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“ A H EALTHY JAMAICA IN A
H EALTHY W ORLD ”

T HE M INISTER ’S M ANDATE
“A Comprehensive Review and Evaluation of the
Regional Health Authorities and their related
entities, with recommendations on the way forward to
a cost-effective, comprehensive and sustainable health
care delivery system for Jamaica in the 21st Century”

Presented to:

The Hon. Rudyard Spencer M. P.


Minister of Health and Environment

(Minister’s Vision)
“Envisions the modernizing of the Jamaican Health
Service sector to achieve a 21st century, best-practice
health care delivery system which addresses the health
problems of the Jamaican people in a comprehensive and
sustainable way. It should provide the conditions for
private investment within the health sector, with the
objective of delivering Health Tourism services globally
and of contributing to financing a best-practice, health
care system for all Jamaicans”

Prepared by: Health Sector Task Force (2007)


Chaired by: Dr. Winston G. Mendes Davidson C.D., J.P.,
MBBS, DTM&H.

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TABLE OF CONTENTS
Page
FOREWORD 8

ACKNOWLEDGEMENTS 9

MEMBERS OF THE TASK FORCE 10

0.0 EXECUTIVE SUMMARY 11

1.0 ESTABLISHMENT OF TASK FORCE 16


1.1 Terms of Reference 16
1.2 Task Force Implementation Framework 17

2.0 METHODS AND MATERIALS 18


2.1 Historical Review of Jamaican Health Sector 18
2.2 Prepare, Administer Instruments and Collect Data from Stakeholders 18
2.3 Limitations: Scope of Review 20

3.0 HISTORICAL PERSPECTIVES OF THE JAMAICAN


HEALTH SECTOR 21

3.1 Principles and Watersheds of Jamaica’s Health Service System 21


3.2 The Plantation System Period Of Slavery (1658 - 1838) 22
3.3 Early Colonial Post-Emancipation Period (1838-1846) 23
3.4 Colonial Post-Emancipation Period (1838-1866) 23
3.5 Crown Colony, Post-Emancipation Period (1867-1900) 24
3.6 The National Health Service System (1900-1938) 26
3.7 The Pre-Independence Internal Self Government Period (1938-1962) 29
3.8 The Post-Independence Period (1962-1972) 32
3.9 Modernisation (Globalisation) Of The Health Services System 1972-1989 37
3.10 Hospital Management and Standardisation 37
3.11 Leadership of Jamaica’s Modern Health Reform Agenda (1967-1980) 38
3.12 Health Administrative Office vis-a-vis Chief Medical Office(1955-1980) 39
3.13 Political Influences In Public Health Management In Jamaica 41
3.14 IMF Conditionality And Its Impact On Primary Health Care
initiatives of the 1970s 43
3.15 Organisational Reforms Prior To The RHAs Introduction 45
3.16 Task Force Conclusions From Historical Review 47

4.0 THE REGIONAL HEALTH AUTHORITIES (RHAs) 51


4.1 Introduction 51
4.2 Conditions Prior To The Establishment Of The Present RHAs 53
4.3 Proposed Administrative Management Centred System (1980) 65

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4.4 Profile Of The RHAs 66


4.4.1 South East Regional Health Authority 67
4.4.2 North East Regional Health Authority 70
4.4.3 Southern Regional Health Authority (SRHA) 71
4.4.4 Western Regional Health Authority 72
4.5 The New Statutory RHA and Its Instrument of Delegation 73

5.0 FINDINGS OF STAKEHOLDERS 76

5.1 Organizational Structure 76


5.2 Recommended Change In Policy Framework For Regions 81
5.3 Task Force Recommendations for Essential Functions Of Regional
Health Organizations 84
5.4 Existing Regional Health Authority Organisation Structure 89
5.5 Recommendations For The New Regional Organisation Structure 90
5.6 Recommended Core Functions Of The Parish Organisation 92
5.7 Recommended Scope And Content Of Primary Health Care 94

6.0 THE HEALTH INFORMATION SYSTEM 97


6.1 Stakeholders’ Key Issues 97
6.2 Task Force Recommendations 100

7.0 MANPOWER 101


7.1 Human Resource Management 101
7.2 Task Force Recommendations 103

8.0 SUPPLIES MANAGEMENT AND PROCUREMENT 105

8.1 Pharmaceuticals 105


8.2 Other Supplies 107
8.3 Task Force Recommendations 107
8.4 Equipment 108
8.5 Task Force Recommendations 108

9.0 FINANCE AND THE RHAs 108


9.1 MOH Grant 140
9.2 User Fee Income 140
9.3 NHF Grants 141
9.4 Fixed Assets 141
9.5 Expenditure 142
9.6 User Fees 143
9.7 Public/Private Partnerships 145
9.8 Task Force Recommendations 146

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10.0 PROJECT MANAGEMENT 147


10.1 Project Planning and Implementation 147
10.2 Task Force Recommendations 149

11.0 PUBLIC/PRIVATE PARTNERSHIPS 150


11.1 Health Tourism, A Consequence of Globalization 150
11.2 Build, Own, Operate and Transfer (BOOT) Model 153
11.3 The BOOT Model: Public/Private Partnership 154
11.4 Achieving A Sustainable World Class Diagnostic Imaging
Sector In Jamaica 158
11.5 Cost Of Services 162
11.6 Impact Of New Tax Measures 163
11.7 Private Radiologists’ Conclusion 164

12.0 CONCLUSIONS AND RECOMMENDATIONS

DIAGRAMS

Diagram 1 -
Ministry of Health Organisational Structure 30
Diagram 2 -
Ministry of Local Government (Local Board : 1938-1976) 31
Diagram 3 -
Population Explosion Of The Late 1960s 34
Diagram 4 -
Core Organisation of the Health Service System (1962-1972) 36
Diagram 5 -
Core Organisation of the Health Service (1972-1976) 47
Diagram 6 -
The Conceptual Framework Outlining the Relative Level of Importance
Of Elements Determining the Jamaican Health Sector (1867-19720) 49
Diagram 7 - The Process and Logic Of Efficient Health Care Service Systems 50
Diagram 8 - Core Organisational Reform Ministry of Health 1980 56
Diagram 9 - The Scope And Content Of Comprehensive Primary Health Care
(1980-2000) 61
Diagram 10 - The Prevention Principles and The Epidemiological Basis For
Primary, Secondary and Tertiary Care Intervention Services 63
Diagram 11 - Proposed Administrative Management Centred System 65
Diagram 12 - Task Force Recommendation (Relationship between Head Office,
Region and Parish) 79
Diagram 13 - Task Force Recommendation – MOH&E (Head Office)
Organisation Chart 80
Diagram 14 - Semi-Autonomous (RHA) Statutory Body 82
Diagram 15 - Fully Integrated Regional Organisation System 82
Diagram 16 - Reporting Responsibilities Between Structures 83
Diagram 17 - Existing Regional Health Authority Organisation Structure 89
Diagram 18 - Task Force Recommendation For The New Regional Organisation
Structure 90

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Diagram 19 - Task Force Recommended Core Functions of the Parish


Organisation 92
Diagram 20 - Task Force Recommended Scope and Content of Primary Health
Care In The Parishes 94

Diagram 21 - Classification of Health Tourism 151

Diagram 22 – The BOOT Model; Public/Private Partnership 154

TABLES

Table 1- Fee Scale for Private Patients 25


Table 2- West Indian Mortality Rates 1928 - 1938 27
Table 3- Comparison of Birth and Death Rates, Selected Areas (1965-1972) 35
Table 4
- Population and Geographical Extension of Health Regions in Jamaica
(1999) 66
Table 5 - Staff Status of the RHAs – January 2008 67
Table 6 - Hospital Profile – SERHA 68
Table 7 - Health Centre Profile - SERHA 69
Table 8 - Hospital Profile - NERHA 70
Table 9 - Health Centre Profile - NERHA 71
Table 10- Hospital Profile - SRHA 71
Table 11 – Health Centre Profile - SRHA 71
Table 12 - Hospital Profile - WRHA 72
Table 13 - Health Centre Profile - WRHA 73
Table 14 - Analysis of 2003/04 Income & Expenditure For Combined RHAs 109
Table 15 - Analysis of 2004/05 Income & Expenditure For Combined RHAs 110
Table 16 - Analysis of 2005/06 Income & Expenditure For Combined RHAs 111
Table 17 - Analysis of 2006/07 Income & Expenditure For Combined RHAs 112
Table 18 - SERHA Expenditure 2004-2006 by Cost Centre 123
Table 19 - SRHA Expenditure 2004-2006 by Cost Centre 127
Table 20 - NERHA Expenditure 2004-2006 by Cost Centre 131
Table 21 - Country Health Expenditure per Capita per Year and
Male /Female Longevity- WHO Estimates 2000 155

CHARTS

Chart 1 - Birth, Death, Marriage Rates (1880-1930) 33


Chart 2A- Income For The Combined RHAs By Year & Source ($JM) 113
Chart 2B- Income For The Combined RHAs By Year & Source (%) 114
Chart 3A- Expenditure For The Combined RHAs By Year & Type (in $JM) 115
Chart 3B- Expenditure For The Combined RHAs By Year & Type (%) 116
Chart 4 - Analysis 2003/2004 Income By Amount (J$M) by RHA and Source 117
Chart 5 - Analysis of 2004/05 Income By Amount (J$M) and By RHA & Source 118
Chart 6 - Analysis of 2006/07 Income By Amount (J$M) By RHA & Source 119

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Chart 7 - Analysis of 2003/04 Collections (J$M) by RHA 120


Chart 8 - Analysis of 2004/05 Collections (J$M) by RHA 121
Chart 9 - Analysis of 2006/07 Collections (J$M) by RHA 122
Chart 10- 2004/05 Actual Expenditure (in J$M) Analysed By Cost Centre 124
Chart 11- SERHA2005/06 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 125
Chart 12- SERHA 2006/07 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 126
Chart 13- SRHA 2004/05 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 128
Chart 14- SRHA 2005/06 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 129
Chart 15- SRHA 2005/06 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 130
Chart 16- NERHA 2003/04 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 132
Chart 17- NERHA 2005/06 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 133
Chart 18- NERHA 2006/07 Budgeted vs. Actual Expenditure (in (J$M) Analysed
By Cost Centre 134
Chart 19- 2004/05 Expenditure Ratios By RHA 135
Chart 20- Analysis of Payables (J$M) At 2005 March 31 By RHA & By Creditor 136
Chart 21- Analysis of Payables (J$M) At 2007 March 31 By RHA & By Creditor 137
Chart 22- Analysis of April – November 2005 Income (J$M) For Combined
RHAs By Source 138
Chart 23- Analysis of April – November 2005 Income (J$M) For Combined
RHAs By Source 139

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APPENDICES

Appendix 1 - List of Stakeholders 187


Appendix 2 – References 201
Appendix 3 – Focus Groups 203
Appendix 4 – Medical Officers of Health 201
Appendix 5 – Policy Issues – All Groups 203
Appendix 6 – Organisation/Structure – All Groups 204
Appendix 7 – Human Resources Management 206
Appendix 8 – Supplies Management and Procurement 207
Appendix 9 – Supplies Management and Procurement (Regions) 208
Appendix 10 - Patient Focus Group Discussion 211
Appendix 11 - Public/Private Partnerships (Radiology) 214

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FOREWORD
The Regional Health Authorities of the Ministry of Health have been
the object of widespread criticism by health professionals, managers and
policy makers since their establishment in 1997. This criticism has been
levelled at problems related to policy, organization, structure, manpower,
finance, supplies and maintenance.
The Government elected in September 2007 made a commitment to an
in-depth comprehensive review and evaluation of the issues and problems of
the Regional Health Authorities with a view to correcting them, in a quest to
modernize the Jamaican Health Service Sector. The objective is to achieve a
modern, 21 st century, best-practice health care delivery system that addresses
the health problems of the Jamaican people in a sustainable and
comprehensive way.
This will provide a platform for private investment in the health sector
with particular reference to Health Tourism, as outlined in the manifesto of
the Jamaica Labour Party.

This comprehensive evaluation will require the services of a small Task


Force of highly competent individuals whose knowledge of and work in the
development of the Jamaican Health Service System will provide an objective
and evidence-based review of opportunities for cross sector collaboration
throughout the Regional Health Authorities.

The goal of modernizing the Jamaican Health Care delivery system is


achievable. Private sector organizations can play a critical role in building
this system. However, given its substantial investment in and ownership of
the health infrastructure, the government must retain the responsibility to
lead and facilitate this process of development with a multi-sectoral
approach.

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ACKNOWLEDGEMENTS

The Task Force wishes to acknowledge the contribution of all persons who
participated in this exercise. Particular mention must be made of the assistance
given by Mrs. Verona Hall (NERHA), Mrs. Joan Guy-Walker (SERHA), Miss Edlin
Thompson (SRHA) and Mrs. Marcia Clarke (WRHA) who arranged the interviews
and focus group discussions. Also the stakeholders who diligently completed
questionnaires, attended focus groups sessions and/or interviews .

We must thank the staff at ISALS (UTECH) and Coke and Associates/Eckler
Partners for accommodating us at their offices. Mr. Kenroy Guthrie, who stayed late
many evenings to help with the printing and patiently collated numerous drafts of
the Report..

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MEMBERS OF THE TASK FORCE

The five-member Task Force appointed by the Minister of Health and


Environment comprises qualified specialists and consultants with knowledge
of the Jamaican Health Service System who possess relevant experience in
health system research and evaluation. Collectively, they share a deep
conviction of the value of health care to the citizens of Jamaica. The Task
Force comprised the following:

Task Force Members:

Dr. Winston Mendes-Davidson, C.D., J.P.


Chairman,
Adjunct Professor
Public Health and Health Technology
University of Technology (UTECH)

Miss Thelma E. Campbell


Former Chief Nursing Officer
Ministry of Health 2000 – 2004

Mr. Fabian Brown


Executive Director
St. Joseph’s Hospital

Hon. Daisy McFarlane-Coke, O.J., C.D.


Actuary
Coke & Associates/ Eckler Partners

Dr. Sheila Campbell-Forrester


(Unable to participate fully because of illness)
Chief Medical Officer
Ministry of Health & Environment

Support Team:

Miss Gaile Sweeney Research Assistant


Miss Jennifer Higgins Administrative Assistant
Mrs. Rosemary Ganley Editorial Assistant

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EXECUTIVE SUMMARY

The work of the Task Force comprised:

• extensive review of recent, relevant studies and research papers of


the Jamaican health care system with particular reference to
reports in the period just before the establishment of the Regional
Health Authorities (“RHAs”) and the first decade of their currency
• detailed historical review of the Jamaican Health Sector showing
its evolution over 250 years
• Interviews with Stakeholders (internal and external) and allied
agencies
• SWOT Analyses
• Guidance of Focus Groups from all the RHAs, held with Technical
Administrative and Primary Care Personnel, in order to identify key
issues as outlined in the Terms of Reference.

Some of these steps overlapped. Then followed the collation of the data,
responses, suggestions and recommendations, preparatory to the drafting of
the Report.

This Report is organized as follows:


Section 1 sets out the Terms of Reference. The methodology adopted by the
Task Force to obtain the data and solicit inputs is dealt with in Section 2. We
conducted interviews, administered questionnaires and facilitated Focus
Group discussions and SWOT Analyses in all the RHAs. Summaries of the
information data and responses obtained from the stakeholders are
presented in Appendix 3 to Appendix 9. The Stakeholders interviewed range
from Patients at Health Centres through all categories of professional ,
technical, administrative and support staff across all the RHAs and the Head
Office (MOH), professional associations ( e.g. MAJ, NAJ, Midwives

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Association, Dental Associations, Jamaica Enrolled Nurses Association,


Private Hospitals Association, the Jamaica Association of Radiologists) up to
Regional Board Chairmen, Chief Epidemiologist, Chief Nursing Officer,
Director HRM & Corporate Services, Principal Finance Officer, the
Permanent Secretary, the Auditor General and the Cabinet Secretary.
The questions addressed related to the objectives of the RHAs, the
determinants and characteristics of the Health Care Services, policies,
organizational structure, financing, manpower and supplies. Participants’
views were also canvassed on the relevance of the global Health Tourism
market to Jamaica’s health care system and Private/Public partnerships in
health service delivery.

Section 3 gives an historical survey of the Jamaican health service delivery


and system over the past 250 years. This was done in great detail quoting
extensively from the available research materials and informed by the
Chairman’s institutional knowledge of the sector. The Report considers the
main drivers of the system and its characteristics prior to the establishment
of the RHAs.

Section 4 examines the operations of the RHAs, the scope for delivery of
health care, the Instrument of Delegation, and organizational structure
against certain paradigms.

Our Findings are discussed in Section 5 to Section 11 under the headings:


• Organizational Structure
• Scope and Content – Primary, Secondary and Tertiary Care
• Health Information System
• Human Resource Management
• Supplies Management and Procurement
• Equipment

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• Finance
• Project Management
• Health Tourism

Recommendations from the groups and the Task Force are highlighted and
indicated throughout the Report. For convenience the specific
recommendations from the Task Force are collated in section 12. Some of
them are:

(1) The RHAs must be changed from semi-autonomous authorities to


become Regional Coordinating and Enabling Organizations. In so
doing, each will be an integral part of the organization and
structure of the Ministry and a strong link between head office and
the Parish, enabling and supporting the function of
implementation – which is the domain of the Parishes

(2) Head Office of Ministry of Health and Environment should focus


on its primary role of policy formulation, policy determination, setting
norms and standards, monitoring and maintaining support functions
for strategic health care delivery.

(3) Maintain the four Health Regions within the current borders.

(4) Reorganise service delivery on the core functions of Primary,


Secondary and Tertiary Health Care

(5) Redefine the role of the Parish Manager to become the leader of
the administrative support team and system; facilitating, enabling
and supporting the efficient implementation of health service
delivery at the parish level.

(6) Re-establish the corporate structure to all hospitals with each


Hospital governed by a Board of Management and not a Health
Committee of the Region or parish. The reporting relationship to
the Board is to be the triumvirate of the Executive Manager, the
Senior Medical Officer and the Director of Nursing Services. This
must become part of a national standardized corporate structure
which becomes part of the prerequisite for public/private

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partnerships and other community alliances including


international recognition and accreditation.

(7) The National Health Fund (NHF) be the executing agency for the
immediate, short term, medium term and long term Information
Technology needs of the Ministry of Health and Environment .

(8) The backlog of HR issues including appointments, promotions,


salary packages, welfare and incentive schemes must be
immediately addressed by a special multi-disciplinary group in
order to improve staff morale.

(9) A National Human Resource Development Strategic Plan be


implemented as a matter of priority and that this be guided by
epidemiologic principles.
(10) HCL be transferred to the NHF as a Department and be fully
integrated into the NHF procurement system.
(11) Policies must be developed for the standardisation of all
categories of equipment especially with regard to energy
conservation and the replacement of parts.

(12) Abolition of User Fees for Primary Health Care in every


community as the first step to fulfil the commitment of the
Government, but ability to pay should inform cost sharing of
Secondary and Tertiary Care.

Throughout the Report are a number of Diagrams to illustrate the points


under discussion, summarise organisational issues and/or present recent
history and experience. Financial data from the RHAs for fiscal 2003/2004 to
2006/2007 are analysed and crystallised in Tables 14 -20 and Charts 2A to
23.

In particular the following diagrams incorporate our main recommendations


for the reorganisation of the roles, functions and reporting relationships of
the segment of the health sector embraced /to be embraced by the reorganised
Regional Health Organisations.

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Diagram 6 Conceptual Framework-Outlining


Levels of Service Delivery

Diagram 12 Relationship between Head Office


(MOH&E) , Region and Parish

Diagram 13 Head Office Organisational Chart

Diagram 16 Reporting Responsibilities Between


Structures

Diagram 18 New Regional Organisation Structure

Diagram 19 Core Functions of the Parish


Organisation

Diagram 20 Scope and Content of Primary Health


Care in the Parishes

The list of the Participants at Interviews and Focus Groups are in Appendix
1. Appendix 2 gives the reference literature and consultancy reports which
were reviewed. Appendix 3 to Appendix 10 summarise the submissions
and comments on the issues which persons considered to have significant
impact the health delivery system.

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1.0 ESTABLISHMENT OF THE TASK FORCE


1.1 TERMS OF REFERENCE
To review and evaluate:
• The policies governing the Regional Health Authorities.
• The organization of the Authorities with special regard to the
structures, functions, manpower, supplies and financing of the
related entities.
• Their capabilities in planning, managing and implementing
programs and projects.
• The financial and technical efficiencies of the Authorities.
• The relationship of the four Authorities to each other and to the
Central and Statutory Authorities of the Ministry of Health and
Environment and its other Statutory Bodies and Agencies.

To make recommendations on the changes needed:


In policy, organization, structure, function, manpower, supplies
and financing of the respective Authorities and/or their entities.

These recommendations must indicate:


How they will contribute to the ordered and rational development
of a modern and efficient health services system capable of delivering
the highest levels of cost-efficient and best-practice health services to
the Jamaican people.

What are the conditions necessary for building public / private


partnerships in attracting private investment so that Jamaica will
become a significant player in the rapidly emerging global health
market?

The Terms of Reference presented an opportunity for the Task


Force to do a comprehensive review, evaluation and analysis of
Jamaica’s health service system, using the Regional Health Authorities
as its point of departure. It also created an opportunity for best-practice
identification in the quest for best solutions. It allowed the Task Force
to recommend necessary revisions of the existing policies,
organizations, structure, functions, programs and projects in both the
health institutional and non-institutional entities of the Regional
Health Authorities and the related entities.

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Some fundamental questions were answered in order to inform a


comprehensive review and evaluation of the Regional Health
Authorities.

These questions were:


• What is the Jamaican Health Care sector? How did it develop?
What are its enabling and disabling characteristics?
• What is the Regional Health Authority?
• What was the justification for its introduction?
• How do the RHA’s relate to the enabling and disabling
determinants and characteristics of the Jamaican Health Care
Services?
• How relevant is the global Health Tourism market to Jamaica’s
health care system?

In keeping with these Terms of Reference an implementation


framework was developed.

1.2 TASK FORCE IMPLEMENTATION FRAMEWORK

The Task Force worked in the period 29 th October 2007 to 12th


February 2008. In this time it developed the following framework for its
Review and Evaluation:
An examination of the Regional Health Authorities (“RHAs”)
with respect to the following:
a) Policies, b) Organization, c) Structure, d) Function, e) Manpower,
f) Supplies, g) Finance.

The capabilities of the RHAs in:


• Planning
• Financial and technical efficiencies
• The relationship between the four RHAs to the central and statutory
authorities of the Ministry of Health and Environment (MOH&E).
• The Task Force was also mandated to recommend to the Minister what
changes are needed in terms of : a) Policies b) Organization c) Structure
d) Function c) Manpower d) Supplies e) Finance.

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• The Task Force was asked to indicate in its recommendations how


these changes will contribute to the ordered and rational development
of a modern, efficient health services system.
• The Task Force undertook to outline the conditions necessary for
building Public /Private partnerships in health to attract private
investment in order that Jamaica may become a significant player in
the global Health Tourism market.

2.0 METHODS AND MATERIALS

STAGE 1

2.1 Historical Review of Jamaican Health Sector


• Identify both driving forces (which enable) and restraining forces
(which disable) change, in order to present a comprehensive review of
the Jamaican Health sector
• Define key processes that enable the achievement of the vision
• Identify key stake holders who manage / control / enable these
processes
• Review the relevant literature.

2.2 Prepare and Administer Instruments to Stakeholders to Collect


Data Derived From:
• Questionnaires / Interview Guides, SWOT Analyses, and Focus
Groups
• Discussion on “What is stopping us from…..”

Collect all relevant information for the study.

STAGE 2

• Define the characteristics of a 21 st Century Health Delivery System


that addresses the health problems of the Jamaican people in a
comprehensive and sustainable way.
• Define the conditions necessary to attract the type and scope of private
investment required for building a viable Health Tourism sector.
• Categorize the problems based on the above criteria.

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• Make recommendations to specifically address the problems identified


by the Task Force during the study.

All Instruments were prepared and tested prior to their administration.


Standardized methods were used by members of the team and support
staff.

STAGE 3

The Task Force:


• Reviewed and analyzed local research papers and documents on the
Jamaican health care system – a means of gathering both primary and
secondary data. In particular we referred to Reports done prior to
regionalization and consultation work done during the ten (10) years of
regionalization. We believe that these are the most current research
documents on the RHAs and the issues identified within these reports
still remain and would be still valid for our analysis.

• Conducted personal interviews with key stakeholders including the


Permanent Secretary, Principal Financial Officer, Regional Directors
and Senior Medical Doctors. Refer to Appendix 1: List of
Stakeholders.

• Facilitated Focus Groups across all four (4) Regions with Technical,
Administrative and Primary Care personnel. The purpose was to
identify key issues as outlined in the Terms of Reference. The theme of
the Focus Group discussions was “What is stopping us from……”

• Prepared a Draft Report on the findings, discussed it among the Task


Force members, finalised and submitted the Report to the Honourable
Minister and the Permanent Secretary.

2.3 Limitations: Scope of Review

While it was pertinent to address the major stakeholders within the


RHAs, due to the time constraints the Task Force grouped various categories

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of workers who may not have necessarily shared the views and concerns of
those who did not participate.

There are very few members or categories of stakeholders who have not
yet submitted reports. We do not anticipate that these inputs would
fundamentally change the conclusions. (See Appendix 1: List of
Stakeholders).

The Task Force worked feverishly to complete the review in the short
period which spanned the Christmas holidays.

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3.0 THE HISTORICAL DETERMINANTS OF THE


JAMAICAN HEALTH SECTOR

3.1 PRINCIPLES AND WATERSHEDS IN JAMAICA’S HEALTH


SERVICE SYSTEM

The Task Force determined that a close look at the history of Health
Care in Jamaica would inform us of the core values which are embodied in
our system over the years. These values have enabled the sustainability of
our system, and they should be revisited if we are to get clarity in
understanding the Ministry’s mission and enable the conditions for a
successful outcome.
The form and content of health service systems always reflect the
prevailing social, economic, political, cultural and religious systems of
countries. Every health service system is culture-bound and reflects the
unique and particular characteristics of its society.
The direction, pace, quality and quantity of Jamaica’s health service
system have been determined, in the main, by the prevailing pattern of
diseases (morbidity and mortality i.e. epidemiology) and conditions affecting
the system both at particular points in time and over different periods.
A brief summary of the two hundred and fifty year history of Jamaica’s
health service system gives evidence that epidemiological determinants have
provided the context, conditions and circumstances for clinical intervention
measures which have determined the organization, structure, functions,
plans and programs of the health service system.
It follows, therefore, that “one solution is never the solution for all” and
every health service system must determine its unique intervention
measures, adapted to the prevailing epidemiological patterns, conditions and
circumstances of the particular country.
Any change in the system, from a policy standpoint or from an
organizational standpoint must satisfy the fundamental criterion of being
evidence-based and having epidemiological justification.
Indeed the history of Jamaica’s health service system is characterized
by a number of watersheds. These have arisen from qualitative changes in
the epidemiological conditions, contexts and circumstances over the past 250
years. One paradigm has endured: it is the essential core paradigm of

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“PATIENT / DOCTOR / DIAGNOSIS / TREATMENT”. It reflects the


essence of the system’s long, enviable health development record.
Historical analysis also identifies the core paradigms at the centre of
the health care delivery value-chain. It speaks to the relative importance and
relationships of different elements in the health care process delivery-system
and value-chain. Exaggerating any one’s importance in the system of values
in the care delivery process is as dangerous as denying the importance of any
element. We will examine to what extent each element has been predominant
in the system.
In this Report, the system of values developed by the science of
epidemiology will inform the conceptual framework. If this is right, then the
relative relationships among elements making up the delivery processes and
value-chain will be right. This is the challenge which faces Jamaica’s health
care system at this critical point.

3.2 THE PLANTATION SYSTEM (PERIOD OF SLAVERY : 1658 to 1838)

Between 1658 and 1798, approximately 281,000 slaves were imported


to Jamaica. Thousands died in the middle passage or became ill and died
after arrival. The period of adjustment to plantation conditions known as
“seasoning” took one to three years. This period was accompanied by
mortality rates of 1/4 to 1/3 of the slaves being “seasoned”. Epidemics were
common on plantations and as many as half the slaves died. At Worthy Park
Estates, of 181 slaves bought, one quarter died in one year from yaws and
dysentery; and of 345 births, 186 children died in a five-year period. Slaves
also died from yellow fever, small pox, TB, worm infestations, maltreatment,
over-work and starvation.
In 1792, passage in Britain of the Consolidated Slave Act called for the
provision of medical facilities and the submission of medical reports from the
colonies as to the numbers of slaves and the causes of death. This took place
134 years after the beginning of the slave trade. Prior to that Act, the cause of
death of a slave was not required to be recorded. Medical officers were
employed by plantations and had responsibility for the health of slave
owners, their families, and their indentured and house slaves. These doctors
were also responsible for general hygiene on the property, the control of
communicable diseases, and births and deaths. Field slaves were treated in
many instances in plantation “Hospitals” or “Hot Houses” and a number of
these were manned by veterinarians.

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Comment: Although morbidity and mortality data for the plantation


owners and their household and indentured serfs were not available,
nevertheless the data speak to the early stratification of the health service
system based on a hierarchy of relative wealth. However, the idea of best care
for the wealthiest and not the neediest does not hold today as the health
system, in the majority of cases, has lost its wealth/hierarchy configuration.
Although access to basic health services of Primary Care is universal ,
remnants of the Jamaican class-structure are reflected in the organization
and structure of the health service system today,. The data also point to the
250 year history of “The Physician” as having the central and leading role
at the core of the health care system in patient care, public and community
health and population medicine.

3.3 EARLY COLONIAL POST-EMANCIPATION PERIOD (1838-1846)

Slavery was abolished in 1838, and many plantations went out of business.
The majority of doctors migrated, leaving only 50 doctors out of 200 doctors
prior to emancipation. Health and social conditions worsened. Ex-slaves had
no social protection, and jobs on the plantations were taken by indentured
labourers (Indians & Chinese). By 1846 the Sugar Equalization Act was
passed which was the final act in destroying the plantation system.

Comment: Whenever there is a fundamental change in the social system,


there are health consequences which may be good or bad. Highly trained and
marketable professionals will always be in demand. Their loss leads to
negative consequences in human development. These data provide early
evidence of the close relationship between health and development. They also
point to the essential role of the physician in health service delivery.

3.4 COLONIAL POST-EMANCIPATION (CROWN COLONY)


PERIOD 1846-1866

As the plantations closed down, worsening social conditions led to a


massive epidemiological crisis in Jamaica. During this period, an outbreak of
cholera in 1850 caused 32,000 deaths; a smallpox epidemic in 1852, and
epidemics of typhoid fever and cholera in 1853 resulted in deaths of a quarter
of the population of Kingston, the victims being buried in mass graves. By
1865, conditions were so poor that it led to the Morant Bay Rebellion.

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By January 1866, a Royal Commission was set up which led to the recall of
the Governor. Jamaica became a Crown Colony in 1866 and this heralded
much needed reforms in the health service system.

Comment: The institutions of the colonial state broke down. Health care
was anarchic. Epidemiological conditions were worse than they had been
during the plantation period. Death, destruction and rebellion were
inevitable.

3.5 CROWN COLONY, POST-EMANCIPATION PERIOD (1867-1900)

In 1867, the Public Health Law was passed and it set up a Central Board
of Health. A Parochial (Local) Board of Health was established in the 14
parishes. The Central Board was established as an Island Medical
Department with a Government Medical Service coming into being. These
Boards endure to this day, albeit in a different form.
Greater emphasis on public health, better roads, safer water supplies, the
enactment of quarantine measures and the provision of dispensaries occurred
throughout Jamaica. People, irrespective of income, were able to obtain drugs
and medical supplies. The Kingston Dispensary was opened in 1870. For
sixty years it had only one doctor. By 1874, the 14 parishes were divided into
40 medical districts and thirty-five District Medical Officers (DMO’s) were
allocated to 14 Parishes. Some Estate Hospitals were reopened and placed
under the administration of the DMOs.

Comment: The Central Board of Health dealt with health issues of


national importance, whereas the implementation of the services to
individuals, groups and populations was the domain of the Local Board of
Health in the parishes.
This change established the crucial relationship between health and
development. Integration took place at the local level through the Parish
Council mechanism, whereby public health, roads and communications, water
supplies, control of disease by quarantine and treatment of illness through
dispensaries were integrated under the auspices of the Parish (Local) Board
of Authority.
The management of the system was the responsibility of the medical
doctor at both the field (parish) level and central level. This organization,
structure and function represented the basis of the Government Medical
Service of Jamaica’s health service system, the essence of which exists today.

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Financing the Health System


During this period the District Medical Officer was paid a retainer by
the Government and allowed a restricted private practice not exceeding six
hundred pounds per year, using the scale of fees in Table 1. DMOs were
expected to perform any other duty designated by the Governor without
charge i.e. to paupers, the constabulary, prison inmates, and residents of
alms houses. They also supervised dispensaries did vaccinations and gave
advice to government.

