Health and Strength: The Public Healthcare System of Trinidad and Tobago (2016)
The Republic of Trinidad and Tobago is a small, twin-island developing nation. With a GDP of US$32 800 per capita(CIA World Factbook, 2015)– the current exchange rate puts US$ 0.15 to TT$ 1, Trinidad and Tobago is considered a middle-income country. Like many middle-income countries, it grapples with wealth disparity amongst the population, and corruption, mismanagement, and inefficiency in government, with the health sector being no different. This paper will explore the public health system framework in Trinidad and Tobago, its successes and challenges specifically through the lens of maternal mortality, and suggestions for improvement, based on Australia’s Medicare, their universal healthcare system.
Trinidad and Tobago’s Public Healthcare System
Trinidad and Tobago offers universal free health services at a number of government-financed, regionally-run institutions. The Government of Trinidad and Tobago funds the public health care system through taxes and other national revenue. Patients do not pay any out of pocket fees for the services they receive at public institutions. Since the Regional Health Authorities Act of 1994, these health services are provided and managed by 5 Regional Health Authorities (RHAs) across the nation. The Ministry of Health allocates an annual budget to each RHA, which is distributed and managed by the RHA’s chairman. In turn, RHAs submit quarterly reports on spending and performance. The 2016 budget for the Ministry of Health was TT$ 4 835 784 248, which includes personnel expenditure, subsidies, and goods and services, and accounted for 7.28% of the 2016 national budget (Government of Trinidad and Tobago Ministry of Finance, 2015).
Under the RHAs, there are 9 hospitals, 9 regional health facilities, and 96 health centres. There is a strong focus on primary care, and health centres offer basic dental care, vaccinations, peri- and neo- natal care, outpatient psychiatric and psychological care, family planning services, dermatological services, urgent care, and general internal medicine. Among the 9 public hospitals, there are four specialised hospitals: maternity, psychiatric, thoracic, and a combined facility for radiotherapy, physical medicine and gerontology (PAHO, 2008). A 2015 estimate reported 2.7 beds per 1000 persons (Oxford Business Group, 2015). Prescriptions written and filled at public facilities are provided for free, as long as they are available. Additionally, RHAs manage the Chronic Disability Assistance Programme (CDAP), which provides a formulary of medications for chronic illnesses ranging from depression to diabetes that are provided free of charge to prescribed public system patients nationwide, both at public and private pharmacies. At TT$ 3 135 343 100, these and other subsidies account for the largest part of the Ministry of Health’s budget.
The public healthcare system is notoriously understaffed. According to 2007 data from the CIA World Factbook, there are 1.18 physicians per 1000 persons. As a developing nation, Trinidad and Tobago is heavily affected by brain drain, and the public health sector is particularly vulnerable, as students who study abroad often settle there. Those who do not emigrate often choose private institutions because of better pay and benefits. In an effort to bolster the numbers of medical professionals, the government has employed various schemes. Since 2003, the Government of Trinidad and Tobago has had a partnership with the United Nations Volunteer programme to provide doctors and nurses (Health in the Americas, 2012). There are also a number of intergovernmental partnerships, namely with Cuba and India, and it is common to be seen by a Cuban nurse or Indian doctor. There have been significant efforts to bolster the sector through education as well, and a number of the tertiary institutions offer courses in nursing, dentistry, and pharmacology.
The public’s trust in the system is less than optimal, with a 2014 study reporting that only 35% of citizens have fair or great trust in the healthcare system (Peters and Youssef, 2014). For those that can afford it, private care is often prefered over public care namely because of the shorter wait times and more attention and care from the physician in private institutions( Rudzik, 2003).
