobago. It comprises both public and private sector doctors and its first mandate is to develop a national health research policy.
6. HEALTH SERVICES.
6.1. HEALTH EDUCATION AND PROMOTION:
The Health Education Division is now linked to health planning in a new Directorate of Policy, Planning and Health Promotion that advises on national health policy. Implementation will take place locally within the Regional Health Departments. This has given rise to a number of interventions. The concept of Health Promotion and the Caribbean Charter of Health Promotion was presented to a group of community and non-government organizations, followed by a series of regional workshopsa and a plan for the prevention of non-communicable diseases.
6.2. MATERNAL AND CHILD HEALTH/FAMILY PLANNING:
From 1990 to 1994, the number of livebirths and still births declined by approximately 17%. Despite this fall in demand and that antenatal services are available to mothers with no charge in the public sector, there has been a decrease in coverage by the antenatal services at the health centre from 66% in 1987 to about 63.5% in 1994. Less than 5% of births were delivered in the private sector but the percentaje of women seeking prenatal care in the private sector is increasing. Economic costs of private deliveries however will make them seek care in the public clinics closer to full term. Total visits are declining but the average number of visits per pregnancy was maintained at six. Neither fetal loss before 28 weeks is notified nor abortion rates, so that livebirth and stillbirth data are used as surrogate for pregnancy rates. Between 1 and 1.5% of deliveries are estimated to be attended by untrained attendants. The General Fertility Rate fell from 91.03 in 1988 to 73.49 in 1991. Family planning services are provided in the Government Primary either as separate sessions or integrated with post-natal services. The National Family Planning Association also provides family planning services. The last survey carried out in 1987 estimated the family planning uptake rate at about 37.4%. The age specific fertility rate for 15-19 year olds fell from 84.0 in 1980 to 59.8 in 1992. By 1994 it was 45.9. These pregnancies represented 13.5% of all pregnancies. The importance of targeting this age group is recognised, but there are no programs at present geared to this age group in the public health sector. The Ministry of Education develops some action in this areas through the Family Life programs, and other projects like the Youth Self Esteem Project. A population policy has been prepared addressing family planning and the related social and cultural issues. The Government funds family planning clinics in most of its health centres but supplies have been a problem in the last few years causing a 30% drop in utilization rates. The Family Planning Association offers subsidized interventions such as tubal ligations and vasectomies. Both organizations offer family life education in schools and workplaces but religious agendas often conflict.
Immunisation programmes are well organised and continue to have consistently high rates of coverage. The program is well monitored, and benefits from being one criterion for acceptance at the school. Drop outs and missed opportunities are usually picked up at this stage. No reliable data are available for Hepatitis B Vaccine coverage, which is made readily available to staff in the Public Health Sector and can be purchased in the Private Sector. In 1994, 8758 (69%) women attending Government primary care clinics for antenatal care were immunized against Tetanus during their pregnancy. This represents 60% of all pregnancies.
6.4. PREVENTION AND CONTROL OF LOCALLY ENDEMIC DISEASES:
The Surveillance System, particularly as it relates to diarrhoeal diseases and Cholera prevention, was reviewed in 1992 by the Ministry of Health. Under and late reporting still remains a problem, and recommendations were made with respect to improving the feedback mechanisms to encourage provider participation. National shortage of resources prevent the full implementation of these recommendations. Active surveillance in sentinel health centres and the major hospitals as well as the use of sentinel physicians are employed in the effort to improve the quality of information.
The following diseases are under surveillance: Cholera, plague, yellow fever, AIDS, malaria, influenza, tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, measles, rubella, tetanus neonatorum, acute haemorrhagic conjunctivitis, dengue, encephalitis, diarrhoeal diseases, gonococcal infections, Hansen's disease, herpes zoster (shingles), leptospirosis, meningitis, meningococcal infections, human rabies, scabies, syphilis, typhoid fever and viral hepatitis .
6.5. TREATMENT OF COMMON DISEASES AND INJURIES:
Treatment for common diseases is readily available from a network of 102 health centres, 7 hospitals and approximately 400 private general practitioners. Public centres are free, including diagnostic and pharmaceutical supplies. Results from the Survey of Living Conditions show that about 50% of clinical care is now being provided in the private sector, from which no reliable data on treatment provided are currently collected. Therefore, no population based data on treatment and clinical coverage are available. Primary clinical care coverage is accessible with 1 health centre per 11,000 population and 1 general practitioner per 2500 population. Some of the health centres are ineffectively utilized due to lack of financial and human resources. This contributes to heavy utilization of emergency units especially in the urban areas.
