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Regional Health Authority REPORT
Regional Health Authority REPORT
“ 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:
(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”
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TABLE OF CONTENTS
Page
FOREWORD 8
ACKNOWLEDGEMENTS 9
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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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TABLES
CHARTS
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APPENDICES
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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.
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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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Support Team:
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EXECUTIVE SUMMARY
Some of these steps overlapped. Then followed the collation of the data,
responses, suggestions and recommendations, preparatory to the drafting of
the Report.
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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.
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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:
(3) Maintain the four Health Regions within the current borders.
(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.
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(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 .
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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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STAGE 1
STAGE 2
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STAGE 3
• 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……”
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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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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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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.
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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.
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.
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Table 1
Fee Scale for Private Patients
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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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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• 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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Diagram 1
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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Diagram 2
MINISTRY OF LOCAL GOVERNMENT
(Local Board: 1938-1976)
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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.
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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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Diagram 3
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Table 3
Africa 47 21 2.6
Caribbean 35 35 2.2
Jamaica 35 7 1.6
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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Diagram 4
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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.
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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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.
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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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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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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.
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Diagram 5
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.
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• 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.
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Diagram 6
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Diagram 7
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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”.
4.1 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 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
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.
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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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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55
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.
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.
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56
Diagram 8
CORE ORGANISATIONAL REFORM MINISTRY OF HEALTH 1980
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57
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
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58
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.
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59
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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60
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.
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61
Diagram 9
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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.
5Goffe report on “Redesigning the Jamaica’s Health Service System” revised 2007 (Goffe &
McCartney)
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64
Diagram 10
COMMUNITY COMMUNITY
State of Health The Health The Health
Centre The Hospitals Centre
Maintain
Prevention Prevention Treatment Rehab
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65
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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66
The RHAs were established under The National Health Service Act of
1997 and implemented through an instrument of delegation.
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67
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
Table 5
STAFF STATUS OF THE RHAs- Jan 2008
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68
SRHA
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
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.
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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69
Linstead ü 50 55%
Table 7
Health Centre Profile -SERHA
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70
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
Table 9
Health Centre Profile - NERHA
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
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72
Table 10
Hospital Profile-SRHA
Table 11
Health Centre Profile (SRHA)
Westmoreland - 143,042
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73
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
A B C
Falmouth ü 60 73.4%
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74
Table 13
Health Centre Profile- WRHA
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
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75
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76
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77
• The structures at the MOH are ‘top heavy’, that is, there are too
many director posts particularly in Administration.
THE RHAs
• The structures at the Regional Health Authorities are ‘Top Heavy’, that
is, there are too many director posts particularly in Administration.
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78
PARISHES
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79
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80
Diagram 12
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81
Diagram 13
TASK FORCE RECOMMENDATION - MOH&E
(HEAD OFFICE)ORGANISATIONAL CHART
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82
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Diagram 14
SEMI-AUTONOMOUS (RHA) STATUTORY BODY
Diagram 15
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84
Diagram 16
Reporting Responsibilities between Structures
NB: All peers (Technical/Administrative) at the various levels will relate within the structure
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85
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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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87
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.
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88
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
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90
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
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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).
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93
Diagram 19
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94
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
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96
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.
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:
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97
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.
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98
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99
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.
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100
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101
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.
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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
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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.
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.
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104
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.
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105
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106
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
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
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109
8.4 EQUIPMENT
• 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.
