Like much of the English-speaking Caribbean, Trinidad and Tobago’s health care system takes inspiration from the UK’s National Health Service. Funded by the national budget, the system provides universal coverage at primary, secondary and tertiary levels, with the Ministry of Health (MoH) responsible for planning, monitoring and evaluating the system and allocating resources to the country’s five Regional Health Authorities (RHAs). Since their creation in 1994 these agencies have been tasked with health care provision at the local level. The two largest, namely, the North West RHA and the South West RHA, each serve some 500,000 residents in Port of Spain and the San Fernando region, respectively. In total the public health service comprises 10 hospitals, 97 health centres and nine district health facilities.
These facilities mean there are 2.7 hospital beds for every 1000 citizens in T&T, only slightly behind the US figure of 2.9 and well above most Latin American and Caribbean nations. However, the country’s 47.4 skilled health care workers per 1000 population is roughly on par with Mexico, and well behind the US (122.7), Brazil (94.9) and Barbados (66.7), according to 2016 data from the World Health Organisation (WHO). In addition to the public health system there is a parallel private system consisting of 10 medical institutions with the capacity to accommodate 39,000 patients. Some 14% of T&T citizens have a private health care plan. According to the World Bank, T&T spent 6% of GDP on health care services in 2014.
In The Pipeline
The newest health care facility in T&T is Acropolis Health Centre, a private facility which opened its doors in February 2016 in San Fernando. “We see strong growth opportunities in corporate care,” Eddison Doyle, the centre’s CFO, told OBG. Two state-owned hospitals are also under construction – the 100-bed Point Fortin Hospital and Arima Hospital – although development of the latter has been scaled back as a result of the economic slowdown. In June 2016 the government announced the number of beds at Arima Hospital, would be lowered from 150 to 110, thus reducing the construction bill from TT$1.5bn ($224.1m) to TT$1.2bn ($179.3m). In his budget speech of September 2016 Colm Imbert, the minister of finance, announced that construction of both hospitals was under way, and that the government was looking to finalise long-term financing arrangements for the facilities.
Thanks to universal coverage T&T performs well in a number of key health indicators. According to the latest available WHO data, 100% of births were attended by trained health care professionals in 2014. Furthermore, between 1990 and 2015 infant mortality rates dropped from 20 per 1000 births to 13. Over 90% of infants receive three doses of the hepatitis B vaccine, and major communicable diseases, such as polio, measles and rubella, have been eradicated, while neonatal tetanus cases fell from 160 at the turn of the century to 10 by 2014.
However, T&T falls behind other regional countries in one key indicator – life expectancy – which stands at 71.2 years (66.6 for men and 73.9 for women), among the lowest in the Americas. Increased wealth and changing lifestyles have led to a rapid rise in the number of citizens on the islands suffering from non-communicable diseases (NCDs). Questions of how to provide treatment and fund the health care system in this new epidemiological situation are central to the development of health policy in T&T today.
Communicable diseases do occasionally present new challenges to health officials. In February 2016 the first confirmed case of Zika was diagnosed in Trinidad, and by June the virus had spread to Tobago. The rate of infection accelerated over the course of the year. Diagnosed cases reached 489 by September 2016, but many thousands of cases were presumed undiagnosed. Among pregnant women, the group most at risk from the disease, the number of diagnosed infections reached 144 in August of that year, according to data from the Caribbean Public Health Agency. By the following November more than 20 babies born with abnormalities resulting from the Zika virus had been identified, according to Dr Karen Sohan, a local authority on obstetrics and gynaecology.
Despite the spread of the disease, health authorities earned praise from the Pan American Health Organisation (PAHO) for reacting quickly to the Zika threat and introducing policies without which the rate of infection could have been far higher. “T&T was ahead of the game, declaring a public health emergency in January 2016, even before it was declared an emergency by the WHO,” Edwin Bolastig, advisor of health systems and services for PAHO/WHO, told OBG. “Following experiences with similar diseases, such as Chikungunya and Dengue, and seeing the spread of the disease in the Caribbean, the authorities in T&T declared early, and they were ready.”
In addition to spraying campaigns to target adult mosquitoes, authorities focused on vector control and cleaning up areas to eliminate mosquitoes in the larvae stage. Public health legislation was revised to increase the fine for unkempt properties that could become mosquito breeding grounds from TT$500 ($74.71) to TT$3500 ($523) and health inspectors were tasked with identifying and sanctioning property owners who failed to comply. Community awareness programmes and regular high-level media campaigns also helped bring the virus under control, according to Bolastig. The MoH also worked with PAHO to bring in sonographers from the US to help scan pregnant women and provide training to local sonographers, radiologistsand neonatal care unit physicians. PAHO also provided second readings for suspected abnormalities in babies from its US-based radiographers. “We recommended that the MoH work to improve ultrasound training and the capacity of sonographers and radiologists to recognise abnormal foetal cranial anatomy, and they are being acted upon right now,” Bolastig told OBG. HIV/AIDS: The other communicable disease that remains an ongoing concern for T&T is HIV. Between 1983 and 2014 there were a total of 27,207 new cases of HIV infection in the country, with 710 cases reported in 2015 – a 51% drop on the 2005 figure of 1453 – according to local press reports. Over the same period there were 6589 cases of AIDS and 4167 AIDS-related deaths. With a total of 11,500 HIV sufferers, T&T is among the five Caribbean countries – along with Jamaica, Cuba, Dominican Republic and Haiti – that account for approximately 96% of the region’s cases. Following a global trend, the demographic constituting the most new cases of HIV infection was young women between the ages of 15 and 24.