Table 1
Fee Scale for Private Patients

Patient Wages Fee for


/- per week Service
Up to 12 Shillings No charge
12 to 25 shillings 1.5 shillings
25 to 50 shillings 2.5 shillings

Comment: In 1867 there was an element of fee-for-service (“patient pays”) in


the system, and a means test was introduced to assist the financing of the
health service system. The principle of the means test which began in 1867 is
still used in our hospitals today. It has served the health services well. In our
thinking, there must be epidemiological justification for any change. One such
justification would be the future capacity of the Government to fully fund
health care delivery services. This is not a real possibility at this time given
the low percentage of the national budget which is presently allocated for
health care.

In 1867 the most highly-trained health professional was given the right to
a geographically-based private practice at the community level. This is
another policy which has existed for over 140 years. The practice has served
us well but now has problems because of the monitoring methods in use.

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THE TASK FORCE RECOMMENDS :


The use of three criteria for monitoring consultants with geographic
private practice. These are: a) Service b) Teaching c) Research. Monitoring
these highly trained and experienced consultants only on the basis of the
number of patients they are able to see per day is not utilising the vast
potential that these professionals have to contribute to the improvement of
patient care.

3.6 THE NATIONAL HEALTH SERVICE SYSTEM 1900-1938

By 1900, there were 48 DMOs and 28 private practitioners serving a


population of 640,000 Jamaicans. Thereafter, there was a steady increase in
private practitioners, later overtaking the number of DMOs. Rapid expansion
of hospital services, with the opening of three additional hospitals between
1916 and 1926, led to a period of “hospitalization” of the health services to the
neglect of the basic community health care preventive services.
In the 1935 report of the Hand Book of Jamaica, the public health report
took up a mere paragraph compared to 10 pages of hospital statistics. This
represented a complete reversal of the situation of the previous ten years.
Between 1918 and 1937, the Rockefeller Foundation supported the
establishment of the health departments and a new cadre “medical officers of
health” along with a new health cadre, the public health inspectors, who were
engaged in the control of communicable diseases such as malaria, hook worm,
TB and yaws.
By 1945, two hospitals had more doctors than the total complement of all
the DMOs in the island. This undesirable proportion led to a shift in the core
paradigm of the health delivery system of the Government Health Service,
which created some dysfunction in the delivery of health care. The 4 shillings
per head allocated for needy-cases was revoked and in 1904 a ticket system
was introduced for patients to access the hospital services. This was the first
attempt to ration hospital services. It reflected a paradigm shift from
community health services to hospital services.

Comment: The need for Public Health leadership at the parish level led to
the first group of Medical Officers of Health and new public health personnel
such as public health nurses and public health inspectors becoming part of
the health team. Massive improvements in public health were seen in the
area of communicable diseases. However, the rapid development of hospital
institutional clinical services (1900-1938) led to increased organizational

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tension between institutional and non-institutional clinical & public health


services. This tension has persisted to this day. It is worse during times of scarce
resources. Indeed this tension was further exacerbated by unprecedented allocation
of resources to the hospital services system, in manpower, finance and
administrative support at the expense of the community / district health care
services. This was the first recorded period referred to as the “hospitalization” of
Jamaica’s National Health Service system. The neglect of community clinical health
practice in the district medical services continued, and led to an exacerbation of
negative public health conditions on the ground.
The lack of prevention, early detection and clinical intervention measures due
to very low budgetary allocation to the Local Board of Health reduced access to basic
health service in the districts nearest to the homes of the population. On the other
hand, rationing of the hospital services because of overcrowding planted the seeds of
a national health crisis which was looming prior to 1938.
Table 2
West Indian Mortality Rates 1928- 1938
1928 1930 1932 1934 1936 1937
Barbados
Death Rate 30.1 23.1 19.0 23.0 18.5 18.5
IMR 331.0 251.0 198.0 256.0 198.0 217.0
British Guiana
Death Rate 27.9 23.0 21.1 24.7 20.4 21.9
IMR 185.0 146.0 139.0 168.0 120.0 121.0
British Honduras
Death Rate 18.2 19.2 20.3 19.2 20.2 18.5
IMR 13. 109.5 104.8 102.8 152.7 122.6
Jamaica
Death Rate 19.7 17.0 17.2 17.0 17.3 15.3
IMR 157.0 141.0 141.0 131.0 130.0 118.5
Leeward Islands
Death Rate 31.4 24.8 20.6 19.7 20.4 20.6
IMR 93.0 125.5 111.2 171.1
St. Kitts
Death Rate 39.8 37.2 27.5 30.7 33.2 36.5
IMR 308.3 186.0 166.7 229.0 164.1 209.0
Nevis
Death Rate 19.4 24.2 11.1 12.3 14.5 14.9
IMR 286.6 155.9 102.2 103.9 177.4 107.1

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A crisis and the failure of Colonial Governance methods throughout the


West Indies led to widespread riots in 1938. This resulted in the British
Crown setting up a Commission of Enquiry chaired by Lord Moyne, known as
the “Moyne Commission”. The wide-ranging recommendations of this
Commission set the stage for far-reaching health policy changes throughout
the Caribbean, most of which are still relevant today.

SOME CONCLUSIONS OF LORD MOYNE’S COMMISSION

• The cure of disease has received much more attention than its
prevention.
• Much ill-health arises from poverty; poverty of the individual, of the
medical departments and of governments.
• Much ill-health is of a preventable nature and much arises from
ignorance.
• The high rate of illegitimacy combined with large families, and a lack of
parental responsibility are serious factors in health.
• Housing accommodation for the poorer people in the West Indies is
generally deplorable & general sanitation is primitive.
• Little improvement in the health of the people is expected no matter
how extensive the hospital facilities are.
• This will continue until such defects are remedied.
• Relatively too large a proportion of the available funds and medical
efforts is expended on curative medicine and too little on prevention.
• There is neglect of rural districts in favour of the urban areas.
• The creation of at least one School of Hygiene with the training of
auxiliary medical personnel is recommended.
• The centralization of medical institutions for the training of all classes
of medical personnel is recommended.
• The reorganization of the medical services for the better balance
between preventive and curative medicine is recommended.
• A minimum of ten percent of the National Budget should be spent on
health care services.

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Comment: The recommendations of Lord Moyne in 1938 identified the


inextricable relationship among health conditions and poverty, illiteracy,
available housing, provision of public health, availability of auxiliary medical
personnel, illegitimacy and irresponsible parenting, community development,
and adequate funding of community health services. These linkages were to
become the conceptual framework which informed the policy, organization,
structure and function of Primary Health Care (PHC) services in Jamaica in
the 1970s.

3.7 PRE-INDEPENDENCE INTERNAL SELF GOVERNMENT


PERIOD (1938-1962)

In 1939, World War 2 intervened and Lord Moyne’s recommendations


were put on hold.
The number of Medical Officers of Health increased from 7 to 17 and
they took over from DMOs at the parish level. In 1944, a New Constitution
gave the Jamaican people more rights with Universal Adult suffrage.
By 1957, internal self-government with Cabinet rule of locally
appointed Ministers of Government came into being. By 1959, Jamaica
gained complete self-government. The problems of the Island Medical
department were still the responsibility of the Colonial Governor.
By 1955, the Medical Department was incorporated into the Ministry of
Health. Jamaica now had a Minister of Health, a Chief Medical Officer and
Permanent Secretary.
A major epidemiological success was the eradication of malaria and
yaws which took place in 1961, while hookworm and TB was reduced
considerably. This was largely the result of the public health team working in
the parishes led by the Medical Officers of Health.

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Diagram 1

MINISTRY OF HEALTH ORGANISATIONAL STRUCTURE


(Central Board: 1938-1962)

Source: W. Mendes Davidson 2007

Comment: The principle of the Chief Medical Officer reporting directly to the
Minister of Health is a fundamental one, for which the historical precedence
exists. All international health organizations, including the World Health
Organization, operate on the basis of the inviolability of an unbroken chain of
command involving the Medical / Health Professional Services and the Chief
Medical Officer / Adviser. To do otherwise would expose the system to the risk
of medico-legal problems with serious consequences.

This was not only a feature of the Central Board of Health but also of
the Local Board of Health where the Medical Officer for the Parish reported
directly to the Parish Council (the political directorate), at the monthly
council meeting of the Local Board of Health.

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31

Diagram 2
MINISTRY OF LOCAL GOVERNMENT
(Local Board: 1938-1976)

Source: Dr. Marilyn Reid-Delevante: (Primary Health Care in Jamaica) 1975

The relationship between the Permanent Secretary and the Chief


Medical Officer should not be an adversarial one but a mutually supportive
one in the same way that the Chief Justice in the Ministry of Justice or the
Chief of Staff of the JDF relates to his/her respective Permanent Secretary.
This core value is defined by the professional process of peer reporting,
professional collaboration, peer review and monitoring and peer responsibility
for highly sensitive diagnostic details. Such a system protects the
fundamental rights of individuals, groups and the population at large. This is
a basic feature of what is referred to as “A mission-critical system” in
which the health care sector has always occupied pride of place.

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Comment: The weakness in the organizational structure of the Ministry of


Health became evident because of the separation of the parish health services
from the central medical services at the end of Colonial Governance and the
beginning of internal self-government.
The Central Ministry of Health was responsible for hospital services while
parish health services were under the jurisdiction of the Ministry of Local
Government. However the parish health services were better integrated with
the community development process in such sectors as water quality control,
vector control, food hygiene, public hygiene in markets and restaurants etc.
The strength of the local government process was to integrate health into the
community development.
The community participation model introduced in the development of the
primary health care services system in the 1970s was implemented to correct
this weakness of inadequate integration of health care services with the
community development process. Such integration was a critical factor in
Lord Moyne’s recommendations. 1 Subsequent research done in Hermitage
and August Town by Davidson (1973-1976) in the Department of Social and
Preventive Medicine and replicated in Olympic Gardens established the
validity of the concept in 1976. It must be noted that there was never any
break in command in the medical services sector, a fundamental professional
principle which had been the policy of Jamaica’s Health Care Service since
1867.

3.8 THE POST-INDEPENDENCE PERIOD (1962-1972)

After the 1961 referendum Jamaica seceded from the West Indies
Federation.
In 1962, Cold War alliances deepened, with people voting out of fear because
of the presence of Russian ships in the harbour. Independence in 1962 led to
membership in the United Nations. Prime Minister Bustamante declared “We
are with the West”.
The Ministry of Health then became preoccupied with hospital
institutional services which became the centrepiece of its policy
implementation. This policy alignment was in keeping with the American
model of a hospital-centred health care system. It increased the tension
among the non-hospital health services to the detriment of public health and
community health services; a repeat of the situation between 1900 and 1938.

1Community Participation in Primary Health Care; W. G. Davidson


Published 1978; Primary Health Care Jamaican Perspective

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This continued “hospitalization” of the Health Services in line with the


American model of a high- cost, hospital-centred health care delivery system
led to the commitment of the largest capital investment ever in the health
sector. This was the building of the Cornwall Regional Hospital.
Investment in this institution by the World Bank created very serious
demands on the Jamaican Health budget as there were many design faults
which had to be corrected. The institution became a mal-application of
European hospital architecture funded by the Bank. The design placed the
boiler under the Casualty Department to provide heating during the winter.
Jamaica does not have a winter season and the heat of the Jamaican summer
became so unbearable that the department had to be abandoned during the
summer. Subsequently, a Type 3 Health Centre was built on the hospital
premises to carry out the work of the Casualty Department.
The Cornwall Regional Hospital consumed over 60% of the national
hospital budget and this led to the gross under-financing of the other 28
hospitals with the subsequent closure of a number of these institutions.

Chart 1
Birth, Death, Marriage Rates 1880 -1930

40

30
Death Rate
20 Birth Rate
Marriage rate
10

0
1880 1900 1910 1920 1930

The data in Chart 1 demonstrate that over a fifty-year period the rate
of demographic transition is of vital significance to epidemiologic analysis and
health service delivery. The institution of marriage and the nuclear family
structure was never a deeply embedded core value in Jamaica. This trend
continues in the twenty-first century. Family health as a category, with a
nuclear family structure is not Jamaica’s reality, as in other Western
cultures. Community Health therefore assumes even greater significance in
epidemiologic strategic planning. This reality must be taken into

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34

consideration in attempts at service delivery designs for record linkages of


individuals, families groups and communities.

Diagram 3

POPULATION EXPLOSION OF THE LATE 1960s

Diagram prepared by Dr. Marilyn Reid-Delevante: (Primary Health Care in


Jamaica)

From an epidemiological standpoint, Jamaica had entered the stage of a


demographic transition. Improvements in the health status of the population
resulted in lower death rates and greater birth rates with high dependency
ratios, and demonstrated the inability of the economy to sustain the rapid
rate of population increase.
The response to the situation was the development of family planning
spearheaded by Dr. Lenworth Jacobs, whose pioneering work was

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35

subsequently adopted as national policy by the Government with the


establishment of the National Family Planning Board in 1967.

Table 3

COMPARISON OF BIRTH & DEATH RATES, SELECTED AREAS 1965-1972

Birth Death Annual %


Area Rate Rate Rate of
Per 1,000 Per 1,000 Population
Increase
World 34 14 2.0

Africa 47 21 2.6

West Europe 16 56 0.6

America N & S 29 32 2.1

Caribbean 35 35 2.2

Jamaica 35 7 1.6

Source: U.N. Demographic Year Book 1972

The Family Planning initiative was funded by the World Bank which
also funded the Cornwall Regional Hospital which added another 400 beds to
the national hospital stock of beds.
Greater privatization was encouraged and the number of private
hospitals beds was increased during this period. There was continued
separation between Central and Local Boards of Health, and health centres
did not receive any budgetary allocation but functioned essentially on an ad
hoc basis.
The Ministry of Health supply system was supported by the
Department of Supplies located in the Ministry of Finance. Each hospital had
a small group of artisans on staff but hospital maintenance was the
responsibility of the Ministry of Works.

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36

Budgetary allocation did not reflect community activities in the field.


The vast majority of health workers continued to be part of the hospital
system, and public health and community health care were neglected.

Results of a Knowledge/ Attitude/ Practice (KAP) study done by medical


students supervised by Dr. Davidson in the Dept. of S&PM in 1994, revealed
that as many as 78% of patients who were seen in the Casualty Department
of the Kingston Public Hospital could have been adequately treated in a
health centre, had the services been available in their own community. This
study was part of the evidence which inspired the strategic development of
the primary health care services in the 1970s.
Indeed, history is repeating itself in the current massive overcrowding
at the Bustamante Hospital for Children in the absence of a properly
organized and structured national Primary Health Care system.

Diagram 4

CORE ORGANIZATION OF THE HEALTH SERVICE SYSTEM (1962-1972)

Source: W. Mendes Davidson (1975)

By 1972 the organizational chart included the newly formed National


Family Planning Board. Two Principal Medical Officers (Medical; hospitals)
and (Health; public health) were supported by Senior Medical Officers and

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37

Medical Officers of Health. These PMOs reported directly to the Chief


Medical Officer who reported directly to the Political Directorate. The chain of
command of the central mission of the health services, the delivery of health
services to the Jamaican people, was therefore unbroken.
This has been one of the most important principles in the delivery of
health care since 1867. The process begins with the patient / doctor
relationship, and diagnosis becomes the critical mission of this relationship.

3.9 MODERNISATION OF THE HEALTH SERVICES SYSTEM 1972-1989

Three unbroken periods of policies drove the development of the health sector
in the next 35 years: 1972-1980 (Michael Manley); 1981-1989 (Edward
Seaga); 1992-2005 (P.J. Patterson). Each period created both quantitative and
qualitative changes which mainly resulted in positive outcomes.
Introduction of the Environmental Control portfolio in 1972 for the
first time in the Ministry of Health was an important policy initiative which
could have had a great impact on the development agenda of the country if
the opportunities had been seized and sustained over the years. This period is
seen as a preparatory step to enable the most far-reaching reforms to take
place within the health service sector in 250 years.

3.10 HOSPITAL MANAGEMENT AND STANDARDIZATION

In 1972, the first task of the new Government was to complete the
Cornwall Regional Hospital and to commission its operations. The funds for
this project were approved and for the first and only time in 250 years the
amount of expenditure on health care was 10.1 % of the National Budget
(1972- 1973). World Bank consultants initiated new systems and protocols for
hospital management, especially with regard to the larger hospitals. This led
to the classification of Hospitals into Type A, B, C, and D. The Type A
hospital was the benchmark for a Regional Hospital service system. This was
a precursor to the development of Centres of Excellence. The policy of the
Hospital Board structure was introduced. All hospitals were governed by a
Board of Management to satisfy international corporate practice standards.
The Minister announced the cancellation of all fees in hospitals. The
rationale was that the revenue collected was far less than the administrative
cost of collecting it. This declaration was underpinned by a political
declaration that “health care was a right and not a privilege”. This was the

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38

declared policy by the Government. The major challenge was the


implementing of this policy in concert with practical, evidence-based
determinants, and to translate this policy into affordable and sustainable
activities.

3.11 LEADERSHIP OF JAMAICA’S MODERN HEALTH REFORM AGENDA


(1967 to 1980)

Jamaica’s modern health reform agenda began in earnest prior to 1967


under the leadership of Professor Sir Kenneth Standard in the Department of
Social & Preventive Medicine at the University of the West Indies. He
influenced the evidenced-based content of the 1974 Green Paper “The Health
of the Nation” presented to the House of Parliament. He was The Chief
Technical Consultant / Advisor to the Ministry of Health (1972 to 1980) and
developed creative policies related to the delivery of health services in
Jamaica, the Caribbean and throughout the developing world. A pioneer and
innovator, he trained the first health auxiliaries, the Community Health
Aides in the Hermitage August Town Research Clinic. Community Health
Aides were introduced en masse to the Jamaican Health Service in the
1970’s.
Sir Kenneth nurtured several young Public Health students, ( the
Parliamentary Secretary in the Ministry of Health from 1976 to 1980 Dr.
Winston Davidson was one of them). In 1973, after Internship and Casualty
Department exposure, Sir Kenneth invited Dr. Davidson to do full-time
service, research and teaching as head of the Hermitage August Town Health
Clinic Unit in the Department of S&PM.
Research on Primary Health Care from a Jamaican perspective was
done in the Hermitage August Town Clinic in the communities of Hermitage
and August Town. Dr. Davidson won a seat as Local Government Councillor
in 1975 and became the Deputy Chairman of the Public Health Committee of
the Kingston and St. Andrew Corporation which is the largest Local
Government Jurisdiction in the country. He witnessed the problems of public
health management which arose between the Central Board of Health and
the Local Board of Health. This exposure inspired the decision to unify the
Boards of Health under one jurisdiction i.e. the Ministry of Health and
Environmental Control between the years 1976 and 1977.
Dr. Davidson applied the Primary Health Care working model
developed at the S&PM clinic at the Olympic Gardens Health Centre between
1975 and 1976 at the request of the Government of Jamaica. This was

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39

successful and the model became the precursor to the full implementation of
“Primary Health Care: the Jamaican Perspective” at the national level
between 1976 and 1980.
Dr. Davidson recruited Dr. Christine Moody to head the newly formed
Primary Health Care Unit in 1977, which was one of the outcomes of the
organisational reform process.
The World Bank Project of the Cornwall Regional Hospital created the
conditions for the organization of the non-institutional health services in the
County of Cornwall as a regional pilot project. This was referred to as “The
Cornwall County Regional Project” and was a pilot project of the Department
of Social & Preventive Medicine at the University of the West Indies.

3.12 Health Administrative Office vis- a- vis


Chief Medical Office 1955-1980

The Health Administrative Office, now Office of the Permanent Secretary


(PS), was responsible for Administrative Support to ensure that the
administrative support systems were in place for the implementation of
policies, plans, norms, standards and technical support systems for all health
services programs and projects. The area of service delivery with respect to
policies, plans, norms, standards and technical support for the
implementation of all health plans, programs and projects was the
responsibility of the Chief Medical Officer. The leadership of service delivery
was the domain of the Chief Medical (Technical / Advisory) Office and in this
regard had never been changed since 1867. The Permanent Secretary’s Office
was established when the Island Medical Department which was under the
jurisdiction of the Governor and the Secretary of State for the Colonies
located in London, became incorporated into the Ministry of Health in 1955.
The Office of the PS maintained daily liaison with the Ministry of Finance
(which controlled the supply management systems), and the Ministry of
Works (which controlled the health maintenance systems) in order to
coordinate the financial, maintenance and supply management systems of the
Ministry of Health, and to carry out the management of the budget of the
Ministry of Health.

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THE RELEVANCE OF THE 1974 GREEN PAPER TASK FORCE


RECOMMENDATIONS TODAY

The following are extracts from the recommendations.


• The establishment of a Central Planning and Evaluation Unit
within the Ministry which would be responsible for the
administration and management of an integrated secondary and
primary health care service.
• T h e e sta b lis h m e n t o f a R e g io n a l M a n a g e m e n t te a m a t
t h e c o u n ty le v e l c o n sis tin g of a R eg io n a l M e d ic a l O ffice r
o f H e a lth , a R e g io n a l H o sp it a l M a n a g e r a n d a R e g io n a l
S e n io r M e d ica l O ffice r.
• Primary Care services should be based at the Health Centres,
which should be upgraded in keeping with their expanded role
in the delivery of comprehensive primary medical care.
• Health Centres should be demographically located, to serve a
specific population, the needs of who should be assessed.
• Para-medical personnel should be used in order to overcome the
shortfal1 in medical personnel in delivering primary care.
• A special programme for the training of such paramedical
personnel should be established, with emphasis being placed on
the needs of the community e.g. M aternal and Child Health,
Nutrition, clinical services.
• Greater emphasis should be placed on community medicine in
training programmes for physicians, nurses and other health
professionals.
• I n v ie w o f th e h ig h co st o f p ro d u c in g a m e d ic a l g ra d u a t e ,
n e w ly q u a lifie d J a m a ic a n d o c to rs t r a in e d a t U W I s h o u ld
b e re q u ire d t o se rv e in th e G o v e rn m e n t S e rv ice – e .g . t w o
y e a rs in a r u ra l a r e a ; th re e y e a r s in a n u r b a n a re a .
• Every effort should be made to retain qualified medical personnel
by improving working conditions, providing adequate
remuneration and providing more facilities for post-graduate
training.
• Streamline the management and pharmaceutical services, using
modern techniques and expertise, to ensure obtaining drugs at the
most competitive prices, thus maintaining adequate supplies.

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• Establish a Central Drug Testing Laboratory to monitor drugs


imported into the Island as well as those manufactured in
Jamaica.
• Restrict the use of proprietary drugs with few exceptions and
import mainly generic drugs.
• I n stitu te a n o m in a l c h a rge fo r d ru g s (i.e. 2 0 o r 3 0 ce n t s) to
h e lp d efra y t h e co s t w h ic h w o u ld a p p ly o n ly to t h o se
e a rn in g o ve r $ 2 0 p e r w ee k .

• Special emphasis should be placed on health education of the


whole community especially the areas of Nutrition, Family
Planning, Maternal and Child Health, and Communicable
Disease Control, stressing the need for immunization.

• Make maximum use of manpower available in the community, by


setting up committees at each Health Centre, who would be able
to help in the launching and implementation of special
programmes in Health Education, Environmental Control, and
Nutrition etc.

3.13 POLITICAL INFLUENCES ON PUBLIC HEALTH


MANAGEMENT IN JAMAICA

The national discussions on the Green Paper occurred in Jamaica at a


time when there was heightening of Cold War global politics. Prime Minister
Michael Manley had just declared the PNP’s political philosophy of
democratic socialism and positioned his country in the domain of the non-
aligned movement, a movement in which he subsequently became a world
leader. The impact on the health sector was immediate as the philosophy of
inclusion informed the declaration that health care was “a fundamental
human right of all Jamaicans” and the ultimate responsibility lay on the
Government to manifest this right.
The consequences of this declaration of democratic socialism unearthed
the spectre of communism which had plagued the political landscape in
Jamaica in the 1962 general elections. This condition immediately placed
Jamaica yet again at the centre of east west cold war political tensions
involving the USA and The Soviet Union and Cuba. These internal and
external political tensions affected Jamaica adversely and led to a flight of
health personnel, almost reminiscent of the 1838 flight of Doctors from

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Jamaica. This necessitated the development of bilateral support agreements


for health personnel from Cuba in order to prevent a collapse of the national
health care system. These agreements further exacerbated the climate of
tensions within the public health sector.

By 1976, the Parliamentary Secretary translated the PNP philosophy of


Democratic Socialism into a coherent set of principles which were formulated
into a new set of health policies referred to as 2Primary Heath Care
Jamaican Perspective. A number of these documents written by the
Parliamentary Secretary between 1975 and 1976 were informed by evidence
from the research project in S&PM. These were made available in a document
which was published in time for the world conference on Primary Health Care
in Alma Ata in the Soviet Union in 1978. This historical record confirms the
reality of the influence of national and global political ideas, events and
circumstances on public health policy and action. Public health practitioners
ignore these conditions at their peril if they are to function with optimum
professional integrity and efficiency in the interest of the population.
There is no fundamental difference between a hospital in Cuba and
that in the USA. Neither is there any difference in the treatment of strep
tonsillitis in Europe or China. Ideological difference does not determine public
health practice; however, it does influence it.
The challenge of good public heath practice is to respect all ideological
streams and to work closely with the prevailing political ideas focusing at all
times on the interest of the population, by constantly engaging in policy
formulation, thereby creating the context, circumstance and condition to
introduce practical evidence based solutions on behalf of the people. In this
regard the formulation of policy must take its cue from the prevailing real
political ideas from which the conceptual frame-work is derived. Policies must
always be in a constant state of upgrade as the evidence of scientific findings
permits.
If the political conceptual framework is irreconcilable with standard
public health practice then the exercise of good judgement must be the
attempt to engage policy makers, relentlessly presenting very clearly
understood scientific evidence to support the position to the contrary. In
the final analysis, it is not about the interests of the public health
practitioner but fundamentally about the peoples’ interests. Policy
formulation as a public health tool is without doubt a necessity for successful

2 “Primary Health Care- Jamaican Perspective”. Published 1978 Ministry of Health

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public health practice especially in a global marketplace of diverse and


disparate ideas.

3.14 IMF CONDITIONALITY AND ITS IMPACT ON PRIMARY HEALTH CARE


INITIATIVES OF THE 1970s

The IMF conditionality in 1979 was very harsh and immediately Public
Health became the first casualty. The West Indies School of Public Health
was closed down. This school was commissioned in the late 1940s (in response
to the recommendation of the Moyne Commission) as an essential institution
for capacity development for the health sector in the West Indies.
The School of Public Health trained Public Health Inspectors, Public
Health Nurses and other members of the Primary Health Care team. The
other training programmes involving other categories of auxiliaries such as
Community health aides, pharmacy technicians, and entomologic assistants
for vector control; nurse practitioners were either drastically cut back or
closed.
The Cornwall School of Nursing was closed and this left a very large
gap in human resource and capacity for health development which the
country has not fully recovered from even after thirty years. The rates of
immunisation decreased, the momentum of the Primary Health Care
programme faltered, and the surveillance of communicable disease became
weakened.
There was cutback in the Primary Health Care budget, out of
proportion to its relative epidemiological significance and we suffered the
public health consequences of this when Jamaica had an out-break of
poliomyelitis, in the mid 1980’s after the disease had been eradicated twenty
five years before. This outbreak threatened the tourist industry and after
many deliberations on the question of confidentiality vs. transparency a mass
immunisation programme against polio was put in place and the mobilisation
of communities led by the Public Health team effectively controlled the
outbreak.
Primary Health Care as a fundamental strategy for the delivery of
health services to the community lost its policy pre-eminence and as a
consequence lost much of its budgetary support. The institutionalisation of a
number of primary health care components in the Jamaican health service
system continued not-withstanding the set-backs and this led to performance
levels way below its potential or its capacity.

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The IMF conditions also negatively affected the Secondary Health Care
sector as Type D hospitals became easy prey for closure. This reality was
made worse because sixty percentage (60%) of the national budget for
hospitals was spent on Cornwall Regional Hospital, which had major
construction and design faults, some of which have yet to be fixed.
As a matter of Government policy, Secondary Health Care took centre
stage after the change of Government in 1980, and the Inter-American
Development Bank (IDB) became a very important player in funding the
Hospitals improvement project against the background of the slowing down of
the regionalisation process started in the 1970s. There was, however,
continuity of the Health Care Reform process in the area of the Secondary
Health Care services by the new government and this was an important
political statement since it demonstrated that the determining factor for
health development was not political expediency but evidence-based
epidemiologic criteria. The hospital improvement project of the 1980s had a
very positive outcome which laid the basis for the modernisation of Secondary
and Tertiary Health Care services in Jamaica.
Summoning the political will to close the Type D hospitals was an
important step in the right direction by the Government of the 1980s since it
was difficult on epidemiological grounds to justify the existence of Type D
hospitals nor could these non-viable facilities be financially justifiable.
In fact these “hospitals” should have been converted to ambulatory day
bed facilities to address the large back-log of ambulatory surgical procedures
and other follow-up outpatient services of the larger hospitals. This would
have been an excellent differentiation of the existing Primary Health care
services. Once again the historical tension between the Hospitals Services
and the Public Health Services was rearing its ugly head.

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3.15 ORGANISATIONAL REFORMS PRIOR TO THE RHAs

By the end of 1970s, the organisational reform was in full flight, with
the integration of the Local Board of Health with the Central Board of Health
and the transfer of the maintenance division from the Ministry of Works to
the Ministry of Health and the Supply Division located in the Ministry of
Finance transferred to the Ministry of Health and Environmental Control.
The Ministry of Health was now fully in charge of the levers of decision
making and this enabled rapid changes to be made in the foundations of the
organisational reform process.
As a matter of policy, reorganisation of the health services was
established on the basis of levels of Care into Primary, Secondary and
Tertiary Health Care Services.
For the first time since 1867 Primary Health Care became a line item
on the budget of the Ministry of Health, the scope, content and extent of
population coverage for comprehensive health services for the Jamaican
people became a reality.
The rationale for reorganisation into levels of care was not merely for
the health services to become more efficient but also to enable the full
integration of the fragmented non institutional services on the ground from
the most basic form to the most complex cutting edge service, from non-
institutional to institutional and from the field level in communities to the
central level in the Head Office of the Ministry. Integration must enable
seamless interrelated functions of all levels of the Ministry led by a single
Head Office.
By streamlining the technical and administrative functions, into
Central and Field responsibilities of the Ministry it would therefore be
possible to put in place a health information system to monitor, evaluate and
track the process in the delivery of services and would also enable the full
integration of all the elements and functions of the Ministry whether these
functions are at the Field level or at the Central level.
After the unification of the Central and Local Boards of Health under
one Ministry (MOH) in the 1970’s it was envisioned that the Central Level
(Head Office of the MOH) would be responsible for policy interpretation
(derived from manifesto political declarations from the democratically elected
Governments), policy determination, policy formulation, national strategic
planning, norms and standards, monitoring, consultative and support
functions to the Field level. The Field level would be responsible for Policy
Implementation and the Implementation of all service delivery, programmes

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and projects. All service implementation functions would therefore be


decentralised to the Field level.
The principle was the separation of the policy formulation and
determination, national epidemiologic and strategic planning, norms,
standards and support functions to be the core functions of the Ministry’s
head office and that these functions be separated from the implementation of
all services (unless in unique circumstances e.g. National Epidemiologic
Emergencies), programs, plans, and projects which are the domain of the
Field level.
In so doing the Ministry of Health would function as one fully
integrated organisation with clearly defined roles and responsibilities for its
three fundamental organisational components:

a) The Head Office

b) The Regions

c) The Parishes.
The Central Level would work closely with the Regional Health
Organisations in enabling the smooth functioning of the levels of care
(Primary, Secondary and Tertiary Health Care service delivery). Critical to
the Organisation of the Health Services is the central role that patient care
and epidemiological principles play in determining outcomes.

The review and evaluation of the Jamaican Health Service System over
250 years provided overwhelming evidence to confirm the definition of the
relative roles and responsibilities and interrelationships of the service
providers to the bottom-line i.e. Patient Care.

Introduction of the Environmental Control portfolio in 1972 for the first


time in the Ministry of Health was a very important policy initiative which
could have had a great impact on the development agenda of the country if
the opportunities were seized and sustained over the years. This period is
seen as a preparatory step to enable the most far reaching reforms to take
place within the health service sector in 250 years.

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Diagram 5

CORE ORGANISATION OF THE HEALTH SERVICE (1972-1976)

The organisational chart at Diagram 5 evolved into this form since 1867 (a
period of over 100 years). Note the line reporting relationships of the
diagnostic chain of command.

3.16 TASK FORCE CONCLUSIONS FROM HISTORICAL REVIEW :

• That the chain of professional command in service delivery leading


directly to the political directorate was NEVER broken and this was a
principle which characterised the development of the health service
system for over 150 years.

• This feature of an unbroken chain of professional command did not


compromise the supportive role of the administrative management
systems during those 150 years.

