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Reform of the Trinidad and Tobago health service: the limits of decentralisation/La reforma del servicio de salud en Trinidad y Tobago: los limites de la descentralizacion/La reforme du service de sante de Trinidad and Tobago: les limites de la decentralisation.

ABSTRACT

With a history of relatively poor performance by its health system, Trinidad and Tobago introduced radical reform under a new Decentralisation Act of 1994, which was intended to be patient-driven, bottom-up, flexible and close to customers, as well provide effective management to achieve the goals of the Ministry of Health (MOH). A critical analysis of the reform in decentralisation and its performance is the subject of this article. Essentially, we challenge through empirical field research the claims of the decentralised health system which in theory had the potential to empower customers, ensure accountability, and had the flexibility to forge accessibility, efficiency, equity and quality health care.

Con un historial de resultados relativamente pobres en su sistema de salud, Trinidad y Tobago introdujo una reforma radical en virtud de la nueva Ley de Descentralizacion de 1994, disenada como un proceso centrado en el paciente, con un enfoque vertical, flexible y de acercamiento a los clientes; a la vez que ofrecia un manejo eficaz con el objeto de lograr las metas del Ministerio de la Salud (MOH). El tema del presente articulo es un analisis critico de dicha reforma para la descentralizacion y sus resultados. Esencialmente, por medio de una investigacion de campo empirica cuestionamos las propuestas del sistema de salud descentralizado, que en teoria tenia el potencial de fortalecer a los clientes, asegurar la responsabilidad, y que tenia la flexibilidad para fomentar una atencion medica accesible, eficaz, equitativa y de calidad.

Du fait des performances historiquement assez pauvres de son systeme de sante, Trinidad-et-Tobago a initie une reforme radicale dans le cadre d'une nouvelle loi de decentralisation, en 1994 ('Decentralisation Act'). Cette reforme devait permettre de batir un systeme guide par les patients, ascendant, flexible et proche des clients, mais aussi garantir une gestion efficace afin d'atteindre les objectifs fixes par le Ministere de la Sante. Une analyse critique de cette reforme en decentralisation et de ses performances, tel est l'objet cet article. En substance, nous contestons, par le biais d'une recherche de terrain empirique, les succes supposes du systeme de sante decentralise qui, en theorie, devait donner plus de pouvoir aux clients, garantir la redevabilite et avoir la flexibilite pour forger l'accessibilite, l'efficacite, l'equite et la qualite des soins de sante.

The more things change ...

Trinidad and Tobago (Trinidad hereafter) has had a history of health care reform which is yet to meet expectations, from either the customer's or the provider's perspective. Changes have included a wide range of reforms, from hiring new hospital managers to a Cabinet-appointed task force, to the appointment of a national hospital management company, and most recently, a delegated decentralised health care system. The current decentralised health system was introduced under a new Decentralisation Act in 1994 which was intended to be patient-driven, bottom-up, flexible, close to customers and to provide effective management to achieve the goals of the Ministry of Health (MOH).

While the decentralised system had the potential to provide the stewardship needed to produce change, the new Regional Health Authorities had to overcome a multitude of health issues on a daily basis. The reform in decentralisation and its performance will be the subject of this critical analysis. Essentially, we shall challenge through empirical field research the claims of the decentralised health system which, in theory, had the potential to empower customers, ensure accountability, and had the flexibility to produce accessibility, efficiency, equity and quality health care. All of this was very much in question because of numerous limitations, which included an understanding of the concept of decentralisation, deciding which type to use, and having the necessary prerequisites for successful implementation. It became clear that decentralisation as a mode of governance for improved health care was as much a technical, administrative issue as it was a cultural and political event. Then there is the problem of managing efficient change in a culture which may not necessarily be inclined to promote best practices but accepts mediocrity as normative. An appropriate implementation method had to be found and applied for satisfactory results. All these factors, ranging from the technical to cultural, economic and political, had set the limits to what could be accomplished.

We shall begin by offering a brief overview of Trinidad and Tobago's health system, followed by a discussion of the concept of decentralisation. The next section enters an extended discourse on the empirical evidence of the performance of the decentralisation reform, followed by an evaluation and the conclusion.

Trinidad and Tobago's aging population

Trinidad and Tobago is a small twin-island state of some 1,864 square miles in the southern Caribbean that has been independent since 1962. The warm climate has made the country prone to many tropical diseases, including malaria, dengue, and leptospirosis. During colonial rule, the agricultural plantation economy required abundant cheap labour, which was derived from African slaves and indentured labourers of Portuguese, Chinese and East Indian origin. Today, with a population of 1.3 million, Africans and East Indians predominate, each comprising about 41 percent. The population comprises an ever-increasing aging community, as well as a significant number of youths, resulting in an ever-increasing number of diseases of the young and the elderly who need special resources. Falls by the elderly and neglect by families are common. Cardiovascular or heart disease, cancer, diabetes, hypertension and cerebrovascular disease or strokes are among the main causes of mortality, disability and even morbidity, primarily among adults (National Policy Document 2002).