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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:
EXPENDITURE:
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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 :
E X P E N D IT U R E :
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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
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CHART 2A
MOH&E – RHAs
INCOME FOR THE COMBINED RHAs BY YEAR & SOURCE
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
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
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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($M
e ) C o m positio
fo r 2003/ 2004 Y ea r fo r 20
M O H G rant
M O H G rant
88%
88.25%
M O H G rant
87.47%
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CHART 3A
MOH&E – RHAs
EXPENDITURE FOR THE COMBINED RHAs BY YEAR & TYPE
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MOH&E – RHAs
EXPENDITURE FOR THE COMBINED RHAs BY YEAR & TYPE
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Analysis 2003/2004 Income by Amount (J$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
12000
10000
8000
Income (J$ M)
6000
4000
2000
0
M OH G rant Fee Income Other Income Donations
Source of Incom e
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
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
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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
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Analysis of 2006/07 Collections by Regional Health Autho
1,800
1,600
1,400
1,200
Collectios (J$M)
1,000
800
600
400
200
0
SERHA WRHA SRHA NERHA ALL RH
Regional Health Authority
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TABLE 18
MOH&E - RHAs
SERHA EXPENDITURE 2004-2006 BY COST CENTRE
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CHART 10
MOH&E - RHAs
South East Regional Health Authority
2004/05 Actual Expenditure (in J$M) Analysed by Cost Cen
5,000
4,500
4,000
3,500
Expenditure-J$M
3,000
2,500
2,000
1,500
1,000
500
0
old sp
Ho Hsp
SA sp
sta ab
Li sp
ce
hT te
ess sp
th .
Ca ept
ria PH
on eHs
JG eH
K& argH
Sp stitu
H
Bu Reh
inc H
ffi
St. thD
lO
cto K
est
wn
Pr tead
Sir bile
N ant
In
ing
M
Ch
na
H
m
pe
Ju
ns
gio
al
ns
Re
ati
Vi
Cost Centre
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CHART 11
MOH&E - RHAs
South East Regional Health Authority
2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by C
6,000
5,000
Expenditure-J$M
4,000
3,000
2,000
1,000
0
Na ma b
St. Hl sp
Pr stea p
pe sp
Sir Jubi H
old Hsp
l C sp
hT te
St th. H ept
ce
sta eha
SA gH
Lin Hs
Ho stH
ess Hs
na H
ns itu
P
Ca thD
ffi
ria K
Bu ngR
lO
wn
Sp Inst
JG lee
inc d
tio nte
K& Mar
he
na
T l
i
gio
Re
cto
Vi
Cost Centre
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CHART 12
MOH&E - RHAs
South East Regional Health Authority
2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by C
7,000
6,000
5,000
Expenditure-J$M
4,000
3,000
2,000
1,000
0
sta hab
p
Lin Hsp
pe p
old sp
J H
na sp
ns te
ess sp
ce
th p
SA Hs
Ho tHs
JG eH
tio teH
Sp stitu
inc H
Ca De
ria P
ffi
Bu gRe
cto K
lO
K& arg
wn
Pr stead
St. Hlth
s
In
Sir ubile
he
Na man
M
hT
in
na
lC
gio
Re
Vi
Cost Centre
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TABLE 19
MOH&E - RHAs
SRHA EXPENDITURE 2004-2006 BY COST CENTRE
TOTAL CASHDONATION
RECEIVED 233,717
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CHART 13
MOH&E - RHAs
Southern Regional Health Authority
2004/05 Budgeted vs. Actual Expenditure (in J$M) Analysed by C
1,800
1,600
1,400
Expenditure-J$M
1,200
1,000
800
600
400
200
pt
pt
pt
p
sp
sp
p
sp
Hs
De
De
rH
De
Hs
nH
rH
wn
th
th
th
no
le
ive
Pe
vil
Hl
Hl
Hl
To
Ju
kR
de
ay
on
th
er
gio
rcy
M
an
el
ac
est
be
nd
on
M
Re
Pe
ch
Bl
iza
are
Li
an
El
Cl
M
St.