• That patient care requires a complex set of MANAGEMENT principles


which are evidence based and which require a unique set of clinical
medical training and collegial consultative culture honed and cultivated
as a medical professional. This must be a prerequisite for being part of
the command leadership of the clinical professional diagnostic value
chain.

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• Any category of health worker or member of the health team may


qualify himself or herself to function as an administrative manager but
the role as administrator cannot take precedence over the fundamental
core value of patient / doctor / diagnosis encounter and the consequential
integrity of the value- chain. Indeed the ethical and medico- legal
consequences may result in cost implications which a number of
jurisdictions have experienced to their peril.

• Such consequences may result from spurious legal challenges and


implications for compromises of professional integrity. The outcome of
such ill-advised change of paradigm may render the practice of clinical
medicine so contentious and so expensive as to become
counterproductive to patient care and epidemiologic outcomes.

• Any change of these time honoured principles MUST only be considered


if there is overwhelming and irrefutable evidence to support the
introduction of such a new paradigm.

• In the final analysis patient care was located at the centre of the health
service delivery system and health services delivery was determined by
the outcome of the diagnosis and the clinical management determined
the form and content of the administrative support system.

Diagrams 6 and 7 capture the essence of the relative elements determining


and ENABLING the sustainability of Jamaica’s Health service system and
the process driving its basic elements.

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Diagram 6

The Conceptual Framework Outlining the Relative Levels


of Importance of Elements Determining the
Jamaican Health Sector 1867-1972

(W. Mendes Davidson Nov. 2007)

This diagram represents the logic of the core competences of the


Ministry of Health. It represents the system of values and their relative
importance without which there would be no logic in the process of delivery of
health care to the Jamaican people. At the centre is “patient care” where the
patient encounters his/her doctor who establishes the diagnosis which then
forms the epidemiological (scientific) basis on which patient management,
plans, programs and projects for service delivery would take place.
Administrative support is derived as a consequence of service delivery which
is derived from the evidence of epidemiology determined by the diagnosis
which arises from the Patient / Doctor Encounter / Diagnosis / Program. See
also Section 5.3.2.

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The next diagram demonstrates the logic of a modern efficient health


service system.

Diagram 7

THE PROCESS AND LOGIC OF EFFICIENT


HEALTHCARE SERVICE SYSTEMS

Source: W. Mendes Davidson December (2007)

Diagram 7 demonstrates the inextricable link and sequential relationship


between patient care diagnostic management and administrative support.

To invert this process and put administration at the centre of the


system in health is to undermine the health care delivery mission and
process. Further this channels scarce resource into areas which satisfy non-
health care agendas to the detriment of patient care. The world is replete
with evidence of the consequences of such a reversal. In some jurisdictions the
costs of health care become prohibitive. An analogy could be that of a fighting
army having its chain of command broken by the military officers reporting to
civilians during a war- a prescription for certain defeat!

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DISCUSSION
The Ministry of Health became preoccupied with hospital institutional
services, which became the focus of policy implementation. This was in
keeping with the American model of a hospital-centred health care system.
The public health agenda was secondary, seen as adjunctive to hospital
services in the health care delivery process. Once again, the error is made on
the question of the institutional vs. non-institutional relationship. As Lord
Moyne pointed out thirty years before: “The cure of disease has received much
more attention than is given to its prevention” and that “Little improvement
in the health of the people is expected, however extensive the hospital
facilities, until these serious defects are remedied”. Moyne also wrote
“Relatively too large a proportion of the available funds and effort is expended
on curative medicine and too little on prevention”.
This observation was made not only by Lord Moyne in 1938, but also in
1867 as a finding of the Royal Commission after the Morant Bay rebellion.
Ignoring this reality plagued the health sector for over 150 years, but it
became a fundamental principle in shaping the organizational reform effort of
the 1970s. The conceptual framework locates and defines the patient / Doctor
(health team relationship) as the essential value in the Jamaican health care
delivery system throughout its 250 year history. This is both a philosophy and
a fundamental principle for service delivery.
Adopting this paradigm will enable rational and optimal relationships,
support mechanisms and systems necessary to create the conditions for a
sustainable health care delivery system. Such a paradigm is the framework
which will enable the vision of the Minister of Health and Environment: “A
21 st Century Modern Health Service System that addresses the health
problems of the Jamaican people in a comprehensive and sustainable
way”.

4.0 THE REGIONAL HEALTH AUTHORITIES (RHAs)

4.1 INTRODUCTION

Since the 1970s the process of unification of the health services created
many challenges. The most serious challenge was the fact that the central
ministry (head office) was carrying out three fundamental tasks
simultaneously in the context of a concentration of power at the head office.
The tasks were:

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• Policy making
• Programme formulation
• Programme execution.

The challenges that existed was due in part to the absence of


institutional knowledge which lead to the needs for organizational reform and
improvement in service standard.

We again quote from the 1974 Green Paper

• High degree of centralisation of the MOH decision making functions


leading to frustration, stagnation and inefficiency.
• Desperate need to decentralise the management of the services to
allow for decision making at the local level, prevent undue delay,
facilitate problem solving and bypass unnecessary bureaucracy.
• Need to integrate the health services under the jurisdiction of one
Ministry (Ministry of Health) rather than the division of health
service authority between the Ministry of Health (Central Board of
Health), and the Ministry of Local Government (Local Board of
Health).
• Supply management and maintenance services were located in the
Ministry of Finance and the Ministry of Works respectively, which
also compounded the problem of undue delays, bureaucratic
mismanagement and waste of resources.
• The need for this reform to begin from the bottom up using the
health centre in communities as the basic essential entity in
building comprehensive Primary Health Care services for all
Jamaicans.
• That any reform must be sustainable and improve the efficiency of
the Health Service system.

The new players in the health sector would have had an insight into the
factors causing the problem and would have been able to arrive at a more
informed analysis and made a more accurate assessment.
Indeed the conditions in 1989 posed much greater challenges than the
1970s because of the greater responsibility of the Ministry to deliver services
now that the levers of power such as the unification of the Boards of Health
under one Ministry and the supply and maintenance divisions were handed
over to the Ministry of Health.

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There was no third party to blame for delays, frustration, stagnation and
unnecessary bureaucratic inertia. This build up of frustration and
desperation resulted in the call for drastic action. Three Ministers within the
short space of five years attempted to grapple with these endemic challenges.
The public health fundamentals are clear, that there are still only two
fundamental organisational streams in the health services sector:
• Health Care Service Delivery (Technical/Professional)
• Administrative Support (Administrative / Managerial)
Both are inextricably linked by the following paradigm:
3 “Health care service delivery determines the content and form of its

administrative support, while, administrative support influences the


outcome of service delivery”
Both fundamental categories possess inherent management systems;
service delivery is essentially a clinical management system and
Administrative support is a non clinical management system. The science of
epidemiology is the basis on which decisions are made for health service
delivery systems and epidemiology and public health organisational
principles should inform the form and content of the administrative support
management system.

4.2 CONDITIONS PRIOR TO THE ESTABLISHMENT OF THE PRESENT RHAs

The concept of 4 Regionalisation is not a new one in Jamaica, and has much to
recommend it. However the major challenge has always been the conceptual
framework, policies and organisational forms which are to be put in place to
justify its introduction.
The outcome of the National debates and consultation on health care between
1974 and 1976 overwhelmingly justified the need for organisational reform of
the Ministry of Health. Some of the factors which arose in the debates and
consultations were the following:
• High degree of centralisation of the MOH decision making functions
leading to frustration, stagnation, inefficiency.

3The Process of Health Care delivery Diagram 6


“ A Healthy Jamaica In a Healthy World” Davidson et al

4The Role of the Health Centre in an Integrated Health Programme in a Developing Country
by Byer et al, in 1966 establishes the case for the regionalisation of services in developing
countries.

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• Desperate need to decentralise the management of the services to allow


for decision making at the local level, prevent undue delay, facilitate
problem solving, bypass unnecessary bureaucracy.
• Need to integrate the Health Services under the jurisdiction of one
Ministry (Ministry of Health) rather than the division of health service
authority between the Ministry of Health (Central Board of Health),
and the Ministry of Local Government (Local Board of Health).
• Supply management and maintenance services were located in the
Ministry of Finance and the Ministry of Works respectively, which also
compounded the problem of undue delays, bureaucratic
mismanagement and waste of resources.
• There is need for this reform to begin from the bottom up using the
health centre in communities as the basic essential entity in building
comprehensive primary health care services for all Jamaicans.
• Any reform must be sustainable and improve the efficiency of the
Health Service system.

Prior to the unification of the Central Board of Health ( in MOH) and the
Local Board of Health (in MLG) between 1976 and 1980, the supply division
for the Ministry of Health was located in the Ministry of Finance and the
Maintenance Division for the Ministry of Health was located in the Ministry
of Works.

The Ministry was driven my its core mission which was service delivery
under the leadership of the Chief Medical Officer and role and responsibilities
of the Permanent Secretary was as chief accounting officer and
administrative support manager to the health services delivery system
located under the professional command of the Chief Medical Officer.
Unification of the Central and Local Boards of Health brought with it a
greater scope of service delivery for the Chief Medical Officer and this
required the reorganisation of the service delivery sectors at the Ministry of
Health into levels of care (Primary Secondary and Tertiary Health Care).
This required the most far reaching health manpower / health team
reconfiguration of the Ministry of Health in its history.
For the first time there was a budget for Primary Health Care. This could
not have taken place prior to unification of the health boards under one
Ministry. This new situation required new scope of work for the CMO and the
reconfiguration of ALL service delivery programmes.

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While this was taking place in the service delivery area, for the first time
the Permanent Secretary was confronted with new direct responsibility for
designing administrative systems to support the parishes and the added
responsibilities of supply management and maintenance of ALL health
institutions. These two areas, maintenance and supply management have
been the Achilles Heel of the Ministry ever since the process of Unification,
which occurred between 1976 and 1980.

The choice of an experienced Permanent Secretary in the late 1970s who had
training in engineering to lead the process of a reconfigured administrative
management and support system in light of the new areas of responsibility of
both supply and maintenance management was not coincidental.

The scope of administrative management was therefore expanded and


the Office of the Permanent Secretary became larger than ever before in the
history of the development of the Jamaican health service.

This new situation however, did not change the fundamentals of the
deeply embedded core value chain of command of the relative roles of the
leadership between the services delivery area and the administrative
management and support area.

The beginning of tensions between these two offices is seen in the


diagram prepared by the collaborative efforts of Permanent Secretary and the
Chief Medical Officer in 1980.

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Diagram 8
CORE ORGANISATIONAL REFORM MINISTRY OF HEALTH 1980

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57

Source Dr. Sonia D. Davidson: Dissertation:


“The future of Doctors in the Delivery of Primary Health Care 1980”

Key to figure:
PMO: Principal Medical Officer; SMO: Senior Medical Officer
MO: Medical Officer of Health; PNO: Principal Nursing Officer
ANO: Assistant Nursing Officer; PDS: Principal Dental Officer
DPS: Director Pharmaceutical Services
DECS: Director Environmental Control Services
DHES: Director Health Education Services

The organisational chart (Diagram 8) by no means exhaustively


represents all the elements of the Ministry of Health in 1980. The areas to be
added include: Project Management (Capital Works), Prison Services, Health
Legislation, Sanitary Engineering Services, Education & Training Services
i.e. Physiotherapy School, School of Public Health, Bureau of Health
Education, In-service Nursing Education, Dental Auxiliary School,
Government Chemist Department, Registrar Generals Department,
Laboratory Services, Personnel and Establishment Division, University
Hospital, National Family Planning Board, Hospital Boards’ Professional
Councils, Bellevue Hospital, Quarantine Services, Central Medical Stores,
Child Feeding Programme, Transport Management.

The administrative management and support functions also had


weaknesses e.g. lack of personnel with formal training in Hospital
Management, Financial Analysts and Health Planners.
The rapid changes and development of the Ministry of Health during 1976 to
1980 was unprecedented. New categories of workers were trained for Primary

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Health Care i.e. several categories of Nurse Practitioners e.g. Family Health,
Paediatric and Mental Health Officers, Pharmacy Technicians, Entomological
Assistants for vector control, Nutrition Educators, Health Educators.

Flight of Health and Medical personnel from Jamaica because of


heightened “Cold War” tensions led to the acceleration of the grave shortages
of medical personnel. This need led to greater bilateral cooperation with Cuba
and (Socialist European) countries and the acceleration of the training of
medical and dental personnel to fill this gap in the long term.
The introduction of Cuban Medical personnel to man the Primary
Health Care facilities and rural hospitals in general and the Bellevue
Psychiatric Hospital in particular resulted in more efficient and
comprehensive service delivery to the Jamaican people.
The organisational reform process enabled and supported as a matter of
policy, the revolutionary changes in the Bellevue Hospital from a custodial
care psychiatric hospital which it had been for over 100 years to a the
decentralised therapeutic hospital with a strong and vibrant community
psychiatry programme. The Bellevue hospital changed from a custodial
institution of approximately three thousand beds to a therapeutic community
outreach institution of just over 1000 beds during the period of five years.
This development took place under the leadership of the SMO of the Bellevue
Hospital, Professor F. W. Hickling, supported by his Cuban counterpart.
Professional leadership in all spheres of service delivery was strong and the
unbroken service delivery value-chain was intact.

Administrative management support of the rapid service delivery


changes taking place in the Ministry was excellent and the Director of Health
Services Administration the late Ms Xenia Ellington was a shining example
of best practice in the efficiencies which she brought to bear in administrative
management support systems in the Ministry of Health. She was a loyal
member of the health team and gave support far in excess of the call of duty.

Primary Health Care created the conditions for community


participation with the development of community health committees some of
which are still in existence today. Community involvement created the
conditions for community participation in accelerated mass immunisations,
breast feeding and nutrition education to combat an epidemic of malnutrition.

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Compulsory immunisation was introduced as a prerequisite for


attending primary school in 1978. The fall in the rates of infections
preventable diseases i.e. diphtheria, whooping cough, tetanus and polio and
tuberculosis in children was unprecedented.
Jamaica was the first Caribbean country to develop a National Formulary
which was implemented under the leadership of Dr. Peter Figueroa who
worked in tandem with the Director of Pharmaceutical Services Mr Lester
Woolery between 1977 and 1980.
“Primary Health Care for All by the year 2000” was the “Declaration of
Alma Ata” in the Soviet Union in 1978 at which forum the Jamaican
delegation led by the Parliamentary Secretary were honoured with
membership of the drafting committee. Jamaica’s achievements of global
leadership in this area went almost unnoticed although it has been said by
reliable sources that this goal was achieved in Jamaica before the end of the
millennium 2000.
Preserving the integrity of the health services sector delivery value-
chain is a precondition for evidence-based health care delivery and therefore
sustainability.

This professional value-chain is reflected in the preservation of the


integrity of the services by utilising the most appropriate organisational
context and form based only on epidemiological criteria and evidence.

Indeed these successful programmes of the 1970s were grounded in principles


derived from tried and proven public health practice and which were crafted
around the long term needs of the patients in their communities.
The public health principle of developing the services designed to meet the
needs of the patients as close to their homes as possible is a very important
enabling strategy for effectiveness and efficiency in the delivery of public
health services.

With the rapid increase in the form and diversity of service delivery,
there is always a concomitant demand for more administrative support
services. The role and responsibilities of the Permanent Secretary in the
MOH had expanded phenomenally by the 1980s as there was even greater
demand for increased administrative capacity to enable efficient and effective
service delivery. To this end a Minister of State in the Ministry of Health was
assigned the responsibility to enable this process.

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This factor sometimes leads to an exacerbation of the tension between


the two roles of Permanent Secretary and Chief Medical Officer. Just as the
introduction of Primary Health Care services also increased the tension
between the Hospital and non-Hospital services throughout our history.

The cause of this phenomenon is linked to the fact that they are competing
interests for scarce resources.
The role of the health team is of vital importance in this regard and the
most important tool or measure which should be used to establish the
priorities for resource allocation in the health services sector is the science of
epidemiology.
In the absence of the application of epidemiological methods, the
development of territorialism and cronyism will develop among health
personnel and may lead to a further deepening of the crisis of management of
and within the system. If these phenomena become institutionalised, the
change-management techniques must be applied within context.

Change management as a methodology is a vital and necessary component


of the reform process. Greater depth of analysis and evaluation of questions
relating to conceptual framework, policies and organisation, structure and
function coupled with fundamental reforms is the only way of breaking out of
this type of institutionalised dysfunctional culture.

The history of Jamaica’s Health Services sector demonstrates that Public


Health / Primary Health Care services are always the immediate victims of
cutbacks in resources, and perhaps that is why a culture of creativity has
developed in public health.

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61

Diagram 9

THE SCOPE AND CONTENT OF COMPREHENSIVE


PRIMARY HEALTH CARE 1980-2000

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62

The new Primary Health Care programme became the first victim of
the IMF conditions beginning in 1979.

This caused setbacks in the possibilities for even greater health service
delivery, the impact of which is still felt thirty years after its introduction.
The experience confirms the public health dictum that mistakes in
public health practice may take a generation to be recognised and even longer
to be corrected.

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63

The organisational chart reflected the thinking with regard to the scope
and content of comprehensive Primary Health Care with minor modifications.
The scope and content of primary health care is exhaustive and each
subcategory requires coherent national policy guidelines. Strategic planning
and development requires the most rigorous participation and collaboration
with the implementation of services in the field and necessary administrative
support.

The institutional framework of the clinical component of primary


health care services is the network of health centres throughout the island.
This is partly documented in the 5Goffe / McCartney report. The report
outlines the health centre network and takes into consideration the
demographic shifts in the system. This is indeed a viable framework as a
starting point in rebuilding the clinical component of the National Primary
Health Care Programme.

It adequately deals with the institutional (Hospital) integration of PHC


clinical services with the hospital system, but is woefully inadequate
regarding the non-institutional public health component and its backward
linkages in the community development process. Epidemiological principles
are involved here and must be clarified.

The “Prevention Model” developed by Public Health Specialists Leavel


& Clarke from the USA 1940s and revised by Mendes-Davidson 1975, below
clarifies the epidemiologic fundamentals related to the principles of
prevention and the relative roles of primary, secondary, and tertiary health
care intervention services. The organisational assignment of primary health
care to the secondary and tertiary system violates these principles.

5Goffe report on “Redesigning the Jamaica’s Health Service System” revised 2007 (Goffe &
McCartney)

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Diagram 10

The Prevention Principles & The Epidemiological


Basis For Primary, Secondary And Tertiary Health
Care Intervention Services.
Source: Leavel & C larke; Revised W. Davidson. 1999. (copyright) Rising Costs:

COMMUNITY COMMUNITY
State of Health The Health The Health
Centre The Hospitals Centre
Maintain
Prevention Prevention Treatment Rehab

Healthy Primary Secondary Primary


Lifestyle Health & Tertiary Health
(Wellness) Care Services Health Care Services
Care
Services
SECONDARY PREVE NTION TE RT IARY PRE VENT ION
PRE-PRIMARY PRE VENT ION PRIM ARY P RE VENT ION
(Decrease Prevalence) (Avert Chronicity)
(M aintain Health & Wellness) (Decrease Incidence)

Diagram 10 illustrates the evidence which confirms the fact of the


violation of both prevention and epidemiological principles when the clinical
institutional component of Primary Health Care (the Health Centres) is
located under the command of the hospitals organisational structure.
The Health Centre is a vital and necessary community based clinical
institution of Primary Health Care. This is taken to mean health promotion,
health risk reduction, early detection, early ambulatory treatment,
community based rehabilitation averting “chronicity” and community
participation.
There is therefore no scientific justification for locating Health Centres
under the command of the hospital services system as is presently the case.
The rationale to attempt justification of this change is the need for
integration of services. This is a vital and necessary outcome but this must
always be placed within the context of sound epidemiological principles,
otherwise the service interventions will be unsustainable.
Health Centres must always be located under the public health
community based Primary Health Care services.
These were the conditions which preceded the establishment of the
Regional Health Authorities.

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65

It is convenient at this stage to consider an organisational chart which


was prepared in 1990 under the leadership of George A Briggs. Diagram 11.
reflected the new thinking arising from the organisational tensions between
Permanent Secretary (Administrative support) and Chief Medical Officer
(Service delivery).

Although that structure was not implemented, nevertheless all its


essential elements were put in place. These changes resulted in a shift in the
policy and paradigm of the Ministry of Health from the patient centred
service delivery system of over 150 years to an administrative management
control centred system.

This is the essence of the policy dysfunction of the present RHAs


system, and one of the focal points of this comprehensive review and
evaluation process. Without addressing this fundamental question, the
mission of this task force would be a pointless exercise.

The rationale is that the Chief Medical Officer should no longer report
directly to the Minister of Health but through the Permanent Secretary. If
this became the standard, then the new paradigm would have organisational
“justification”, therefore, for all health and medical professionals in the area
of service delivery to report to administrators. Implementing this policy in a
number of areas in the RHA has had the most far reaching dysfunctional
effect on service delivery in the history of the health service sector in Jamaica
and is at the heart of the dysfunctions of the present Regional Health
Authorities.

Diagram 11
4.3 PROPOSED ADMINISTRATIVE MANAGEMENT CENTRED SYSTEM (1980)

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4.4 PROFILE OF THE RHAs

The RHAs were established under The National Health Service Act of
1997 and implemented through an instrument of delegation.

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It is referred to as an “Act which repealed the Hospital (Public) Act”.


The Instrument of Delegation highlights:
“The rationalization of the administration within a decentralized structure
will improve efficiency and accountability in the use of resources,
organizational communication and facilitate decision making with locally
based managers responsible for the operation of each region. The autonomy of
each region within a given framework will eliminate delays which have hither
to adversely influence the efficiency with which healthcare has been made
available to the public……..

The Regions were determined by examination of and analysis of geography,


proximity of facilities in several parishes, the traditional patterns of
utilization of health facilities, the transportation flows, as well as feasibility
studies undertaken” (George A. Briggs, Instrument of Delegation, March
1998). The four Authorities are:
• South East Regional Health Authority (SERHA)
• Southern Regional Health Authority (SRHA)
• Western Regional Health Authority (WRHA)
• North East Regional Health Authority (NERHA).

Table 4
Population and Geographical Extension of
Health Regions in Jamaica, 1999
REGION EXTENSION POPULATION DENSITY (p/km²)
(Km²)
JAMAICA 10,991 2,590,400 236
North East 2,637.1 356,000 135
South East 2,387.7 1,214,700 509
Southern 3,238.8 562,300 174
Western 2,726.9 457,400 168

Source: Planning and Evaluation Unit-MOH, Statistical


Institute of Jamaica (1999)

Table 5
STAFF STATUS OF THE RHAs- Jan 2008

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REGION EP PS SAP As. Vac. U Vac. Temp S US OC XS

SERHA 2,326 217 926 73 668 40

SRHA

WRHA 917 104 2 268 11 498 355 62

N ERHA 1,503 791 64 333 34 238 16 368

Key:-
EP: Established Posts; P S: Permanent Staff
SAP: Staff in Active Post; As: Assigned; Vac: Vacancy; U Vac.: Unclear Vacancy
Temp S: Temporary Staff; U S: Unknown Status; OC: On Contract; X S: Excess

4.4.1 SOUTH EAST REGIONAL HEALTH AUTHORITY

This region provides health care for the total population of 1,214,700
(1999 estimates) from the parishes of Kingston, St. Andrew, St. Thomas and
St. Catherine.

In terms of people coverage, it is the largest Regional Health Authority


with responsibility for 47% of the total population.

SERHA has the most populous parishes: KSA and St. Catherine, the
latter being the largest geographically parish in Jamaica.

Table 6
Hospital Profile- SERHA

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Institution Type Bed Occupancy Remarks


Complement Rate
A B C

Kingston Public ü 505 89.4% National Referral Hospital

Victoria Jubilee ü 197 (80)* 60% Specialist – Obstetrics and


Gynaecology
*Bassinet

Spanish Town ü 242 132%

Bustamante ü 253 60% National Referral Hospital


Hospital for for paediatrics
Children

Princess Margaret ü 122 70%

Linstead ü 50 55%

Bellevue ü 900 90% Specialist – Psychiatric


Hospital

National Chest ü 98 37% Cardio-thoracic/Pulmonary


facility

Sir John Golding ü 70 68% Rehabilitative facility

Hope Institute ü 44 58% Oncology facility

Table 7
Health Centre Profile -SERHA

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Parish Type Type 2 Type 3 Type Type Satellite Total


1 4 5
Kingston &
St. Andrew 14 8 14 - 3 8 47
St. Catherine 9 9 6 1 - 25
St. Thomas 9 4 3 1 - 17
Total for
Region 32 21 23 2 3 8 89

Health Care is delivered through a network of ten (10) hospitals and


Eighty one (81) Health Centres. There were also eight (8) satellite clinics.
Five (5) of the ten (10) hospitals within the region are also specialist or
National Referral Hospitals. (See Table 7) Some of these institutions also
accept patients referred from other Caribbean islands.

SERHA employs approximately 5,000 individuals from a variety of


medical and non-medical groups. These include staff directly involved with
health care delivery, for example nurses, doctors, technologists, pharmacists,
health record administrators, attendants and public health inspectors.
There are other staff members who work to ensure that the health care
delivery system functions at an optimal level and give support to those
charged with the direct delivery of health care. These include among others
the Management Information staff, Maintenance Teams, Human Resource,
Administrative and Accounting staff.

SERHA is managed by a team of directors led by the Regional Director


who reports to a Board, which is appointed by the Minister of Health. The
region is funded by allocations from the Ministry of Health and User Fees
collected at its institutions, project support and donations.

4.4.2 NORTH EAST REGIONAL HEALTH AUTHORITY

The NERHA comprises the Parishes of St. Ann, St. Mary and Portland
with a geographical extension of 1,018 square miles (2,637 square kilometres)
and a total estimated population of 356,000. This constitutes 14% of the

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71

general population and makes it the least populous of the four RHAs. Located
on the northern coast of the island the North East Region houses some of the
most important tourist resorts and attractions. It received the smallest share
of the MOH Grant.
Table 8
Hospital Profile- NERHA

Institution Type Bed Occupancy


Complement Rate Remarks
A B C
St. Ann’s
Bay Hospital ü 249 85%
Annotto Bay Hospital being
Hospital ü 95 57.1% upgraded to a B
facility.
Port Maria
Hospital ü 60 50%
Port Antonio
Hospital ü 95 49 %

Table 9
Health Centre Profile - NERHA

Parish Type 1 Type 2 Type 3 Type 4 Type 5 Total

St. Ann 11 8 4 1 - 24

St. Mary 18 8 4 - - 30

Portland 12 3 1 1 - 17
Total for 41 19 9 2 - 71
Region

NERHA has responsibility for a health network of seventy-five (75) Health


Centres with different degrees of resolution capabilities. There are four (4)
General Hospitals, one (1) Type B, the regional referral Hospital in St. Ann’s
Bay, St. Ann, and three (3) Type C hospitals one (1) in Port Antonio Portland,
and one (1) each in Annotto Bay and Port Maria in St. Mary.

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4.4.3 SOUTHERN REGIONAL HEALTH AUTHORITY (SRHA)

The SRHA manages Health Care delivery in the parishes of Clarendon,


Manchester and St. Elizabeth. It serves a population of 554,500(1997est.)
with 71.1% under 25 years (National average 55.6%) and 8.3% over 65 years
and provides care through a net-work of 5 hospitals and 78 Health Centres.

Table 10
Hospital Profile-SRHA

Institution Type Bed Occupancy Remarks


Complement Rate
A B C
Mandeville ü 220 95%
Regional
May Pen ü 150 70% Hospital being
upgraded to a B
facility
Black River ü 97 77.5%
Percy Junior ü 121 60%
Lionel Town ü 45 36%

Table 11
Health Centre Profile (SRHA)

Parishes Type 1 Type 2 Type 3 Type 4 Type 5 Total


Clarendon 13 11 8 - - 32
Manchester 12 5 6 1 - 24
St. Elizabeth 8 7 6 1 - 22
Total for Region 33 23 20 2 - 78

4.4.4 WESTERN REGIONAL HEALTH AUTHORITY

WRHA serves a population of 467,461 (1999 estimates) in four parishes


distributed as below:

Westmoreland - 143,042

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Hanover - 68,978
St. James - 180,728
Trelawny - 74,713
The coverage was 17% of the total population on 25% of the land area.
It manages four (4) hospitals, three (3) Type C and the Cornwall Regional.
Of the eighty two (82) Health Centres, forty (40) are Type 1.

Table 12
H ospital Profile- WRHA

Institution Type Bed Occupancy Remarks


Complement Rate

A B C

Cornwall ü 342 86.3%


Regional

Savanna-la ü 140 88.4% Two (2) private


Mar beds included.

Falmouth ü 60 73.4%

Noel Holmes ü 38 51.1%

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Table 13
Health Centre Profile- WRHA

Parish Type Type Type Type Type Satellite Total Remarks


1 2 3 4 5

St. James 13 7 3 - 1 - 24

Hanover 8 7 2 1 - 1 19

Trelawny 9 6 2 1 - - 18

Westmoreland 10 5 5 1 - - 21

Total for 40 25 12 3 1 1 82
Region

4.5 THE NEW STATUTORY RHA AND ITS INSTRUMENT OF DELEGATION

The literature reveals that the creation of the 6 Regional Health


Authorities was signed off in March, 1998 by George A Briggs, Permanent
Secretary in the Ministry of Health. This document created the deepest
departure from the fundamentals of the Health Service delivery system that
has taken place in the 250 year history of the Jamaican health service
organisation. Review indicated a conceptual flaw in both organisation and
structure of the RHAs. This has caused serious concerns for the effective
functioning of the Jamaican Health service system.
Fundamental conceptual flaws of the document are now outlined.

6Instrument of Delegation George Briggs Permanent Secretary Ministry of Health, March


1998.

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There are four, semi-autonomous Statutory Regional Authorities with


their respective corporate structures creating the conditions for five Health
Authorities (if the Head Office of the Ministry of Health is taken into
account).
Each of the five entities is carrying out roles of policymaking,
programme formulation and programme execution. This breaches the
fundamental principles of good health service management, which ought to
have clearly defined roles and responsibilities specific to levels of function
within the health service matrix. This is a major point of departure from the
historic principles and practice of public health in the development of the
Jamaica’s health service system.
There is a noticeable absence of documented justifiable evidence to
support such a fundamental change
The balkanisation of the health care delivery system into five semi-
autonomous parts while at the same time asserting that “integrated health
care” is the objective is a contradiction.
The imposition of Administrative Management as the core-value of each
health service system and not “Patient care”, inverts patient care at the
centre of the health services delivery process. This paradigm contradicts 250
years of time-honoured principles governing the evolution of the health
service delivery process in Jamaica.
There is an absence of epidemiologically justifiable evidence coupled
with contradictions of fundamental principles of public health practice in
service delivery. The dysfunctional outcomes are therefore not surprising.
The delegation of “policies, resources and management objectives,
within which the local authorities will have greater freedom to manage”,
without a careful analysis of the epidemiological contexts, circumstances and
conditions of the Ministry as a whole, defies the most basic principles of
management of health services.

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There seems to be a lack of understanding and a neglect of the


principles governing medical professional practice e.g. peer review, peer
consultation, peer advice and supervision, peer reporting, collegial referral,
patient care / health team coordination; medical ethical principles governing
patient / doctor relationships, patient / doctor rights and responsibilities,
medico legal issues governing patient care and service delivery.
Breaking the chain of professional command in patient care by having
medical professionals reporting to administrators who may have neither
knowledge of nor competence in patient care nor population medicine is not
recommended. This could creates serious problems in health service delivery
with medico-legal consequences.
Destroying the corporate board structure of Jamaica’s hospitals by
removing all the Boards of Management and replacing them with a system
where the Senior Medical Officer of the institution and the Director of
Nursing Services of the hospital reports to a CEO who may not have nursing
or medical knowledge, is also flawed. The CEO then reports to a Health
Committee chaired by an administrator. In a litigious jurisdiction such
hospitals operating without a Board of Management and therefore without an
universally acceptable corporate structure would be closed down without
recourse. The implications for medico- legal consequences are far reaching.
Role misrepresentation, poor communication, contradictory policies,
gaps in service delivery, fragmentation of service delivery, overlapping of
functions, exacerbation of resource challenges, are a few of the outcomes.
Results from the findings of the historical review of the Jamaica’s health
service confirm the validity of the foregoing analysis.

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5.0 FINDINGS OF STAKEHOLDERS


5.1 ORGANISATIONAL STRUCTURE

Responses from the Focus Groups, Interviews and Administered


Questionnaires highlighted the following structural issues, which impact
negatively on staff performance and the service delivery:

THE MINISTRY (Head Office)

• Roles and functions at the MOH overlap. For example, Health


Protection and Promotion and Health Systems Integration.

• Too much bureaucratic humbug.

• The structures at the MOH are ‘top heavy’, that is, there are too
many director posts particularly in Administration.

• Make all top posts contractual - e.g. 5 years with possibility of


renewal conditional on satisfactory performance.

THE RHAs

• The lack of decentralisation of some roles and responsibility.

