regional health authority report

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“A HEALTHY JAMAICA IN A

HEALTHY WORLD”

THE MINISTER’S MANDATE“A Comprehensive Review and Evaluation of theRegional Health Authorities and their relatedentities, with recommendations on the way forward toa cost-effective, comprehensive and sustainable healthcare delivery system for Jamaica in the 21st Century”

Presented to:

The Hon. Rudyard Spencer M. P.Minister of Health and Environment

(Minister’s Vision)“Envisions the modernizing of the Jamaican HealthService sector to achieve a 21st century, best-practicehealth care delivery system which addresses the healthproblems of the Jamaican people in a comprehensive andsustainable way. It should provide the conditions forprivate investment within the health sector, with theobjective of delivering Health Tourism services globallyand of contributing to financing a best-practice, healthcare system for all Jamaicans”

Prepared by: Health Sector Task Force (2007)Chaired by: Dr. Winston G. Mendes Davidson C.D., J.P.,

MBBS, DTM&H.

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TABLE OF CONTENTSPage

FOREWORD 8

ACKNOWLEDGEMENTS 9

MEMBERS OF THE TASK FORCE 10

0.0EXECUTIVE SUMMARY 11

1.0 ESTABLISHMENT OF TASK FORCE 16

1.1 Terms of Reference 161.2 Task Force Implementation Framework 17

2.0 METHODS AND MATERIALS 182.1 Historical Review of Jamaican Health Sector 182.2 Prepare, Administer Instruments and Collect Data from Stakeholders 182.3 Limitations: Scope of Review 20

3.0 HISTORICAL PERSPECTIVES OF THE JAMAICANHEALTH SECTOR 21

3.1 Principles and Watersheds of Jamaica’s Health Service System 213.2 The Plantation System Period Of Slavery (1658 - 1838) 223.3 Early Colonial Post-Emancipation Period (1838-1846) 233.4 Colonial Post-Emancipation Period (1838-1866) 233.5 Crown Colony, Post-Emancipation Period (1867-1900) 243.6 The National Health Service System (1900-1938) 263.7 The Pre-Independence Internal Self Government Period (1938-1962) 293.8 The Post-Independence Period (1962-1972) 323.9 Modernisation (Globalisation) Of The Health Services System 1972-1989 373.10 Hospital Management and Standardisation 373.11 Leadership of Jamaica’s Modern Health Reform Agenda (1967-1980) 383.12 Health Administrative Office vis-a-vis Chief Medical Office(1955-1980) 393.13 Political Influences In Public Health Management In Jamaica 413.14 IMF Conditionality And Its Impact On Primary Health Care

initiatives of the 1970s 433.15 Organisational Reforms Prior To The RHAs Introduction 453.16 Task Force Conclusions From Historical Review 47

4.0 THE REGIONAL HEALTH AUTHORITIES (RHAs) 514.1 Introduction 514.2 Conditions Prior To The Establishment Of The Present RHAs 534.3 Proposed Administrative Management Centred System (1980) 65



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4.4 Profile Of The RHAs 664.4.1 South East Regional Health Authority 674.4.2 North East Regional Health Authority 704.4.3 Southern Regional Health Authority (SRHA) 714.4.4 Western Regional Health Authority 72

4.5 The New Statutory RHA and Its Instrument of Delegation 73

5.0 FINDINGS OF STAKEHOLDERS 76

5.1 Organizational Structure 765.2 Recommended Change In Policy Framework For Regions 815.3 Task Force Recommendations for Essential Functions Of Regional

Health Organizations 845.4 Existing Regional Health Authority Organisation Structure 895.5 Recommendations For The New Regional Organisation Structure 905.6 Recommended Core Functions Of The Parish Organisation 925.7 Recommended Scope And Content Of Primary Health Care 94

6.0 THE HEALTH INFORMATION SYSTEM 976.1 Stakeholders’ Key Issues 976.2 Task Force Recommendations 100

7.0 MANPOWER 1017.1 Human Resource Management 1017.2 Task Force Recommendations 103

8.0 SUPPLIES MANAGEMENT AND PROCUREMENT 105

8.1 Pharmaceuticals 1058.2 Other Supplies 1078.3 Task Force Recommendations 1078.4 Equipment 1088.5 Task Force Recommendations 108