In contemporary Trinidad, the state of the health care system is unsatisfactory, as evidenced by the high dissatisfaction levels and public outcry in the media and the courts. Problems facing the health service were identified in the multitude of reports commissioned by the State dating as far back as 1937 with the Moyne Commission of Inquiry, and most recently, the Gladys Gaffoor Commission (2008). In 1945, the West India Royal Commission Report observed that few recommendations by the several commissions appointed from time to time on the medical and health service had been implemented (Axelsson, Marchildon, and Labrador 2007, 238). Two and a half decades later, in 1970, an editorial in the Trinidad Guardian reported similar failures in the implementation of reports and promises made (Trinidad Guardian 1970, 7). A World Health Organization (WHO) report of 2000 concluded that "... strategies and goals are inappropriate and at best inadequate, making health solutions piecemeal, health standards unachievable and affecting the poor predominantly" (World Development Indicators 2000).

More recently, in 2008, the revelations of the Gaffoor Commission of Inquiry were frightening, especially in light of added inputs (material, financial and human resources) to address the multitude of issues in the present health care system. The list included:

1. A severe shortage of health care professionals in all areas of the public health sector.

2. A lack of comprehensive training programmes resulting in poor quality service, chiefly at the primary health care level.

3. Alleged negligence of doctors and nurses.

4. Indiscipline among staff

5. Ineffective strategies for compensating and retaining staff

6. Improper financial management.

7. Inadequate health care for women.

8. High rates of neonatal and infant mortality.

9. Inadequate policies regarding procurement of equipment and medical supplies.

10. A lack of effective preventative maintenance programmes for equipment and health care facilities.

11. Dilapidated toilets and kitchen facilities at many health care institutions.

12. An insufficient number of beds.

13. Lack of storage facilities.

14. An insufficient blood supply at the blood bank.

15. An inadequate ambulance service (Gaffoor et al. 2007, vol. 2)

The Ministry of Health (MOH) wanted to improve performance measured by national health indicators, particularly customer satisfaction, and to bring health care standards closer to the level of First World countries. In the latest phase of reforms in 1994, there was the introduction of a decentralised system of regional authorities. Decentralisation was thought to provide a strategic and effective option for health systems reform (Chitah and Bossert 2003, 357-69), including community and other stakeholder participation. Rondinelli pointed out the potential benefits of decentralisation: overcoming the central control and limitations of national planning; avoiding bureaucracy or "red tape"; increasing awareness and sensitivity to local problems; increasing political and administrative 'penetration' of national government policies and improving the relationship with and representation by local people, who are often ignored by the central government (Rondinelli 1983, 189).

Decentralisation, it was argued, would therefore contribute to further democratisation, improved and more efficient administration, more effective development, and good governance. With improved administrative efficiency and performance (Bankauskaite and Saltman 2007), increased accountability and efficiency in resources and logistics (Nunn 2005) decentralisation became increasingly popular as a management tool to "achieve multiple objectives, such as democracy, allocative and technical efficiency, local responsiveness and innovation" (Bankauskaite and Saltman 2007). One assessment report claimed that health systems from many developing countries were suffering "grossly inefficient and inequitable resource allocation, declining quality, and demoralised work forces" (Wright et al. 2003, 201-9). The inequity of resources between different sections of the populace necessitated a new instrument--decentralisation--"to attain allocative efficiency in the face of different local preferences for local public goods" (Litvack, Ahmad and Bird 1998, 5). Many countries, particularly Third World countries such as Trinidad and Tobago, bought into decentralisation to deal with complex challenges in the health sector, increasing expectations and poor health service. Some countries which were experiencing the failure of their health care systems were forced to experiment with different methods of health care delivery to better deliver service. Decentralisation "by default" (Davis, Hulme, and Woodhouse 1994, 253-69) rather than design took place.

Decentralisation; Conceptual analysis

Decentralisation cannot be used effectively unless there is a clear understanding of the concept and the form that is to be used. Decentralisation is the transfer of work previously carried out by a centralised authority to a peripheral or localised body. It appears very straightforward but it can have significantly different interpretations emphasising different things, making its use prone to ambiguity. Therefore decentralisation, whether it is geographic, administrative or decision-making; scientific, political or ad hoc, is not simple and requires clarification. James Fesler alluded to this complexity: "Decentralization is an apparently simple term. Yet the appearance is deceiving and often leads to simplistic treatments that generalize too broadly, start from a doctrinaire position predetermining answers to concrete problems, or concentrate on a single phase of decentralization to the exclusion of others" (Fesler 1965, 536).

A four-fold typology of decentralisation set forth in a seminal World Health Organization publication has become conventional (Bossert 1998, 3):

a. deconcentration, in which authority and responsibility are shifted to regions or district offices of the Ministry of Health;

b. devolution, which shifts authority and responsibility to other institutions of government such as states or municipalities;

c. delegation, which creates semi-autonomous agencies to carry out functions which were once controlled by the Ministry of Health;

d. privatisation, which shifts responsibility and control to private owners (Bossert et al. 2003, 95-100). These four forms are not in practice discrete, but are manifested instead in different combinations with various overlaps and grey zones. However, understanding these forms is necessary and their essential variations can be graphically represented as seen in Table I.

