CNCD conundrum: Chronic mismatch in health services

KENWYN NICHOLLS

THE MAIN task of any healthcare system is to provide healthcare services demanded by the population. That the TT health system was “underperforming” in this regard goes as far back as 1988. Although not appreciated then, TT’s health system, as was the case in most developing and developed countries, was already in a struggle to meet 21st century challenges: a longer living population afflicted by largely preventable conditions that are lifestyle-related and socially determined.

The system in place at the time (which, unfortunately, still exists today) was appropriately geared towards acute hospital-centric care, a response to the 20th century challenges posed by infectious disease.

An IDB-funded study performed by foreign-based consultants in 1993-94 revealed the underperformance was, in fact, a mismatch between public healthcare services demanded by the population and what was and had been supplied by successive governmental bodies over the years.

A final report from the contracted consultants (comprising 27 documents) was tabled in 1994. The documents included a national health services plan (NHSP), as the guiding document for the reforms, that detailed how and when changes recommended in the other 26 documents were to be instituted. The health sector reform programme (HSRP) came into being.

In 1996, the IDB approved US$192 million in loan financing (including US$32 million of counterpart funds provided by the government) to rationalise the existing services based on the framework developed by the consultants; the Ministry of Health was the executing agency.

Central to the proposed radical reform of the system was the passage of the Decentralisation Act of 1994 to achieve a patient-driven, bottom-up system that would bring customers (patients) closer to the services: regional health authorities (RHAs) were created. To ensure cohesion in service delivery, the ministry would itself undergo reorganisation to assist policy development, planning, regulating, financing, and monitoring and evaluation of the RHAs.

In respect of service delivery, the HSRP placed emphasis on prevention and health promotion at the primary level with a particular focus on primary-level management of chronic diseases. Why the HSRP did not achieve this latter objective is irrelevant to the intent of this article. Interested parties will find that post-mortems on the fate of TT’s HSRP abound in the relevant literature.

In 2007 the Gafoor Report, the product of a commission of enquiry (CoE) on the TT health services, found a multitude of inefficient services and processes – lab, X-rays, pharmaceuticals, etc – and recommendations were made to correct those deficiencies. In 2015, the incoming government appointed a committee to look into the state of the public health services. The Welch Report was laid in Parliament in 2017 but was not debated.

Fast-forward to November 19, 2023. At a meeting convened by the Joint Select Committee for Social Services and Public Administration, patients and nursing staff offered stories of staggering administrative inefficiencies, long waits for critical medical procedures, lost files, and RHAs struggling to deliver quality care. Bottom line: public health services had continued to underperform over the years, and no one, not even the lawmakers, was happy.

What has become apparent is that little had changed in the delivery of public health services going back to the mid-1990s. Overloaded public hospitals; long wait times for labs, X-rays and specialist consultations; reduced efficiency of health service delivery and so on signal that the system is overburdened. Hospital-centric care is unsuited to provide the continuous care needed for patients with chronic disease, let alone address the socio-economic norms associated with an ageing population.

The full-page colourful ads in the daily newspapers trumpeting the number of patients seen at A&E, and the number of those that were followed-up by hospital doctors and nurses in their homes, are not examples of compassionate, customer-focused healthcare as emblazoned on the ads, but rather a testimony of failure to develop what is required: the integrated, person-centred system that emphasises life-long primary care that is closer to the community.

It gets worse. Failure to confront and control NCDs (non-communicable diseases), already at epidemic levels in TT, means excess morbidity and mortality. The domino effect kicks in: medical beds in the nation’s hospitals are overcrowded with patients with cardiovascular events including myocardial infarction, congestive heart failure and strokes; eye wards – patients with retinal disease at high risk for blindness; orthopaedic wards with lower-leg amputees; all consequences of poor or inadequate treatment of their diabetes/hypertension at an earlier stage in the community.

Finally, in my previous letter I raised the issue of worsening equity in the overall health system since in TT, as elsewhere, globally people of lower socio-economic status have a higher incidence of CNCD (chronic non-communicable diseases) but were experiencing lesser access to quality care (Trinidad Express, 8/12/2023). Now, according to a high official from the TT Cancer Society, not having monetary resources to access private-sector care could be deadly. This is totally unacceptable.

Thirty years have passed since TT uncovered that the ills of the health system were related to its inability to effect the transformation needed to meet 21st century challenges. All the ingredients are, and have been, there to make the needed adjustments as described earlier.

It is mosquito season. With infectious diseases looming, further delay is not an option.