9.0 FINANCE AND THE RHAs 1089.1 MOH Grant 1409.2 User Fee Income 1409.3 NHF Grants 1419.4 Fixed Assets 1419.5 Expenditure 1429.6 User Fees 1439.7 Public/Private Partnerships 1459.8 Task Force Recommendations 146



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10.0 PROJECT MANAGEMENT 14710.1 Project Planning and Implementation 14710.2 Task Force Recommendations 149

11.0 PUBLIC/PRIVATE PARTNERSHIPS 15011.1 Health Tourism, A Consequence of Globalization 15011.2 Build, Own, Operate and Transfer (BOOT) Model 15311.3 The BOOT Model: Public/Private Partnership 15411.4 Achieving A Sustainable World Class Diagnostic Imaging

Sector In Jamaica 15811.5 Cost Of Services 16211.6 Impact Of New Tax Measures 16311.7 Private Radiologists’ Conclusion 164

12.0 CONCLUSIONS AND RECOMMENDATIONS

DIAGRAMS

Diagram 1 - Ministry of Health Organisational Structure 30Diagram 2 - Ministry of Local Government (Local Board : 1938-1976) 31Diagram 3 - Population Explosion Of The Late 1960s 34Diagram 4 - Core Organisation of the Health Service System (1962-1972) 36Diagram 5 - Core Organisation of the Health Service (1972-1976) 47Diagram 6 - The Conceptual Framework Outlining the Relative Level of Importance

Of Elements Determining the Jamaican Health Sector (1867-19720) 49Diagram 7 - The Process and Logic Of Efficient Health Care Service Systems 50Diagram 8 - Core Organisational Reform Ministry of Health 1980 56Diagram 9 - The Scope And Content Of Comprehensive Primary Health Care

(1980-2000) 61Diagram 10 - The Prevention Principles and The Epidemiological Basis For

Primary, Secondary and Tertiary Care Intervention Services 63Diagram 11 - Proposed Administrative Management Centred System 65Diagram 12 - Task Force Recommendation (Relationship between Head Office,

Region and Parish) 79Diagram 13 - Task Force Recommendation – MOH&E (Head Office)

Organisation Chart 80Diagram 14 - Semi-Autonomous (RHA) Statutory Body 82Diagram 15 - Fully Integrated Regional Organisation System 82Diagram 16 - Reporting Responsibilities Between Structures 83Diagram 17 - Existing Regional Health Authority Organisation Structure 89Diagram 18 - Task Force Recommendation For The New Regional Organisation

Structure 90



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Diagram 19 - Task Force Recommended Core Functions of the ParishOrganisation 92

Diagram 20 - Task Force Recommended Scope and Content of Primary HealthCare In The Parishes 94

Diagram 21 - Classification of Health Tourism 151

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

TABLES

Table 1 - Fee Scale for Private Patients 25Table 2 - West Indian Mortality Rates 1928 - 1938 27Table 3 - Comparison of Birth and Death Rates, Selected Areas (1965-1972) 35Table 4 - Population and Geographical Extension of Health Regions in Jamaica

(1999) 66Table 5 - Staff Status of the RHAs – January 2008 67Table 6 - Hospital Profile – SERHA 68Table 7 - Health Centre Profile - SERHA 69Table 8 - Hospital Profile - NERHA 70Table 9 - Health Centre Profile - NERHA 71Table 10- Hospital Profile - SRHA 71Table 11 – Health Centre Profile - SRHA 71Table 12 - Hospital Profile - WRHA 72Table 13 - Health Centre Profile - WRHA 73Table 14 - Analysis of 2003/04 Income & Expenditure For Combined RHAs 109Table 15 - Analysis of 2004/05 Income & Expenditure For Combined RHAs 110Table 16 - Analysis of 2005/06 Income & Expenditure For Combined RHAs 111Table 17 - Analysis of 2006/07 Income & Expenditure For Combined RHAs 112Table 18 - SERHA Expenditure 2004-2006 by Cost Centre 123Table 19 - SRHA Expenditure 2004-2006 by Cost Centre 127Table 20 - NERHA Expenditure 2004-2006 by Cost Centre 131Table 21 - Country Health Expenditure per Capita per Year andMale /Female Longevity- WHO Estimates 2000 155