• Bureaucratic structure delays decision making, slows the


communication process and causes inefficient use of resources.

• The structures at the Regional Health Authorities are ‘Top Heavy’, that
is, there are too many director posts particularly in Administration.

• The technical structure at the Regions needs to be broadened to


accommodate technical experts to coordinate the implementation of
programmes.

• All three structures (Ministry of Health, Regional Health Authority


(Regional Office) and Parish need to be reviewed bearing in mind that
the goal is to provide patient centred care.
• Inconsistency in the region and parish structures, this is attributed to
the lack of an approved structure “signed off’” by the MOH.
.

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• Lack of corporate structure for hospital management which facilitates


decision making. Currently the CEO decision making powers are
limited. For example, to purchase critical pharmaceutical items such as
drugs, the request has to be sent to the Parish Manager who supports
the request then sends the request to the Region for processing. The
step in the process of reporting to the Parish Manager should be
omitted.

• Lack of autonomy in performance of functions of the CEO.

• The lack of parish administrators to manage the day to day


administrative support operations of the parish.

• Reduce in the number of RHAs from four to two (MAJ).

• Increase in the number of RHAs from four to five (NAJ).

PARISHES

• Lack of standardisation of structure.

• Technical officers of the professions supplementary to medicine,


working without supervisors.

• Dysfunctional reporting relationships between the technical and non-


technical staff; for example, Medical Officer of Health reporting to a
Parish Manager, and the professional nurse chain of command to non-
technical persons.

Summary of Suggestions from Interviews


(1) Create a structure with a ratio of Administrators to Technical Staff
relevant to the delivery of service.
(2) More input by technical staff.
(3) Revision of parish structure and standardize structures
across regions.
(4) Review parish managers’ role and function – abolish role of Parish
Manager.
(5) Effect Organizational changes within the RHAs

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including making all top positions contractual (5 years with renewal).


(6) Health is a technical Ministry and must be led by technical people.
(7) Re-orientation of the Permanent Secretary, Regional Directors and
Administrators to recognize their role as supportive and facilitatory
and change the “I am in charge” mentality.
(8) Align resources with programs and technical director determining
resource allocation within the health policy and priorities.

Task Force Recommendations


1) Head Office of MOH&E should focus on its primary role of
policy formulation, policy determination, setting norms and standards,
monitoring and maintaining support functions for strategic health
development.
2) Reorganise service delivery on the core functions of Primary, Secondary
and Tertiary Health Care.
3) The RHA must be changed from a semi-autonomous authority to being
a regional coordinating and enabling organizational system. In so
doing, it will be an integral part of the organization and structure of the
Ministry and a strong link between head office and the parish, enabling
and supporting the function of implementation.
4) Develop a HR system which recognizes the relative roles of the
members of the health team in service delivery and the supporting
relationship of the administrative teams and systems.
5) Ensure that there is a national standard for the establishment of the
operations of organizations and structures at the regional and parish
levels.
6) Redefine the role of the Parish Manager to become the leader of the
administrative support team and system; facilitating, enabling and
supporting the efficient implementation of health service delivery at the
parish level.
7) Reinstitute the health team approach as the basic management
standard for service delivery both in the hospitals and the non-hospital
sectors. This approach will enable the coordination of technical
functions necessary for the efficient management of service delivery.
8) Re-establish the corporate structure to all hospitals with each hospital
governed by a Board of Management and not a Health Committee of
the region or parish. The reporting relationship to the Board would be
the triumvirate of the Executive Manager, the Senior Medical Officer
and the Director of Nursing Services. This must become part of a

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national standardized corporate structure which becomes part of the


prerequisite for public/private partnerships and other community
alliances including international recognition and accreditation.
9) Each Hospital Board must have representation from the region or the
parish as indicated in order to enable the coordination and integration
of the levels of care in service delivery.

Diagram 12

TASK FORCE RECOMMENDATION


(RELATIONSHIP BETWEEN HEAD OFFICE, REGION AND PARISH)

Source: W. Mendes Davidson (2007)

Diagram 12 highlights the integrated and interrelated role and


responsibilities of the head office, its Regions and Parish organisations.

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Diagram 13
TASK FORCE RECOMMENDATION - MOH&E
(HEAD OFFICE)ORGANISATIONAL CHART

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All Statutory Agencies and Departments not included in the diagram


must have a direct line reporting relationship with the Permanent
Secretary who is the Ministry’s Accounting Officer.

The Task Force recommends the organisational framework at


Diagram 13 which identifies the very essential directors and principals
in the critically necessary areas to be given leadership of a reorganized
MOH&E. There are many other portfolios which are not represented in
the diagram the details of which are to be decided according to
epidemiological and resource capabilities. These portfolios we regard as
very essential and necessary to achieve the objectives of a modernised
Jamaican Ministry of health which will be equal to the challenges of the
twenty first century. This is by no means exhaustive but will evolve as
the conditions change and the situation demands.
What is important is the development of multidisciplinary
decision making teams at the Central Level in order to fully integrate
policies, norms, standards, and support functions for the Regional and
Parish Levels service delivery and administrative support functions
and operations.
This is vital for successful execution of the respective portfolio
responsibilities at Head Office.
The health team approach MUST be an important factor in the
annual performance appraisal of all staff, including principals and
directors. Use the contract terms to ensure satisfactory performance.

5.2 RECOMMENDED CHANGE IN POLICY FRAMEWORK FOR REGIONS

The RHAs be changed from Semi-Autonomous Statutory Body as in


Diagram 14, to a fully integrated Regional Health Organization System as in
Diagram 15. The integration would be both vertical i.e. with the Head Office
and Parishes and also Horizontal, i.e. with the other Regional Organisations.

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Diagram 14
SEMI-AUTONOMOUS (RHA) STATUTORY BODY

Diagram 15

FULLY INTEGRATED REGIONAL ORGANISATION SYSTEM

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84

Diagram 16
Reporting Responsibilities between Structures

Chief Medical Office


MOH&E

Principal M edical Officer


Regional Technical Administrators

Senior Medical Officer


Parishes

NB: All peers (Technical/Administrative) at the various levels will relate within the structure

The Regions would then have the following responsibilities for:


1. Health services development, coordination, facilitation, review,
monitoring and support systems and processes for program and
project planning and implementation at the Parish level.
2. Coordinating the implementation of national health policies with
and between the Parishes at the FIELD level.
3. Functioning as nodal points in a National Health Information
System linked to a Ministry of Health, national network
infrastructure, located, directed, and managed from the HUB
(Network Operating Data Centre) of the National Health Fund.
4. Health Information Systems and resource allocation (Manpower,
Materials and Money) to the parishes.
5. Forming the bridge between the Ministry (Head Office) and the
Parishes, which are the responsible entities for MOH&E health
services implementation.
6. Inter-regional coordination. All systems and processes within
regions adhering to national standardized systems of practice and
interoperability enabling the free movement of resources between
regions as the need arises.
7. Determination of needs unless in cases of national emergencies
and vertical mission critical programmes.

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8. Physical resources of the region which belong to the MOH&E


although the Regions hold these in trust and must account for
them. Periodic audits must be mandated.

5.3 TASK FORCE RECOMMENDATIONS FOR ESSENTIAL


FUNCTIONS OF REGIONAL HEALTH ORGANISATIONS

5.3.1 Essential Functions of Regional Health Organisation: Field level


enabling and supporting mechanisms for health service
implementation

Ø Oversee National Policy implementation within the Region.


Ø Facilitating Health Care Strategic Planning and enabling its
implementation.
Ø Giving direction to the parishes and charting the course to be taken in
the Region to achieve improvements in population health within the
national policy and plan.
Ø Facilitating intersectorial coordination within the Region and enabling
the integration of health programs with other social sectors in
communities.
Ø Coordination of Health Care Delivery implementation within the
following field institutional framework and contexts: Primary Health
Care; Secondary & Tertiary Health Care; Other Public Health &
Environmental Related Healthcare Delivery systems and programs.
Ø Coordination and Support of National Emergency and Centralised
(Vertical) Programmes Implementation at the field level
Ø Technical Support and coordination especially for Epidemiology /
Surveillance which is of National and Global significance.
Ø Enabling Clinical and Non-clinical Governance / Quality Assurance
and ISO standards for all Health Institutions and programs.
Ø Monitoring of Service Level Indicators (SLIs) at the parish levels,
whether these resources are related to clinical or non-clinical services.
Ø Management of the resources available to the parishes through strong
and efficient administrative support systems regarding manpower,
materials and money (HR, Finance, Information Technology, Operations
and Maintenance, Projects and Audits).
Ø Advocacy role for all health facilities / parishes; that is, strong
representation of the issues, constraints etc to the national level for
support.
Ø Establish and coordinate the health information systems deployment
and utilisation in the region

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Ø Inter Regional collaboration, consultation, communication and


exchange to foster inter regional integration to enable national service
delivery synergies in both primary, secondary and tertiary health care.

5.3.2 LOCATE PATIENT CARE AND SERVICE DELIVERY AT THE CENTRE


OF THE HEALTH CARE DELIVERY VALUE-CHAIN

LEVEL 1
Patient/doctor (Health team encounter): Making the diagnosis: The
fundamental building block of the health services system.

LEVEL 2
Diagnostic support systems: Laboratories, Diagnostic Centres, Other
investigative modalities.

LEVEL 3
Technical and Institutional contexts, circumstances and conditions:
(Organisation i.e. Levels of Care, Structures and Collegial professional
relationships, Related Institutional entities and the Application of
Epidemiologic scientific methods of analysis).

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Levels 1 to 3 more than any other will determine the form, content and
scope of the services which in the final analysis will determine the
structure and administrative support systems needed to satisfy the
health service needs of the Jamaican population.

LEVEL 4
Administrative, Financing and other support systems and mechanisms.

LEVEL 5
Private sector and global relationships e.g. bilateral and multilateral
agreements/ international relations & support systems.

Levels 4 to 5 will influence the quantity and quality of service delivery.

A change in paradigm from Service Level Agreements (SLAs), operable


between independent corporate entities, to Service Level Indicators as
between inter-related organisational entities, which would then be used as
reference indicators to map out qualitative and quantitative benchmarks and
standards during service delivery of programmes and projects in all Primary,
Secondary & Tertiary Health Care services and administrative support
systems.

By changing this paradigm we will achieve the following objectives:

(i) Putting service level operations in epidemiological contexts; in so


doing we would be able to match clinical and non-clinical
standards to epidemiological reference points and therefore
measure project and program outputs region by region, parish by
parish, institution by institution and community by community in
a standardised way.
(ii) Fully integrating and standardising the functions of the Head
Office, Regions and Parishes into a single organised and
inextricably related entity.
(iii) The implementation process would become more precise and
objective since it has become more indicative and therefore data
driven rather than subjective and relationship driven.
(iv) These indicators are derived from the collaborative work between
the regions the field and the head office. The subculture of
subjectivism and cronyism which has reared its ugly head in the
RHAs would gradually become a thing of the past.

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1. We recommend that in order for the process of decentralization to be


meaningful, it must go hand in hand with a measure of regional
autonomy in the following areas in accordance with National standards
and operational guidelines:
§ Independence in the recruitment of manpower with free
transferability of contract to any region subject to release
from and acceptance by of the respective Region.
§ Independence in the procurement of material resources,
maintenance and supplies with the power to outsource
where justified.
§ Management of its own budget.
§ Autonomy in personnel management functions.
§ Reporting to the central administration by way of
management and financial audits and epidemiological norms
and standards.
§ Involvement in the national strategic planning process
during a specified calendar period every year.

2. Re-institution of Hospital Management Boards is a vital precondition if


there is going to be the possibility of public / private partnerships to
build Centres of Excellence and to attract private investments in the
hospitals to rebuild capacity. Further this is necessary to enable
training of health personnel for accreditation purposes, and for the
sustainability of the network system of Secondary and Tertiary Health
Care.

3. Establish a triumvirate of reporting relationship to the Board of


Management of all hospitals. These include a) SMO b) Director Nursing
c) CEO.

4. Line item budgets MUST be established for Primary Health Care


services at every level of function of the health services system; Policy,
Region and Field.

5. The Hospitals will account for their budgets through their respective
Boards of Management. These are Secondary and Tertiary Health Care
categories.

6. At the Head Office or policy level the Secondary and Tertiary Health
Care unit will also have portfolio regulatory responsibility for
laboratories, diagnostic centres and other service delivery related
entities as well as health research and development entities. The
placing of Primary Health Care under the direction of the person
responsible for Secondary Health Care was a grave error.

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89

Diagram 17 presents the current structure of the RHAs. Diagram


captures the organisational structure being recommended by Task Force.
Note the fundamental paradigm change that is being recommended:

from an administration / management centred health


system where the diagnostic chain of command is
broken with technical personnel reporting to and
supervised by non-technical administrative personnel

to a patient centred delivered service delivery.

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Diagram 17
5.4 EXISTING REGIONAL HEALTH AUTHORITY
ORGANISATIONAL STRUCTURE

Regional Health
Authority (Board)

Parish
Committee

Regional
Director

Regional
Technical Director of
Director Finance
(Med. Officer)

Director, HR Director of
& Operations &
Industrial
Relation

Dir. Mgmt.
Information
Systems
Parish
Manager

Medical HR Manager Operations CEO


Officer of Managers
Health

Source: Paul S Ellis: Review of Performance RHAs report; Nov. 21 st 2007

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91

Diagram 18
TASK FORCE RECOMMENDATION FOR THE NEW
REGIONAL ORGANISATION STRUCTURE

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92

The essence of the functions and operations at the Field Level (Region
& Parish) is service delivery. In this connection the most important function
at the Regional Level is Public Health Leadership. This leadership is
represented in the organisational chart as a Principal Medical Officer (PMO,
Regional Technical Administrator).

It is recommended that the posts of Regional Technical Director and Regional


Director should be combined to become one Senior Technical post at the PMO
level and should be designated Regional Technical Administrator. The
qualifications of that individual must satisfy the following:

This leadership must embody the following characteristics:

a) Must be part of the diagnostic professional value-chain of command i.e.


Medical Doctor.
b) Must have public health training and practice
c) Must have had a successful operational (service delivery) field
experience for at least five years.
d) Must have acceptable certification in administrative management.

Administrative Support Weaknesses


There are three areas of fundamental weaknesses in the National Health
Service system:
• Human Resource Management
• Maintenance
• Supplies

The Task Force recommends that these Administrative support functions


are given priority and targeted for special attention in the organisational
framework of the Regional Organisation.

Regional autonomy in these areas is vital, although every Region must


conform, from a policy standpoint, to a uniform set of National Standards,
without compromise.

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Diagram 19

TASK FORCE RECOMMENDED CORE FUNCTIONS


OF THE PARISH ORGANISATION

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The Parish organisation (Diagram 19) is the essence of the Ministry’s


service delivery system and MUST be designed in keeping with the public
health and epidemiological demands of communities within the parishes and
the Institutions (Hospitals) in the Parishes and the Regions. In so doing the
intervention measures will be targeted specifically to the needs of the
patients in communities and within the hospitals system.

The management of the health care delivery process is best carried out
by disaggregating the functions of the clinical and non-clinical components
drilling down to its most basic unit. This will facilitate the proper auditing of
the service to enable the measurement of cost per unit output of Primary
Health Care service; a vital and necessary activity for budgeting purposes.

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95

Diagram 20

TASK FORCE RECOMMENDED SCOPE AND CONTENT


OF PRIMARY HEALTH CARE IN THE PARISHES

Diagram 20 outlines the scope and content of the sub-categories which


comprise a comprehensive Primary Health Care system and portfolio which
must be the portfolio responsibility of the PMO, Primary Health Care.

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The institutional framework of the Primary Health Care system


revolves around the network of Health Centres (in the communities, districts,
and the parishes) and the parish Public Health Departments. These
Departments function as the hub for coordination and integration of clinical
and non-clinical functions of Primary Health Care delivery services. Without
a proper functioning electronic health information system, the qualitative
leap needed to modernise Primary Health Care will never take place.

A framework for the Health Centre redesign located in the Goffe and
McCartney report is suitable as a starting point for Primary Health Care
institutional delivery services. Although there are gaps, this should not be a
deterrent to begin the development of an implementation plan.

The present practice of combining Primary, Secondary and Tertiary


Care under one Director at the Head Office demonstrates a very serious gap
in knowledge of public health principles and practice and the scope and
content of Primary Health Care. This criticism must also be levelled at the
other technical directorates at the Head Office where the combination of
portfolio responsibilities bear no relationship whatsoever to epidemiologic
principles or public health logic.

Diagram 10 (the prevention model see page 62) puts the respective
domains of responsibilities in both public health and epidemiologic contexts
for clarification. It identifies four interconnected and interrelated stages of
Prevention:

The first stage Pre-Primary Prevention is a state of health


maintenance and wellness. This is the primary context of the Health
Promotion intervention strategy. Health promotion however may be applied
right across the prevention spectrum.

The second stage is Primary Prevention, which is represented in an


epidemiologic context as measures designed to decrease the incidence (the
occurrence of new cases) of disease. This is the domain of Primary Health
Care intervention measures and is comprised entirely of community based
delivery services. Primary Health Care services may be applied right across
the prevention spectrum and health promotion is only one of its many pillars.

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97

The third stage is Secondary Prevention which is represented in an


epidemiologic context as intervention measures designed to decrease
prevalence (all cases old and new) of diseases. This is the domain of
Secondary and Tertiary Health Care and is institutional care which is
represented as Non-Community Based services. However Secondary and
Tertiary Health Care services are organically connected, overlap and are
interrelated to Primary Health Care both at the Health Centre and public
health management levels as the diagram describes.

The fourth stage is Tertiary Prevention which is represented in an


epidemiologic context as averting “chronicity” or rehabilitation i.e. re-
motivates, retrain, re-socialise, reintegrate. This is essentially a community
based intervention service of chronic disease management and is the domain
of Primary Health Care in close collaboration with the Secondary Care
referral system.

The head office needs to be aware of these time honoured principles and
must show public health and epidemiologic justification before it assigns
portfolio responsibilities to directors. Otherwise the organisation will build
the structures around personalities rather than principles. This would be a
definite prescription for territorialism, subjectivism and cronyism.

It is evident that much work needs to be done in acquiring institutional


knowledge of the scope and content of Primary, Secondary and Tertiary
Health Care. In so doing, this would correct obvious errors in organisational,
structural and functional configuration.

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6.0 THE HEALTH INFORMATION SYSTEM

6.1 Stakeholders’ Key Issues

• There is no standardization of the very limited management


information system being used across the regions. The more rural
parishes lack connectivity from the network providers of the country.
• There seem to be consistency across regions in terms of software usage.
The major software in use are HRMIS, MAXIMO, PAS, Free Balance
and Great Plains. NERHA has however developed computer software
“in house” to satisfy its needs.
• Interconnectivity is done through LAN and WAN.
• Patient Administrative System (PAS) for the management of patient
records is implemented in few hospitals and clinics.
• There is limited use of the PAS; there are some modules that are not
being used.
• The Human Resource Management Information System (HRMIS) is
linked to payroll in all regions; however the capacity for human
resource management is not being maximized.
• The software MAXIMO does not work. It was highlighted that the
system was non-functional for six (6) months in 2006 and currently is
not working.
• Most of the software being used though insufficient are providing basic
information. However, collectively most stakeholders suggest
improvements are needed in the system.
• Majority of the MIS staff including those at leadership level do not have
the capacity for managing the system.
• Funding for the purchase of computer equipment is inadequate.

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DISCUSSION
The institutional framework of the Primary Health Care system revolves
around the network of Health Centres (in the communities, districts, and the
parishes) and the Parish Public Health Departments. These Departments
function as the hub for coordination and integration of clinical and non-
clinical functions of Primary Health Care delivery services. Without a proper
functioning electronic health record system there is no possibility of having a
seamless integration of the clinical components of Primary Health Care, and
Secondary Health Care. Indeed the qualitative leap needed to modernize
Primary Health Care will never take place without the deployment of an
electronic health record system.

In order to achieve a modern health service delivery system the Health


Information System must achieve the following outcomes:
• Real time access to patient information.
• Reliable connectivity.
• Greater efficiencies in the management of information.
• Greater efficiencies in processing of patients and patient /health care
provider encounters.
• Ability to monitor service delivery in every health facility in real-time.
• Better and more efficient access online to morbidity and mortality data
from the parishes and regions.
• Ability to quickly and more accurately establish norms and standards
for service delivery.
• Referral of patients and their information to other facilities in real-
time.
• Saving time in enabling the integration of Primary, Secondary and
Tertiary clinical services.

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100

• Enabling integration of clinical services between Health Centre and


institutions such as hospitals, public health departments, the regions
and head office.
• Enabling the referral of patients between the public and private
sectors.
• Saving time in patient management and therefore saving lives.
• Better accountability of drug utilization in clinics hospitals and
pharmacies in the public and private sectors.
• Real-time access to hospital service delivery statistics for monitoring
and evaluating service delivery in these institutions and follow up in
the communities.
• More efficient data mining for greater capabilities in strategic health
planning capacity at the MOH Head Office in collaboration with the
Regions and the Parishes.
• More efficient use of professional resources in Tele-Radiology, Tele-
Dermatology, Tele- Pathology, Tele-Consultations, Home Health, Tele-
Mental Health, Tele-Mentoring etc.
• The use of web-based video conferencing for meetings and coordinating
functions of the Regions Parishes and Head Office.
• More efficient management of emergency medical conditions.
• Greater capability in the coordination of service delivery and
administrative support systems especially in the supply chain and
maintenance systems.
To achieve the outcomes listed above the two most important requirements
are:
(i.) A modern web-based electronic patient health record system
which meets the requirements of international standards of
interoperability and sits as the core of the health information
technology software application system for service delivery.

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101

(ii). A robust multi-service Internet Protocol (IP) network


infrastructure (Tele-Health network) dedicated to the unique
specifications of the Ministry of Health clinical service delivery
system.

These two criteria represent the core of the Health Information System
which provides the platform for the integration of other information system
such as supply management systems, human resources management
systems, financial management systems and maintenance management
systems. All of these represent the administrative support systems in the
health sector.
Significant capacity building work is necessary in order to ensure that the
Ministry of Health and Environment achieve these outcomes. This point was
made by different categories of staff.
The reasons are the following:
(i) The PAS system which Ministry of Health has deployed does not have the
capability of a modern web-based electronic health record system
necessary to meet the requirements of international standards of
interoperability and portability (HL7 compliant) for the National Health
Service System.
(ii) MIS unit at the Ministry of Health does not have the professional
expertise or the resources or to build a Multi-service IP network
infrastructure capable of running a mission critical Tele-Health network.

6.2 TASK FORCE RECOMMENDATIONS


The Ministry of Finance, when faced with a similar challenge developed
Fiscal Services which is an independent entity with a professional
management structure and an adequate budget subject to monitoring and
oversight by the Ministry.

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102

The Task Force recognizing the critical and urgent need to satisfy the
requirements of a National Health Information System recommends that:
• National Health Fund (NHF) should be the executing agency for the
immediate, short term, medium term and long term Information
Technology needs of the Ministry of Health and Environment .
• NHF should further develop its IT division into a department and
continues to develop the IT professional capacity to do the following:
a) Implement the deployment of a modern web-based
electronic patient health record system which meets the
requirements of international standards of
interoperability and sits as the core of the health
information technology software application system for
service delivery of the patient health information system.
b) Implement the building and deployment of a robust multi-
service Internet protocol (IP) network infrastructure (Tele-
health network) dedicated to the unique specifications of
the Ministry of Health service delivery system.
c) Recruit, train, and deployment of all IT personnel and
development of systems throughout the MOH&E and
Environment.

7.0 MANPOWER

7.1 HUMAN RESOURCE MANAGEMENT


Key Issues- Stakeholders
1) Shortage of staff particularly specialist nurses (critical care, dialysis, theatre
nurses, ophthalmic, nurse midwives), midwives and enrolled assistant
nurses.
2) Non-appointment of staff acting in clear vacancies.
3) Size of the workforce is insufficient for the various administrative and

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103

support functions.
4) Lack of job tenure and employees working without established posts.
5) Rapid staff turnover of all levels of staff.
6) Inadequate staff orientation programme (SRHA).
7) Interregional inconsistencies with regards to pay scale, level of
employment, and leave.

8) Limited training programmes exist for Artisans - Plumbers, Carpenters,


and Biomedical Technicians.
9) Insufficient incentive schemes / programs that may be used as tools to
improve staff morale.
10) Remuneration packages are not justified by years of employment and
training.
11) Lack of transparency in the management of human resource issues.
12) No clear human resource appeals process.
13) Inadequate funding for staff development.
14) Lack of comprehensive Manpower plan.
15) Poor working conditions.

DISCUSSION

When the scope of Primary Health Care is laid bare, and the epidemiological
trends of the next thirty (30) years are assessed, the manpower needs of the
categories of workers required for successful health care delivery services are
protean. All categories of staff interviewed reported that the HR performance
at every level of the health service system was very poor in areas of
recruitment, selection , promotion, appointments, training and communication.

The current size of the workforce is insufficient for the various


administrative and support functions. A shortage was reported in almost
every speciality area of employment: Nursing, Medicine, Midwifery,
Pharmacy, Health Records, Cashiers, Leave Clerks, Parish Auditors, Social
Workers and Dieticians. With “no post”, “unclear vacancies”, and a category
described as “excess”, the current health care cadre situation is unrealistic.

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104

The lack of a comprehensive orientation programme for all levels of


staff of the Regions, and lack of posts, low remuneration packages, high staff
turnover and in some instances poor working conditions have resulted in a
strain on the system.

The general consensus among all level of workers is they are frustrated
and de-motivated when they cannot do what they are trained to do. NERHA
and SRHA staff were disgruntled with the number of years individuals have
been working in some cases ten (10) to twenty five (25) years without being
appointed.

Of approximately thirty recommendations of the Ying report in 1996,


the first one called for the establishment of a Centralized HRD Planning Unit
and the development of a National Manpower Master-Plan. Ten years have
elapsed and the Central Office HRM Division/Department does not possess
the capability of addressing core manpower issues of policy analysis,
forecasting and planning. Moreover, the database to achieve this is non-
existent.

7.2 TASK FORCE RECOMMENDS THAT:

• The backlog of HR issues including appointments, promotions, salary


packages, welfare and incentive schemes must be quickly addressed by
a special multi-disciplinary group in order to improve staff morale.
• A National Human Resource Management Strategic Plan be
implemented as a matter of priority and that this be guided by
epidemiologic principles.
• The leadership in the service delivery and administrative support areas
together with the epidemiologist in charge of strategic planning must
be involved in the design, development and final documentation of all
National Human Resource Development Plans.

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• MOH&E should develop an effective HR policy that uses a multi-


disciplinary approach that relates to clearly defined functions of service
delivery and administrative support.

• The William’s Report of 2007 recognized that “expertise is necessary to


develop an appropriate National Human Resource Manpower Plan” for the
sector in general and each specific Regional Health Authority in particular.
The Task Force agrees with this recommendation but emphasizes that the
effort must be one of priority but must take place simultaneously with the
organizational reform and reclassification exercise currently being undertaken
by the Ministry of Finance and Planning.

• An immediate staff audit be done to ascertain the staff’ complement


necessary, based on the epidemiological requirements in each Region
and in every parish.

• Reclassification of posts and positions in keeping with the proposed new


organization structure and functions at the central, regional and parish
levels.
• The projected 2014 Proposals (Goffe / McCartney 2007 Report) related
to the classification of staffing for Primary Health Care and Mental
Health Staffing by Regions be given the highest priority. These services
are important for the largest and most vulnerable sections of the
Jamaican population.
• The RHAs should institute training for maintenance personnel at all
levels, in collaboration with UTECH, NCTVET, and MIND and like
organizations with special emphasis on Artisans and Bio-Medical
Technicians.
• A systematic approach must be developed for international recruitment
and for training and certification of local staff.

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106

• International recruitment must be the domain and sole responsibility of


Head Office and not the Regions, while local recruitment must remain
the prerogative of the Regions and Parishes. This should foster greater
transparency in the management of Human Resources matters.
• The appeals procedure for disgruntled workers MUST be swift,
transparent and impartial.
• The Ministry of Health and Environment should establish very close

cooperation and collaboration with our universities, especially the


University of Technology. This is necessary to accelerate the education
and training not only of the traditional health sector personnel but also
the non-traditional such as

those persons in the areas of new technologies required by the

diversified global health sector.

8.0 SUPPLIES MANAGEMENT AND PROCUREMENT


Key Issues by Stakeholders

8.1 Pharmaceuticals
• Health Corporation Limited, the Government Agency which
supplies drugs to the RHAs usually supplies approximately 60%
of the Institution’s order; the gap has to be filled by purchasing
drugs on the open market.
• Unavailability of credit facilities within regions for the
procurement of drugs on the open market.
• Inadequate budgetary support to purchase pharmaceuticals from
the open market
• Inadequate inventory control system to facilitate ordering, and
distribution of drugs.

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107

Suggestion from Focus Group

• Lobby for an increase in the budgetary allocation for the purchase of


pharmaceuticals.
• Review procurement guidelines to make it easier to reorganize and
capitalise HCL to increase efficiency.

7 Undercapitalization of Health Corporation Limited (the Government


importer and distributor of pharmaceuticals and medical supplies) and
inadequate budgetary provisions for the RHAs results at times in stock outs
of drugs and medical supplies.
As a result, hospitals end up having to supplement shortages with emergency
purchasing from local private sector distributors at higher prices. The
situation is further compounded by the fact that at the end of September
2007, HCL sales to RHAs represented an average service level of 50 percent
and an average service level of 76 percent for critical drug items.
On the other hand, the amounts collected by HCL on behalf of the RHAs, as
at September 30 th, 2007 were still inadequate to deal with the overhang in
amounts owed, with $225.6 million still being owed to HCL, with an average
aging of nearly two months.
Unfortunately, the Drugs and Therapeutic Committees (a useful
mechanism for monitoring drug usage in hospitals) do not appear to be
meeting or are meeting irregularly in most hospitals. Hence, there is no
timely feedback mechanism to inform HCL’s procurement unit when there
are changes in therapy.

8.2 OTHER SUPPLIES


Key Issues from Stakeholders

7A Review of the Performance of the Reg iona l Hea lth Authorities By: Paul S. Ellis,(Lecturer – UTech &
Management Consultant) November 21, 2007

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108

• Shortage of supplies impacting negatively on patient care.


• Inadequate funding to purchase supplies.
• Delay in the procurement process which hinders efficiency. For
example, the practice of getting three quotes before the decision is
taken to purchase.
• Lack of a management information system for supply
management.
• Currently, management is not making use of economy of scale in
purchasing supplies.

8.3 THE TASK FORCE RECOMMENDS THAT:


• The Health Corporation Limited (HCL) be reorganised and capitalised
to improve its capacity and its efficiency.
• HCL be transferred to the NHF as a Department and be fully
integrated into the NHF procurement system.
• All HCL systems be fully computerised for procurement, inventory
control, supply and distribution.
• Health Corporation Limited should expand the Drug Serve Pharmacies
in hospitals throughout the Regions. All reports confirm this to be a
“best practice”.
• Drug Serv Pharmacies to be included in Primary Health Care Facilities
in all Regions.

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8.4 EQUIPMENT

Key Issues from Stakeholders

• Non-Functional Equipment.
• Inadequate Maintenance.
• Lengthy procurement procedure for approval of requests for equipment
e.g. Three quotes are needed for purchase of an item yet only one or two
places possess licences for the specific equipment.
• Special donations to purchase equipment when paid into the Regions
are held by the Region and is not released to be applied for the intended
purchases (SERHA and NERHA).
• Maintenance of specialised equipment should be out-sourced.
• Establish mobile maintenance teams in each parish.
• Increase training of Artisans, Electricians and Biomedical Technicians.
• Procurement of equipment is being affected by inadequate financing
and limited capacity of procurement officers.

8.5 THE TASK FORCE RECOMMENDS THAT:

• Assets Register (of Property, Machinery, Equipment, Fixtures, Vehicles


Stocks and Supplies, etc.) be set up and maintained up-to-date, in every
Region as a matter of priority.
• Policies must be developed for the standardisation of all categories of
machinery and equipment, especially with regard to energy
conservation and replacement parts.
• Outsourcing of maintenance of specialised equipment.
• Increase training opportunities for Maintenance personnel.
• Equip a Mobile Maintenance team for each parish.

9.0 FINANCE AND THE RHAs


Next follow a series of Tables and Charts derived from financial data supplied
by the RHAs and MOH&E.

