Making public health probe a success

THE EDITOR: As reported in the print media, there was yet another meeting of the Joint Select Committee on Social Services and Public Accounts on June 26, as it continued its probe of manifest poor performance in TT’s public health sector. The focus this time was on long wait times in the A&E departments, and for medical testing. Invitees were CMO Dr Roshan Parasram and CEO of the NWRHA, Anthony Blake.

According to newspaper reports, the CMO’s opening salvo was that long wait times in the A&E departments of the RHAs were in part due to the prevalence of NCDs (non-communicable diseases). This apparently unflinching response is unsurprising, given that well before the turn of the century the nation’s hospital beds have been occupied by patients experiencing complications associated with NCDs.

What should have concerned members of the JSC, however, was the CMO’s follow-up remarks, which alluded to goings-on in society that further aggravated the situation; and the Ministry of Health's policy and programme “to deal with that at the primary care level through prevention.” Parasram went on to add that “it is something that takes five to ten years to be in process."

Before taking a nuanced look at the CMO's statements, it is useful to examine CEO Blake’s contribution to the debate as he sought to explain the long wait times for tests. He cited, firstly, shortage of and difficulties in retention of nursing staff that affected his institutions’ ability to achieve the desired nurse-to-patient ratios.

And, secondly, heavy patient load that resulted in overuse of critical equipment, leading to maintenance issues and subsequent breakdowns, complicated by issues with suppliers re lack of adherence to warranty clauses and obtaining replacement parts. Bottom line: extended wait times for needed tests.

The goings-on in TT society alluded to by the CMO were the ministry's efforts to meet the United Nations Sustainable Development Goal 3: “ensure healthy lives and promote well-being for all,” which the ministry was trying to achieve by offering free universal care in the public system; and recent government policy of offering such care not only to nationals, but non-nationals as well (assume the CMO was referring to Venezuelans residing in TT legally).

Indeed, these events may be “aggravating” the long wait times situation but one only has to read the HSRP Report (1994), the Gafoor Report (2006) and the Welch Report (2016) to know that extended wait times and a myriad of other issues have led to sub-par service in the public health system since the waning years of the last century.

Multiple ministry publications including the National Strategic Plan for the Prevention and Control of Non-Communicable Diseases: Trinidad and Tobago, 2017-2021, have cited that TT, as elsewhere, has a longer living population with the attendant rise in prevalence of preventable NCDs in this grouping that are lifestyle-related and socially determined. I am at a loss as to why the CMO passed on this most dominant factor.

As an aside, Venezuelans residing in TT are younger and unlikely to be afflicted with NCDs. And TT as a member state of the UN is committed to achieving SDG goals and targets. Moot statements?

The JSC has held many meetings over the past few months – some public, others virtual – in its probe of the public health system. In addition to the last meeting’s focus on extended wait times, lost patient charts, ailing people using their meagre resources to escape the public system – going to a private sector, even overseas – shortages of critical drugs, etc are indications of a struggling, overburdened system.

Global consensus has persisted for well over four decades that health and well-being of populations are effectively, equitably and efficiently achieved through the primary healthcare approach where these services are close to the community, continuous, comprehensive, co-ordinated and people-centred.

In the current situation, the A&Es of the RHAs are the first contact and with few exceptions are not close to the community. NCD patients frequently present themselves to the A&Es already in stage 4 renal failure, severe heart disease, advanced retinopathy, devascularised limbs and so on, all of which could have been prevented with proper primary care and public health services in place.

At a JSC meeting with the public and nursing staff in the Cabildo Building in late November 2023, Idi Stuart, head of the TTRNA, made an interesting comment: that the smaller RHAs were working “reasonably well” while larger ones struggle to deliver quality care. Are smaller RHAs (with small hospitals and small communities) better able to achieve the desired PC characteristics?

In the 21st century, life expectancy and quality of life are directly related to how a country manages CNCDs (chronic non-communicable diseases). According to Worldometer, in 2024 life expectancy in Guadeloupe is ranked 14th worldwide (83.45 years), France 16th (83.35), Martinique 17th (83.34), Barbados 65th (77.86), Grenada 87th (75.49) and TT (74.87). French health services are decentralised into provinces, adherent to centrally determined public health policies.

The JSC in the current trajectory runs the risk of producing a report that makes recommendations to fix the problems in the RHAs, while leaving the basic platform – determined geographically (an aerial decentralisation) – intact. Thus yet another Gafoor or Welch Report would be produced, with recommendations, and more money would be thrown at the dysfunctional RHAs – spinning top in mud.

An alternative approach would be to examine the Decentralisation Act 1994 to determine whether the rationalisation that birthed the RHAs back then remains relevant in today’s scenario, where greater capacity now exists, to fashion a decentralisation of health services on a platform of primary care and public health (a functional decentralisation).

KENWYN NICOLLS

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