CHARTS

Chart 1 - Birth, Death, Marriage Rates (1880-1930) 33Chart 2A- Income For The Combined RHAs By Year & Source ($JM) 113Chart 2B- Income For The Combined RHAs By Year & Source (%) 114Chart 3A- Expenditure For The Combined RHAs By Year & Type (in $JM) 115Chart 3B- Expenditure For The Combined RHAs By Year & Type (%) 116Chart 4 - Analysis 2003/2004 Income By Amount (J$M) by RHA and Source 117Chart 5 - Analysis of 2004/05 Income By Amount (J$M) and By RHA & Source 118Chart 6 - Analysis of 2006/07 Income By Amount (J$M) By RHA & Source 119



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Chart 7 - Analysis of 2003/04 Collections (J$M) by RHA 120Chart 8 - Analysis of 2004/05 Collections (J$M) by RHA 121Chart 9 - Analysis of 2006/07 Collections (J$M) by RHA 122Chart 10- 2004/05 Actual Expenditure (in J$M) Analysed By Cost Centre 124Chart 11- SERHA2005/06 Budgeted vs. Actual Expenditure (in (J$M) Analysed

By Cost Centre 125Chart 12- SERHA 2006/07 Budgeted vs. Actual Expenditure (in (J$M) Analysed

By Cost Centre 126Chart 13- SRHA 2004/05 Budgeted vs. Actual Expenditure (in (J$M) Analysed



By Cost Centre 130Chart 16- NERHA 2003/04 Budgeted vs. Actual Expenditure (in (J$M) Analysed



By Cost Centre 134Chart 19- 2004/05 Expenditure Ratios By RHA 135Chart 20- Analysis of Payables (J$M) At 2005 March 31 By RHA & By Creditor 136Chart 21- Analysis of Payables (J$M) At 2007 March 31 By RHA & By Creditor 137Chart 22- Analysis of April – November 2005 Income (J$M) For Combined

RHAs By Source 138Chart 23- Analysis of April – November 2005 Income (J$M) For Combined

RHAs By Source 139



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APPENDICES

Appendix 1 - List of Stakeholders 187Appendix 2 – References 201Appendix 3 – Focus Groups 203Appendix 4 – Medical Officers of Health 201Appendix 5 – Policy Issues – All Groups 203Appendix 6 – Organisation/Structure – All Groups 204Appendix 7 – Human Resources Management 206Appendix 8 – Supplies Management and Procurement 207Appendix 9 – Supplies Management and Procurement (Regions) 208Appendix 10 - Patient Focus Group Discussion 211Appendix 11 - Public/Private Partnerships (Radiology) 214



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FOREWORDThe 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, 21st century, best-practice health care delivery system that addresses

the health problems of the Jamaican people in a sustainable and

comprehensive way.

This will provide a platform for private investment in the health sector

with particular reference to Health Tourism, as outlined in the manifesto of

the Jamaica Labour Party.

This comprehensive evaluation will require the services of a small Task

Force of highly competent individuals whose knowledge of and work in the

development of the Jamaican Health Service System will provide an objective

and evidence-based review of opportunities for cross sector collaboration

throughout the Regional Health Authorities.

The goal of modernizing the Jamaican Health Care delivery system is

achievable. Private sector organizations can play a critical role in building

this system. However, given its substantial investment in and ownership of

the health infrastructure, the government must retain the responsibility to

lead and facilitate this process of development with a multi-sectoral

approach.