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TABLE 14
MOH&E - RHAs
Analysis of 2003/04 Income & Expenditure for Combined RHA

% of Total % of
Total 2003/04 Income Expen
$M
INCOME:

MOH Grant 8,292.79 88.2%


Fee Income 1,043.88 11.1%
Other Income 60.34 0.6%
Donations 0.0%
Total Income 9,397.01 100%

EXPENDITURE:

Salaries etc. 7,899.57 84.1%


Travelling 534.31 5.7%
Rental 23.46 0.2%
Salaries,Travelling, Rental etc. 8,457.34 90.0%
Utilities 402.79 4.3%

Purchase of Other Goods and Services 1,770.74 18.8%


Purchase of Fixed Assets 37.36 0.4%
Total Expenditure 10,668.22 113.5%

Surplus/(Deficit) (1,271.21) -13.5%

Source: Data submitted by MOH&E, RHA

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TA B LE 15
MOH&E - RHAs
A n aly sis o f 2 0 0 4 /0 5 In co m e & E x p e n d itu re fo r C o m b in e d R H A s

% o f T o tal % o f T o ta l % of M OH
T o ta l 2 00 4 /0 5 In c o m e E xp e n d itu r e G rant M th ly . A v g .
$M $M
IN C O M E :

M O H G ra n t 8,6 33 .1 2 8 7.5 % 81 .8% 10 0.0 % 71 9 .4 3


F e e In c o m e 1,1 40 .1 7 1 1.6 % 10 .8% 1 3.2 % 9 5 .0 1
O th e r In c o m e 57 .6 5 0.6 % 0 .5% 0.7 % 4 .8 0
D o n a tion s 38 .7 9 0.4 % 0 .4% 0.4 % -
T o ta l In co m e 9,8 69 .7 3 10 0.0 % 93 .5% 11 4.3 % 81 9 .2 5

E X P E N D IT U R E :

S a la rie s e tc. 7,6 16 .9 3 7 7.2 % 72 .2% 8 8.2 % 63 4 .7 4


T r av e llin g 5 36 .5 4 5.4 % 5 .1% 6.2 % 4 4 .7 1
R en ta l 27 .2 3 0.3 % 0 .3% 0.3 % 2 .2 7
S a la rie s,T ra v e llin g , R e n ta l etc . 8,1 80 .6 9 82 .8 9 % 7 7.5 1% 94 .7 6 % 68 1 .7 2
E lec tric ity 2 41 .7 9 2.4 % 2 .3% 2.8 % 2 0 .1 5
W a te r 1 63 .0 1 1.7 % 1 .5% 1.9 % 1 3 .5 8
T e lep h o n e 77 .8 5 0.8 % 0 .7% 0.9 % 6 .4 9
U tilities 4 82 .6 5 4.9 % 4 .6% 5.6 % 4 0 .2 2

D rugs 7 26 .8 5 7.4 % 6 .9% 8.4 % 6 0 .5 7


M ed ic a l g a s es 1 25 .4 2 1.3 % 1 .2% 1.5 % 1 0 .4 5
D ie ta ry 1 12 .1 1 1.1 % 1 .1% 1.3 % -
S e cu r ity 1 67 .9 3 1.7 % 1 .6% 1.9 % 1 3 .9 9
C le a n in g an d P o rte r in g 2 44 .3 7 2.5 % 2 .3% 2.8 % -
T o iletr ies 33 .8 7 0.3 % 0 .3% 0.4 % -
L a u n d r y E xp e n se s 23 .9 1 0.2 % 0 .2% 0.3 % -
F o o d & D rin k 97 .6 6 1.0 % 0 .9% 1.1 % 8 .1 4
M a in te n a n c e - B u ild in g 34 .6 4 0.4 % 0 .3% 0.4 % 2 .8 9
M a in te n a n c e - E q u ip m en t 67 .2 3 0.7 % 0 .6% 0.8 % 5 .6 0
M a in te n a n c e - V eh ic les 38 .7 9 0.4 % 0 .4% 0.4 % 3 .2 3
O th e r 1 99 .6 2 2.0 % 1 .9% 2.3 % 1 6 .6 3
P u r c h a s e o f O th e r G o o d s a n d S e rv ic es 1,8 72 .4 1 1 9.0 % 17 .7% 2 1.7 % 12 1 .5 1
P u r c h a s e o f F ix ed A s s e ts 19 .2 8 0.2 % 0 .2% 0.2 % -
T o ta l E x p e n d itu r e 1 0,5 55 .0 3 10 7 % 1 0 0% 12 2 % 84 3 .4 6

S u rp lu s /(D e fic it) $ (6 85 .3 0 ) -6.9 % -6 .5% -7.9 % $ (2 4 .2 1


Source: Data submitted by MOH&E, RHA

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TABLE 16
MOH&E - RHAs
Analysis of 2005/06 Income &Expenditure for Combined RHAs
% of Total % of Total % of MOH
Total 2005/06 Income Expenditure Grant Mthly. A
$M $M
INCOME:
MOH Grant 5,802.82 82.1% 82.1% 100.0% 483
Fee Income 912.81 12.9% 12.9% 15.7% 76
Other Income 60.44 0.9% 0.9% 1.0% 5
NHF Grants 287.40 4.1% 4.1% 5.0% 23
Donations 2.68 0.0% 0.0% 0.0%
Total Income 7,066.15 100.0% 100.0% 121.8% 588

EXPENDITURE:
Salaries etc. 5,033.48 71.2% 71.2% 86.7% 419
Travelling 396.59 5.6% 5.6% 6.8% 33
Rental 15.80 0.2% 0.2% 0.3% 1
Salaries ,Travelling, Rental etc. 5,445.88 77.1% 77.0% 93.8% 453
Electricity 179.20 2.5% 2.5% 3.1% 14
Water 116.78 1.7% 1.7% 2.0% 9
Telephone 46.02 0.7% 0.7% 0.8% 3
Utilities 342.01 4.8% 4.8% 5.9% 28
Drugs 470.62 6.7% 6.7% 8.1% 58
Medical gases 68.68 1.0% 1.0% 1.2% 9
Dietary 74.56 1.1% 1.1% 1.3% 10
Security 101.70 1.4% 1.4% 1.8% 14
Cleaning and Portering 156.74 2.2% 2.2% 2.7% 22
Toiletries 27.22 0.4% 0.4% 0.5% 3
Laundry Expenses 13.53 0.2% 0.2% 0.2% 1
Food & Drink 69.59 1.0% 1.0% 1.2% 9
Maintenance - Building 52.39 0.7% 0.7% 0.9% 6
Maintenance - Equip 37.03 0.5% 0.5% 0.6% 4
Maintenance - Veh 17.16 0.2% 0.2% 0.3% 2
Others 159.29 2.3% 2.3% 2.7% 20
Purchase of Other Goods and Services 1,248.49 17.7% 17.7% 21.5% 165
Purchase of Fixed Assets 33.09 0.5% 0.5% 0.6%
Total Expenditure 7,069.46 100% 100% 122% 647
Surplus/(Deficit) $ (3.31) 0.0% 0.0% -0.1% $ (59
Source: Financial Data supplied by MOH&E, RHA

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TABLE 17
MOH&E - RHAs
Analysis of 2006/07 Income & Expenditure for Combined RHAs

% of Total % of Total % of MOH


Total 2006/07 Income Expenditure Grant Mthly
$M $M
INCOME:
MOH Grant 11,487.28 86.9% 84.5% 100.0%
Fee Income 1,605.09 12.1% 11.8% 14.0%
Other Income 106.05 0.8% 0.8% 0.9%
NHF Grants 23.49 0.2% 0.2% 0.2%
Donations 4.56 0.0% 0.0% 0.0%
Total Income 13,226.48 100.0% 97.3% 115.1% 1
EXPENDITURE:
Salaries etc. 9,929.57 75.1% 73.1% 86.4%
Travelling 770.01 5.8% 5.7% 6.7%
Rental 34.23 0.3% 0.3% 0.3%
Salaries, Travelling, Rental etc. 10,733.81 81.2% 79.0% 93.4%
Electricity 342.46 2.6% 2.5% 3.0%
Water 176.93 1.3% 1.3% 1.5%
Telephone 66.58 0.5% 0.5% 0.6%
Utilities 585.98 4.4% 4.3% 5.1%
Drugs 852.75 6.4% 6.3% 7.4%
Medical gases 118.97 0.9% 0.9% 1.0%
Dietary 114.84 0.9% 0.8% 1.0%
Security 194.36 1.5% 1.4% 1.7%
Cleaning and Portering 266.48 2.0% 2.0% 2.3%
Toiletries 60.40 0.5% 0.4% 0.5%
Laundry Expenses 26.41 0.2% 0.2% 0.2%
Food & Drink 128.07 1.0% 0.9% 1.1%
Maintenance - Building 78.41 0.6% 0.6% 0.7%
Maintenance - Equip 46.90 0.4% 0.3% 0.4%
Maintenance - Veh 25.35 0.2% 0.2% 0.2%
Others 301.23 2.3% 2.2% 2.6%
Purchases of Other Goods and Services 2,214.19 16.7% 16.3% 19.3%
Purchase of Fixed Assets 54.36 0.4% 0.4% 0.5%
Total Expenditure 13,588.34 103% 100% 118% 1
Surplus/(Deficit) $ (361.86) -2.7% -2.7% -3.2% $
Source: Financial Data supplied by MOH&E, RHA

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CHART 2A
MOH&E – RHAs
INCOME FOR THE COMBINED RHAs BY YEAR & SOURCE

C om po sitio n o f T ota l In com e C om po sition


for 2003/ 04 Y ear for 20

O th er
O ther Incom e
F ee Incom e 60
1,044
F ee In com e
1,140

M O H G rant
8,293

C om po sitio n o f T ota l In com e C o m po sitio


for 2005/ 2006 Y ear fo r 2

N H F G rants
2 87 O ther Incom e
O ther Incom e D onations
10 6
60 3 F ee Incom e
F ee Incom e 1,605
91 3

M O H G rant
5 ,8 03

Source: Data submitted by MOH&E, RHA

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CHART 2B
MOH&E – RHAs
INCOME FOR THE COMBINED RHAs BY YEAR & SOURCE

C om
T otal Inpo
com e 2003/04
sition Y ear
of T otal In com($M
e ) C o m positio
fo r 2003/ 2004 Y ea r fo r 20

O ther Incom e O ther


Fee Incom e O ther Incom e
Fee Incom e 1% Incom e
11% 0.64%
11.11% 0.86%
Fee Incom e
12.92%

M O H G rant
M O H G rant
88%
88.25%

C om p osition of T ota l In co m e C om p ositio


for 2004/ 2005 Y ear fo r 200
O ther O ther
Incom e Incom e
0.58% 0.80%
D onations
0.39%
F ee Incom e Fee Incom e
11.55% 12.14%

M O H G rant
87.47%

Source: Data submitted by MOH&E, RHA

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CHART 3A
MOH&E – RHAs
EXPENDITURE FOR THE COMBINED RHAs BY YEAR & TYPE

Composition of Total Expenditure Composition of Total Ex


for 2003/04 Year Security & for 2004/05 Yea
Maintenance To
309 Clean/Portering
244
Fixed Assets Dietary, Food &
Other Purchases
37 Drink
1,771
210
Drugs & Med.
Utilities gases
403 852
Salaries, travel,
rental etc. Utilities
8,457 483

Composition of Total Expenditure Composition of Total Ex


for 2005/06 Year for 2006/07 Year
Security & Clean/Portering
Security & Clean/Portering Toil/Laundry
Maintenance 266 To
Maintenance 157 41
208 Dietary, Food & 345
Others Drink
Dietary, Food & 159 243
Drink Fixed Assets
144 33 Drugs & Med.
gases
Drugs & Med. 972
Gases Utilities
539 586
Utilities Sal, travel, rental
342 etc.
5,446

Source: Financial Data supplied by MOH&E, RHA


CHART 3B

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MOH&E – RHAs
EXPENDITURE FOR THE COMBINED RHAs BY YEAR & TYPE

C om p osition of T o tal E xpe nditure C om position of T otal E


fo r 2003/ 04 Y e ar for 200 4/05 Y e
C lean/P orterin g Toil/L
2.3% 0.
Se curity &
D ietary, Fo od & M aintenance
F ixed A ssets
O ther Purchases D rin k 2.9%
0.4%
16.6% 2.0%
D rugs & M ed.
U tilities
gases
3.8%
S alaries, 8.1%
travelling, re ntal U tilities
e tc. 4.6%
79.3%

Co m po sition of T otal E xp end iture C om p ositio n of T otal E


for 20 05/06 Y ear for 2 006/ 07 Y e

C lean/P ortering To il/Laundry Security & C lean/Po rtering


Security & M aintenance 2.0%
2.2% 0.6% T
M aintenance D ietary, Foo d & 2.5%
2.9% O th ers
F ixed A ssets D rink
D ietary, Fo od & 2.3%
0.5% 1.8%
D rink
2.0% D rugs & M ed.
gases
D rugs & M ed. 7.2%
G ases
U tilities
7.6%
U tilities 4.3%
Sal, travel, ren tal
4.8% e tc.
77.0%

Source: Financial Data supplied by MOH&E, RHA


CHART 4
MOH&E – RHAs

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Analysis 2003/2004 Income by Amount (J$M) by RHA and So

10,000

9,000

8,000

7,000

6,000
Income (J$ M)

5,000

4,000
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3,000

2,000

1,000

0
MOH Grant Fee Income Other Income Donations To
Source of Income

Source: Financial Data supplied by MOH&E, RHA


CHART 5
MOH&E – RHAs
Analysis of 2004/05 Income by Amount (J$M) and by RHA & S

12000

10000

8000
Income (J$ M)

6000

4000

2000

0
M OH G rant Fee Income Other Income Donations

Source of Incom e

Source: Financial Data supplied by MOH&E, RHA

CHART 6
MOH&E - RHAs

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Analysis of 2006/07 Income (J$M) by Amount (J$M) by RHA &

14000

12000

10000
Income (J$ M)

8000

6000

4000

2000

0
M O H G rant Fee Incom e O ther Incom e N H F G rants D onations

Source of Income

Source: Financial Data supplied by MOH&E, RHA

CHART 7

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MOH&E – RHAs
Analysis of 2003/04 Collections (J$M) by RHA

1 200

1 000

800
Collections (J$M)

600

400

200

0
SE RHA W RHA SRHA NE RHA ALL RHA

-200
R egional H ealth Authority

Source: Financial Data supplied by MOH&E, RHA


CHART 8
MOH&E - RHAs

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Analysis of 2004/05 Collections (J$M) by RHA

1,400

1,200

1,000

800
Collections (J$M)

600

400

200

0
SERHA NERHA WRHA SRHA TOT

-200
Regionial Health Authority

Source: Financial Data supplied by MOH&E, RHA


CHART 9
MOH&E - RHAs

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Analysis of 2006/07 Collections by Regional Health Autho

1,800

1,600

1,400

1,200
Collectios (J$M)

1,000

800

600

400

200

0
SERHA WRHA SRHA NERHA ALL RH
Regional Health Authority

Source: Financial Data supplied by MOH&E, RHA

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TABLE 18
MOH&E - RHAs
SERHA EXPENDITURE 2004-2006 BY COST CENTRE

2004/2005 EXPENDITURE 2005/2006 EXPENDITURE


COST CENTRE BUDGETED ACTUAL BUDGETED ACTUAL
$ $ $ $
Regional Office 111,251,957 72,982,000 129,482,905
Kingston Public Hospital 1,456,555,636 1,424,915,551 1,739,832,932
Victoria Jubilee Hospital 354,035,850 341,685,349 426,767,398
Sir John Golding Rehabilitation Centre 101,921,935 515,666,069 585,110,263
Bustamante Hospital for Children 548,751,825 168,539,575 169,069,798
National Chest Hospital 169,702,294 30,755,694 32,397,724
Hope Institute 32,154,172 668,198,832 738,442,936
Spanish Town Hospital 674,822,913 78,095,944 72,796,826
Linstead Hospital 65,568,876 216,731,188 204,287,008
Princess Margaret Hospital 183,697,363 643,148,122 633,079,768
Kingston & St. Andrew Health Dept. 530,414,997 334,494,078.00 320,994,311
St. Catherine Health Department 292,094,408 171,994,597.00 161,046,911
St Thomas Health Department 136,422,369
TOTAL EXPENDITURE 4,657,394,595 4,667,206,999 5,213,308,780
TOTAL ALLOCATION RECEIVED 3,914,299,028 3,865,116,999 4,248,304,258
TOTAL FEE COLLECTED 503,800,000 433,726,009 578,000,000 616,400,815
OTHER INCOME 52,426,424 216,885,044 243,134,332
DONATIONS 4,414,253 4,158,643
TOTAL CASH DONATION RECEIVED 4,404,865,714 4,660,002,043 5,111,998,048

Source: Financial Data supplied by MOH&E, RHA

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CHART 10
MOH&E - RHAs
South East Regional Health Authority
2004/05 Actual Expenditure (in J$M) Analysed by Cost Cen

5,000

4,500

4,000

3,500
Expenditure-J$M

3,000

2,500

2,000

1,500

1,000

500

0
old sp

Ho Hsp

SA sp
sta ab

Li sp
ce

hT te

ess sp

th .
Ca ept
ria PH

on eHs
JG eH

K& argH
Sp stitu

H
Bu Reh

inc H
ffi

St. thD
lO

cto K

est

wn

Pr tead
Sir bile

N ant

In
ing

M
Ch
na

H
m

pe
Ju

ns
gio

al

ns
Re

ati
Vi

Cost Centre

Source: Financial Data supplied by MOH&E, RHA

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CHART 11
MOH&E - RHAs
South East Regional Health Authority
2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by C

Budgeted Expenditure Actual Expenditure

6,000

5,000
Expenditure-J$M

4,000

3,000

2,000

1,000

0
Na ma b

St. Hl sp
Pr stea p
pe sp
Sir Jubi H
old Hsp

l C sp

hT te

St th. H ept
ce

sta eha

SA gH
Lin Hs
Ho stH

ess Hs
na H

ns itu
P

Ca thD
ffi
ria K

Bu ngR
lO

wn
Sp Inst
JG lee

inc d
tio nte

K& Mar
he
na

T l
i
gio
Re

cto
Vi

Cost Centre

Source: Financial Data supplied by MOH&E, RHA

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CHART 12
MOH&E - RHAs
South East Regional Health Authority
2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by C

Budgeted Expenditure Actual Expenditure

7,000

6,000

5,000
Expenditure-J$M

4,000

3,000

2,000

1,000

0
sta hab

p
Lin Hsp
pe p
old sp
J H

na sp

ns te

ess sp
ce

th p
SA Hs
Ho tHs
JG eH

tio teH

Sp stitu

inc H

Ca De
ria P
ffi

Bu gRe
cto K
lO

K& arg
wn

Pr stead

St. Hlth
s

In
Sir ubile

he
Na man

M
hT
in
na

lC
gio
Re

Vi

Cost Centre

Source: Financial Data supplied by MOH&E, RHA

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TABLE 19
MOH&E - RHAs
SRHA EXPENDITURE 2004-2006 BY COST CENTRE

COST CENTRE 2004/05 EXPENDITURE 2005/06 EXPENDITURE


BUDGETED ACTUAL BUDGETED ACTUAL
$ $ $ $

Mandeville Hospital 326,433,538 522,876,570 492,299,303 652,448,

May Pen Hospital 207,687,113 267,841,841 390,998,733 369,304,

Lionel Town Hospital 54,939,016 47,993,990 50,731,049 66,929,

Black River Hospital 131,808,891 135,191,578 151,292,921 159,939,

Percy Junor Hospital 139,112,608 146,349,718 135,693,999 184,657,

Clarendon Health Department 179,994,732 197,502,083 178,762,176 230,862,

St. Elizabeth Health Department 138,440,570 134,009,459 129,727,014 152,855,

Manchester Health Department 119,511,052 130,298,456 113,455,503 145,091,

Regional Administration 54,032,480 108,376,969 68,929,303 139,600,

TOTAL EXPENDITURE 1,351,960,000 1,690,440,664 1,711,890,001 2,101,690,

TOTAL CASHDONATION

RECEIVED 233,717

Source: Financial Data supplied by MOH&E, RHA

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CHART 13
MOH&E - RHAs
Southern Regional Health Authority
2004/05 Budgeted vs. Actual Expenditure (in J$M) Analysed by C

Bud geted Expenditure Actual Expenditure

1,800

1,600

1,400
Expenditure-J$M

1,200

1,000

800

600

400

200

pt
pt

pt
p

sp
sp
p

sp
Hs

De
De
rH

De
Hs

nH

rH
wn

th
th

th
no
le

ive
Pe
vil

Hl
Hl

Hl
To

Ju
kR
de

ay

on

th

er

gio
rcy
M
an

el

ac

est
be
nd
on
M

Re
Pe

ch
Bl

iza
are
Li

an
El
Cl

M
St.

C ost C entre

Source: Financial Data supplied by MOH&E, RHA

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CHART 14
MOH&E - RHAs
Southern Regional Health Authority
2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by C

B u d ge te d E x p e n d itu re A c tu a l E xp e n d itu re

2 ,5 0 0

2 ,0 0 0
Expenditure-J$M

1 ,5 0 0

1 ,0 0 0

500

t
t
t

ep
sp

ep

ep
sp
sp

sp
sp

D
H

D
H

rH

lth
wn

lth
or

lth
n
le

ive
Pe

un

rH
H
nH
vil

To

kR
de

yJ
ay

te
do
M
an

el

et
rc
ac

es
on

ab
M

Re
Pe

en

ch
Bl

liz
Li

ar

an
.E
Cl

M
St

C o s t C e n tr e

Source: Financial Data supplied by MOH&E, RHA

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CHART 15
MOH&E - RHAs
Southern Regional Health Authority
2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by C

B u dg e te d E xpe nd itu re A c tual E xpe nditu

2 ,5 0 0

2 ,0 0 0
Expenditure-J$M

1 ,5 0 0

1 ,0 0 0

500

pt

pt
sp

sp
sp

sp

sp

De
De

De
H

rH
H

nH

rH
wn

lth
th

th
no
le

ive
Pe

H
vil

Hl

Hl
To

Ju
kR
de

ay

on

eth

ter
rcy
M
an

el

ac

nd

es
on

ab
M

Pe

ch
Bl

are

liz
Li

an
.E
Cl

M
St
C ost C en tre

Source: Financial Data supplied by MOH&E, RHA

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TABLE 20
MOH&E - RHAs
NERHA EXPENDITURE 2004-2006 BY COST CENTRE

2003/ 2004 EXPENDITURE 2005/2006 EXPENDITURE


COST CENTRE BUDGETED ACTUAL BUDGETED ACTUAL B
$ $ $ $
Regional Office 69,056,193 82,555,953 68,749,262 73,445,124

St. Ann's Bay Hospital 379,218,833 472,056,163 439,909,576 506,042,758

Port Maria Hospital 89,612,331 94,439,900 86,738,968 93,402,205

Annotto Bay Hospital 130,738,793 165,159,810 150,954,411 168,926,320

Port Antonio Hospital 144,649,857 159,504,933 152,944,019 162,835,727

St. Ann Health Department 152,827,726 171,567,785 167,113,818 172,763,537

St. Mary Health Department 120,396,471 135,870,222 130,752,130 136,696,387

Portland Health Department 116,080,779 127,601,541 122,947,816 129,535,023

TOTAL EXPENDITURE 1,202,580,983 1,408,756,307 1,320,110,000 1,443,647,081

CASH DONATION RECEIVED 1,208,756 151,340

Source: Financial Data supplied by MOH&E, RHA

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CHART 16
MOH&E - RHAs
North East Regional Health Authority
2003/04 Budgeted vs. Actual Expenditure in (J$M) Analysed by C

Budgeted Expenditure $M Actual Expenditure $M

1,600

1,400

1,200
Expenditure-J$M

1,000

800

600

400

200

0
sp

sp

p
ce

pt

pt
Hs

Hs
yH

yH

De

De
ffi
lO

io
ria

lth

th
Ba

Ba

ton
Ma
na

nH

H
Hl
tto
n's
gio

An

nd
ry
rt
An

no

An
Po

Ma
Re

rtla
rt
An

Po
St.

St.

Po
St.
Cost Centre

Source: Financial Data supplied by MOH&E, RHA

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CHART 17
MOH&E - RHAs
North East Regional Health Authority
2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by C

Budgeted Expenditure Actual Expenditure

1,600

1,400

1,200
Expenditure-J$M

1,000

800

600

400

200

0
sp

sp

pt
sp
ce

pt
Hs
yH

yH

De
aH

De
ffi
lO

io

lth
Ba

th
Ba
ari

ton

nH
na

Hl
tto
n's
gio

An

ry
An

rt

no

An

an
Po

Ma
Re

rt
An

rtl
Po
St.

St.

Po
St.
Cost Centre

Source: Financial Data supplied by MOH&E, RHA

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CHART 18
MOH&E - RHAs
North East Regional Health Authority
2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by C

Budgeted Expenditure Actual Expenditure

1,800

1,600

1,400
Expenditure (J$ M)

1,200

1,000

800

600

400

200

0
p

sp

p
sp
ce

pt

pt
Hs

Hs
yH
yH

De

De
ffi
lO

io
ria

lth

th
Ba
Ba

ton
Ma

nH
na

Hl
tto
n's
gio

An

ry
rt
An

no

n
An
Po

Ma
Re

rtla
rt
An

Po
St.

St.

Po
St.
Cost Centre

Source: Financial Data supplied by MOH&E, RHA

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CHART 19
MOH&E - RHAs
2004/05 Expenditure Ratios by Regional Health Authori

100

90

80

70

60
Percentage (%)

50

40

30

20

10

0
Sal as % of TE S&T as % of TE S&T as % of MOH Grant S&T as
Expenditure Ratio

Source: Financial Data supplied by MOH&E, RHA

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CHART 20
MOH&E - RHAs
Analysis of Payables (J$M) at 2005 March 31 by RHA & by Cr

2,500

2,000

1,500
Payables (J$ M)

1,000

500

0
Statutory Deductions Utilities Drugs Others
Creditor

Source: Financial Data supplied by MOH&E, RHA

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CHART 21
MOH&E - RHAs
Analysis of Payables at 2007 March 31 by RHA & by Credi

2,500

2,000

1,500
Payables (J$ M)

1,000

500

0
Statutory Deductions Utilities Drugs Others
Creditor

Source: Financial Data supplied by MOH&E, RHA

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CHART 22
MOH&E - RHAs
Analysis of April - Nov. 2005 Income (J$M) for Combined RHAs b

1,200

1,000

800
Income (J$ M)

600

400

200

0
April May June July Aug Sept Oct

Source: Financial Data supplied by MOH&E, RHA

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CHART 23
MOH&E - RHAs
Analysis of April - Nov. 2005 Expenditure (J$M) for Combined RH

1,200

1,000

800
Expenditure-J$M

600

400

200

To ing

ink
rit y

Fo ry
ies

ase gs

Fix s
l
Tr etc.

nta

Cle Mtnc
Se ietar

r
d

he
dG Dru
ilit

un
r

Dr
Re

rte

A
Ot
l

D
Sa

Ut

La

&
Po
y&
&

ed
s&

il &

od
&
el
av

an
cu
Me

Type of Expenditure

Source: Financial Data supplied by MOH&E, RHA

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141
9.1 MOH GRANT
The MOH grant continued to be the most significant source of income
for the Regional Health Authorities, averaging $8.55 billion over the last four
fiscal years. For the years examined this grant was 82% to 88% of the total
income of all the RHAs, individually and combined. In 2005/2006 it was down
to 82% but hovered at 86%-88% for fiscal 2003/04, 2004/05 and 2006/07.
The pattern was erratic as shown in Table 14 to Table 17. There was a slight
increase (4%) of the 2004/05 Grant over the 2003/04. But in 2005/06 there was
a significant 33% reduction, followed by 97% increase of 2006/07 over
2005/06. (See also Charts 2A, 2B and Charts, 4, 5 and 6.)

The MOH Grant represented, on average, 86 % of the MOH Budget


which was of the order of 5 % of GDP. Given the competing calls on the
national budget and the prognosis for its growth during the next few years, it
is clear that in the absence of a radical change in the financial policy, the
RHAs will have to access other funding sources to maintain viability. This
will have to be done if they are to acquire the assets and technology necessary
to upgrade their service delivery to achieve the level required to attain
recognition in keeping with international standards. The annual income
currently covers staff emoluments, utilities and drugs, with very little left for
asset maintenance and the other vital necessities.

9.2 USER FEE INCOME


Over the last quadrennium, except for fiscal 2005/06, the User Fee
income grew from $1 billion to $1.6 billion. This remained at 11% to 12% of
the MOH Grant. This is also illustrated in Tables 14 – 17 and Charts 2A and
2B.

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142

9.3 NHF GRANTS


The NHF made grants in 2005/06 and in 2006/07. The first of these
was for $287 million. The second was much less - $23 million. This
precipitous fall was partly due to the lack of capacity of the Regions to
implement projects in a timely manner, due in no small part as we were
informed to the cumbersome and bureaucratic procurement system and
procedure.

9.4 FIXED ASSETS


The financial data supplied hardly mentioned the Fixed Assets,
(buildings, plant, machinery and equipment) which, from observation, are of
significant value. If these are not owned by the RHAs then there is no need
to include them in the financials. The RHAs do not pay rental/leases so the
preservation of these assets and their replacement and upgrading are not
directly or indirectly their responsibility. This does not augur well for the
preservation or maintenance of the assets.
This point was stressed by the 8 Auditor General when he met with the
Task Force. He stated that there was great difficulty in getting information
on the identification and the value of the Assets from the RHAs. Further that
there was a failure on the part of these RHAs to adhere to the Public Bodies
Management and Accountability Act. In addition, when posts are classified
and emoluments attached the RHAs did not comply with procedures. There
was a disconnect between the level of services and the resources.

Actual purchases of Fixed Assets by the RHAs were relatively minor; at less
than 0.5 % of annual income.

8 Auditor General Adrian Strachan lamented the fact that there was poor financial
accountability throughout all the Regions

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143

9.5 EXPENDITURE
Altogether, the RHAs spend more than their annual income. The gap is
met mainly by delayed payment of Statutory Deductions and Pension Scheme
contributions. These late payments are to the detriment of the staff whose
National Housing Trust, National Insurance Scheme, and Pension
entitlements are at risk. This is not a fiscally satisfactory method of funding
the budgetary shortfall.
The Task Force was advised that the statutory deductions are now being
taken out at source by the Ministry of Finance to offset the practice of delayed
payment to Inland Revenue and NHT. This is a welcome change.
As expected, given the nature of the service, the staff emoluments bill was the
most significant expenditure each year. In excess of 80% of the annual income
was absorbed by staff costs. Purchase of other goods and services constitute
the remaining 20%. Surprisingly utilities were less than 5% of the income.

The RHAs gave analyses of their expenditure by Cost Centres. The hospitals
were allocated the larger amounts in each case (63% to 66% overall).

There are gaps in the financial accountability.

In light of this situation, it is clear that 5% of the national budget to the


health sector is not adequate, given the demand for services. The call for the
Government to spend no less than 10% of the National Budget on Health
Care since 1938 was only realised in fiscal year 1972/3. There was no other
period in Jamaica’s history when the expenditure in the health sector has
been more than single digit as a percentage of the National Budget. The
range of expenditures is between 4.5% to 7.5% over recent years.
Given the present budgetary challenges, any call for no less than 10% of
the National Budget is not anticipated to yield any significant change in
budgetary allocation to the RHAs in the short term. Of course, with a new

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144

Government in place, until the first budget is presented, speculation as to the


resource allocation would be quite premature.

9.6 USER FEES


The reduction in User Fees which was introduced in 2007 (for children
18 years and younger) will negatively impact on the financing of the RHAs
budgets unless there are other initiatives to increase collections. Over 95% of
stakeholders who were interviewed strongly recommended that User Fees be
continued at this time and that those who have the ability to pay should pay
but that provision should be made for the indigent, the infirm, the
handicapped and the elderly with relief through targeted programs such as
PATH.
The total amount of fees collected in both the Hospitals and the Health
Centres account for approximately $1.6 billion dollars per year. If there is a
cessation of User Fees collected in the hospitals the replacement cost to the
National budget would amount to approximately $3.2 billion dollars in fiscal
year 2007 to 2008. This amount would have to be found to maintain the
health status quo (of fiscal year 2006/2007), in fiscal year 2007/2008.
The $1.6 billion accounts for approximately 12% of the Health Budget.
From our analysis this amount was not disaggregated from Health
Centre User Fees and therefore we could not precisely establish the amount
of fees which were collected from the Health Centres as compared with the
Hospitals. However, based on our knowledge of the average costs per patient
using the hospital services versus the Health Centre the ratio of 8:1 or 10:1
would give a guesstimate of the relative incomes from User Fees in the
Hospitals vs. the Health Centres.
On average, less than 20% of persons who are ill will justify a place in a
Hospital while greater than 80% of patients can be managed quite well in a
Health Centre. Hence the most important need of the Jamaican people is
Primary Health Care where over 90% of the population will seek health care
if high quality services are available and there is a good consultation and

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145

referral system for diagnostic and laboratory tests as well the availability of
specialists when needed.
The call for the abolition of User Fees in Hospitals will have a series of
domino effects which have to be managed carefully as there is the real
possibility for very serious health consequences. It is not practical to stop only
User Fees in Hospitals without affecting the usage of Health Centres. The
result of eliminating User Fees at hospitals would be the same as a policy of
free health care to the entire population. The consequential funding cost
would be extremely difficult to quantify or manage.
Based on the financial data that were presented to the Task Force there
are a number of realistic options open to the Government which would satisfy
the Governments compassionate desire to improve access of the people to
universal health care while at the same time to rationally manage the process
over a more extended time frame.
The immediate consequences of abolishing Hospital User Fees are
beginning to be apparent. Most of the patients would then gravitate to the
hospitals. It has been shown that in the case of the Bustamante Hospital for
Children they recently had an estimated three-fold rise in patient load. This
policy would undermine the Primary Health Care system and push the
country into a service delivery tailspin as 80% of patients who should be seen
in Health Centres would develop health seeking behaviour in the free
Hospital Service system.
The cost implications of this must also be taken into consideration. A
sum of $3.2 billion dollars would be required to replace the User Fees given
up. With an expected three-fold rise patient load there has to be an increased
service delivery cost to offset this load in the hospitals. This is conservatively
estimated to be of the order of at least $1 billion. Additionally there will be
need for plant upgrade and refurbishing to meet increased hospital usage. It
is estimated that additional funds amounting to approximately 2 to 4 billion
dollars would be needed for this purpose. The total cost of implementing the
policy the consequences of which could be managed without chaos would be

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146

an additional sum to the health budget which would be approximately $6.2 to


$8.2 billion dollars. This Task Force is not required to supply exact estimates
of this consequential shortfall of income to the RHAs. We merely mention
this in passing.