Delegated decentralisation and privatisation

The form of decentralisation chosen in Trinidad for re-organising the health system was not devolution or deconcentration but delegated decentralisation and privatisation. According to Rondinelli, the latter refers to the transfer of government decision-making and administrative authority for clearly defined tasks to organisations or firms that are either under its indirect control or are independent. The delegated service is specific and is financed by the central body. However, the delegated body is free to provide the service in any method it so chooses within the guidelines set out by the central body through legislation. The failure of existing public services to provide the required public goods and services forced governments to use delegated decentralisation as a feasible means to effect improvement in their health service (Cohen 1999).

Furthermore, additional advantages of delegation are less political interference, more flexibility, less rigidity and less bureaucracy. It therefore has the potential to be more efficient and cheaper. In delegated decentralisation, legal authority is more binding and is more likely to be implemented and adhered to, it is argued. A body delegated to carry out a set of functions can further utilise services through privatisation or deconcentration. Delegation can improve efficiency in performing a particular task. However, it may not improve the effectiveness, which depends to a large extent on the policies of central bodies, the delegated functions, the commitment of the new layer of managers, and the optimum use of resources made by decentralised bodies.

Apart from choosing the appropriate form of decentralisation, the necessary prerequisites with the appropriate environmental conditions are required. According to Litvack and his associates, "Decentralisation largely depends on where, when, and how it is done" and "initial conditions determine the level of trust, the reputation of the various actors, the existence (and rigidity) of constraints to institutional change, and so on" (Litvack, Ahmad and Bird 1998, 5). There must be accountability, capacity, good policy and design, committed players, a strong centre, and strong political commitment. In addition, decentralisation requires both adequate transfer of powers and accountability (Ribbot 2002). It should create "incentives that hold each entity accountable for its responsibilities and make explicit the institutional relations between each entity" (Litvack, Ahmad and Bird 1998, 5) by ensuring transparent budgeting processes and public procurement procedures. Decentralisation should diffuse responsibilities across different entities, distribute fiscal instruments to all levels of government, and create incentives for fiscal accountability (Litvack, Ahmad and Bird 1998, 5).

Decentralised bodies must therefore possess adequate capacity which is defined as having the necessary infrastructure, operating systems and human resources to effect meaningful and effective change. This should precede decentralisation. Stakeholders must be included in all spheres, namely consultations and decision-making, in the preparation of policy documents and project design. Effective decentralisation therefore depends on committed players in an organisation, which has the capacity, accountability and appropriate policies and designs. Decentralisation also requires a strong centre; creation of organisational structure and culture; provision of sufficient resources; and a strong political will. Unsatisfactory outcomes of decentralisation with ill effects are the result of poor resource allocations and inadequate human resource capacity (Prud'homme 1995, 201); unsuitable choice of type of decentralisation; and sub-optimum or inappropriate environmental conditions.

The outcome may not be achieved even with so-called expansion in structure and process because, even if there are adequate inputs, the production mix may be wrong, which can lead to undesirable outcomes. Furthermore, the outcomes may still not be achieved if there is inadequate implementation or non-implementation when there is the right increase in inputs and the right mix. There is a big gap between what actually gets done and what is enacted as public policy. This is known as the "implementation gap". According to Lipsky, policy may be set by persons who actually implement policy and not necessarily the policy-makers i.e. "implementation on its head" (Lipsky 1978). This is so because policy can be interpreted as what actually gets done and not what is stated to be done. Further, the desired goals of health care decentralisation may not have been addressed either intentionally or otherwise.

Privatisation, according to Rondinelli, is the transfer of services to non-governmental institutions and "involves shifting responsibilities for activities from the public sector to private or quasi-public organisations that are not part of the government structure" (Rondinelli 1983, 189). The notion of privatisation as a form of decentralisation is still controversial; some researchers argue it is a type of decentralisation, while others disagree (Collins and Green 1994, 459). It comprises a range of techniques such as asset sale, contracting out, internal market, private partnerships, liberalisation and others (Bankauskaite and Saltman 2007). This form of decentralisation is being practised more and more because public service employees of many Third World countries have difficulty delivering optimum health care to patients, whether it is because of central control or bureaucratic structure. Hence, privatisation took centre stage for a number of reasons: marketisation, the introduction of new public sector management and the failure of the existing health systems (Mills and Broomberg 1998, 33). Traditional bureaucratic organisations tend to be inefficient. Furthermore, public bureaucracies may not serve the public interest since they would more likely serve their own interest or that of powerful groups in the society (Walsh 1995). It was also thought that private organisations would bring a certain degree of specialisation and flexibility to changing conditions and demand (McCombs and Christianson 1987, 703-22).