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ACKNOWLEDGEMENTS

The Task Force wishes to acknowledge the contribution of all persons who

participated in this exercise. Particular mention must be made of the assistance

given by Mrs. Verona Hall (NERHA), Mrs. Joan Guy-Walker (SERHA), Miss Edlin

Thompson (SRHA) and Mrs. Marcia Clarke (WRHA) who arranged the interviews

and focus group discussions. Also the stakeholders who diligently completed

questionnaires, attended focus groups sessions and/or interviews .

We must thank the staff at ISALS (UTECH) and Coke and Associates/Eckler

Partners for accommodating us at their offices. Mr. Kenroy Guthrie, who stayed late

many evenings to help with the printing and patiently collated numerous drafts of

the Report..



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MEMBERS OF THE TASK FORCE

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

Environment comprises qualified specialists and consultants with knowledge

of the Jamaican Health Service System who possess relevant experience in

health system research and evaluation. Collectively, they share a deep

conviction of the value of health care to the citizens of Jamaica. The Task

Force comprised the following:

Task Force Members:

Dr. Winston Mendes-Davidson, C.D., J.P.Chairman,Adjunct ProfessorPublic Health and Health TechnologyUniversity of Technology (UTECH)

Miss Thelma E. CampbellFormer Chief Nursing OfficerMinistry of Health 2000 – 2004

Mr. Fabian BrownExecutive DirectorSt. Joseph’s Hospital

Hon. Daisy McFarlane-Coke, O.J., C.D.ActuaryCoke & Associates/ Eckler Partners

Dr. Sheila Campbell-Forrester(Unable to participate fully because of illness)Chief Medical OfficerMinistry of Health & Environment

Support Team:

Miss Gaile Sweeney Research AssistantMiss Jennifer Higgins Administrative AssistantMrs. Rosemary Ganley Editorial Assistant



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EXECUTIVE SUMMARY

The work of the Task Force comprised:

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

the Jamaican health care system with particular reference to

reports in the period just before the establishment of the Regional

Health Authorities (“RHAs”) and the first decade of their currency

• detailed historical review of the Jamaican Health Sector showing

its evolution over 250 years

• Interviews with Stakeholders (internal and external) and allied

agencies

• SWOT Analyses

• Guidance of Focus Groups from all the RHAs, held with Technical

Administrative and Primary Care Personnel, in order to identify key

issues as outlined in the Terms of Reference.

Some of these steps overlapped. Then followed the collation of the data,

responses, suggestions and recommendations, preparatory to the drafting of

the Report.

This Report is organized as follows:

Section 1 sets out the Terms of Reference. The methodology adopted by the

Task Force to obtain the data and solicit inputs is dealt with in Section 2. We

conducted interviews, administered questionnaires and facilitated Focus

Group discussions and SWOT Analyses in all the RHAs. Summaries of the

information data and responses obtained from the stakeholders are

presented in Appendix 3 to Appendix 9. The Stakeholders interviewed range

from Patients at Health Centres through all categories of professional ,

technical, administrative and support staff across all the RHAs and the Head

Office (MOH), professional associations ( e.g. MAJ, NAJ, Midwives



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Association, Dental Associations, Jamaica Enrolled Nurses Association,

Private Hospitals Association, the Jamaica Association of Radiologists) up to

Regional Board Chairmen, Chief Epidemiologist, Chief Nursing Officer,

Director HRM & Corporate Services, Principal Finance Officer, the

Permanent Secretary, the Auditor General and the Cabinet Secretary.

The questions addressed related to the objectives of the RHAs, the

determinants and characteristics of the Health Care Services, policies,

organizational structure, financing, manpower and supplies. Participants’

views were also canvassed on the relevance of the global Health Tourism

market to Jamaica’s health care system and Private/Public partnerships in

health service delivery.

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

and system over the past 250 years. This was done in great detail quoting

extensively from the available research materials and informed by the

Chairman’s institutional knowledge of the sector. The Report considers the

main drivers of the system and its characteristics prior to the establishment

of the RHAs.

Section 4 examines the operations of the RHAs, the scope for delivery of

health care, the Instrument of Delegation, and organizational structure

against certain paradigms.