9.7 PUBLIC/PRIVATE PARTNERSHIPS


Finally, the Hospital management system which is currently
functioning without a corporate structure or Board of Management will have
to be radically changed, if it is to play the critical role in the public / private
partnership arrangement for investments in the sector to lead the anticipated
Health Tourism development and to grow the service for regular population
access..
Abolishing User Fees in hospitals at this time would weaken the
Government’s bargaining position for public / private partnerships as it would
undermine investor confidence with respect to return on investments in a
business climate where the health services are essentially free. It would be
very difficult to justify the need for public / private partnerships and for
creating investments for Centres of Excellence as a business venture located
within designated hospitals in a situation in which the policy in reality
provides free hospital care.
Medical “Health Tourism” as a Jamaican niche market would be very
difficult to implement in this context.
This is, therefore a mountain of epidemiologic, public health and health
economic evidence to warrant caution in the application of this policy on cost
sharing.
However, the following proposal is recommended in keeping with a
more viable and sustainable policy option which is epidemiologically
justifiable on the question of relieving the cost of the disease burden on the
Jamaican population and exercising the principle of compassionate relief.

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147

9.8 TASK FORCE RECOMMENDS


Abolition of User Fees for Primary Health Care in every community as
the first step to fulfil the commitment of the Government in their Election
Manifesto.
In the absence of accurate primary data on the amount of User-Fees collected
at Health Centres, we have estimated that some eight to ten percent of $1.6
billion dollars could be accounted for was being derived from Health Centres.
This would be an approximate figure of $200 million annually.
A gap of approximately $200 million as compared with $1.6 billion in the
health budget would be more manageable at this time. From an epidemiologic
standpoint better access to Primary Health Care would lead to earlier
detection, diagnosis and treatment of diseases closer to the patients’ homes.
This would create lesser burdens on the hospitals because of less
complications and more preventive and successful curative care. The cost
savings would be significant bearing in mind that the health centres system
which functions well will serve eight to ten times more patients than those
seen in hospitals at less costs in a much shorter time.

Another step : Primary Health Care services should be improved almost


immediately by utilising Primary Care physicians and specialists in a night
shift (say, between six to ten p.m.) in communities distributed right across
the island. Remote districts could be served by Mobile clinics. This
recommendation is in keeping with the findings of the Goffe / McCartney
Report.

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148

Possible sources of required additional income are the following:


(1). Grants from the National Health Fund.
(2). Savings as a result of the application of information and
communication technology to the health service system.
(3). Public / Private partnerships resulting in new investments in the
health sector to implement an aggressive Health Tourism Industry
and extend the services for the citizens. The charges (for tourists and
nationals) would have to incorporate economic costs as well as
funding for asset maintenance, replacement and upgrade.
(4). Bilateral or Multilateral Grant funding.

10.0 PROJECT MANAGEMENT


10.1 PROJECT PLANNING AND IMPLEMENTATION
Key Issues from Stakeholders
• The cycle time for contracts and tender become lengthy given the nature of
the competitive bidding process.
• The Head Office has not been involved in the scope of work and does limited
monitoring for Projects in progress.
• There is a lack of Project Management staff.
• Inflation affects the timeliness of projects and their completion.
• There is a lack of procedures to address additional funding for project
overruns.
• Projects that are approved for a particular RHA are sometimes routed to
other projects across other regions.

THE PROJECT PROCESS


The project process for the RHAs has a framework that has result-chain
logic and social mapping that is used in the management of projects, though
when regionalization was introduced project management was not a part of
the regional structure.

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149

Projects are conceptualized in the RHAs and the cycle time for contracts
and tender can become lengthy. Under the guidelines, proposals are
developed within the regions and forwarded to the Project Management and
Implementation Unit (PMIU) in the Ministry of Health. Technical projects
are sent to the Chief Medical Officer for input, then to the Permanent
Secretary for approval. Once approved by Head Office, projects are sent to
the funding agency (NHF) Institutional Benefits Committee for
considerations.
Smaller projects are reviewed for correct specifications by PMIU and
sent to the National Health Fund for funding. After that there is no
communication between the RHAs and the MOH PPU except for a monthly
report. A reporting relationship exists between the NHF and the RHAs, and
the RHAs with the contractors. Although a monthly progress report is
requested, there is limited monitoring by the PMIU of projects and variations
from the scope of work. The regions are obligated to report to the NHF and
for large projects the NHF has a representative onsite.
NHF has a monitoring system varying according to the project size.
For all incomplete projects it was the reporting mechanism is non-
existent. The Technical Directors approve the additional scope of work
without knowledge of the source of additional funding. It was reported that
funds for projects not yet started or routed to other regions within a given
timeframe are placed in non-interest earning accounts at financial
institutions. Project Management is a dynamic field and given the low
remuneration packages in the public sector, the persons in this field are
wooed by the private sector.

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150

DISCUSSION
The project process as described did not seem to develop within a
national strategic planning framework. The process seems to be more in
keeping with an ad hoc needs responsive framework. Because of the
weaknesses in the Regional management system, from a policy,
organizational, structural and functional standpoint there can be no
immediate change in the process of project management until there are
changes in the areas outlined. There is no organizational logic between the
Head Office and the RHAs to permit a rational and efficient project
management system, because there is a fundamental disconnection between
the head office and the field level from a project planning, programming and
implementation standpoint. There is duplication, overlapping and omission of
functions, between RHAs and Head office with little capacity to monitor,
establish norms and standards or to efficiently harness the resource capacity
to effectively and efficiently implement projects.
The fact that there have been many instances of successful outcomes
speaks to the high calibre of achievement of a number of functionaries who
persist in spite of the awesome obstacles.

10.2 TASK FORCE RECOMMENDATIONS


The Task Force recommends that every RHA should have within its
organizational structure, a Project Management and Implementation Unit.
This should be complemented by a vibrant planning and evaluation process at
the Region and Parish Levels. (See diagram on Regional Organisation).
The Task Force recommends that the MOH&E determines the appropriate
measures to modernise the guidelines for the tender process.
Project overruns are sometimes unavoidable because of the
unpredictable nature of the health service delivery process which has to
respond to disease complications and diagnostic discoveries which change
costs assumptions. This is particularly prevalent during emergencies and
national outbreaks of diseases and epidemics.

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151

The Task Force recommends that the appropriate policy be developed


to deal effectively with cost over-runs which may be justified by
epidemiologic determinants rather than human error or deliberate under
pricing.

11.0 PUBLIC / PRIVATE PARTNERSHIPS

11.1 HEALTH TOURISM, A CONSEQUENCE OF GLOBALISATION

“Medical Tourism, broadly defined, is travel undertaken for the purpose


of availing cost effective health care”.
Global analysis indicates that the global medical tourism market
comprised over 19 million trips in 2005, with a total value of $20 billion
experiencing double-digit growth in medical tourism, which is forecast to
grow to 40 million trips, or 4% of global tourism volume by 2010
(Source: International Travel Trade market).

Thailand attracts 600 000 medical tourists per year and is projected to attract
one million foreign patients. (Source: Medical Tourism Assoc. Inc).
Medical tourism is a rapidly growing industry with countries like
Mexico, Brazil, Argentina. Costa Rica, Dominican Republic, Peru,
Singapore , Hungary, India, Israel, Jordan, Lithuania, Malaysia,
South Africa, Thailand, Cuba and the Philippines actively promoting it.

India is a recent entrant into this sector. Some estimates say that
foreigners account for 10 to 12 per cent of all patients in top Mumbai
hospitals despite roadblocks like poor aviation connectivity, poor road
infrastructure and absence of uniform quality standards.

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152

Diagram 21

CLASSIFICATION OF HEALTH TOURISM

This classification in Diagram 21 is very important. It is very useful for


planning a coherent national strategy that could accurately inform the
development of sustainable business models for Health Tourism.

This classification of Health Tourism consists of three distinct but


interrelated categories:

v The First is WELLNESS HEALTH TOURISM which is estimated to be a


multibillion dollar global business of which a small part is the spa industry.
Jamaica’s ethnic medicines can become a vibrant niche industry in this
important category. This industry demands a large number of workers
especially in the complementary and alternative medicine area.

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153

v A national policy which addresses the issues relating to complementary and


alternative medicine in Jamaica is needed urgently. The standards and
regulatory branch in the Ministry of Health must be given the support to
proceed with this as a matter of priority. This is particularly important as
there needs to be documentation of the modes of complementary medicine as
we seek to establish a registry for this unregulated industry which has grown
exponentially. A registry of practitioners of complementary medicine in
Jamaica is needed urgently.

v The Second is MEDICAL HEALTH TOURISM which has attracted a


number of investors to Jamaica. The conditions for medical health tourism in
Jamaica are favourable when we compare not only prices but other critical
factors of our Jamaican people’s history and culture with regard to their
function in the services industries. There are however some structural
organisational and policy constraints which must be addressed before we can
hope to be part of this global $50 billion dollar market growing in countries
which are much less endowed or capable than Jamaica at rates of 15% to 20%
per annum.
v There is a need for the development of Hospital Centres of Excellence,
additional investment, a partnership of public health and the private sector,
and a National Tele-health multi-service internet protocol network
connecting broadband to all components of the health sector whether private
or public. A Universal web-based patient electronic health record system
integrated with IP voice, video and data services is needed.
v Jamaica presently has both the know-how and the resources to develop these
initiatives.
v Central to this, is the organisational reform of the MOH&E which is a
precondition for this advance to take place with least cost and in a sustained
way.

v The Third component is CONVALESCENT OR RETIREMENT VILLAGE


HEALTH TOURISM. This industry is estimated be the most lucrative of all
the categories and growing at a phenomenal rate globally. Jamaica is poised
to be a significant player in this industry. In order to have an excellent
sustainable Retirement Village Health Tourism industry one ought to have
an excellent Medical Health Tourism industry and a vibrant and sustainable
Wellness Health Tourism industry.
v All three components of this industry are interconnected.

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154

11.2 BUILD, OWN, OPERATE AND TRANSFER (BOOT) Model

In order to jump start the Development of Health Tourism Services in


Jamaica, the Task Force recommends the following model.

Ø Allow Private entities to build and own bed capacities and medical facilities
in existing Hospitals and Clinic spaces with a lease period of not less than 30
years for transfer back to the Government, in the process creating a brand
e.g. “Caribbean Health Tourism, Centres of Excellence”

Ø Allow Private investor entities to manage existing beds where possible if


there are no opportunities to build.

Ø Government will make available all Clinical Teams for service delivery as a
paid service to be decided by negotiation between the parties.

Ø Provide Physical resources if available (Operation Theatres, diagnostic


facilities etc. to increase capacity of the Centres of Excellence making
available bed spaces in the Centres of Excellence.

Ø Provide “Doctor-On-Call” and emergency services coverage to Hotels and


retirement villages for both pre-operative and convalescence Health tourism
patients and clients.

Ø Allow a minimum of 10 Year Tax Holiday on Income to Private Investors

Ø Charge a Percentage of the revenue, to cover all recurrent Costs of the health
teams plus a Profit that can be used to subsidize patients in the general
sections of the Government Hospitals.

Ø The Government should work out a cost sharing mechanism from the
revenues of the clinical teams that’s mutually beneficial so that the
Government may recover its investment costs in land, buildings, machinery
and equipment.

Ø The Hospital and its Management Board may choose to outsource any service
to the Centre of Excellence if this is economically feasible.

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155

Diagram 22

THE BOOT: PUBLIC / PRIVATE PARTNERSHIP

CENTRES OF EXCELLENCE
Private entities with state of the
EXISTING GOVERNMENT
art facilities: built, owned,
HOSPITAL SERVICES Govt
operated and managed by
Teams of High level Professional
investor group; to be transferred
Clinical staff e.g. (Consultants
back to the Government after
Doctors, Specialist Nurses etc)
long term (30 to 50 year) lease
(BOOT)

RESORTS & HOTELS


Patients have pre-operative (2-3 days)
stay in resort facility; Return to hotel
after treatment and being stabilised to
remain for extended vacation, if
necessary

Source: W. Mendes Davidson & S. Kumar 2008

This model creates a golden opportunity for developing long term


relationships with partners and trusts, in keeping with global trends in the
development of the health service system. Health Tourism is also a best fit
industry for Jamaica and indeed the Caribbean as the tourism industry is an
embedded industry in the vision, culture and practice of the Jamaican and
Caribbean peoples.

The Task Force is mindful of the critical importance of its


recommendations, but more importantly the urgent need to follow up on the
vital changes to make this model a reality.

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156

Table 21

Country Health Expenditure Per Capita Per Year


& Male / Female Longevity; W.H.O Estimates-2000
United States $4187 73.7M/79.7F
Germany $2713 73.8M/80.1F
Switzerland $2644 75.6M/83F
Luxemburg $2580 74.5M/81.4F
Denmark $2574 72.9M/78.1F
Japan $2373 77.6M/84.3F
France $2369 74.9M/83.6F
Jamaica $149 75.2M/77.4F

Table 21 illustrates the strategic position Jamaica holds in terms of cost


per capita per year of health care and the qualitative return it receives
manifested by its life expectancy. Jamaica has the potential for a highly
competitive Health Tourism product and there is every justification to
participate fully and without reservation in this very important Global
Industry.

Below are the results of the interviews with Corporate Personnel and
Private Groups who are currently significant investors of large amount of
capital over many years in the Jamaican health sector. They have taken
major risks with no special incentives.

11.3 PROPOSALS FOR PUBLIC / PRIVATE PARTNERSHIPS BY


PRIVATE ENTITIES
113.1 Representatives from the AIC Group

Conditions for a vibrant Public Private partnership in the Jamaican


health sector.
Based on this type of information and the nature of health care, a prudent
investor traditionally looks at the types of products & services offered i.e. the

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price of entry, the market that is being serviced, and the expected returns or
revenue streams.
Barriers to investment are traditionally related to the following:
• Low return on investment concerns
• Capacity
• Pricing
• Volume of business
• Utilization
• Ability to Pay
• Taxes
• Technology
• Infrastructure
• Support
• Restrictions

The private sector investors seek risk mitigation and predictability of


profits. This can only be achieved in an environment of predictable capacity,
costs and ability to pay.
Focus should be placed on developing a framework that would achieve
these conditions.
The primary areas that the Jamaican government might need to focus on
in order to attract investors are:

(i) Clinical Service Strategies which clearly define the


boundaries between the public, private and public/private areas.

The current health care system allows for both public and private hospitals to
coexist offering similar products. They recommend that the GOJ introduce

a) Government (MOH) certified product offerings to potential partners.


b) Controls on specialization.
c) Limiting entrance to those areas in which certified partners have
invested.

(ii)Clinical Service Compensation Scheme and an


Attainable Return on Investment:
The current system endorses market pricing with limited government
support or control and yet the cost of entry is yielding unprofitable results.

Examples of incentives that would attract investors would be:

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• Mandate Insurance companies to design full health care products that


are affordable;
• Pass legislation to mandate employers to carry these insurance policies
to cover their employees;
• Managed pricing of services certified by MOH;
• Tax incentives for both the investor and participants.

(iii) Entry into the Defined Clinical Services should have


Protective Barriers:

There is no control over who enters the various markets on the Island; as
such it is all based on the availability of capital. They recommend that the
following incentives would assist:
Government guaranteed loans and / or initiatives for funding;
Allow a 10 year moratorium on the health care environment to allow
the system to rebuild itself;
Remove barriers related to duties, licenses and withholding taxes for a
period of 10 years.

(iv) Infrastructure and Support:

Hospitals on the island are all starting to age, are space challenged, needing
repair, upgrading or expansion due to constantly growing demand. In
addition, most of the technical support is directed by offshore companies.
They recommend that the following incentives would help:
• Initiatives for importing products, equipment and resources needed to
develop, install / build and rollout any investment related to the health
sector;
• Endorsed tracking / reporting and IT systems that would enable easy
access to funds for payments without barriers;
• Establish certified training centres for technical support related to
hospital equipment servicing.

(v) ACCREDITATION AND IMPORTING / EXPORTING RESOURCES:

There appears to be no controls over the quality of service or standardized


monitoring over the level of service provided at the various hospitals. In
addition, the hospitals are always faced with staff shortages while certain

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service sectors (i.e. nurses, doctors, etc.) continue to emigrate. Incentives that
might assist in meeting these concerns include:

• Legislate compliance with international standards;

• Establish standardized quality of services with regular monitoring;

• Tax breaks for allowances for training, research and development;

• Offer initiatives to partner with educational institutions for developing


and training health professionals;

• In developing this mandate, a partnership needs to be formed with the


private sector and there has to be a beneficial reason for this
investment;

• If an incentive is derived for the investor and in turn the Jamaican


people benefit, then only would the Government have achieved its
objectives.

11.3.2 ACHIEVING A SUSTAINABLE WORLD CLASS DIAGNOSTIC


IMAGING SECTOR IN JAMAICA – IMPERATIVE FOR NATIONAL
DEVELOPMENT- Presentation by THE RADIOLOGY GROUP

INTRODUCTION
The impact of imaging technology on the achievement of best-practice
standards in modern health care is incontrovertible. Despite limited public
resources, Jamaica has been blessed with a very high standard of imaging
capacity and diversity due to the vision and entrepreneurship of a small band
of private radiologists. However, the Government has an important role to
play in ensuring the sustainability of this very important health sector and to
establish similar high quality in the public hospital system. To achieve this
goal will require a unique brand of private/public sector partnership to ensure
the best possible health care for every single Jamaican and also to open the
door for developing a viable health tourism market.

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The Radiology group recommends:

(i) INCENTIVES NEEDED FOR GROWTH IN THE PRIVATE DIAGNOSTIC


IMAGING SECTOR
• Abolition of all tax regimes on the importation of diagnostic imaging
equipment and related ancillary supplies.
• Provision of special low interest US Dollar loans for the purchase of
equipment.
• Granting of special tax credits or tax holidays for establishing imaging
centres in the underserved rural Jamaican communities.
• Regional and international government to government discussions to
open a window of opportunity for Jamaican radiologists to provide off
shore Tele-Radiology services to other countries that may benefit and
be in need of such services.
• Government support and collaboration with the Jamaica Association of
Radiologists in enabling and charting a course towards entry into the
rapidly growing worldwide Health Tourism market.

(ii) PRIVATE SECTOR/PUBLIC SECTOR COLLABORATION & UTILIZATION OF


PRIVATE RADIOLOGISTS IN GOVERNMENT HOSPITALS

Given the inadequate quality and diversity of diagnostic imaging


services in the public hospital system, it is time to consider a new paradigm of
initiatives to induce private radiologists to participate in the provision of
imaging services at public hospitals. Because of the shortage of radiologists in
the country, this can only be achieved by a radical departure from the
traditional film-based radiology system to one that is completely digital and
amenable to networking through a comprehensive island wide Picture and
Archiving Communications System (PACS).
The concept is that once the network is in place, private radiologists
could be contracted to remotely interpret and issue reports on line in a timely
fashion on all imaging studies performed on government hospital patients
from a computer console located in their office, their home or even if they are
on vacation on a specially configured lap top computer.
The initial cost of purchasing the necessary hardware would be quite
considerable but would be recoverable over time by the tremendous savings
from the eventual abandonment of utilizing very expensive X-ray film.

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(iii) DIVESTMENT OF GOVERNMENT HOSPITAL RADIOLOGY DEPARTMENTS

The concept outlined in the preceding paragraph could actually be


taken one step further in which private radiologists could be actually invited
to completely take over and manage on a lease basis, the entire operation of
radiology departments in Government Hospitals.
Special arrangements would naturally have to be entrenched in order
to ensure that all patients would receive the same level of service, regardless
of their personal financial capacity or incapacity.
It would also be worthy of consideration to establish individual Centres
of Excellence in different imaging modalities. For example, the National
Chest Hospital, unencumbered as it is by the high level of trauma cases seen
at the Kingston Public Hospital, could be transformed into a designated high
end National Interventional Radiology Centre, to which patients from all over
the island could be referred for the more sophisticated biopsy, drainage and
vascular interventional procedures.

(iv) TRAINING OF RADIOLOGY PERSONNEL

For imaging services in Jamaica to take the necessary quantum leap


towards world class standards, it will be necessary to increase the cadre of
radiologists, radiographers and ultra-sonographers graduating from the
University of the West Indies training system. It may even be necessary to
consider setting up parallel training programmes for radiographers at the
University of Technology and Northern Caribbean University, so that the
yearly output of radiographers can be increased exponentially.

(vi) IMPACT OF NEW TAX MEASURES ON THE DELIVERY OF MEDICAL


SERVICES IN JAMAICA

The Radiologists noted the historical development of imaging services in


Jamaica under the following three headings:
(a) Availability of high technology equipment.
(b) Accessibility of services in a reasonable time period.
(c) Cost of services.
(a) Availability of High Technology Equipment
The record shows that practically all of the major technological innovations in
diagnostic imaging have been first introduced by private sector radiologists
and not the University Hospital. The history is now tracd:
• Mammography for the early detection of breast cancer was introduced
in the early 1980’s by Dr. Freddie Clarke.

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• The University Hospital and KPH did not obtain mammography units
until 20 years later.
• Diagnostic ultrasound was introduced by Dr. Freddie Clarke in the
early 1980’s.
• CT scans were introduced by Eureka Medical Centre in 1986.
• Spiral CT was introduced by Kingston Radiology and Imaging Services
in 1997.
• Low field strength MRI was introduced at Eureka in 1996.
• Medium field strength MRI was introduced by Dr. Trevor Golding in
1998.
• The University Hospital installed a high field strength MRI scanner in
2002
• Bone densitometry for early detection of osteoporosis and risk of spinal
and hip fractures was introduced by Dr. Freddie Clarke in the mid
1990s.
• To date, neither The University Hospital nor KPH can perform bone
densitometry.
• The first state of the art Linear Accelerator for radiation therapy was
installed by Dr. Freddie Clarke and Dr. Venslow Greaves in 2002.
• The public sector continues to use outdated Cobalt radiotherapy units
at Kingston Public Hospital and Cornwall Regional Hospital.

(b) ACCESSIBILITY TO SERVICES IN A REASONABLE TIME PERIOD

Sophisticated technology is of little value to a society if the services


provided are not available on a consistent and timely basis. The record will
show that it is far easier to access services on short notice in the private
sector compared to the public sector.

This is mainly due to three reasons.


• The endemic culture in public sector institutions lends itself to
inefficiencies and a reluctance to “go the extra mile” in stepping up
patient throughput beyond an arbitrary standard level.
• The clogging of the system at the University Hospital and Kingston
Public Hospital by referrals from public sector hospitals and clinics
island wide of those patients who cannot afford private health care.
• The private sector is more responsive to urgent medical situations for
the following reasons:
Ø The more experienced radiologists are in the private sector and
not the public sector.

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Ø The entrepreneurial risk involved in setting up private imaging


centres mandates a “turn back no patient” approach even beyond
normal closing time.
Ø The staff who work in private imaging centres are usually better
paid and more highly motivated.
Ø The absolute need to offer quality service and achieve patient and
referring physician satisfaction in a highly competitive private
practice environment.
Ø The public imaging sector is therefore unable to cope with the
massive work load which would ensue if private radiologists were
forced out of the system by repressive tax measures.

(c) COST OF SERVICES

Prior to the budget presentation of 2003, a radiologist was faced the


following harsh realities in establishing a private imaging centre:
• The equipment is very expensive, running into hundreds of thousands
of US dollars, and in the case of an MRI scanner, in excess of one
million dollars (US$ 1M).
• Financing cannot be secured from a Jamaican dollar loan because of
prohibitively high local interest rates.
• US dollar financing must therefore be obtained at the risk of losses
from devaluation of the Jamaican dollar such as what is being
experienced at the present time.
• A 10% import duty requirement on medical equipment has been in
place since the 1980’s.
• The former administration permitted a “Payment in Kind”
arrangement whereby services are provided to patients in public
hospitals in lieu of the dollar amount owed for import duty.
• This has eased the burden of having to borrow extra money to pay the
duty in a lump sum.
• The 10% import duty applies not only to landing the equipment itself
but also to imported spare parts which may be required from time to
time, even during the free warranty service period or in cases where the
Radiologist has a prepaid service agreement with the manufacturer.
• The unfair competition scenario in which although not pioneering a
particular service, the University Hospital will eventually obtain
similar equipment and can afford to under price the service because as
a Government entity, it is not personally liable to repay any loan and is
not subject to any duty regime on purchases of equipment or supplies.

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(vi) IMPACT OF NEW TAX MEASURES

The proposed implementation of a 15% GCT and 2% Import Cess


regime on imaging equipment and supplies, inclusive of even X-ray
film, will over time, completely wipe out private imaging centres for
the following reasons.

The increase in operating costs in tandem with the need for more
Jamaican dollars to purchase the same number of US dollars for overseas
debt service will have to be passed on to the patient. However, exempt as it is
from all import duties and taxes, the University Hospital will have no need to
increase its fees. More patients requiring CT and MRI scans will therefore
head to the University Hospital thus clogging up the University Hospital
system beyond its ability to cope.

The de facto increase in the purchase price of equipment will make it


impossible for the private Radiologists to retool and upgrade their equipment
on a timely base thus “trifling with Jamaica’s health services” and making it
impossible for us to maintain “world class” standards.

A practical example of the “cost push” effect of the proposed tax


measures on the cost of equipment retooling and upgrading is illustrated in
Appendix 11.

(vii) CONCLUSION-PRIVATE RADIOLOGISTS

There was a time not too long ago when patients requiring MRI scans
and other sophisticated imaging procedures had to go to Miami, if they had
money and a US visa. Those that had the money but not the visa had to make
do with less than “world class” medical care because the necessary tests were
not available in Jamaica. Over the past twenty years, the brave men and
women of the private radiology sector have propelled Jamaica to the pinnacle
of imaging quality and diversity in the English speaking Caribbean.
The proposed new tax measures will turn back the clock on the
tremendous gains we have made and encourage radiologists in training to
market their skills in more practitioner-friendly overseas markets.
We urge the government not to be “penny wise and pound foolish”. The
country cannot function without a viable private imaging sector. The
University Hospital and KPH have never been and will never be able to cope
with the heavy work load left behind by a decimated private imaging sector.

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The 15% GCT must be rolled back in order to safeguard the health of our
children and our children’s children.
History will not judge us kindly if we fail to convince the government
that the medicine they have prescribed will not only sound the death knell for
private imaging centres but will also sound the death knell for a countless
number of poor Jamaican sick people who will die because the overburdened
public hospital sector will not be able to respond to their needs in time to save
their lives.

TASK FORCE RECOMMENDATIONS:

• Proposals to give protection or preference to the new players in the


market place go counter to existing Government open market policy.
Given GOJ commitment to improving population access to high quality
health care, the proposal for abatement/relief of import duties on
medical equipment is worthy of consideration. Access to Diagnostic
Imaging equipment, Dialysis Machines, MRI, Laboratory Equipment
and related ancillary supplies should be opened up for locals all over
the island.

• The Ministry of Health should develop and implement a policy to


facilitate a support mechanism for the establishment of Public/Private
Partnerships in Health Care delivery. This should include
standardisation of service quality, monitoring and compliance with
international standards.

• Government guaranteed loans and or initiatives for US$ funding would


help to encourage other professionals to enter the market for services
that require expensive, high tech diagnostic equipment.

• Allow tax holidays on Health Tourism investments similar to the


incentive regime that applies to infrastructure plant, machinery and
equipment for ordinary tourism.

• All investments in Health Tourism must satisfy international


standards and should enhance Brand Jamaica.

• GOJ to establish certified training centres for technical support related


to hospital equipment servicing. Partnerships with educational
institutions to develop programmes for identified health and allied

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professionals, to ensure sufficient personnel for continuation and


development of the services

• Training, Research and Development Allowances to be added to support


medical service delivery .
.
• Regional and International Government to Government discussions to
open a window of opportunity for Jamaican Diagnostic Facilities
including Diagnostic Radiology, Laboratories, Telemedicine Systems
experts in Medical information technologies to provide off shore
Telemedicine services including Tele-Radiology, Tele-Pathology, Tele-
Dermatology Tele-Consultation, Surgical and Medical Procedural Tele-
Mentoring, Tele-Home Dialysis Health Services etc, to other countries
that may benefit and be in need of such services.

• Government to continue to support and collaborate with Specialist


Associations (e.g. Medical Association of Jamaica and Jamaica
Association of Radiologists) in enabling and charting a course towards
entry into the rapidly growing worldwide Health Tourism market.

11.3.3 THE NATIONAL HEALTH FUND

Since its establishment in 2004 as a health financing agency the National


Health Fund (NHF) has developed and maintained a very high level of efficient
management. It has carried out its mandate faithfully and is a model of corporate
efficiency and propriety. The impact of the NHF individual benefits plan on the
epidemiology of chronic disease in Jamaica is being evaluated. Preliminary
indications are pointing towards a positive outcome.

The NHF model was developed in Jamaica by Jamaicans using the principles
of prevention embodied in the science of epidemiology to determine the policy
framework, its organisation, structure and function. The policy framework targets
the most epidemiologically prevalent condition in the Jamaican population i.e.
chronic diseases. The NHF functions as a strategic health financing institution
utilising prevention principles embodied in wellness, mitigating the development of

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the incidence prevalence and averting “chronicity” of diseases i.e. Primary,


Secondary and Tertiary prevention.

The NHF has been a very important source of project funding for the RHAs;
the problem has been the inability of the Regions to execute their projects because
of lack of capacity or the inordinate cumbersome nature of the procurement process.

Financing is targeted within that framework. This demonstrates that


whenever epidemiologic criteria are used as the basis for the financing of public
health service delivery, the main beneficiaries are the patients and the system will
benefit from greater efficiency, accountability and sustainability.

The financial independence of the NHF has been critical to its operational
success. To maintain good governance, whilst ensuring the NHF is able to pursue
its mandate efficiently and provide the assurances required in the provision of
benefits, it is recommended that the CEO be designated an Accounting Officer by
the HMOF&P under Section 16 of the Financial Administration & Audit Act.
Executive Agency status is not recommended as the NHF is a statutory
organisation with administrative and financial guidelines provided by the NHF
Act. The CEO shall then be responsible to the HMOH under the NHF Act for the
operations of the NHF and to the HMOF&P under the FAA Act for its financial
administration.

It is further recommended that more creative measures further increase the


funding of the NHF to offset the decline in revenues as a result of the decrease in
the prevalence of cigarette smoking. The effect of the consequences of alcohol use on
traffic accidents and the disease of alcoholism have an impact on the disease burden
and cost to the health service.

This lack of designation of the CEO as an Accounting Officer for this


Statutory financial institution which accounts for the turnover billions of taxpayer
dollars must have been an oversight since it is a necessary responsibility in keeping

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with proper corporate standards and practice that the responsibility of the CEO in
accounting to the Board of management of the NHF for every expenditure of the
institution must never be in question.

The Task Force recommends this change in status of the CEO to an


accounting officer be made with very soon.

11.3.4 HEALTH INFORMATION SYSTEM

The NHF has successfully implemented an electronic patient adjudication


system for the use of drugs by patients suffering from any one or more of the fifteen
most prevalent chronic diseases in Jamaica using a network of pharmacies across
the island.
Since March 2007 the NHF has successfully built up its technological
capacity in preparation to deploy a National Electronic Health Record System
developed for the use of all doctors universally and institutions throughout the
Jamaica. This software is presently being beta tested in preparation for its
deployment throughout the National Health Service System during the second
quarter of 2008.
The present status of the National Health Information System at the head
office of the Ministry of Health is flawed and has been a source of much concern by
every category of health personnel. The findings of the Task Force review and
evaluation confirm this.
In light of the urgency of the need of the MOH&E to deploy a national Tele-
health network infrastructure as a pre-requisite for Health Tourism and in order to
deploy its electronic health record system, which represents the core of the Health
Information System it is recommended that the health information system
requirements of the health sector be administered by the National Health Fund
which has a track record of an efficient organisation geared to provide these services
to the healthcare providers.