One of the foremost challenges facing effective treatment of the disease is the apparent reluctance of T&T’s citizens to go to public testing sites, either because of the length of the process or for fear of victimisation. Speaking at a HIV symposium in Port of Spain in March 2016 Annmarie Libert De Four, HIV and AIDS coordinator at MoH, said, “We have a lot of young females who do not want to go to the health centres because they may see health care providers who they feel would not understand what they are going through.” However, T&T has performed well at preventing vertical transmission of HIV, and for the last five years has maintained a 2% infection rate for every 100 babies born to HIV-positive mothers. “T&T has developed a very proficient antenatal programme, and has been able to capture pregnant women for testing,” Bolastig told OBG. Between 2009 and 2014 the number of pregnant women tested for HIV rose from 12,325 to 19,208 in the country, with positive tests peaking at 233 in 2012 before dropping to 162 in 2014, according to data from UNAIDS.
The new government has also returned the national HIV Coordinating Unit to the office of the Prime Minister. The unit had previously been under the purview of the MoH. Health experts have recognised this as a welcome move, given the inter-ministerial approach required to tackle the issue. T&T also follows the 90-90-90 targets set by UNAIDS for the year 2020, which aim for 90% of infected people to have awareness of their condition, with 90% of that group receiving anti-retroviral drugs and 90% of those under treatment having a viral load at a level wherein the patient is considered to be HIV free. In late 2016 Terrence Deyalsingh, minister of health, said T&T would access funds available from the US government through its President’s Emergency Plan for AIDS Relief in order to tackle HIV, telling local press, “we need every dollar in the fight against HIV/AIDS.”
By far the biggest challenge for the T&T health sector, however, is the rise in NCDs. According to 2012 data from the WHO, the probability of a T&T citizen dying from the four main NCDs – cardiovascular disease, cancer, respiratory diseases and diabetes – was 26.2%, the second highest in the Americas. The islands’ increasing wealth and resulting sedentary lifestyles of its citizens has led to a rapid rise in obesity rates. A 2013 report by the UN Food and Agriculture Organisation listed T&T as the sixth-most obese country worldwide with an adult obesity rate of 30%. “T&T faces a major challenge with regards to NCDs, and obesity is the biggest precursor to contracting an NCD,” Dr Akenath Misir, the country’s chief medical officer, told OBG. “Almost two-thirds of the current health care budget is designated to dealing with NCDs.”
Tackling the NCD crisis is complicated by a lack of statistical data. The latest figures, which date from 2007, show heart disease accounted for 45% of NCD deaths in T&T, followed by cerebrovascular diseases (27%) and hypertensive diseases (11%). At a July 2016 media conference on the state of the health sector, Deyalsingh said that the MoH would convert the cancer registry to include records of NCDs, and that the collected data would inform school intervention programmes and improve screening processes for cancer patients.
To date, the MoH has focused its response to rising NCDs through the provision of secondary and tertiary care in the shape of the Chronic Disease Assistance Programme (CDAP). Under the scheme, patients suffering from diabetes, cardiac diseases, glaucoma hypercholesterolemia, Parkinson’s disease and other NCDs have access to free prescription drugs. Since July 2015 citizens have been able to access CDAP services and products through a National Health Card, a smart card that registers and records prescriptions, allowing for easy collection of medications, improving efficiency.
While CDAP drugs can extend the lives of patients, the MoH’s main aim is to reduce the incidence of NCDs. “The key focus for the coming years is to switch policy efforts towards preventative and primary care,” Misir told OBG. “The reasons for high incidences of NCDs in T&T are complex and include cultural value systems and family histories. We need a cross-ministerial approach to tackling the problem.”
Lobbying by members of the medical community for the government to increase taxes on alcohol and tobacco achieved its goal in 2016 after years of efforts. Imbert announced that taxes on alcohol and tobacco would be increased by 15% and 20%, respectively, starting from October 2016. However, T&T’s per capita alcohol consumption of 6.6 litres is close to the regional average and many health care professionals are convinced that the high sugar content of local foods holds a greater share of blame for the NCD rate. Although a “sugar tax” has yet to be proposed by the government, the idea has been raised by numerous public figures, including Asha Permanand, alderwoman of the Port of Spain Corporation. Government and health care experts are working with local food producers to encourage the reduction of sugar content in foodstuffs, with the sugar tax remaining a last resort.