7. TRENDS IN HEALTH STATUS.
7.1. LIFE EXPECTANCY AND MORTALITY:
Life expectancy at birth has risen from 53 years for males and 56 for females in 1946 to 66.9 years for males and 71.6 for females in 1980. The gains since then have been smaller and for 1990 the values were 67.9 years for males and 72.7 for females. Life expectancy at age 65 has shown a much smaller growth: from 10.1 years for males and 12.7 for females in 1946 to 13.2 years for males and 15.6 for females in 1990.
The registered infant mortality rate has oscilated between 11 and 13.8 per thousand live births in the period from 1985 to 1994. The highest value was registered for this last year. The estimated perinatal mortality rate for 1994 was 22 per one thosand live births. The registered maternal mortality rate for 1975 was 120 per 100 thousand live births. The rate decreased to 80 oer 100 thousand live births in 1980 and 40 in 1985. It has increased to 50 per 100 thousand live births in 1990 and to 75 in 1004. Heart disease is responsible for 40% of all deaths with a rate of 193.1 per 100 thousand population for both sexes in 1994. Other important causes of death are cancer (rate of 94.9 per 100 thousand population), diabetes (90.6), stroke (82.2), communicable diseases (60.6) and injuries (53.1). In terms if years of potential life lost below 65 years of age for males, injuries represent 31.5% of the total, communicable diseases 18.6%, heart disease 12.0% and cancer 8.0%. For females the percentajes are 16.1% for cancer, 14.3% for communicable diseases, 14.2% for heart disease and 14.6% for injuries.
Studies in the 70s reported a prevalence of Diabetes of 13%. In 1995, the National Health Survey reported a prevalence of self reported diabetes of 9.6% for males 35 years and over and 12.6% for females. Diabetes occurred more frequently in persons of East Indian descent. Surveys indicate a prevalence of hypertension of 27% in persons 35 years and over. In the National Health Survey, 1995 self reported hypertension was 18.2% in males and 28.1% in females. The only significant risk factors were a family history and BMI>30. Seven percent of respondents 35 years and over in the National Health Survey, 1995 reported that they had had a heart attack. The prevalence rose to 12% after age 65. Nine percent of persons over 65 reported having experienced a stroke. A history of hypertension was the most significant risk factor (OR 6.5) and age over 65 (OR 3.8). For communicable diseases, 55 cases of leprosy were reported in 1994 and 36 in 1995, malaria 19 and 20, respectively, measles 18 and 57, tuberculosis 105 and 125.
Self-reported disability (all kinds) in the National Health Survey of 1995 was 10.2% for males and 14.7% for females in the group aged 15 to 24. The percentajes increse steadily to 45.6% for males and 55.2% for females aged 65 years and more.
8. OUTLOOK FOR THE FUTURE.
8.1. OVERALL ASSESSMENT AND STRATEGIC ISSUES:
Over the last two decades, Trinidad and Tobago has made substantial progress in controlling communicable diseases and reducing infant mortality. The country is now well into the demographic and epidemiological transitions, resulting in a shift in the major causes of morbidity and mortality toward chronic conditions and non-communicable diseases. Injuries, especially traffic accidents, also represent a major cause of years of life lost and hospital admissions.The sustainability of these successes may be at risk, since the system is unable to respond in a timely and cost effective manner to the changing needs of the population. The main effect of the inability of the system to respond to these new needs has been a lack of resources to the more cost effective public health interventions like health promotion. There has also been a significant growth of an unregulated private sector over which the MoH has little influence and from which little information is received to reflect the national health situation. The end result is increasing household expenditure on health care with little evidence that health status improves proportionately. This analysis formed the foundation of the design phase of the HSRP.
8.2. FUTURE VISION AND PROPOSED STRATEGY FOR RENEWING HFA - INSTITUTIONAL REFORM OF THE MOH:
The major change that is needed in the interest of sustainability is the assumption of new roles and functions by the different players in the sector. The change will involve shifting authority and responsibility from both central to local and from local to provider unit levels. New partners or alliances will emerge with the private sector or non-governmental sector in terms of providing services and new ways of working with communities and individual users of the services will be required.
At the RHA level, there is a big pool of managerial resources who are very aware of what needs to be done both for the staff and the communities but who have not been empowered to match the use of resources to their needs. For service delivery to be improved, RHA staff will also have to be encouraged to push autonomy as far as it is possible to the provider unit level.
In terms of the actions and strategies required for renewing HFA after 2000, the implementation of many programs in the health sector will be eased by the decentralisation strategy, however, the multisectoral/intersectoral policy framework for health must be established at Central Government level by a new MoH who is empowered to do that job. It will also be critical for the links to be made to Public Service Reform and to support the institutional strengthening of other key Ministries in like roles and functions like the new MoH.