C ost C entre
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CHART 14
MOH&E - RHAs
Southern Regional Health Authority
2005/06 Budgeted vs. Actual Expenditure (in J$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$M
1 ,5 0 0
1 ,0 0 0
500
t
t
t
ep
sp
ep
ep
sp
sp
sp
sp
D
H
D
H
rH
lth
wn
lth
or
lth
n
le
ive
Pe
un
rH
H
nH
vil
To
kR
de
yJ
ay
te
do
M
an
el
et
rc
ac
es
on
ab
M
Re
Pe
en
ch
Bl
liz
Li
ar
an
.E
Cl
M
St
C o s t C e n tr e
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CHART 15
MOH&E - RHAs
Southern Regional Health Authority
2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by C
2 ,5 0 0
2 ,0 0 0
Expenditure-J$M
1 ,5 0 0
1 ,0 0 0
500
pt
pt
sp
sp
sp
sp
sp
De
De
De
H
rH
H
nH
rH
wn
lth
th
th
no
le
ive
Pe
H
vil
Hl
Hl
To
Ju
kR
de
ay
on
eth
ter
rcy
M
an
el
ac
nd
es
on
ab
M
Pe
ch
Bl
are
liz
Li
an
.E
Cl
M
St
C ost C en tre
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TABLE 20
MOH&E - RHAs
NERHA EXPENDITURE 2004-2006 BY COST CENTRE
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CHART 16
MOH&E - RHAs
North East Regional Health Authority
2003/04 Budgeted vs. Actual Expenditure in (J$M) Analysed by C
1,600
1,400
1,200
Expenditure-J$M
1,000
800
600
400
200
0
sp
sp
p
ce
pt
pt
Hs
Hs
yH
yH
De
De
ffi
lO
io
ria
lth
th
Ba
Ba
ton
Ma
na
nH
H
Hl
tto
n's
gio
An
nd
ry
rt
An
no
An
Po
Ma
Re
rtla
rt
An
Po
St.
St.
Po
St.
Cost Centre
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CHART 17
MOH&E - RHAs
North East Regional Health Authority
2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by C
1,600
1,400
1,200
Expenditure-J$M
1,000
800
600
400
200
0
sp
sp
pt
sp
ce
pt
Hs
yH
yH
De
aH
De
ffi
lO
io
lth
Ba
th
Ba
ari
ton
nH
na
Hl
tto
n's
gio
An
ry
An
rt
no
An
an
Po
Ma
Re
rt
An
rtl
Po
St.
St.
Po
St.
Cost Centre
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CHART 18
MOH&E - RHAs
North East Regional Health Authority
2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by C
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
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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
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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
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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
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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
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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
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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.)
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142
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).
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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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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.
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151
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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Diagram 21
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153
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154
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 Government will make available all Clinical Teams for service delivery as a
paid service to be decided by negotiation between the parties.
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
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)
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156
Table 21
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.
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157
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 current health care system allows for both public and private hospitals to
coexist offering similar products. They recommend that the GOJ introduce
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158
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.
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.
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159
service sectors (i.e. nurses, doctors, etc.) continue to emigrate. Incentives that
might assist in meeting these concerns include:
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 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.
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163
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164
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.
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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165
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.
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166
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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167
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.
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.
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168
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.
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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.
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171
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.
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.
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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
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20. The staff appeals process MUST be swift, transparent and impartial.
PHARMACEUTICALS
EQUIPMENT
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175
FINANCES
28. Retain User Fees for Secondary and Tertiary Care with
appropriate , sensitive system for exempting the indigent.
PROJECTS
HEALTH TOURISM
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176
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.
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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APPENDICES
Name Institution
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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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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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
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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
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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
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Dentists
Name
1. Winston Grey
3. Sandra Hill-Cameron
4. Irving McKenzie
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Administrative Group
Name Position Institution/Region
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APPENDIX 2 - REFERENCES
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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.
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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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Region: SRHA
Group: Primary Care Group
(Dietetic, Nursing Supervisor, Chief Radiographer, Parish Pharmacist, Social
Worker, Matron, Ward Sister, Chief Medical Technologists)
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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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§ 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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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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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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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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Focus Group:
SERHA
Participants: Administrators
Date:
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.
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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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APPENDIX 4
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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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.
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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APPENDIX 5 -
§ Key Issues/Challenges
(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.
(9) User fees to be continued for patients with the ability to pay.
(12) Need greater and more systematic approach to public/ private sector
partnership for fundraising and service delivery.
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APPENDIX 6 - Organisation/Structure
ALL GROUPS
Ø Key Issues
§ Ministry of Health
§ 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
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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ALL GROUPS
Key Issues/Challenges
Suggestions
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Ø Key Issues
Pharmaceuticals
• Need for improved stock levels and repair materials for equipment
maintenance.
Suggestions
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• 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
• International
competitive tender
(18 months.)
• 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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APPENDIX 10
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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.
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APPENDIX 11
Easy PDF Creator is professional software to create PDF. If you wish to remove this line, buy it now.
217
NET RESULT
Easy PDF Creator is professional software to create PDF. If you wish to remove this line, buy it now.