Mercerisation is a major strategy to improve efficiency, equity and accessibility and was introduced in many countries worldwide as part of structural change (Kaufman and Fang 2002, 108-16). However, there are many undesirable effects, namely conflicts between efficiency and the undermining of equity; a focus on profit-making services at the expense of less profitable or non-profitable but essential services; diverting attention away from main centres of health delivery; poor care without proper monitoring; higher contractual prices or lower prices with poor quality of care. It is therefore argued that "the theoretical claims of which contracting reforms are argued to improve efficiency themselves remain ambiguous" (Kaufman and Fang 2002, 108-16). The success of privatisation includes a socio-political economic environment in which corruption is discouraged and transparency, close monitoring and an effective legal system are encouraged (Kaufman and Fang 2002, 108-16). Privatisation is recommended when services cannot be accomplished, are inadequately done or sometimes politically expedient to do. Therefore it may not always be done because of genuine administrative necessity. Many privatised services may not be market-driven or even cost-effective. Further, it can encourage regular workers to perform in ways which may further foster privatisation, leading to a drain on the financial resources of the health budget and further depriving citizens of basic health services, especially when workers of the public health system also indulge in these privatised services.

In Third World countries this problem is more critical since there is a shortage of trained medical personnel, a shortage of specialised equipment and certain services. The internal market must be supportive and complementary without being competitive or counterproductive for healthcare workers, managers or other non-medical staff. However, the hard evidence of improved efficiency is partial at best, and it is far from clear that efficiency gains exceed the high transaction costs associated with privatisation. This is partly because the internal market is less than competitive and not fully functioning. Competition between providers, while slowly increasing, remains severely restricted. The contracting process may utilise inadequate information, a lack of uniform standards, guidelines and specifications, and weak management.

Privatisation also competes with basic health services which are needed by the poor and the less fortunate. In addition, there is a significant cost to it which has the potential to siphon money from the health service and this may further compromise basic health care. It is a route which avoids dealing with the fundamental challenges of decentralisation, for example, improving infrastructure, human resources and operational systems. When resources (human, economic and managerial) are limited or not optimally utilised, privatisation encourages diversion of funds to private projects without developing human capital, infrastructure and operational systems; even starving growth and development in human resources. Privatisation, therefore, must be well thought out before being implemented to avoid a drain on resources and demotivation of health care workers. It can therefore prove counterproductive with increased cost and worsening health outcomes.

The form and function of decentralisation in Trinidad

Decentralisation, which was supposed to be revolutionary in Trinidad and Tobago, took the form of delegated decentralisation and, later on, privatisation. Such an instrument as delegated decentralisation to bring about the much-needed change in the health care service has been questioned by fellow researchers and practitioners in the field. With decentralisation in Trinidad a number of infrastructural changes were made which took the form of five regional health authorities (RHAs). It brought with it a high-level management structure; added management departments such as the quality department, which include auditing, research, etc. However, the MOH retained centralised power for all matters of policy, while much authority was transferred to the decentralised authorities to "run the affairs of each region" with directives from a board chosen by the MOH. Such an arrangement set in motion an intervention aimed at bringing health management closer to customers, both internal and external. However, it created a system which was inadequate; replete with its own limitations; ambiguity in roles; and conflicts between the central government and the newly established RHAs with their own agenda.

Many have cautioned on the use of this instrument because rather than dealing with health care, it becomes a haven or a "turf" for political spoils, etc. Decentralisation as a system to provide good health care governance can therefore be caught up in issues that may be divorced from health management or managing for health, such as making the health service goal-oriented, customer-focused using research and evidence (measure and monitor), transparency and accountability.

Many Third World governments are forced to please the populace and feel they cannot depend on the delegated bodies to do appropriate tasks to do so, or fulfill the obligations of the ministry, political or otherwise. This constant demand forces governments to either take back decision-making power or hand over decision-making to these authorities, depending on the Minister of Health or the competence of management. This clearly limits the capacity of the delegated authorities to do their job. This practice is quite evident in Trinidad and Tobago. Many times the centralised structure feels they must have a say and so management assumes a dichotomous role moving "to and fro", demonstrating the "pendulum effect".

Table 2 gives the functions delegated to the RHA by the Decentralisation Act, compared to the functions of the centralised body. One recognises a major gap between the delegated power of the RHA and the intended autonomy of delegated decentralisation. Furthermore, even these adopted policies or policy intent may not be implemented or even implementable. This policy intent is greatly dependent on the approval of the Minister of Health. In fact if the Minister chooses, the RHA can have a fair amount of real power. He can take a hands-on approach and nearly all delegated powers can be in the hands of the centralised MOH, making the RHA impotent and thus adding to the bureaucracy and cost overhead; or the Minister can take a hands-off approach and leave the RHAs with plenty decision-making and autonomy. The Minister can also assume control of some of their functions by recentralisation or can decentralise to a new group of players. In fact this took place in 2003 when many RHA services that were being inefficiently handled or not performed were privatised with directions from the Minister of Health. This practice continues to the present day.