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

• Organizational Structure

• Scope and Content – Primary, Secondary and Tertiary Care

• Health Information System

• Human Resource Management

• Supplies Management and Procurement

• Equipment



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• Finance

• Project Management

• Health Tourism

Recommendations from the groups and the Task Force are highlighted andindicated throughout the Report. For convenience the specificrecommendations from the Task Force are collated in section 12. Some ofthem are:

(1) The RHAs must be changed from semi-autonomous authorities tobecome Regional Coordinating and Enabling Organizations. In sodoing, each will be an integral part of the organization andstructure of the Ministry and a strong link between head office andthe Parish, enabling and supporting the function ofimplementation – which is the domain of the Parishes

(2) Head Office of Ministry of Health and Environment should focuson its primary role of policy formulation, policy determination, settingnorms and standards, monitoring and maintaining support functionsfor strategic health care delivery.

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

(4) Reorganise service delivery on the core functions of Primary,Secondary and Tertiary Health Care

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

(6) Re-establish the corporate structure to all hospitals with eachHospital governed by a Board of Management and not a HealthCommittee of the Region or parish. The reporting relationship tothe Board is to be the triumvirate of the Executive Manager, theSenior Medical Officer and the Director of Nursing Services. Thismust become part of a national standardized corporate structurewhich becomes part of the prerequisite for public/private



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partnerships and other community alliances includinginternational recognition and accreditation.

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

(8) The backlog of HR issues including appointments, promotions,salary packages, welfare and incentive schemes must beimmediately addressed by a special multi-disciplinary group inorder to improve staff morale.

(9) A National Human Resource Development Strategic Plan beimplemented as a matter of priority and that this be guided byepidemiologic principles.

(10) HCL be transferred to the NHF as a Department and be fullyintegrated into the NHF procurement system.

(11) Policies must be developed for the standardisation of allcategories of equipment especially with regard to energyconservation and the replacement of parts.

(12) Abolition of User Fees for Primary Health Care in everycommunity as the first step to fulfil the commitment of theGovernment, but ability to pay should inform cost sharing ofSecondary and Tertiary Care.

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

under discussion, summarise organisational issues and/or present recent

history and experience. Financial data from the RHAs for fiscal 2003/2004 to

2006/2007 are analysed and crystallised in Tables 14 -20 and Charts 2A to

23.

In particular the following diagrams incorporate our main recommendations

for the reorganisation of the roles, functions and reporting relationships of

the segment of the health sector embraced /to be embraced by the reorganised

Regional Health Organisations.



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Diagram 6 Conceptual Framework-OutliningLevels of Service Delivery

Diagram 12 Relationship between Head Office(MOH&E) , Region and Parish

Diagram 13 Head Office Organisational Chart

Diagram 16 Reporting Responsibilities BetweenStructures

Diagram 18 New Regional Organisation Structure

Diagram 19 Core Functions of the ParishOrganisation

Diagram 20 Scope and Content of Primary HealthCare in the Parishes

The list of the Participants at Interviews and Focus Groups are in Appendix

1. Appendix 2 gives the reference literature and consultancy reports which

were reviewed. Appendix 3 to Appendix 10 summarise the submissions

and comments on the issues which persons considered to have significant

impact the health delivery system.



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1.0 ESTABLISHMENT OF THE TASK FORCE1.1 TERMS OF REFERENCE

To review and evaluate:

• The policies governing the Regional Health Authorities.• The organization of the Authorities with special regard to the

structures, functions, manpower, supplies and financing of therelated entities.

• Their capabilities in planning, managing and implementingprograms and projects.

• The financial and technical efficiencies of the Authorities.• The relationship of the four Authorities to each other and to the

Central and Statutory Authorities of the Ministry of Health andEnvironment and its other Statutory Bodies and Agencies.

To make recommendations on the changes needed:In policy, organization, structure, function, manpower, supplies

and financing of the respective Authorities and/or their entities.

These recommendations must indicate:How they will contribute to the ordered and rational development

of a modern and efficient health services system capable of deliveringthe highest levels of cost-efficient and best-practice health services tothe Jamaican people.