However, such fiscal measures are unlikely to be the magic bullet to lower NCD rates in T&T. “Sin taxes can have unexpected consequences, with people sometimes associating higher prices with better quality,” Anton Cumberbatch, technical advisor at the Centre of Health Economics, University of the West Indies, told OBG. “We need to fundamentally reorientate T&T society, encouraging exercise, good diet and healthy ageing. This has to move beyond policy to become real activities with measurable outcomes that we can analyse in three to four years’ time.”
In July 2016 Deyalsingh announced that the MoH was working with the Inter-American Development Bank to devise a national NCD strategy, but as of January 2017 no further details had been made available. Nevertheless, on a visit to the T&T Medical Association’s annual conference in July 2016, Michael Marmot, president of the World Medical Association, said there was a “real desire in T&T to get serious about action on the social determinants of health and to improve the conditions in which people are born, grow, live, work and age.”
Budget & National Insurance
At the same conference, Deyalsingh outlined the increasing cost of treatment in T&T. Between 2005 and 2015, TT$40bn ($6bn) was spent on health care, with the annual public and private bill rising from TT$2.6bn ($388.5m) in 2009 to an estimated TT$6.08bn ($908.5m) in 2016. If costs continued to spiral, Deyalsingh said, it would soon be impossible for the government to provide the level of health care required by citizens. In the 2017 budget a total of TT$5.7bn ($980.5m) was earmarked for health care spending, up from TT$5.2bn ($777m) the previous year. While the shift to a primary care model may help reduce the incidence of NCDs in the long term, in the medium term the financial burden is set to rise. Meanwhile, citizens of T&T are increasingly seeking treatment outside of the public health service. According to WHO data from 2014, a total of 48% of health care expenditure in the country is in the private sector, with 82% of that spending being out of pocket.
An additional inefficiency of the system stems from the fact that even those citizens with private health care plans are free to use the public system and often choose to do so for some treatments, such as dialysis, which the state outsources to private providers.
“We cannot deny people care, we have universal health care. We need to move to a Costa Rica model, where private insurance is used for co-payment of treatment,” Misir told OBG. With costs set to rise, a new approach to funding the health care system is required. “In 2016 the provision of universal health care means a very different thing to what it meant in 1970,” Cumberbatch told OBG. “The demands for care of elderly and NCD sufferers have expanded rapidly. Rather than have the government pay for the entire expansion of services, we need to find supplementary financing, and the best way to do tat is by employer/ employee contributions.”
The debate around moving T&T towards a national health insurance model, predominant in Latin America and the Spanish Caribbean, has been ongoing since the 1990s. However, the election of the People’s National Movement (PNM) to government in 2015 has seen the policy gain momentum, with Imbert telling Parliament in December 2015 that a national health insurance system would be in place and operational before the end of 2018. In his 2017 budget statement in September 2016, Imbert said that the government was far advanced in determining the most appropriate health insurance model.
He also said the private sector will be engaged in the process and that, when operational, the system will allow all members of the public to access high-quality health care at any institution, private or public, regardless of their financial situation.
As well as providing services for private health plans and out-of-pocket treatments, T&T’s private clinics have been increasingly used by the public sector for outsourcing certain treatments and procedures. According to Misir, almost all dialysis, cardiac surgery and radiation treatments for cancers are provided by the private sector, and the CDAP is also delivered through private clinics. The introduction of national health insurance looks likely to be a major boost to private operators, as patients will be given greater freedom of choice.
One major area of opportunity in the coming years will be in the IT and data management segment. “Data production, accuracy and analysis is a real problem in T&T,” Cumberbatch told OBG. “Under the current system, taxes pay for health care but the spending is not linked to the delivery of services. One of the most important aspects of national health insurance is that it links payment to performance and the generation of information.” If a new information system is to be set up in T&T, it is likely to need outside support. Misr told OBG, “The private sector will play a key role in the creation of new information systems, using cloud and electronic medical records.”
The proposed introduction of national health insurance has also given momentum to efforts to increase accreditation of health care facilities and treatments across the country. At present there are no accreditation requirements in T&T, and only a few facilities catering to health insurance firms and the country’s small-scale health tourism sector have received international accreditation. The National Health Services Accreditation Authority Bill, which aims to create the infrastructure for a local accreditation process, was brought to the House of Representatives in 2013 but has yet to be passed into law.
While T&T’s health care system has displayed strong results when dealing with existing communicable diseases, such as HIV and Zika, work is still urgently needed to develop a long-term strategy to deal with rising NCDs in the nation. The switch to a national health care insurance system – with increased focus on portability of services, record-keeping and primary care – combined with an expanded role for cost-efficient private sector clinics and surgeries, would provide a strong foundation on which to build health care policy for the future.
As with other sectors of the T&T economy, the highly unionised labour force can make major changes politically difficult to pass, but the PNM’s restated commitment to national health insurance and the weight of evidence supporting calls for reform mean that public and private sector interests are beginning to converge.