While there are a number of private hospitals and providers, there is little to no data on the amount or demographics of people who use the service, though there is a distinct class divide between public versus private care use. According to Rudzik’s 2003 study, more than two thirds of the patients using the public healthcare system at the primary level (i.e. at health centres and facilities) were not employed outside of the home, and 50% had an annual income below TT$ 10 000 (approximately US$ 1500) (Rudzik, 2003). The mean income for the study was TT$ 1245, further highlighting the economic status of patrons of the public health system.
Maternal Mortality in Trinidad and Tobago
The underlying issue of understaffing can be seen succinctly in the scope of maternal mortality. Maternal mortality is defined as “ death of a woman while pregnant or within 42 days of termination of pregnancy” (WHO). Maternal deaths can be attributed to abortion, embolism, hypertension, sepsis, other direct causes, and indirect courses (Says et al, 2014). Says et al. published a systematic analysis to determine the largest causes of maternal death worldwide. Their analysis reviewed data from over 79 countries from 2003 to 2009, and found that indirect causes and haemorrhage were the leading causes of maternal deaths worldwide.
The reported data estimates in Kassebaum et al.’s 2014 review help frame maternal mortality rates on a global scale. Kassebaum’s data was estimated using various statistical methods, including the Cause of Death Ensemble model.
Table 1
2013 estimates of maternal mortality ratios from select countries and regions.
| Maternal Mortality Ratio per 100 00 live births for 2013 | |
| Worldwide | 209.1 (186.3 – 233.9) |
| Developed countries | 12.2 (10.4 – 13.7) |
| Developing countries | 232.8 (207.3 – 260.6) |
| Caribbean | 150.0 (40.1 – 64.2) |
| Trinidad and Tobago | 49.7 ( 36.4 – 65.6) |
| Australia | 4.8 (3.7 – 5.9) |
| United States of America | 18.5 (14.8 – 22.9) |
Source. Author generated; data from Kassebaum et al.
Note. Data in parentheses are 95% uncertainty levels.
In Trinidad and Tobago, the maternal mortality rate currently stands at 63 deaths per 100 000 live births (2015 estimate, CIA World Factbook), a drastic rise from the 2009 rate of 16.1 per 100 000 live births. In 2015, there were a number of highly publicised maternal death cases within the public health system, bringing national attention to the issue. Two such cases were that of Keisha Ayers, 24, and Rose Gordon, 34. Ayers died in April of 2015, a week after giving birth to her first child, and numerous complaints about stomach pain and severe vomiting. The autopsy revealed that Ayers had an infection caused by the 13 gallstones in her bladder, and the cause of her death was attributed to bilateral pulmonary thrombo-emboli, and deep vein thrombosis (Dowlat, 2015). Gordon died in January of 2016 after delivering her baby via C-section at the Tobago Regional Health Authority’s Scarborough General Hospital. The initial press release described Gordon as “a high risk patient” (Thompson-Forbes, 2016), and the subsequent autopsy attributed her death to collapsed lungs, preeclampsia, and hypovolemic shock “due to blood loss from the vessels that were severed … in the right and left broad ligaments” (Williams, 2016). Gordon’s death aligns with Says et al.’s regional results, which place haemorrhaging and hypertension as the leading causes of maternal deaths in Latin America and the Caribbean.
The tragic and ultimately avoidable deaths of these two women succinctly capture some of the challenges Trinidad and Tobago’s public healthcare system faces. In the case of Rose Gordon, three physicians were suspended following her death, including one of Tobago’s only two obstetric-gynecologists. While the doctors were investigated, the integrity of such an investigation is compromised when there is so little choice. In the case of Keisha Ayers, her gallbladders suggest a lack of consistent perinatal monitoring, another outcome of an understaffed and inefficient system. After her surgery, she was shuffled between her home and the hospital and given inadequate care and attention, despite her repeated complaints of pain and vomiting in the week following the birth. Even though the public healthcare system offers services that should prevent tragedies like this, how can a system so vastly understaffed and undermanned respond effectively?