Non-adopted powers are retained by the MOH. Furthermore, some of the adoptable powers as given over to the RHAs are usurped by the central government, at the discretion of the Minister of Health. Professor Bossert, in his analysis of decision-making in decentralised bodies, concludes that the greater the degree of control and decision-making authority by the decentralised bodies, the greater the chance of improved health outcomes. However, in many developing countries, the amount of power given to decentralised bodies keeps shifting between the MOH and the RHAs. This "pendulum effect" is unhealthy and displays the lack of confidence in the RHAs by the MOH or the over-guarding of power by the MOH.

Even though delegated decentralisation was chosen, with obvious limitations, in practice the MOH rarely used delegated decentralisation as the key method of demonstrating success or of transforming the health service. Two other forms of decentralisation continued, namely devolution, which continued to run under local government; deconcentration, which continued with the vertical services, namely insect vector control, cancer treatment, HIV, venereal disease; and privatisation, which was expanded to deliver medical services in selected areas that were not offered by the government service.

Implementation effects: Empirical description of performance

Stewardship was a major pillar of the health reform. In the decentralisation programme, measures were taken to improve health care in terms of management of training and numbers. Middle-management seminars were conducted. However, the RHAs expanded their numbers significantly. Before 1994, the Ministry of Health was managed by a Chief Medical Officer and a number of principal medical officers, county medical officers and medical chiefs of staff. Top management comprised the Chief Medical Officer (CMO), Principal Medical Officer Services (PMOS) such as environment and public health, PMO institutions, and county medical officers of health (CMOH). Later, the MOH added hospital administrators (HA) to each major hospital. In 1994, with the introduction of decentralisation, RHA management was expanded to include RHA managers (RHAM), including the Chief Executive Officer, Executive Medical Director of Health, general managers of Nursing, Finance & Supply Chain, Operations, Human Resources, Planning & Development, Patient Support Services, and Commissioning & Projects; county medical officers of health, facility managers, a Hospital Administrator, a Medical Director, a Manager of Quality Improvement, a Property Service Manager, an IT/IS Manager, an Internal Audit Manager, a Communication Specialist, a Senior Legal Officer, a Radiology Regional Coordinator, and a Security Services Manager.

These comprise the executive team of the decentralised health system of each RHA, which many claim to be top-heavy. And this team excludes the RHA's board members. In addition, there still existed some managers and supervisors from before the creation of the RHAs, plus the continued input from the MOH. In the case of the South-West Regional Health Authority (SWRHA), managers employed both before and after decentralisation include the Hospital Administrator; Assistant Hospital Administrator and Nursing Administrator; other supervisors such as a Personnel Industrial Relation Officer II, Administrative Officer II, Medical Social Worker, Medical Laboratory Technician III, Medical Records Officer, Senior Radiographer, Senior Physiotherapist, Senior Pharmacist, Hospital Supplies Officer, Hospital Engineer II, Medical Photographer II, Senior Dietician, Supervisor of Attendants, Domestic Supervisor, Daily Paid Foreman, Transport Foreman, Laundress II, Seamstress II, Charge hand Other Services, Medical Librarian, Senior Telephone Operator, Customer Relations Officer, Hostel Manageress and Processing Supervisor.

These managers, together with other managers of technical and clinical heads, are the leaders of the health care service. However, their responsibilities had not been clearly spelt out, leading to much duplication, de-motivation, etc. Management continued to practise operations and customs which were dysfunctional, non functional and counterproductive, such as the block appointment systems, the shuttle service, the use of doctors to perform routine non-medical duties, admitting patients on chairs or benches, and the continued use of unqualified managers, etc. Furthermore, there was no meaningful assessment and feedback of their performance. It is difficult to manage without measurement and monitoring, yet the RHAs applied little scientific or systematic evaluation. To address performance gaps, more managers and supervisors were employed to run the affairs of the organisation, with additional cost and not necessarily addressing the fundamental issues.

The performance of management is clearly identified in how they make use of resources: a. Human resources: International standards dictate a reasonable ratio of nurses to doctors. The Trinidad and Tobago system reveals major implementation gaps. The number of doctors increased from 6.53 per 10,000 in 1990 to 11.65 in 2005, while the nurses decreased from 20.90 in 1990 to 18.32 in 2005 (Table 3). Many First World countries have a higher staff-patient ratio. Canada has a doctor population ratio of 34 per 10,000 and a nurse population ratio of 75 per 10,000, giving a nurse/doctor ratio of 2.2 to 1. In Trinidad and Tobago, the nurse/doctor ratio decreased from 3.20:1 in 1990 to 1.57:1 in 2005. While the increase in doctors is highly desirable, the dispro-portionately small number of nurses is counterproductive to the health institution as a whole. In the case of the San Fernando General Hospital of the South-West Regional Health Authority (SWRHA), the number of specialist medical officers increased from 65 in 1992 to 112 in 2006. However, this still did not meet international levels. Furthermore, the increase of doctors was not matched by a similar increase of nurses (872 in 1992 to 795 in 2006). The number of physicians per 10,000 of the population for de-veloped countries ranges from as high as 49 in 2005 for Greece to 15 for Turkey. For nurses, the number of nurses per 10,000 ranges from 153 in 2002 for Iceland and 75 for France in 2004, while some of the less staffed countries like Portugal had 44 per 10,000.

