The evidence base for healthcare related decision-making in Regional Health Authorities

OBJECTIVES: To evaluate the evidence base used in policy and healthcare decision making by the Regional Health Authorities in Trinidad. DESIGN AND METHODS: The study focused on the five Regional Health Authorities (RHAs) in Trinidad where senior administrative employees at each Regional Health Authority were purposively sampled and interviewed using a structured questionnaire. Responses were initially reviewed individually to determine types of evidence used within each RHA. All responses were secondly compared between the various RHAs. RESULTS: All RHAs participated; each had an observatory type unit which was responsible for data collection, collation and production of reports on an annual basis. Reports focused on the number of patients accessing services (e.g. specialist clinics and surgical procedures), patient demographics and patient access to health services. All RHAs had annual service agreements with the Ministry of Health which acted as a guide with targets and as a check on accountability of money spent. Decision making in each RHA was tiered by financial cap; most decisions were made by the Chief Executive Officer and/or Board of Directors within their caps; decisions requiring monetary investment over the RHA limit had to be approved by the Ministry of Health. CONCLUSION: This study revealed that RHAs had systems in place whereby they engaged in evidence-based practice utilising the Authority’s observatory data plus other information sources, ran trial periods and economic analyses for healthcare related decision making.

Preparedness of healthcare facilities for a public health emergency in a Caribbean country

OBJECTIVE: To review basic, critical elements of emergency preparedness and response capacity in the healthcare system of Trinidad and Tobago. DESIGN AND METHODS: A descriptive study involving one major hospital and one randomly selected health centre in each Regional Health Authority (RHA). Responders were chosen by purposive sampling and structured face-to-face interviews were carried out. Data collection was undertaken using modified versions of two previously validated data collection tools. RESULTS: All 5 hospitals in each RHA and 4 of 5 health centres participated. Emergency response plans existed in all healthcare facilities reviewed; however plans were not regularly tested. An investigation team can be assembled in 24 hours and a patient referral system was in place in all hospitals. There appeared to be access to stockpiles in all facilities. There was a gap in ongoing infection control measures including the absence of regular personal protective equipment (PPE) training for staff. CONCLUSIONS: There was an urgent need for systematic rather than ad hoc measures for testing existing plans and staff training in their roles and responsibilities during an acute public health event should one occur. For infectious diseases with high case fatality rates such as avian influenza and Ebola, it is critical for front line staff to be aware of infection control measures including how to properly use PPE. Governments should take the opportunity of the Ebola outbreak in West Africa to utilize public health capacity to catalyse the systematic strengthening of core capacities for alert and response to meet their International Health Regulations (IHR) 2005 obligations.

Implementing a continuous quality improvement programme in healthcare

Although the healthcare industry supports the view that TQM is the way of managing for the future, the implementation of CQI programmes could be problematic. This is because of certain characteristics that are unique to healthcare organisations and professionals, as evidenced by the studies in the UK, the USA, and the Bahamas. Based on the study at Princess Margaret Hospital, similarities in experiences were discovered. Some of the recommendations made were that:- sessions on CQI principles should be conducted specifically for top management, with a view that they too will employ these principles in their daily work; every effort should be made to involve physicians and to communicate that 'quality' includes them as well; adequate funding should be provided to implement and sustain quality programmes; all staff should be trained and involved in quality methods; a 'phased-in approach' should be used, this has been found to be more successful in implementing CQI; the patient must be seen as a priority in the equation, and therefore plans should be made to include them in their own care; staff should be rewarded and given incentives for quality improvement success (AU)

Reforme de los sistemas de salud en America Latin y el Caribe: situacion y tendencias / Health sector reform in Latin America and the Caribbean: situation and trends

In the early 1990s, most Latin American and Caribbean countries were beginning, or planning to begin, health sector reform processes. This paper presents the status and trends of health sector reform at the end of the 1990s. The authors relied on information in 20 health system and services profiles completed by the Pan American Health Organization between August 1998 and October 1999. The analysis, which follows a methodology that had been applied earlier, was organized on two different levels: (1) monitoring the reform processes (dynamics and content) and (2) evaluating their outcomes. In looking at the dynamics of the reform processes, the article examines the content in which they take place and the actors involved in their different phases: inception, design and negotiation, implementation, and evaluation. The description and analysis of the contents of health sector reform inititives are organized into 12 broad thematic areas. Outcomes evaluation was only possible in the eight countries that provided enough pertinent information, and should be viewed as preliminary. Nevertheless, the article does present detailed information on the outcomes of health sector reform in terms of equity, effectiveness and quality, efficiency, sustainability, and societal participation and control. The article also discusses the potential causes and determining factors for the observed outcomes (AU)

Health sector reform in the Republic of Trinidad and Tobago

The Republic of Trinidad and Tobago lies at the southern-most end of the Caribbean chain of islands. The estimated population in 1998 was 1.28 million of whom 27 percent were under 15 years of age and 6.3 percent were 65 or older. The population consists of a rainbow of persons of diverse cultural and ethnic antecedents. The leading causes of mortality and morbidity are heart diseases, neoplasms, diabetes mellitus, and cerebrovascular diseases. Trinidad and Tobago supports its population through petroleum and its downstream industries and from growing manufacturing and tourism sectors (AU)

Confronting ageing as a Caribbean reality

This article acknowledges the increased life expectancy which Caribbean populations presently experience. It draws upon data collected throughout the region and identifies some of the main concerns which families, communities and governments need to address, in order to ensure that the elderly will not be severely disadvantaged as a consequence of their increased life expectancy. The article recommends closer cooperation between governmental agencies and non-government organizations (NGOs) in determining the needs of the elderly, as well as the provision of services for them (AU)

Public-private mix-up

A mixed health care system has emerged in the Caribbean over the past 30 years. Available information suggests that some 60 percent of PHC contacts, 30 percent or more out of out-patient consultations, and 10-15 percent of in-patient episodes occur in the private sector. The private sector caters mainly for the needs of those of working age. This is because in most Caribbean countries, the elderly, those of school age, the mentally ill and the handicapped received free or heavily subsidized care. Diabetics and hypertensives also receive free or subsidized care in many countries, regardless of their income or wealth. Many who are eligible for free or subsidized care from government healthcare providers also buy care in the private sector. The issue of the private-public sector relationship in the Caribbean is complex because of the nature of the private sector and how it has emerged. What is quite clear is that the situation need to be improved and this will require considerable political courage and management skill. This is especially so where many senior government doctors also practice in the private sector and, in some circumstances have compromised their management integrity. The growth of the private health sector in the Caribbean has created a set of strategic problems for ministers of health and the health sector broadly. These include: (1) contractual arrangements for government doctors (2) poor continuity of care and poor quality primary medical care (3) problems of access to PHC in rural areas (4) over medicalization, and escalation in the number of diagnostic tests and lack of control over the range of medicine available over the counter(AU)