Healthcare and Maternal Health in Australia
Much like Trinidad and Tobago, Australia has a two-tiered healthcare system with both public and private providers. Currently, the Australian maternal mortality ratio stands at 6 per 100 000 live births (CIA World Factbook, 2015). The leading causes of maternal deaths are infections, cardiac deaths, embolism, and haemorrhage, and there has been a decline in eclampsia related deaths (Kildea et al., 2008). Australia’s healthcare is considered one of the best in the OECD. All Australian citizens and permanent residents are eligible for free healthcare through Medicare, Australia’s national healthcare scheme. Like Trinidad and Tobago, universal health coverage is funded through taxes. The system is decentralised with state and territory governments being responsible for the running of their systems. Funding comes from both the Commonwealth government and state and territory governments.
At the provider level, practitioners can opt-in on the Medical Benefits Schedule (MBS). With the MBS, there are set fees for services and items covered by Medicare, and the government reimburses the practitioners. Within this system, providers can set their fees at higher than the MBS, and the patient then pays the difference out of pocket or with private insurance. Providers also have the option of bulk billing– charging the government directly for the service– or charging the patient, who is then reimbursed 100% of the schedule fee. The latter has been made easier with the advent of electronic claiming (mydr.com.au).
The structure of the Australian health system makes this a much easier process to regulate. There is a register of all practitioners and providers, and a well developed database that is accessible through the patient’s health card. Their more efficient system allows for better maternal health outcomes because patients are better monitored, and accessing resources is easier.
Suggestions for the Trinidad and Tobago Health Sector
Trinidad and Tobago’s public health system and maternal health outcomes would be improved by incorporating elements of Australia’s Medicare system. Despite various governments’ promises to implement a national health insurance scheme, such a programme remains yet to be seen. In 2015, a national health card was introduced with the intent of making access to public health sector services easier, and reducing the incidence of fraud. This health card offers an opportunity to improve data infrastructure. With an improved data infrastructure, the risk of patients falling through the cracks is reduced because their health records will always be accessible. In terms of providers, a registry of providers and practitioners and something similar to Australia’s Medical Benefits Scheme could prove to be a possible solution to the labour shortage within the public health sector. In the short term, it would reduce the pressure on the public sector, and in the long term, it would encourage doctors to remain and work in Trinidad and Tobago. In addition to a registry of practitioners, there would also need to be consistent quality control in both the public and private sectors. Practitioners ability to choose the final cost of their services would encourage healthy competition without compromising the quality of services that patients receive or the revenue the doctors earn. It would also potentially reduce the socioeconomic disparities in healthcare access that are so prolific now.
Trinidad and Tobago recently held their national elections, and the new government is ambitious and eager to prove their worth. Perhaps with this new government, there will be effective policy changes to help the Trinidad and Tobago health system achieve its full potential. This transitionary period may be the opportunity to finally implement the National Health Service, a promise that has been in the works for over 15 years, and passed through at least five changes of government. Women and the working class would benefit exponentially.
References
“Australian Health System: How It Works – myDr.com.au.” Resource. Accessed May 1. http://www.mydr.com.au/first-aid-self-care/australian-health-system-how-it-works.
Dhalai, Richardson. 2016. “Docs Feel ‘Discomfort’ over Docs’ Suspensions.”Trinidad and Tobago Newsday, January 10.http://www.newsday.co.tt/news/0,222345.html.
Dowlat, Rhondor. 2015. “Autopsy on First-Time Mom Shows 13 Gallstones Led to Infection.” Trinidad Guardian, April 21, sec. News.http://www.guardian.co.tt/news/2015-04-20/autopsy-first-time-mom-shows-13-gallstones-led-infection.
———. 2016. “New Mom Dead after C-Section at Mt Hope.” The Trinidad Guardian Newspaper, April 20.http://www.guardian.co.tt/news/2015-04-19/new-mom-dead-after-c-section-mt-hope.