Fluctuation in numbers of staff, compounded by inappropriate hirings, compromises both short-term and long-term services and is not cost-effective. Many services may have to be abandoned, improperly serviced or done by other professionals who are then unable to perform their own jobs properly. Sometimes there would be overstaffing because of the fall in services, which further added to under-productivity. Management practices were also not acceptable and showed wide variations from international standards.

b. Financial allocation: From 1994, with the coming of the RHAs, while the Ministry had to allocate funding for the running of these authorities, allocation still had to be made for the Ministry's operation. This allocation never decreased, as noted in Table 4, even though many of these services were being transferred to the RHAs. Even expenditure on personnel of the MOH kept increasing yearly.

Personnel expenditure of the MOH increased from $301.2 million in 1990 to $497.9 million in 2007 and $317.9 million in 2008, representing a $166.4 million or a 55.3 % increase over the years. However, the increase up to 2007 was $196.7 million or 65.3%. Goods and services increased from $117.4 million to $572.9 million in 2008--an increase of $455.5 million or 388.1%. Minor equipment and purchases increased from $1 million to $7.5 million in 2008, representing an increase of $6.5 million or 639.4%. Current transfers and subsidies to the RHAs increased from $52.9 million to $1,833.4 million, an increase of $1,780.5 million or 334%. Current transfers and subsidies to the RHAs were spent mainly on salaries (more than 85%). Even though a large number of staff and services were transferred to the RHAs between 1994 and 2007, the personnel expenditure of the MOH increased from $364.8 million to $497.9 million. However, this increase may have resulted partly from the significant number of MOH employees, though dwindling, that continued to work in the RHAs. Current transfers and subsidies spent mainly on salaries, increased from $34.8 million to $1,403.8 million in 13 years. Even the total money spent in health more than quadrupled from $613.8 million to $2,692.2 million; goods and services went up by $332.6 million from $137.4 million to $470 million.

c. Infrastructure: Problems of doctor availability, health facility accessibility and overcrowding persist (see Table 5). According to Stacey Moore, "Dozens of patients with heart, liver and kidney ailments as well as a number of elderly patients were forced to sleep on benches, in wheelchairs and on the floor" of the San Fernando General Hospital, which has been plagued with an acute shortage of available beds (Moore 2008, 2). The addition of beds and the transfer of patients to private hospitals made no or little difference to the overcrowding, which persists up to today. From 2008, patients who could not get a bed spent much of their sickest moments just "waiting to get a bed" in the most inhumane conditions before commencing their medical treatment. Unlike developed countries where treatment begins while waiting for a bed, patients at Trinidad and Tobago's major health care institutions are, by and large, not given any treatment.

Privatisation as cop-out

Privatisation was a tool created to assist in plugging gaps in the existing health service. It was meant to assist in achieving the goals of the MOH and the people of the country. This was fostered through the large revenue generated from Trinidad and Tobago's gas boom. Delegated decentralisation was not operating at its fullest to bring home the needed care as expected by the providers and the users. The numerous complaints in the media, the long waiting lists for surgeries and certain investigations led the government to address some of these areas through privatisation. Privatisation included lab investigations, using private beds, elective and emergency surgeries, and so on. In fact, many of the problems identified by the existing health service were taken up by the MOH and re-decentralised through private arrangements. The results of privatisation encouraged the government to expand the services to include even the ones being carried out by the RHAs. The government's focus on improving the RHAs was diverted to the privatised service, weakening the main health care provider. Resources were therefore used to fund this initiative, which demotivated staff, siphoned resources from basic health care, and stagnated or stifled the capacity and growth in RHAs.

In 2008, more than $42 million was paid to private organisations for a number of services, including surgeries, investigations and training. These were handled by the centralised MOH. By and large, training of existing medical workers of the highest calibre was absent. Many physicians or surgeons who needed sub-specialty training went abroad and never came back. Contractual arrangements never catered for continued on-the-job training so that many investigations or surgeries had to be done outside Trinidad and Tobago or outside the public service. There is a shortage of doctors with specialised and sub-specialty training. However, the MOH employs more doctors but only adds to the lower level of staff which underperforms because of inefficiencies in the services, among other things.

Cultural obstacles

The RHAs, even with added human, economic and infrastructural resources, failed to make meaningful outcomes as evidenced by poor satisfaction levels, high infant mortality rates and maternal mortality rates. The maternal mortality rate decreased slightly from 54.3 in 1990 to 52.2 in the years 2004-2007. The perinatal mortality rate worsened from 20.1 in 1990 to 23.2 in 2004-2007 and the Neonatal Mortality Rate (NMR) also increased from 9 in 1990 to 13.5 in 2004. The global satisfaction score was 38.4% (inpatients). The RHAs generated a suboptimal production mix in terms of human resources and operating processes.