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The NHF would be responsible for providing the required technology


platform and supporting infrastructure to implement a national Health Information
System. This system would ensure that patients and the public would have
available the facilities needed for modern comprehensive care that can only be
achieved through systems that allow health practitioners to access and share
patient information in a timely manner. The source of funding for building such an
infrastructure has already been approved by the Ministry of Health.
This source of funding is derived from a bilateral agreement between the
Government of Jamaica and the Government of the Peoples Republic of China. The
bilateral agreement has been in an advanced state of planning and preparedness
and may be implemented before the end of the second quarter of 2008.
The Task Force recommends that these funds be made available to the
National Health Fund with the mandate to build a national Tele-health network
infrastructure to connect all institutions of the MOH&E for an integrated voice,
data and video service to begin the process of modernising the Jamaican health
service system and to build a viable Health Tourism industry.
This would ensure that the basic infrastructure for Heath Tourism would
be in place and the way paved for vast opportunities for new business in Health
Tourism in the global marketplace.

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12.0 CONCLUSIONS AND RECOMMENDATIONS

The Task Force Review was welcomed by the various segments of the health
service sector. The RHAs have been in existence for a decade and the
Stakeholders are not fully cognisant of their roles and functions. Critical
concerns were HR issues; lack of appropriate information technology; supplies
management and financing. The link between the Regions and the Ministry
and existing reporting relationships came in for a lot of criticisms. The
professional groups are very sensitive to the dysfunctions in the
organisational structures of the RHAs.

In this Report specific recommendations are dealt with under the topics as
outlined in the Terms of Reference and presented to the stakeholders. For
the sake of completeness we now list all our recommendations together. It
will be noted that a number of these are exactly as made by the stakeholders
in the Review.

The Task Force Recommends the Implementation of the Following:

POLICY , ORGANISATION & STRUCTURE

1. The RHAs must be changed from semi-autonomous authorities to


become Regional Coordinating and Enabling Organizations. In so
doing, each will be an integral part of the organization and structure of
the Ministry and a strong link between head office and the Parish,
enabling and supporting the function of implementation – which is the
domain of the Parishes

2. Head Office of Ministry of Health and Environment should focus on its


primary role of policy formulation, policy determination, setting norms and
standards, monitoring and maintaining support functions for strategic
health care delivery.

3. Maintain the four Health Regions within the current borders.

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4 Reorganise service delivery on the core functions of Primary,


Secondary and Tertiary Health Care

5 Redefine the role of the Parish Manager to become the leader of the
administrative support team and system; facilitating, enabling and
supporting the efficient implementation of health service delivery at
the parish level.

6. Develop an HR system which recognizes the relative roles of the members of


the health team in service delivery and the supporting relationship of the
administrative teams and systems.
6. Ensure that there is a national standard for the establishment of the
operations of organizations and structures at the regional and parish levels.

7. Redefine the role of the Parish Manager to become the leader of the
administrative team and systems; facilitating, enabling and supporting the
efficient implementation of health service delivery at the parish level.

8. Reinstitute the health team approach as the basic management standard for
service delivery both in the hospitals and the non-hospital sectors. This
approach will enable the coordination of technical functions necessary for
the efficient management of service delivery.

9. Re-establish the corporate structure to all hospitals with each hospital


governed by a Board of Management to which will report the Executive
Manager, the Senior Medical Officer and the Director of Nursing Services.
Each Hospital Board must have representation from the Region or the
parish in order to enable the coordination and integration of the levels of
care in service delivery.
.

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MANAGEMENT INFORMATION SYSTEM

10. The National Health Fund (NHF) be the executing agency for the
immediate, short term, medium term and long term Information
Technology needs of the Ministry of Health and Environment.

11. The NHF further develops its IT division into a department and
continues to develop the IT professional capacity to do the following:
i. Develop and implement a modern web-based electronic
patient health record system which meets the
requirements of international standards of
interoperability and sits as the core of the health
information technology software application system for
service delivery of the patient Health Information
System.
ii. Implement the building and deployment of a robust
multi-service Internet protocol (IP) network
infrastructure (Tele-health network) dedicated to the
unique specifications of the Ministry of Health service
delivery system.
iii. Recruitment, training, and deployment of all IT
personnel and development of MIS throughout the
MOH&E.

MANPOWER

12. The backlog of HR issues including appointments, promotions,


salary packages, welfare and incentive schemes must be
immediately addressed by a special multi-disciplinary group in
order to improve staff morale and efficiencies.

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13. A National Human Resource Development Strategic Plan be


implemented as a matter of priority and that this be guided by
epidemiologic principles.

14. MOH&E should develop an HR policy using a multi- disciplinary


approach that relates to clearly defined functions of service delivery
and administrative support,

15 The Williams’ report of 2007 recognized that “expertise is necessary to


develop an appropriate National Human Resource Manpower Plan” for
the sector in general and each specific Regional Health Authority in
particular. The Task Force agrees with this recommendation but
emphasizes that the effort must be one of priority and should take
place simultaneously with the organizational reform and
reclassification exercise currently being performed by the Ministry of
Finance and Planning.

16. A staff audit should be done to ascertain the staff’ complement


necessary to deliver the quality care based on the epidemiological
requirements in each Region and in every parish.

17. Reclassification of posts and positions in keeping with the proposed


new organization structure and functions at the central, regional and
parish levels.

18. The RHAs should institute training programmes in collaboration with


UTECH, NCTVET, MIND and like organizations for maintenance
personnel at all levels, with special emphasis on Artisans and Bio-
Medical Technicians.

19. International recruitment must be the domain and sole responsibility


of Head Office, and local recruitment the prerogative of the Regions

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and Parishes. This should foster greater transparency in the


management of Human Resources.

20. The staff appeals process MUST be swift, transparent and impartial.

PHARMACEUTICALS

21. Health Corporation Limited (HCL) be reorganised and capitalised


to improve its capacity and its efficiency. A good fit would be to
absorb it fully as a department of the NHF to benefit from its
fully computerised for procurement, inventory control, supply and
distribution management.

22. Drug Serv Pharmacies be established in hospitals in all the Regions .


Reports confirm this to be a SRHA best practice and could be expanded
to selected Primary Health Care facilities.

EQUIPMENT

23. Assets Register (of Property, Machinery ,Equipment,


Fixtures, Vehicles Stocks and Supplies ) must be established in
every Region as a matter of priority and maintained up- to- date.

24. Policies must be developed for the standardisation of all categories of


equipment, especially with regard to service and maintenance, energy
conservation and replacement parts.

25. Outsourcing of maintenance of specialised equipment.


.
26. Equip and staff a Mobile Maintenance team for each parish.

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FINANCES

27. Abolition of User Fees for Primary Health Care in every


community as the first step to fulfil the commitment of the
Government.

28. Retain User Fees for Secondary and Tertiary Care with
appropriate , sensitive system for exempting the indigent.

29. Lobby for increased budgetary allocation to the MOH&E. Target:


minimum of 10% of National Budget.

PROJECTS

30. Establish a Project Management and Implementation Unit in


every Region.

31. MOH&E should determine the appropriate measures to


modernise the guidelines for the tender process. These should
address situations where over-runs are caused by the changes in
epidemiologic determinants rather than human error.

HEALTH TOURISM

32 The BOOT model is offered as a method that would jump start


the development of Health Tourism Services in Jamaica Refer to
sections 11.2. to 11.6. A national Tele-health network
infrastructure is needed to connect all the institutions to the
MOH&E. Funds identified from the Peoples’ Republic of China
should be channelled through NHF which has demonstrated its
ability to successfully operate a national health record system.

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176

PUBLIC /PRIVATE PARTNERSHIP

33. To answer the case for GOJ granting similar tax incentives for
private sector investment in Health Care Delivery as given to
investors in standard tourism ventures, the MOH&E should
facilitate infrastructural development in investment initiatives in
order to enhance public/ private partnerships. Refer to pages 164-
165.

NATIONAL HEALTH FUND (NHF)

34 The CEO of the NHF be designated an Accounting Officer by the


HMOF&P under Section 16 of the Financial Administration & Audit Act.
More creative measures be utilized to capitalise the NHF to offset the decline
in revenues as a result of the decrease in the prevalence of cigarette smoking
in the country.

35. The Health Information System requirements of the health sector be


administered by the National Health Fund which has a track record of an
efficient organisation geared to provide these services to the healthcare
providers.

36. The NHF utilize funding derived from bilateral agreement between the
Government of Jamaica and the Government of the Peoples Republic of
China for building a National Tele-health Network infrastructure to connect
all institutions of the Ministry of Health for an integrated voice, data and
video service to begin the process of modernizing of the Jamaican Health
Service system and to build a viable Health Tourism industry.

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177

APPENDICES

APPENDIX 1 - LIST OF STAKEHOLDERS

LIST OF PARTICIPANTS INTERVIEWED

Senior Medical Officers

Name Institution

1. Patrick Bhoorasingh Kingston Public Hospital (KPH)


2. Nadine Bourg (for Ray Fraser) Annotto Bay
3. Winston Dawes May Pen
4. Bradley Edwards
5. Sonia Henry Bustamante Hopsital for children
6. Yumkalla Kamara Falmouth
7. Jeremy Knight PC, Portland
8. John McRae Black River
9. Maureen Irons Morgan Bellvue Hospital
10. Onyema Njoku Hanover
11. Dingle Spence SMO(H) Hope Institute
12. Gregory Thomas Cornwall Regional Hospital
13. Mikael Tulloch-Reid National Chest Hospital
14. Peter Wellington Mandeville

CEOs
Name Institution Region
1. Everton W. Anderson Cornwall Regional Hospital
2. Helen Brooks Linstead Hospital SERHA
3. Diana Brown Black River Hospital SRHA
4. David Coombs Princess Margaret SERHA
5. Beverly Douglas Lionel Town Hospital SRHA
6. David Dobson Spanish Town Hospital SERHA
7. Paulette Elliot M. R. Hospital SRHA
8. Gary Francis Annotto Bay Hospital NERHA
9. Eon Jarrett St. Ann's Bay NERHA
10. Brent Nation Port Antonio NERHA
11. Nadia Nunes-Howe May Pen Hospital SRHA
12. Stanhope Scott Percy Junor Hospital SRHA
13. June Tyme Port Maria Hospital NERHA
14. Hazel Waite NCH/HI/SJGRC SERHA
15. Lorene Whinstanley Sav-La-Mar Western

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Technical Focus Group


Name Institution Post
1. Yvonne Amair Cornwall Regional Hospital (CRH) Registered Pharmacist
2. Rosalee Brown CRH/WRHA Registered Dietician
3. Dianne Campbell Stennett Westmoreland Health Department Medical Officer (Health)
4. Diahann Dale WRHA Reg. STI/HIV Prog. Coord.
5. Denise Forsythe CRH/Physiotherapy Charge Physiotherapist
6. Bancroft Haughton CRH Radiographer
7. Kevin Johnson CRH Senior Medical Physicist
8. Denise Malcolm Noel Holmes Hospital Director of Nursing Services
9. Basel McFarlane WRHA REHO
10. Rae Ponnada St. James Health Department Medical Officer (Health)
11. Alicia V. Smith Sav-La-Mar Hospital Pharmacist
12. Gregory Thomas CRH SMO

SRHA
Name Position Parish
1. Desmond Brenniton DMOII Clarendon
2. Sonia Copeland MO(H) Clarendon
3. L. Darbon R.E.H.O. SRHA
4. John Falconer FNA Clarendon
5. Cislin Hall Registered Midwife St. Elizabeth
6. Marcia Harris Lawrence PHN Clarendon
7. Zeen Lalor C.H.A. St. Elizabeth
8. D. A. Ledford MO(H) St. Elizabeth
9. Faith Lylle HEO Clarendon
10. Errol McLean Pharmacist St. Elizabeth
11. J. Nation Dental Nurse Clarendon
12. Carlton Nichols PPO Clarendon
13. Charmaine Palmer-Cross DCPHI Clarendon
14. Carlisa Pearson HEO Clarendon
15. K. Pate-Robinson DMOI MHD
16. C. Ramsay Dental Nurse Clarendon
17. Valene Reid-Wright PHN St. Elizabeth
18. George Sloley CPHI Manchester

SRHA - Group 2
Name Position Institution/Parish
1. Denise Brown-Anderson Dietetic Assistant Clarendon
Chief Radiographer/
2. Lorna Harold Gray Ultrasonographer Manchester
3. Donovan Leon Chief Medical Technologist SRHA
4. Shaureal Llewellyn-Johnson Nursing Supervisor Manchester
5. Keith Lowe Director Technician May Pen
6. Ruby E. Melville Social Worker Manchester
7. Jacqueline Pennicook Matron Lionel Town Hospital
8. Verda N. Richards Regional Dietitian SRHA
9. Michele Shaw Parish Pharmacist Manchester
10. Inez Sunamon Matron Lionel Town Hospital
11. Juliet Y. Vaughan-Mason Acting Deputy Matron Clarendon

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12. Saidie Williams-Allen Ward Sister Manchester


Administrative Group - SRHA

Name Job Title Institution/Parish


1. Yvonne Alexander-Gayle Health Records Administrator St. Elizabeth
2. Bueretta Beckford Acting Operations Manager Mandeville Regional Hospital
3. Hyacinth D. Bromley Matron St. Elizabeth
4. Sandia Chambers Parish Administrative Officer Manchester
Parish Administrative Officer
5. Eugena Clarke-James (Acting) Clarendon
6. Verrol Ebanks Parish Accountant (Acting) St. Elizabeth
7. Angella Henry Personnel Officer Manchester
8. Jacqueline Jackson Parish Administrative Officer St. Elizabeth Health
9. Etinel Locke Operations Manager May Pen Hospital
10. Keitha O'Gilvie Personnel Officer St. Elizabeth
11. Norman W. Rose Parish Accountant Manchester
12. Pauline Rose-Campbell Parish Health Records Tech. Manchester M.H.D
13. Beverton Roye Deputy C.P.H.I. St. Elizabeth
14. Vivienne Wallace Health Records Administrator Mandeville Regional Hospital
15. Nadene Williams Acting Accounting Mandeville Regional Hospital

Parish Managers

Name Region
1. Michael Bent Southern Clarendon
SERHA - Kgn & St. And. Health
2. Godfrey Boyd Serv.
3. Carmen M. Foster Western
4. Claudette Lewis South East
5. Verlie James WRHA - Hanover
6. Alwyn Miller Southern - St. Elizabeth
7. Valencia Pearson-Maponya Western / St. James
8. Yvonne Pitter Southern - Manchester
9. Beulah Stevons SERHA
10. Tatlin Tider Western

Nursing Associations

Name Position / Instititution

1. Beverly Bryan-Maragh Jamaica Enrolled Nurses


Association (JENA)
2. Aseta Edwards-Hamilton Jamaica Midwives Assn
(Secretary)
3. Allan Jeffrey JENA President
4. Ilene Murray JENA
5. Carmen Walker Sutherland Jamaica Midwives Assn (President)
6. Carmelita Wheeler Jamaica Midwives Assn (1st V.P)

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180

SERHA
Name Job Title Institution/Parish
1. Jean Allen Parish Accountant St. Catherine Health Services
2. Henry Anglin Administrator BHC
3. Judy Creary Telecom Dept. KPH
4. Joan Golding Personnel Manager St. Catherine Health Services
5. Maureen Golding Personnel Officer Bellvue Hospital
6. Junett Hayle Health Records Victoria Jubilee Hospital
7. Dwight Holtham Accountant K.S.A.
8. Evlin Hyatt-Beckford Administrator S.T.H. Medical Records
9. Carol Hussey-Myers Budget Cash Flow Officer
10. Karlene Taylor McKenzie Parish Administrative Officer K.S.A.
11. Regent Walker-Smith Personnel Officer S.T.H. D
12. Lorna Watson Health Records Primary Care
13. Diana Williams Health Records K.S.A.
14. Colleen Wright Operations Manager S.T.H.D.

Name Institution/Parish
1. Dianne Campbell-Stennett Westmoreland
2. Sandra Chambers KSA
3. Diahann Dale WRHA
4. Tamu Davidson SERHA
5. Hurbert Elliot KSA
6. Dawn Graham Padilla KSA
7. Lambert Innis A.G.M.C.
8. Yvonne Munroe MOH
9. Ramachondray
Naragomatharty SERHA, St. Thomas
10. Heather Reid Jones SERHA, St. Catherine
11. Andrew Salmon St. Catherine
12. P. L. Weir KSA
13. Yasmin Williams MOH

Technical Group – KPH


Name Job Title Institution/Parish
1. Leeford Bennett Chief Medical Tech. II CHC
2. Diane Buckley-Smith Registered Nurse KPH
3. Patsy Gilling Acting Dept. SR S.T.H.
4. Muslaw Gooden Registered Nurse PMH/St. Mary
5. Khaleela Henry Registered Nurse Midwife V.J.H.
6. Daphne Hutchinson Medical Technologist Spanish Town
7. Angella Jennison Ward Assistant KPH
8. Angella Lee-Grant Ward Assistant / Public Health Insp. Princess Margaret, St. Thomas
9. Vera Morgan Nurse Anaesthetist Princess Margaret
10. Norell-Lee Morrison-
Ramsay Senior Physiotherapist KPH
11. Ruth Nash Chief Pharmacist S.T.H.
12. Dayanand Sawin MOH Orthopaedics BHC/KSA
Medical Technologist/Union
13. Basil Walker Delegate St. Thomas

Western Regional Health Authority

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181

Name Position
1. Maung Aung Regional Technical Director (Acting)
2. Raymond Kitson-Walters Finance Director
Operations and Maintenance
3. Cladius Ramsay Director
4. Anthony Smikle Procurement Manager
5. Nadine Stewart MIS Director
6. Arthur Warren Human Resource Director

Technical Focus Group - NERHA

Name Post Institution/Parish


1. Judith Atkinson Linton Pharmacist SABH
2. Deon Barrett Dietitian St. Ann's Bay Hospital
3. Christine Buchanan Med. Tech. SABH
4. Barbara Burke D.N.S. Port Antonio Hospital
5. Caroll DaCosta EN St. Ann's Bay Hospital
6. Nichole Dawkins Emergency Physician St. Ann's Bay Hospital
7. Primrose Edwards W/A St. Ann's Bay Hospital
8. Colita Fraser-Howard RN St. Ann's Bay Hospital
9. Yi. Han Radiographer St. Ann's Bay Hospital
10. Jeremy Knight Medical Officer (H) Portland
11. Paulett Long Carr Matron St. Ann's Bay Hospital
12. Arlene L. McGill rep. S.M.O. SABH
13. Jean Rowe D.N.S. Annotto Bay Hospital
14. Barbara Sinclair Ward Sister Port Antonio Hospital
15. Linda D. Sutherland-Hines D.N.S. Port Maria Hospital
16. Debra Treasure Physiotherapist SABH
17. Patrick Wheatle Medical Officer (H) SAH Dept

Administrative Group - NERHA


Name Position
1. Nordia Campbell Assistant Internal Auditor
2. AnnMarie Davidson Reg. Health Records Administrator
3. Leon Francis Chief Porter
4. Patrice Gavin Systems Administrator
5. Caroline Grant Bassan Cashier
6. Rowena Hayle CCO/Regional Office Manager
7. A. Higgins Accounting Clerk
8. Cordelyn Jackson Secretary
9. Lenworth Jones Driver
10. Horesa Martin Acting Parish Administrator
11. Desmond Matthews Accounting Technician
12. Jeannette Parris Senior Accountant
13. Joy Ridley Cashier
14. L. Badre Singh Accounting Clerk
15. R. Taylor Parish Administrator
16. Patrice Thompson Accountant - SABH
17. Doreen Wilson Human Resource Officer (Acting)
Primary Health Care
Name Position Institution/Parish

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182

1. Beverly Bisasor-Richards D/N St. Ann


2. Maxine Blake-Hylton C.I. St. Ann
3. A. Paul Brown DCSHI St. Mary
4. Aylete Brown Hall F.N.P. St. Ann
5. Charmaine Clarke Secretary Portland Health Department
6. Jennifer Gilmore SPHN Portland
7. Arthur Green DMO STHC
8. Meris Hopkins Regional Nutritionist St.Mary Health Department
9. Valrie McLeary HEO Portland
10. Vinnette Mitchell-Forrester P.D.A.C. (D/N) Portland
11. Dorrett Norrine C.I. Portland
12. Sabrina Palomino Nutrition Assistant St. Mary
13. Joan Robinson-Mcpherson VPHI (Acting) Portland
14. Desrene Strachan D/A St. Ann
15. Beverley Samuels SPHN (Acting) St. Mary
16. George Wilson C.H.A. Portland

Dentists
Name
1. Winston Grey
3. Sandra Hill-Cameron
4. Irving McKenzie

Region Board Chairmen


Name
1. Mr. Kenny Benjamin Bustamante Hospital for Children
2. Mr. W. Levy, J.P. May Pen Hospital
3. Mr. Lyttleton Shirley SERHA
4. Mr. Whilston Taylor KPH & VJH
5. Mr. Michael Whittingham NERHA

Ministry of Health - Head Office


Name Position
1. Dr. Grace Allen Young Permanent Secretary
2. Dr. Peter Figueroa Chief Epidemiologist
Director, Human Resource Mgmt &
3. Mrs Gail Hudson Corporate Services

4. Mr. Lincoln Walters Director, Systems & Information


Technology Unit
5. Nigel Logan Principal Financial Officer
6. Dr. Leila McWhinney-
Dehaney Chief Nursing Officer
Director, Health Promotion and
7. Dr. Eva Lewis Fuller Protection
Director, Health Services Planning
8. Dr. Denise Duncan-Goffe & Integration
9. Mrs Princess Thomas
Osbourne Director, Standards & Regulation
10. Dr. Earl Wright Director, Mental Health

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183

National Health Fund


Mr. Rae Barrett Director

Auditor General's Department


Mr. Adrian Strachan Auditor General

Office of the Cabinet


Hon.Dr. Carlton Davis Cabinet Secretary

Administrative Group
Name Position Institution/Region

1. Jacquelinie Allen-Blake Health Records Technician Trelawny Health Dept.


2. Nezlyn Bowen Hospital Administrator CRH
3. Margaret Clarke-Thompson Accounting Clerk Trelawny Health Dept.
4. Henviella Harrison Regional Health Records Admin.
5. Dawn Harvey Senior Hospital Administrator CRH
6. Celia Huggan Personal Manager Regional Office
7. Angella Lumley Powell Assessment Officer Falmouth Hospital
8. Geneve McCulloch Medical Records Administrator Sav. Hospital
9. Maria McGhie Checking Officer WRHA Accounts
10. Orlain Nembhard Patient Affairs Manager (Acting)
11. Patricia Pennycooke Telephone Operator Supervisor Sav. Hospital, WRHA
12. Myrna Scott Medical Records Technician Lucea Hospital
13. Kirkland Simms Records Officer St. James Health Dept.
14. Darion Smith Assistant Internal Auditor
15. George Thomas Parish Administrator St. James Health Dept.
16. Marcellen Wheatle Health Education Officer
17. Charmaine Williams- Parish Administrator Hanover

Private Hospitals Association of Jamaica


Patrick Rutherford President, CEO Andrews Hospital
Bill Poinsett CEO Nuttall
Dr. Neville Graham Chairman Winchester Medical
Faith Williams Administrator Winchester Medical

Private Sector Group


Joe Sterazza AIC
Roshan Sapra AIC

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184

APPENDIX 2 - REFERENCES

(1) Allen-Young G. E. (2006). Ministry of Health Regional Health Authorities


Human Resources Policies and Procedures Manual.
(2) Annual Report 2004. (2005). Ministry of Health. Policy Planning &
Development Division.
(3) Belvett O. Decentralisation of Health Services. A success Story. Presentation
to the Permanent Secretaries Board.
(4) Briggs G. (1998). Regional Health Authorities. Instrument of Delegation.
Ministry of Health.
(5) Cabinet Submission (2003). Appointment of Members to Parish Health
Committee and Hospital Committees.
(6) Change Management Consultation Report.
(7) Civil Service Establishment Act (2006). Jamaica Printing Press
(8) Corporate Strategic Planning Work Plan: Ministry of Health.
(9) DAH Consulting Inc. (2004). Consultancy to Evaluate the Implementation of the
Health Sector Improvement Programs in Jamaica: Bitran y Asociados,
Health Care Organizers and Advisors.
(10) DAH Consulting, Inc. (2004). Evaluation of the Scope, Process and Impact of
the Health Sector Reform Programmes.
(11) Daniel H. S. (2004). Service Level Agreement discussions in January 2005:
Letter.
(12) Decentralisation of the Ministry of Health. A Green Paper (MAJ).
SWOT Analysis Dr. Shiela Campbell-Forrester CMO
(13) Department of Operations & Maintenance. (2007). North East Regional Health
Authority. Regional Maintenance Plan 2007-2008 (Draft).
(14) Duncan-Goffe D. & McCartney T. (2005). Redesigning the Health System in
Jamaica. A Proposal.
(15) Executive Summary of Organisational Structures and Staffing of the four RHAs
Jamaica Social Policy Evaluation (JASPEV) Project. Jamaica 2015.
(16) Government’s Response to the Annual Progress Report on National Social
Policy Goals 2003. Office of the Cabinet Government of Jamaica.
(17) Exemption Process for all Health Centres except Montego Bay Type V.
(18) Figueroa P. (2007). Interview with Professor Figueroa re Health Reform.
(19) Graham S. (2007). Report on Change Management Meetings with Senior
Directors. Ministry of Health.
(20) Institutional Benefits Project Status Report October 2007. Approved Projects that
are in Progress (MOH and RHAs).
(21) Interim Report by the Sub-Committee on the Development of Reorganization
Proposals for the Ministry of Health and Environmental Control. 14 th
July 1977.
(22) Junor J. A. (2006). Human Resource Council Submission. (Draft).
(23) Management Services Branch. (2000). Ministry of Health South East Regional
Health Authority. Proposed Organisational Structure Human Resource
Development.
(24) Ministry of Finance & Planning. (2002). The Financial Administration and Audit
Act. Instructions.
(25) Ministry of Health. Major Health Reform Programmes.

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(26) Ministry of Health. (1998). Regional Health Authorities Policy Framework


Document.
(27) Ministry of Health. (1996). Report of the Task Force on Health Sector
Manpower Education and Training.
(28) Ministry of Health. (1997). Technical Services Head Office. Detail Functions
and Staffing Patterns of Technical Units.
(29) Moyne L. (1930’s). Moyne Commission Report.
(30) National Health Services Act, 1997.
(31) North East Regional Health Authority. Human Resource Department Business
Plan 2007/08.
(32) North East Regional Health Authority. Job Specification and Description
National Health Fund. (2007). Projects Achievements – 2006 April to
2007 May. Objectives 2007 April to 2008 December. North East
Regional Health Authority Projects.
(33) Operations and Maintenance Budget (2005-2008).
(34) Oral Health Services Level of Care Document
(35) Organisation of the Statistics & Information Services Division
(36) Osbourne, P. (2006). A Summary Description of the roles and function.
Ministry of Health: Standard and Regulation Division.
(37) Osbourne P. Standards and Regulations Division Annual Report January –
December 2005.
(38) Osbourne P. (2007). - Expected Outcome of “Short Term” Consultancy to the
Ministry of Health on Matters Related to Complementary and
Alternative Medicine (CAM) 2008/2010. Terms of Reference.
(39) P. A. Consulting Group. (2007). Public Sector Reform Unit. Ministry of Health
Change Management Final Report Incorporating.
(40) P. A. Consulting Group. Public Sector Reform Unit. Ministry of Health Change
Management Programme: Draft Final Report. Focal Point Consulting.
(41) PIOJ (2007). 2030 National Development Plan Jamaica Health Chapter.
(42) Policy Analysis of HSRP & the Decentralisation Programme.
(43) Prince L. A. (2001). A Comparative Review of the Cost and Benefits of
Centralisation Vis-à-vis Decentralisation of Health Benefits and Costs.
(44) Public Bodies Management and Accountability Act (2001).
(45) Public Services Regulations (2006). Human Resources Policies and Procedures.
Staff Orders for the Public Service.
(46) Purvis. G. P. (2002). Strategic Planning for Accreditation Standards and
Regulation Division (Final Report): Ministry of Health.
(47) Ramsay C. (May 10, 2007). Maintenance Restructuring – Staff Promotion and
Recruitment.
(48) Ramsay C. (October 16, 2007) Project Unit the Way Forward. (Memo).
(49) Ramsay C. (2006). Standard Operating Procedures (SOP) for Vehicles
involved in an Accident. WRHA.
(50) Regional STI/HIV/AIDS Programme Management Meeting. 14 September 2007
at SRHA Board Room.
(51) Regional Technical Services Document (1998).
(52) Reid U. V. (1999). Regional Technical Functions and Staffing. A Working
Document. Report. PAHO/WHO/Ministry of Health Report.
(53) Report of the Complementary Medicine Committee or the Ministry of Health

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Advisory Panel (Volume 1). December 2001 – May 2003.


(54) Service Level Agreement. (2005). North East Regional Health Authority. 3 Year
Agreement. 2005/2006 – 2007/2008.
(55) Service Level Agreement. (2005). South East Regional Health Authority. 3 year
Agreement. 2005/2006 – 2007/2008.
(56) Service Level Agreement. (2005). Southern Regional Health Authority. 3 Year
Agreement. 2005/2006 – 2007/2008.
(57) Service Level Agreement. (2005). Western Regional Health Authority. 3 year
Agreement. 2005/2006 – 2007/2008.
(58) South East Regional Health Authority 3 rd Quarter Performance Review (2006).
(59) St. James Public Health Services (Health Department).
(60) St. James Public Health Services (Health Department) Standard Operating
Procedure (SOP) Complaints.
(61) St. James Health Department Standard Operating Procedure. Protocol for seeing
Walk-In Clients at Montego Bay Type V Clinics.
(62) Standard Operating Procedure (SOP) Patient Billing and Exemption Reporting.
(63) Standards and Regulation Division Annual Report. (2005).
(64) Stanhope S. A Review of Decentralization of the Health Care Services in the
Southern Region - Jamaica. The Health Workers Perspective.
(65) Summarized report on the Performance of Portland Parish Health Committee
- 2007.
(66) Terms of Reference for Consultant to develop a Corporate Plan for the Ministry
of Health.
(67) Thomas N. (2007). Western Regional Health Authority Maintenance Monthly
Report.
(68) Ward E. & Grant A. (2005). Epidemiological Profile of Selected Health
Conditions and Services in Jamaica 1990 – 2002. Report of the Health
Promotion and Protection Division. Ministry of Health.
(69) Western Regional Health Authority. Acceptable use Policy.
(70) Western Regional Health Authority. Hardware and Software Policy.
(71) Western Regional Health Authority. User Password Policy.
(72) Western Regional Health Authority. Human Resource Department Annual
Report 2006-2007.
(73) Western Regional Health Authority. Organisation Chart.
(74) Western Regional Health Authority Transport Department Status.
(75) Williams H. A. (2007). Project to Document Organisation Structures and
Staffing for North East Regional Health Authority. Appendices showing
Organisation Structures and Excess Listings.
(76) Williams H. A. (2007). Project to Document the Organisational Structures and
Staffing of the North East Regional Health Authority. Report.
(77) Williams H. A. (2007). Project to Document Organisation Structures and
Staffing for South East Regional Health Authority. Appendices showing
Organisation Structure and Excess Listing.
(78) Williams H. A. (2007). Project to Document the Organizational Structures &
Staffing of the South East Regional Health Authority. (Report).
(79) Williams H. A. (2007). Project to Document the Organisation Structures and
Staffing for Western Regional Health Authority. Appendices showing
Organisation Structures and Excess Listing.

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187

(80) Williams H. A. (2007). Project to document the Organizational Structures &


Staffing of the Western Regional Health Authority. (Report).
(81) Wright E. Mental Health Reform. The Development of Community Mental
Health Services & Deinstitutionalization.
(82) ZTE Corporation (2005). Telemedicine System in Jamaica.