“Draft Estimates of Expenditures for the Financial Year 2016.” 2016. Government of Trinidad and Tobago Ministry of Finance. Accessed April 25.http://www.finance.gov.tt/budget-statement-2016-presentation/.
“Health Care System and Health Policy in Australia.” 2016. Accessed May 4.http://www.commonwealthfund.org/grants-and-fellowships/fellowships/australian-american-health-policy-fellowship/health-care-system-and-health-policy-in-australia.
“Health in the Americas, 2012 Edition: Trinidad and Tobago Volume.” 2012.Pan American Health Organisation.http://www.paho.org/saludenlasamericas/index.php?option=com_docman&task=doc_view&gid=149&Itemid.
“Health Systems Profile, Trinidad & Tobago. Monitoring and Analizing Health Systems Change / Reform. Third Edition.” 2008. Essential Medicines and Health Products Information Portal, World Health Organisation. October.http://apps.who.int/medicinedocs/en/d/Js18708en/.
Kassebaum, Nicholas J, Amelia Bertozzi-Villa, Megan S Coggeshall, Katya A Shackelford, Caitlyn Steiner, Kyle R Heuton, Diego Gonzalez-Medina, et al. 2016. “Global, Regional, and National Levels and Causes of Maternal Mortality during 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013.” The Lancet 384 (9947): 980–1004. doi:10.1016/S0140-6736(14)60696-6.
Kildea, S, Wendy Pollock, and L Barclay. 2008. “Making Pregnancy Safer in Australia: The Importance of Maternal Death Review.” The Australian & New Zealand Journal Of Obstetrics & Gynaecology48 (2): 130–36.
Michael C. Belcon, Nasar U. Ahmed, Mustafa Z. Younis, And Moye Bongyu. 2009. “Analysis Of National Healthcare Systems: Searching For A Model For Developing Countries – Trinidad And Tobago As A Test Case” Public Administration & Management 14 (1): 40–74.
Peters, Dexnell, and Farid F. Youssef. 2014. “Public Trust in the Healthcare System in a Developing Country.” The International Journal of Health Planning and Management, December, n/a – n/a. doi:10.1002/hpm.2280.
Rafeeq, Hamza, and Rosemarie Paul. 2000. “Health Sector Reform in the Republic of Trinidad and Tobago.” Revista Panamericana de Salud Pública 8 (1-2): 61–68. doi:10.1590/S1020-49892000000700023.
Rudzik, Alanna E F. 2003. “Examining Health Equity through Satisfaction and Confidence of Patients in Primary Healthcare in the Republic of Trinidad and Tobago.” Journal of Health, Population and Nutrition 21 (3): 243–50.
Say, Lale, Doris Chou, Alison Gemmill, Özge Tunçalp, Ann-Beth Moller, Jane Daniels, A Metin Gülmezoglu, Marleen Temmerman, and Leontine Alkema. 2014. “Global Causes of Maternal Death: A WHO Systematic Analysis.” The Lancet Global Health 2 (6): e323–33. doi:10.1016/S2214-109X(14)70227-X.
“The World Factbook.” 2016. Accessed April 25.https://www.cia.gov/library/publications/the-world-factbook/geos/td.html.
Thompson-Forbes, Cassandra. 2016. “Tobago Mom Dies after C-Section.” The Trinidad Guardian Newspaper, January 4.http://www.guardian.co.tt/news/2016-01-04/tobago-mom-dies-after-c-section.
“Trinidad and Tobago’s Public Health Care System Works to Expand Services While Coping with Labour Shortages.” 2015. Oxford Business Group. August 10.http://www.oxfordbusinessgroup.com/overview/trinidad-and-tobagos-public-health-care-system-works-expand-services-while-coping-labour-shortages.
Williams, Elizabeth. 2016. “Three Physicians Suspended.” Tobago News, January 12.http://thetobagonews.com/eng-en/index.php/home/headlines/item/1470-three-physicians-suspended.