The government's decentralised health system, which had the potential to empower customers, ensure accountability, and had the flexibility to produce accessibility, efficiency, equity and quality health care was very much in question because of the limitations of what it could do to make the much-needed difference. These limits included an understanding of the concept of decentralisation, deciding which type to use, having the necessary prerequisites and applying it in the right context. Disaggregating delegated decentralisation as a science of governance for improved health care is important as much as it is a political struggle. The changing centre of power, politics, poor leadership, decentralisation choice, negative cultural practices, the absence of research and evidence-based decision-making, poor utilisation of resources, and the implementation gap have all limited the effectiveness of the decentralisation process. Management will be more inclined to act if results are seen on a timely basis. I have coined the three Ms--measure, monitor and manage--in our quest to reform the health service.

Even with the limitations of adoptability, the pendulum effect, and obtaining the most appropriate form of decentralisation, delegated bodies wielded significant powers since management had huge resources at their disposal. However, there were serious drawbacks in the implementation strategy. Decentralisation is not a scientific intervention, although many health care providers profess that outcomes can be improved by this intervention. Decentralisation, with all its noble intentions and possibilities, did not produce the desired effects, even in terms of organisational performance demonstrated through intermediate indicators. Management can be distracted by the continued struggle for power, for resources, and to expand political patronage, to assist the powerful. The limits extend beyond so-called rationality. A new management arm was created to improve performance but, unfortunately, was not entirely focused on management. Many managers lacked the capacity and commitment to address the day-to-day running of the affairs of the RHAs. There are claims that many managers used their position to assist their friends and relatives to obtain services at the institutions.

Culture is an important driving force that can help organisations to achieve their goals. An organisation's culture is the sum total of the "beliefs, values, attitudes, and norms of behaviour, for example the established routines, traditions, ceremonies and reward systems" shared by individuals of the organisation (Davies 2002, 111-19). The culture influences how people and workers behave; however, culture can be changed by managers through example and organisational practice (Atkinson et al. 2000; Grindle 1997 cited in Merson et al. 2006, 8-65). Decisions are still made in "the absence of performance indicators" and "unwillingness to measure perfor-mance". This culture seems to pervade many health organisations in public hospitals in Trinidad, making them difficult to manage. Management through reaction and crisis management are widely used. Such negative cultural traits can hinder the progress of an organisation and can form the basis of further research as the key for transformation of the health services and organisations.

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Table 1: Characteristics of the different forms
of decentralisation for various parameters

Activity                 Devolution           Deconcentration

Management style         Autonomous.          Not autonomous
                        Has decision          Administrative
                        making powers     efficiency. No decision
                                               making power.

Internal customers/    Health care by       Administrative sub-
workers               elected authority     section of Ministry
Communication/Line                               of Health
of administration         Indirect                Direct

External customers        Empowered         Minimal empowerment
Voice of the people

Ownership:                   Yes                    No
Human resources

Ownership:                   Yes                    No
Material resources

Ownership:                   Yes                    No
Financial resources

Activity                   Delegation             Privatisation

Management style      Partially autonomous.        Autonomous.
                       Have administrative          Has full
                         power and some        administrative, DM
                       DM and flexibility.       and flexibility

Internal customers/        Health Care        Private Organisation
workers                  Authority + / -      No direct or indirect
Communication/Line     Ministry of Health         communication
of administration      Indirect with times
                            of direct

External customers          Empowered               Empowered
Voice of the people

Ownership:             Variable depending              Yes
Human resources           on degree of
                           delegation

Ownership:             Variable depending              Yes
Material resources    degree of delegation

Ownership:                  Partially                  Yes
Financial resources

Source: Author generated

Table 2: Delegated decentralisation responsibilities
versus centralisation responsibilities

                                  Delegated Decentralisation

                 Function            Section            Subject

HR               Board             13.1 to 13.5

                 Management            4.2               Board
                                    11.1, 11.2        Seal of RHA

                 CEO                   10.4           Termination
                                       10.6           Authority
                                                        to CEO

                 Execution of       12.1, 12.2            CEO
                 Document

                                  26.1a to 26.1c      Recruitment
                                                     Compensation

                 Other

                                  30.1, 30.3a to
                                      30.3d             Pension

Operational                          6a to 6h           Routine

                                     8.1, 8.2      Legal Proceedings

                                        9           Legal Liability

                                       20.1         Contracting for
                                                      goods and
                                                       services

                                       25.1            Auditing

                                    35a to 35h           Legal

Infrastructure   Infrastructure    15.1 to 15.3       Expenditure

Finance          Finance            23a to 23e        Expenditure

                                  Centralisation

                 Function            Section           Subject

HR               Board              Function
                                  delegation to
                                   committees.

                 Management            4.3           Head Office
                                     5.1, 5.2          Policy-
                                                    Responsibility
                                                   of the Minister.