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188

APPENDIX 3

FOCUS GROUPS
Region: Western Region
Group: Admin, Technical
Reports To:
Role:
POLICIES STRUCTURE FINANCIAL
POLICY DEVELOPMENT ORGANIZATONAL FINANCIAL RESOURCES
§ Some policies were not STRUCTURE § Inadequate funding
discussed e.g. MGD, A&E, § Too many Regions.
MOH expectations were § Top Heavy (A,T) PROPOSED STRATEGIES
unrealistic § Some functions can be
§ PHI had input in the Solid merged. USER FEES
Waste policy. Groups who § Unclear functions/ § Should not be abolished:
said input was sought- duplications (A,T) Exemptions:
Physiotherapy, PHI. § Technical Structure is § <18 years except for
§ Physicist-Policies not backed still in draft form pregnant clients below
by Legislation- X-ray policy (Technical staff at the the age of 16 years.
manual but no legislation Regional level is weak) § Age 60 years
about the effects of radiation. (Admin is strong). § Indigents.
§ MOH has not adopted a § Ratio of Admin. to
monitoring role. Technical Staff
should be of relevance
POLICY COMMUNICATION to the delivery of
§ Consultation required in Service. Comment:
changes of policies for e.g. § Decentralization was
- Human Resource designed for
- Fees for Service administrative staff to
- Stand By On Call Allowance control delivery of
for Nurses.(interpreted Service
differently by each Region)
§ Chief Pharmacist for
POLICY IMPLEMENTATION CRH also has the
SLA responsibility of
§ Unfunded mandate sent to Regional Officer
the region for implementation PARISH STRUCTURE
§ Try to implement policies if § Overlapping of Role of
pressured. Parish Manager and
§ A&E policy not reviewed to Medical Officer
include suggested changes. § Parish /Regional roles
§ Policies are ambiguous- Lead competing
to various interpretations. § Technical officers
without immediate
supervisors.
Challenges in Policy HUMAN RESOURCE
Implementation § HR and maintenance
§ Lack of Resources (MMF), the two biggest
Procurement procedures ,For disappointments.
example, staff workshops, § Region lacks strategic
materials. planning.

MONITORING § Problems with

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189

§ Lack of Monitoring by the performance appraisal


MOH. Needs competent § Cadre inadequate
persons to give guidance. § No accommodation for
new positions
§ Audit from the MOH is § Non-appointment of
infrequent. staff (A, T, PC.)
§ Two (2) Auditors in Western § Chief Pharmacists
Region. CRH also works as
Regional Pharmacist.
Recommendation: § Pharmacists – 64
§ Independent monitoring vacancies.
Body (Sanctions). PROPOSED CHANGES
§ Region: Need for a
Nursing position to
integrate Secondary
and Primary Care.
Parish:
§ Overlapping of roles
and functions.

SUPPLIES MANAGEMENT INFORMATION Best Practices


SYSTEM
PROCURMENT PRACTICE§ § Manual – Majority of § Medical Doctor as
Major problem with HCL Hospitals and Regional Director
unable to supply health centres. § Hospital on the same
pharmaceuticals so Region USAGE building as Regional
has to purchase on the open § Only Two hospitals
Health Authority.
market). No line of Credit have PAS.
when supply is out of stock. § The system is RD understands
inadequate and not
Recommendation: § User friendly.(Needs All these enhance the
§ Reorganize HCL (debts need upgrading as it relates problem solving process.
to be written off) and the to STI& HIV
entity recapitalized. programmes).
§ Poor quality of paper used for § HR System linked to
printing medical records payroll at Regional
§ Delay in getting requested Health Authority
maintenance equipment and § Parish HR System is
sundries because of operated manually.
procurement procedures of § Patient affair System is
getting 3 quotes. manually operated in
each parish.
Recommendation:
§ Outsource Maintenance of
Equipment
§ Each Parish should have a
maintenance team
§ Training of Artisan Plumbers,
electrician carpenters
NCTVET Certification

21 ST CENTURY JAMAICA Concerns

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190

§ Computerization (A,T,P) § New graduates have ‘no’


§ Efficient Transportation clinical skills.
System ( preventive maintenance)
§ General upgrading of
infrastructure (A,T,PC)
§ Modern Communication
System (A,T,PC)
§ Increase cadre of Health
workers (A,T,PC)
§ Increase training of Technical
and para-medical staff,
pharmacists, physiotherapists,
radiographers. (A,T,PC)
§ Increase compensation for staff
§ Introduction of Welfare
programme for staff with
emphasis on Occupational
Health and Safety (OH&S).
§ More Autonomy for region.
§ Customer Service.
§ Expansion of Emergency
Response Service.
§ Expansion of the Services at
Health Care Facilities.
§ Quality Assurance.
§ Clinical Governance.
§ Standardization of RHAs
processes at the RHA and
parish Level. (Apply sanctions)
§ Upgrade facilities at Falmouth
Hospital to match with the new
A&E department.
§ Stop self referral to hospital.
§ Attract and retain Staff.
§ Training of Administrators in
Technical field.
§ Improve infrastructure of
Health Centres.
§ Projectise programmes.
§ Programme plans and
budgeting need to be done
simultaneously.
§ Need for Psychologists, Social
Worker for staff. (OH& S)
§ Staff Welfare.
§ Policy for staff to Access
health care.
§ Increase the # of facilities for
social cases.
§ Staff representative to be
accommodated on Board.

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191

FOCUS GROUP
Region: WRHA
Group: Primary Care Group
(Public Health Inspector, Driver, Midwife, Community Health Aide, Dental
Nurse, Pharmacist, Health Education Officer, Lab Tech., Senior Public Health
Nurse, Family Nurse Practitioner, Secretary)
POLICIES STRUCTURE FINANCIAL
POLICY DEVELOPMENT OVERVIEW CAPABILITIES
§Top Down § Overlapping in § Lack of funding
management functions. § Potential exists for Dental
§ Top heavy. services
POLICY § Lack of communication § Patient needs are not met
between regions – no § Quality of work reduced
IMPLEMENTATION
team approach.
§Use of creativity § Lack of monitoring of regions
§Apply a shift system § Proposed changes CI position USER FEES
§ No autonomy
§ Should not be abolished
§ Inconsistency in
§ Rationale: Money needed,
CHALLENGES processes vs. practices
unaware of cost recovery
§ Manpower supply § Lack of focus on Primary
by region
§ Office Space Care § Overcrowding
§ Structure of building § Proactive not reactive
HUMAN RESOURCE MGT
§ HR Policies not
consistent with reality
§ Lack of uniformity in HR
practices
§ Understaffed
§ No new post, staff
motivation
§ Vacation leave (35 days –
14 days)
COMMUNICATION
§ Operate mostly on a
“tru-tru” System.
§ Meetings - face to face
SUPPLIES MANAGEMENT INFORMATION SYSTEM 21 ST CENTURY JAMAICA
PROCURMENT TYPE § Greater autonomy to PC
PRACTICES § Manual making them more
§ Pharmaceutical (3) independent.
CAPABILITIES § Build fully equipped Type 5
§ Sundries (3)
§ Inadequate in all parishes with a team.
§ Maintenance Supplies (2)
§ 1 printer: 5 computers § Improve infrastructure
§ Equipment
§ Overloading § Standardization of processes
CHALLENGES § Improve investor relations.
§ No relatedness of IS § Include mandate for
§ Inadequate computer development.
§ Better monetary incentives
for PC.
§ Better MIS system.
§ Increase equipment supplies.

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192

Region: SRHA
Group: Primary Care Group
(Dietetic, Nursing Supervisor, Chief Radiographer, Parish Pharmacist, Social
Worker, Matron, Ward Sister, Chief Medical Technologists)

POLICIES STRUCTURE FINANCIAL


POLICY IMPEMENTATION OVERVIEW CAPABILITIES
§ Top Down § Concept is good § Lack of funding
§ Sonographers – § Regions need to be § Patient needs are not met
International Code of monitored § Quality of work reduced
Ethics, Training Register § No equity in the region
§ Social Workers initate § No autonomy USER FEES
Actions. § Disparity with knowledge § Should not be abolished
§ Lab Techs – operate on base in region. § Rationale: Money needed
own standards. to supply the regions
§ Nurses – meeting and needs.
seminars, education
workshops and regional HUMAN RESOURCE
workshops. MANAGEMENT
§ No new post.
POLICY
§ Staff motivation.
IMPLEMENTATION § Retirement benefits.
§ Use of creativity. § Radiographer – high
turnover due to
CHALLENGES insecurity.
§ Allied health profession § Quality of work
Disregarded. stemming from HR
§ Decision is left to people issues.
on the ground. § Lack of standards for
§ Board composite. contractors esp. nursing
§ Reactive approach by assistant.
management to problems. COMMUNICATION
§ Meetings
§ Face to face
SUPPLIES MANAGEMENT INFORMATION SYSTEM 21 ST CENTURY
JAMAICA
PROCURMENT TYPE § Improve infrastructure
PRACTICES § Manual § Standardization of
§ Pharmaceutical (4) processes
§ Sundries (2) CAPABILITIES § Improve human resources
§ Maintenance Supplies (2) capabilities
§ Inadequate
§ Equipment § Improve equipment
§ Better Procurement
CHALLENGES practices
§ No relatedness of IS § Staff participation in the
§ No computer decision making/policy
development
§ Staff facility – nurses
§ Improved funding
§ Appropriate funds
§ Better MIS system
FOCUS GROUP

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193

Region: All
Group: Senior Medical Officers
Reports To: Parish Manager, CEO
Role: Supervise technical and clinical services.
POLICIES STRUCTURE FINANCIAL
POLICY DEVELOPMENT ORGANIZATONAL FINANCIAL
§ Bottom Up approach STRUCTURE RESOURCES
§ Crisis approach § Top Heavy § Poor, under-budgeted
§ Lack of communication of § Good idea but needs a § Improve allocation of
how policies are team approach and funds across region
developed more technical
§ Unaware of the budget
ο Parish+ Regional involvement
Boards allocation for hospital.
§ Current structure too
§ Financial liabilities for
ο Central government bureaucratic and
medication, utility bills
ο Regions inefficient
§ Limited fundraising
ο Technical + § Inverted
Management staff § Cumbersome
ο Hospital Management § Imposed without
Committee (SMO , understanding service PROPOSED
senior nurses, Admin. STRATEGIES
Staff) PROPOSED CHANGES § Collaboration
§ Lack of involvement in § Change in reporting (private/public)
the policy process structure § Fundraising
§ Developed guidelines for ο SMO should not § Emphasis should be on
patients and technical report to the Parish accountability
staff. Manager. § Lack of standards to
POLICY ο Establish positions monitor for shortfalls
COMMUNICATION in the parish. § Increase fee collection
§ No/minimal ο Include a § Better Billing
communication. Maintenance § Better Payment options
§ Adhoc with no set Supervisor for each § More autonomy over
standards parish. budget
§ Review and develop Meetings § Improve capacity (MIS)
policies with team (Hope § Abolish role of Parish § Increase budget
Inst.) Manager
ο SLA § More input needed by USER FEES
ο Meetings technical staff § Should not be abolished.
ο Develop patient care § SMO to report to region § Rationale:
guidelines ο Misuse of privileges
POLICY IMPLEMENTATION MODES OF ο Hospitals need the
§ Rationalization for new COMMUNICATION Money.
policies. ο Over utilization of
§ Emails
§ Educate staff on services.
§ Meetings
institutional policies ο Should be tailored.
§ Face to Face
§ Wider policy is
§ Indirect – go through
problematic
PM or CEO
§ Procedures manuals act
§ Difficulty with HR
as guides.
§ RTD*

CHALLENGES MONITORING
§ Change management § More dialogue with

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194

issues with staff. policymakers.


§ Adapting to policies from § More ongoing monitoring
central government. by central government.
§ Institutions capacity is
inconsistent with policy
goals.
§ Methods of policy
development – project/
team driven for
sustainability.
§ Communication with
administrative
bureaucrats.
§ Technocrats and
bureaucrats relationships.
§ Medical staffing issues
§ Underdeveloped cadre of
workers (para-medical).
§ Lack of resources.
§ Define job description.
SUPPLIES MANAGEMENT INFORMATION SYSTEM
PROCURMENT USAGE
PRACTICES § No IS
§ Poor, under-budgeted § Manual IS or retrieval
§ Unaware of the budget are
allocation for hospital. ο Timely
§ Financial liabilities for ο Accurate
medication, utility bills
§ Limited fundraising
21ST CENTURY
JAMAICA
§ Proper Infrastructure
(equipment).
§ Adequate Staff (Medical,
Nursing).
§ Financial sufficiency.
§ Developed defined
standards nationally.
§ SMO to recommend and
follow hiring of staff.
§ Private partnership in
Medicare.
§ Extensive investigations to
be contracted out.
§ Communication network
with RHAs.
§ Developed system of
accountability.
§ Decrease administrative
staff in the region.
§ Abolish PM posts.
§ Give more power to the
SMOs’ and CEOs; +
Administrators

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195

§ Public/Private Partnership
§ Electronic Integrated records
§ Clinical Research
§ Improve Transport systems
§ Retool Radiological
Laboratory services in the
hospitals + PC
§ Strengthen PHC to reduce
load on hospitals.
§ Public/Private Partnership.
§ Develop training
opportunities in the sub-
specialties and distributing
them evenly in the country.
§ Develop all island
communication systems.
§ Proper and efficient
procurement systems
(centralize)
§ Reviews allocation of
Health Budget.
§ Implement a functioning
laboratory system.
§ Simplification +
rationalization of regional
structure.
§ Redefine role of SMO/MOH
in management structure.
§ Redefine role CMO with
respect to PS.
§ Separation of training vs.
non training posts for
registrars/residents.
§ Incorporate clinicians in
MOH structure.
§ Create centres of excellence
outside the University
Hospital.
§ Preventative maintenance
program.
§ Excellent Customer Service
§ Excellent HR (teamwork,
staff perception)
§ Frequent Audit and Review

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196

FOCUS GROUP
Region: All
Group: Chief Executive Officer
Reports To: Parish Manager
Role: Manage day to day operations of the hospital.
POLICIES STRUCTURE FINANCIAL
POLICY ORGANIZATONAL FINANCIAL RESOURCES
DEVELOPMENT STRUCTURE § Poor
§ Through RHA with inputs § Structures are not § Most day to day needs are
from the parish (5) uniformed across satisfied
§ Developed by HR (1) region § Weak and counterproductive
§ Done by MOH (10) § Top Heavy (1)
§ Possibility to collect 50% of fin.
§ Inputs from mgmt team § PM does not interface
(3) with hospital CEO Needs
§ Inverted § Improve allocation of funds across
POLICY COMMUNICATION § Cumbersome region
§ No Participation (2) § Imposed without § Ability to manage but not
§ Little Participation (1) understanding service given the responsibilities.
§ Submission of documents § Unaware of the budget
§ Discussions in meetings PROPOSED allocation for hospital.
§ Contribute via interaction CHANGES § Give the hospital the
with PHRO during Region responsibility to manage the
design. imprest a/c
§ Yes (4)
§ Budget is inadequate
§ No (
POLICY § Greater autonomy
IMPLEMENTATION § Lengthiness of PROPOSED STRATEGIES
§ Staff workshops, response § Collaboration (private/public)
materials time § Fundraising
§ Consultations § Increased Budgetary § Emphasis should be on
§ Face to face interaction allocation accountability to Unit
§ Budgets, time based § Reduce the number of Manager
action sheet managers at HOD and § Provide more autonomy to
§ Circulation of draft establish PA to larger hospitals
documents to senior manage § Payoff existing debt
managers the day to day § Provide realistic budget
§ Change management operations. based on operational plan
meetings Parish coupled with user fees and
§ Audits § Yes (4) fundraising.
§ Approval/input from the § No (1) § Develop a development plan
PM and ensure consensus § Parishes to be more in § Inclusion of experienced
§ Staff Meeting charge of PHC MOH personnel who are
§ Training sessions § Increase autonomy of proficient in Government
§ Programme Planning PM Accounting.
§ Change in reporting
CHALLENGES
structure
§ Recommendations are USER FEES
ο SMO should not
never implemented or § Should not be abolished.
report
considered. § Rationale:
to the Parish
§ Change management ο Misuse of privileges
Manager.
issues with staff. ο Hospitals need the money
ο Establish positions
§ Clinical staff may identify ο Country cannot afford “free”
in
gaps not previously health care

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197

discovered. the parish. o It supplements the


ο Include a budget
Maintenance o Infrastructure needs to
Supervisor for each be upgraded first.
§ Parish Managers are parish.
often ο Meetings
invited to represent the § Abolish role of Parish
views of hospital Manager
personnel
and may not be well § More input needed by
equipped to do so. technical staff
§ Lack of financial § SMO to report to
resources region
in adequate for
implementation. MODES OF
§ Lack of manpower. COMMUNICATION
§ Resistance to change.
§ E-mails
§ Lack of participation.
§ Memo
§ Lack of interest by some
§ Letters
groups. § Fax
§ Internet
§ Meetings
§ Face to Face
§ Indirect – go through
PM
or CEO
§ Difficulty with HR
§ RTD*
MONITORING
§ More dialogue with
Policymakers.
§ More ongoing
monitoring
by central
government.

SUPPLIES INFORMATION
MANAGEMENT SYSTEM
PROCURMENT USAGE
PRACTICES § Electronic
§ Manual
POOR (2) § Limited PAS.
§ Can be timely when
FAIR (8)
everything works.
GOOD (4)
§ Verbal has some
EXCELLENT (0) amount
P F G E of inaccuracies.
Ph 2 6 3 § Standardization need
Sun 1 2 5 3 across region.
§ Manual IS or retrieval
MS 2 5 2 2
are fairly:
Eq. 6 2 4 - Timely
§ Supervisors need more - Accurate

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198

training in procurement
Practices.
§ A procurement officer is
needed to coordinate
purchases for the entire
hospital.
21 ST CENTURY
JAMAICA
§ Proper Infrastructure
(equipment)
§ Adequate Staff (Medical,
Nursing)
§ Financial sufficiency
§ Developed defined
standards
nationally.
§ SMO to recommend and
follow hiring of staff
§ Private partnership in
Medicare
§ Extensive investigations
to
be contracted out.
§ Communication network
with RHAs
§ Developed system of
accountability
§ Decrease administrative
staff in the region.
§ Abolish PM posts.
§ Give more power to the
SMO’s and CEO’s +
Administrators.
§ Public/Private
Partnership
§ Electronic Integrated
Records
§ Clinical Research
§ Improve Transport
systems
§ Retool Radiological
Laboratory services in the
hospitals + PC.
§ Strengthen PHC to reduce
load on hospitals.
§ Public/Private
Partnership
§ Develop training
opportunities in the
subspecialties and
distributing them evenly
in
the country.
§ Develop all island
communication systems

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199

§ Proper and efficient


procurement systems
(centralize)
§ Reviews allocation of
Health
Budget.
§ Implement a functioning
laboratory system
§ Simplification +
rationalization of regional
structure.
§ Redefine role of
SMO/MOH
in management structure
§ Redefine role CMO with
respect to PS.
§ Separation of training vs.
non-training posts for
registrars/residents.
§ Incorporate clinicians in
MOH structure.
§ Create Centres of
Excellence
outside the University
Hospital.
§ Preventative maintenance
program.
§ Excellent Customer
Service
§ Excellent HR (teamwork,
staff perception)
§ Frequent Audit and
Review

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200

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201

Focus Group:
SERHA
Participants: Administrators
Date:

Policy Structure Human Resource


§ Developed from the RHA
Ministry of Health and § Top heavy (ineffective)
handed down. § High attrition rate in the
§ SLA unrealistic. Civil works department
§ Region attracts qualified
Engineers but do not
retain them because of
inadequate compensation
§ Inadequate posts for:
- Records Clerks and
Cashiers
- Limited promotional
opportunities for these
groups.

Parish
§ Inconsistency in Structure
across parishes.
§ Artisans without paper
Qualifications.
§ Need for reclassification of
posts (Electrician trained
by HEART classified as
TS1)
Recommendations:
§ Partnership with
HEART for training
and certification.
Supplies Management FINANCIAL RESOURCES
§ Regularise Impress
account and make
Manager Accountable
§ Impress Account ( Inadequate)
Sir John Golding $10,000;
Hope Institute $10,000;
National Chest Hospital
$20,000.

M OD ERNIZA TION C ONC ERNS R EC OM M EN DATIONS

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202

R E QUIRED
§ Decentralization was for § Reduce RHA staff and
decision making to be done increase parish staff.
closer to service delivery – § Take decision making closer
- This is not happening, all to service delivery.
decisions are made at the
RHA
- It takes a long time to make
the decision, when it is done
it is outdated.
§ Written recommendations
are not considered.
§ When financial irregularities
are uncovered steps are not
taken to address them

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203

APPENDIX 4

MEDICAL OFFICERS OF HEALTH

Policy:
- The policy and the beginning was flawed.
- The Ministry of Health is a technical one and yet the technical personnel is
usually ignored.
- There is a deterioration in the standard of care.
- There is a clear lack of standardization with respect to the SLA. E.g.:
environmental health.

Recommendation:
- There is a need to revisit the post of parish manager with a view to name these
persons administrators.
- There is a need to merge the regions, the question is whether there is a need for
all of 4 regions.

Structure:
- Structures across the regions are not uniform- in accordance with each regions
requirements. An example is the KSA where the structure at the Bustamante
Hospital for Children has a greater more defined than at the parish level.
- There has not been any real empirical data provided since the establishment of the
Regions.
- Lack of consultation.
- Top down approach.
- Parish Manger should not be responsible for evaluating MOH, especially on
technical competencies and where there exist such variance is salary scale.
- Lack of standards.

Personnel:
- There is an issue as to the qualification of RTD as they are often taking technical
decisions that impact on the parishes.
- There are concerns as it relates succession planning.
- The region have more personnel for HR than the Ministry itself.
- Staff should be allocated/apportioned in relation to Parish size and growth and in
relation to the needs and priorities.
- There is a lack of strategies planning for HR.
- The 1972 personnel policy must be revised.
- The issues of employee benefits needs attention.
- There is an issue of a shortage of skilled personnel. E.g.: Occupational and Speech
Therapist.
- The reporting responsibility for the Nursing supervisors for Parish must be
revised.

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204

Concerns:
- RHA in its present form was established by a Permanent Secretary unilaterally.
- There are too many directors, there seems to be five ministries.
- CEO evaluating SMO.
- There is a lack of standards as it relates to evaluation standards.
- The operations and maintenance areas are the weakest.
- The region lacks support, especially in the area where MOH is having to do
- administration.

Role of the Parish Managers:


- Parish mangers are too involved in operational details.
- Reporting responsibility should be re-evaluated.
- There needs to be a clarity of the roles of the Parish Manager as distinct from the
Medical Officer of Health, as it relates the levels of authority.
- There are clerks at the regional offices taking technical decisions, this is serious
cause for concern.

Communication
- There is a need to establish a clear policy.
- There is a need for an effective and efficient MIS.
- Information flow is seriously lacking.
- Systems of communication now in place in deficient.
- MOH are not regarding enough to be allocated a computer while all clerks at the
region is equipped with computers.
- The poor communications stifles any prospects for benefits for staff.

Finance:
- Region was never adequately financed at start up.
- Funds when generated at the parish all go to the Region and never redistributed.
- An example of lack of support is where BHC had to independently solicit services
privately and where doctors are paying for the internet services in areas such as
the intensive care unit.

Procurement
- The system of procurement needs to be reviewed.

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205

APPENDIX 5 -

POLICY ISSUES –ALL GROUPS

§ Key Issues/Challenges

(1) Need for greater participation in overall process, to replace the


predominantly top-down approach.

(2) A need for a system wide accepted norm in handling/treating issues of a


policy nature.

(3) Lack of capital budget.

(4) Need to ensure that policies are related to demographics and geography and
epidemiology.

(5) Need to review the procurement policy to ensure greater efficiency and
accountability.

(6) Need to encourage greater use and integration of sources of technology.

(7) A need to encourage greater partnership and inter-relation between regions


and M.O.H. as well as stakeholders.

(8) Technicians - Artisans, biomedical, plumbers, carpenters are required in


each parish.

(9) User fees to be continued for patients with the ability to pay.

(10) Need to establish effective Patient Administrative System which is


interactive and interoperable across the regions/parishes.

(11) Need greater uniformity of purpose and process across regions.

(12) Need greater and more systematic approach to public/ private sector
partnership for fundraising and service delivery.

(13) Establish system to encourage greater “e” communication to reduce paper


and save money.

(14) Need flatter structure.

(15) CEOs should be only in regional hospitals.

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206

APPENDIX 6 - Organisation/Structure

ALL GROUPS

Ø Key Issues

§ Ministry of Health

(1) The lack of decentralization of roles and responsibilities.


(2) Overlapping of roles and functions.

§ RHA

(1) Top heavy; need for merging some functions; current structure too
bureaucratic and inefficient
(2) Unclear functions / duplications.
(3) Draft form of technical structure.
(4) Weak technical staff at the region.
(5) Dysfunctional reporting relationships (technical to non-technical)
(6) Lack of corporate structure for hospital management.
(7) RHAs have created four ministries in one.
(8) Reduction in the number of Regional Health Authorities.

§ Parish Structure

(1) Dysfunctional practice of Medical Officers reporting to Parish Managers


rather than to SMOs, and the absence of professional nursing management
systems.
(2) Technical officers of the profession being supplementary to medicine without
immediate supervisors
(3) Lack of standardization among regions.

Ø Suggestions

(1) Create structure with a ratio of Administrators to Technical Staff relevant to the
delivery of service.
(2) More input by technical staff.
(3) Revision of parish structure with a view to standardize structures across regions.
(4) Review parish managers’ role and function – abolish role of parish manager.
(5) Effect Organizational changes within the RHAs and Ministry including
making all top positions contractual (5 years with renewal).
(6) Health is a technical Ministry and must be led by technical people. There
needs to be a re-orientation of the Permanent Secretary and Regional Directors and

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207

Administration to recognize their role as supportive and facilitatory and not to have
an “I am in charge” mentality. Resources must be better aligned with programs and
technical director must determine resource allocation within the health policy
and priorities.

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208

APPENDIX 7 - HUMAN RESOURCE MANAGEMENT

ALL GROUPS
Key Issues/Challenges

(1) The Ministry of Health Human Resource Management System is dysfunctional.


(2) The size of the staff cadre needs to be reviewed in order to relieve the strain on the
system and to improve morale.
(3) Improved incentive schemes/programs are needed.
(4) A comprehensive harmonisation programme is needed which would include all the
regions.
(5) More emphasis must be placed on the recruitment process to ensure better
management of staff replacement processes.
(6) More emphasis to be placed on a comprehensive orientation process.
(7) More emphasis to be placed on staff development with the requisite awards and
compensation given after training.
(8) There is need for comprehensive H.R. software to adequately manage the task.
(9) H. R. to facilitate/lead an effective communication channel/process is needed.
(10) Improvement in remuneration packages should be considered.
(11) More consideration should be given to the rotation process.
(12) Industrial Relations process must be better managed.
(13) Greater emphasis is needed on effecting change of culture to improve work/attitude
and efficiency.
(14) Greater relationship-building among unions and management staff should be
encouraged.
(15) Improvement in processes of accountability must be sought.
(16) Systematic approach to the appraisal system is needed.
(17) Improvement in the process of responding to staffing, replacements, etc is needed.
(18) A realistic cadre needs to be established.
(19) End overlap and duplication of functions.

Suggestions

(1) Develop manpower plan.


(2) Appoint staff working in clear vacancies.
(3) Encourage training and certification of staff (NCTVET)
Artisans – plumber, carpenter, biomedical technician

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209

APPENDIX 8 - Supplies Management and Procurement Practices

Ø Key Issues

Pharmaceuticals

• Health Corporation, the Government Agencies which supplies drugs to


the RHAs usually supply approximately 60% of the Institution’s order, the
gap has to be filled by purchasing drugs on the open market.

• Inadequate budgetary support to purchase pharmaceuticals from the open market

• Lack of systematic approach to the procurement process.

• Unavailability of credit facilities within regions for the procurement of drugs.

• Inadequate inventory control system to facilitate ordering, of drugs and


distribution

• Unavailability of software to facilitate purchasing process.

• Need for improved stock levels and repair materials for equipment
maintenance.

Suggestions

(1) Budget to be increased.


(2) Review procurement guidelines.
(3) HCL to be reorganized with possibility to recapitalize.
(4) Equipment maintenance to be outsourced.
(5) Improved training for maintenance personnel, with parishes being
adequately staffed.

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210

APPENDIX 9 - Supplies Management and Procurement


(Regions)
SERHA SRHA WRHA NERHA
Pharmaceuticals • Major problem • Poor – HCL
with HCL supplies only
(unable to supply 60% of order.
pharmaceuticals • Region
so Region has purchases
to purchase on drugs on the
the open open market at
market). higher prices.
• Gifts of
pharmaceuticals.

• No line of credit • Inadequate


when supply is • Paperless
out of stock. Parish
procurement
• Poor quality of
process.
paper used for
• Software
printing medical
developed
records.
in-house for
purchasing.
• interconnected
Equipment • Limited • Delay in getting • Non functional
shopping for requested • Money donated
X-rays. Place maintenance for equipment
orders in equipment and cannot be
accordance with sundries sourced/used
demand. because of • Procurement
• Hospitals and procurement Committee and
HD receive 2 procedures of the length of
deliveries getting three (3) time it takes to
monthly. quotes. approve
• Facilitate requests for
emergency purchases.
delivery.

• Hospitals are
given “cut-off”
dates monthly
to meet
scheduled
delivery.

Maintenance
Recommendation • Reorganize HCL • Increase
s (debts to be budget
written off) and • Procurement
recapitalize the
guidelines to
entity.
be reviewed to
• Outsource

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211

maintenance of include
equipment. essential and
• Each parish non-essential.
should have a
maintenance
team.
• Training of
artisans
(plumbers,
electricians,
carpenters) -
HEART
NCTVET
Certification

HCL Principal Finance


Officer
Pharmaceuticals • RHA terms of • Ranges from good to
purchase 30 days poor depending on the
• Credit policy institution.
implementation is • There have been
futile. concerns about
internal control.
• MOH advises HCL
• Procurement practices
supply RHAs
need to be automated.
regardless of
current debt.
• Buying process is not
properly financed.

• International
competitive tender
(18 months.)

Supplies Equipment • Procurement of


equipment is
challenged by
finances and lack of
skilled procurement
personnel.

Maintenance • Lack of funds to


ensure adequate
maintenance.

• HCL needs more


working capital to
ensure timely and
adequate supplies.

• HCL delivery
schedule needs to be
revised.
• GOJ budget cover
70% of needs for

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212

procurement.

General Recommendation
Ministry of Health has to play a greater role in monitoring the project process to avoid project overruns.

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213

APPENDIX 10

PATIENTS’ FOCUS GROUP

SERHA SRHA WRHA NERHA

Comprehensive Montego Bay St. Ann’s Bay


Health Centre Type V H. C.
Type V
Access to § They were able § No § They were able § At the St. Ann’s
Care to get interviews to get Bay Health
transportation to conducted. transportation to Centre some
health centre. health centre. patients
complained
of inability to
find bus fares
and sometimes
missed their
appointments.
Environment § Clean § Clean § Over crowded
environment environment with limited
but overcrowded but overcrowded seating.
with limited .
space for staff
to work and for
patients’ seating.
Patients
suggested that
more signs are
needed to point
patients to the
different
treatment areas.
§ At this clinic
there are 200 to
300 walk-ins
daily.
Staff § Generally good. § Generally good. § Complained
Attitude § Complained a about
about attitude of inappropriate
records clerk behaviour of
and security. security
personnel and
records clerk.

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214

Waiting § Patients were § Patients were § Patients said


Time dissatisfied with dissatisfied with they had to wait
the waiting time. the waiting time. up to 4 hours
to be seen by the
doctor. although
they had
appointments
(chronic disease
clinics).

§ More doctors and § More doctors and § More doctors and


nurses are nurses are nurses are
needed to needed to needed to
treat patients. treat patients. treat patients.
Pharmacy § Patients stated § Patients stated § Satisfied with
that they were that they were the service at
unable to get all unable to get all the pharmacy.
the prescribed the prescribed
medications at medications at
the pharmacy, the pharmacy.
therefore it’s an Therefore it’s an
increased cost increased cost to
to them. them.

§ The waiting time


is very long and
patients stated
that they had to
hand in their
prescriptions for
assessment of
cost of drug,
then wait for
their names to
be called, collect
the prescription,
go to the cashier
in another
location, pay for
the medication,
return to the
pharmacy, hand
in the

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215

prescription and
wait. This
process takes up
to 3 hours to
complete and
sometimes the
medications are
not dispensed,
they are asked to
return the
following day.

Quality of § Patients stated § Patients stated § Patients stated


Service that the service that the service that the service
was good and was good and was good and
worth the worth the wait. worth the wait.
wait.
User Fees § Those who can § Those who can § Those who can
pay should pay. pay should pay. pay should pay.

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216

APPENDIX 11

Source: Public Private Partnerships –Radiology Group.

IMPACT OF NEW TAX MEASURES ON THE COST OF EQUIPMENT


UPGRADING
Example

A quotation was received by a Radiologist from General Electric in February


2003 for several new pieces of imaging equipment, including a high tech
digital system not yet available in Jamaica or the English speaking
Caribbean. Lease financing was approved by an overseas leasing company.

General Electric Invoice US$1,000,000.00


10% Import Duty US$ 100,000.00
TOTAL US$1,100,000.00

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217

The Effect of New Tax Measures on Viability of Equipment


Upgrading Project

General Electric Invoice US$1,000,000.00


10% Import Duty US$ 100,000.00
15% GCT US$ 150,000.00
2% Import Cess US$ 20,000.00
TOTAL US$1,270,000.00

NET RESULT

The Radiologist is unable to come up with the additional US$170,000.00 and


the equipment upgrading project may have to be shelved because the leasing
company requires a bank guarantee for this amount which may be
unobtainable in light of the devaluation of the Jamaican dollar.

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