                 CEO                   10.1          Appointment
                                       10.2

                 Execution of
                 Document

                 Other                26.1b          Ministerial
                                                     Guidelines

Operational

                                       25.2          Auditing and
                                     to 25.4          Accounting

Infrastructure   Infrastructure    16.1 to 16.5       Property
                                                       dealings

                                     17a, 176        Funds of an
                                                      authority

                                    18a to 18f     Financial powers
                                                   of an authority

Finance          Finance             19a, 19b       RHA Borrowing
                                                        money.

                                       24.2           Varying of
                                                    financial year

Source: Generated by the author from information obtained from
Act of Parliament, Act No. 5 of 1994, Regional Health Authorities,
Republic of Trinidad and Tobago.

Table 3: Numbers of nurses, doctors and the nurse-doctor
ratio in Trinidad & Tobago between 1990 and 2005

        Doctors per   Nurses per   Nurse/doctor
Year    10000         10000        ratio

1990    6.53          20.9         3.2

1991    7.44          20.59        2.77

1992    8             18.93        2.37

1993    8.43          18.17        2.16

1994    8.98          16.78        1.87

1995    9.39          17.07        1.82

1991    7.57          12.42        1.64

1997    7.44          10.81        1.45

1998    9.27          19.16        2.07

1999    9.31          15.39        1.65

2000    10.1          10.19        1.01

2001    9.74          15.49        1.59

2002    8.26          15.72        1.9

2003    8.09          16.71        2.07

2004    10.02         17.92        1.79

2005    11.65         18.32        1.57

Source: WHO statistics

NOTE: Table made from bar graph.

Table 4: Money dispersed in different services ($TT million)

                                  Minor      Current
        Personal     Goods &    Equipment   transfers/
       Expenditure   Services   Purchases    Subsidy

1990      301.2       117.4        1.0          52.9
1991      336.4       124.2        1.4          41.3
1992      372.2       115.6        1.4          29.9
1993      382.0        94.3        0.2          21.3
1994      364.8       137.4        0.1          34.8
1995      373.3       163.2        0.3          46.0
1996      368.8        92.2        0.3         157.0
1997      329.9        87.3        0.1         203.2
1998      255.8        86.1        0.4         171.5
1999      356.2       102.9        0.3         260.5
2000      330.0       125.0        0.7         288.0
2001      353.8       143.0        1.0         358.5
2002      401.1       138.8        1.3         462.9
2003      540.5       184.1        2.7         522.3
2004      468.5       252.2        2.3         700.0
2005      427.2       344.3        5.2        1205.8
2006      404.0       381.6        3.1        1185.4
2007      497.9       470.1        6.6        1403.8
2008      317.8       572.9        7.5        1833.4

       Current
       transfer
       to stat.
       & similar     Debt      Development
        bodies     servicing    Programme    Total

1990      4.6          0           20.2       497.3
1991      5.8          0           15.7       524.8
1992      5.8          0           19.9       544.6
1993      5.5          0           85.7       589.0
1994      5.7          0           71.0       613.8
1995      6.2          0           84.9       673.8
1996      6.7          0           16.8       641.7
1997      6.7          0           36.1       663.2
1998      5.5          0           14.8       534.1
1999      7.7          0           32.6       760.2
2000      9.0          0           70.5       823.2
2001      8.8          0          152.2      1017.4
2002      9.7          0          113.9      1127.7
2003     10.2          0          111.6      1371.4
2004     12.3          0          143.2      1578.4
2005     13.1          0          237.1      2232.8
2006     13.3          0          147.1      2134.4
2007     16.0          0          297.9      2692.2
2008     15.5          0          396.7      3143.8

Source: Annual reports of Public Accounts of the
Republic of Trinidad and Tobago

Table 5: Health infrastructure in Trinidad & Tobago

                                                       International
Domain               Variable           Actual           Benchmark

                       bed           Overcrowding       Sufficient
                   availability       and lack of     beds and good
                                         care          health care
                                                       administered

                  bed population       2.75 per        3.4 beds per
                       ratio         1,000 (1993)      1,000 Canada

                                       2.30 per        3.4 beds per
                                     1,000 (2004)      1,000 Canada

                  occupancy rate     72.7% (07),      85% Canada (02)
                                      54.5% (04)
                                     Trinidad and
                                        Tobago

                  bed utilisation    overcrowding           85%

Accessibility     patient/doctor    Wide variation    470 patient for
to Doctor         ratio (clinic)                          every
                                                       doctor-Canada

                                      1,685 (St.      470 patient for
                                     George East),        every
                                    5,886 (Tobago),    doctor-Canada
                                    3,196 (Caroni)

Accessibility-    patients/clinic   Wide variation        Uniform
venue                  ratio

                   health care      6,392 (Caroni),         N/A
                  facility (LHO)    1,731 (Tobago)

Source: Ministry of Health statistical data, 2009;
CMOH data on LHO 2005; WHO data 2008
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