What are the conditions necessary for building public / privatepartnerships in attracting private investment so that Jamaica willbecome a significant player in the rapidly emerging global healthmarket?

The Terms of Reference presented an opportunity for the TaskForce to do a comprehensive review, evaluation and analysis ofJamaica’s health service system, using the Regional Health Authoritiesas its point of departure. It also created an opportunity for best-practiceidentification in the quest for best solutions. It allowed the Task Forceto recommend necessary revisions of the existing policies,organizations, structure, functions, programs and projects in both thehealth institutional and non-institutional entities of the RegionalHealth Authorities and the related entities.



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Some fundamental questions were answered in order to inform acomprehensive review and evaluation of the Regional HealthAuthorities.

These questions were:

• What is the Jamaican Health Care sector? How did it develop?What are its enabling and disabling characteristics?

• What is the Regional Health Authority?• What was the justification for its introduction?• How do the RHA’s relate to the enabling and disabling

determinants and characteristics of the Jamaican Health CareServices?

• How relevant is the global Health Tourism market to Jamaica’shealth care system?

In keeping with these Terms of Reference an implementationframework was developed.

1.2 TASK FORCE IMPLEMENTATION FRAMEWORK

The Task Force worked in the period 29th October 2007 to 12thFebruary 2008. In this time it developed the following framework for itsReview and Evaluation:An examination of the Regional Health Authorities (“RHAs”)with respect to the following:a) Policies, b) Organization, c) Structure, d) Function, e) Manpower,f) Supplies, g) Finance.

The capabilities of the RHAs in:• Planning• Financial and technical efficiencies• The relationship between the four RHAs to the central and statutory

authorities of the Ministry of Health and Environment (MOH&E).• The Task Force was also mandated to recommend to the Minister what

changes are needed in terms of : a) Policies b) Organization c) Structured) Function c) Manpower d) Supplies e) Finance.



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• The Task Force was asked to indicate in its recommendations howthese changes will contribute to the ordered and rational developmentof a modern, efficient health services system.

• The Task Force undertook to outline the conditions necessary forbuilding Public /Private partnerships in health to attract privateinvestment in order that Jamaica may become a significant player inthe global Health Tourism market.

2.0 METHODS AND MATERIALS

STAGE 1

2.1 Historical Review of Jamaican Health Sector• Identify both driving forces (which enable) and restraining forces

(which disable) change, in order to present a comprehensive review ofthe Jamaican Health sector

• Define key processes that enable the achievement of the vision• Identify key stake holders who manage / control / enable these

processes• Review the relevant literature.

2.2 Prepare and Administer Instruments to Stakeholders to CollectData Derived From :

• Questionnaires / Interview Guides, SWOT Analyses, and FocusGroups

• Discussion on “What is stopping us from…..”

Collect all relevant information for the study.

STAGE 2

• Define the characteristics of a 21st Century Health Delivery Systemthat addresses the health problems of the Jamaican people in acomprehensive and sustainable way.

• Define the conditions necessary to attract the type and scope of privateinvestment required for building a viable Health Tourism sector.

• Categorize the problems based on the above criteria.



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• Make recommendations to specifically address the problems identifiedby the Task Force during the study.

All Instruments were prepared and tested prior to their administration.Standardized methods were used by members of the team and supportstaff.

STAGE 3

The Task Force:• Reviewed and analyzed local research papers and documents on the

Jamaican health care system – a means of gathering both primary andsecondary data. In particular we referred to Reports done prior toregionalization and consultation work done during the ten (10) years ofregionalization. We believe that these are the most current researchdocuments on the RHAs and the issues identified within these reportsstill remain and would be still valid for our analysis.

• Conducted personal interviews with key stakeholders including thePermanent Secretary, Principal Financial Officer, Regional Directorsand Senior Medical Doctors. Refer to Appendix 1: List ofStakeholders.

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

• Prepared a Draft Report on the findings, discussed it among the TaskForce members, finalised and submitted the Report to the HonourableMinister and the Permanent Secretary.

2.3 Limitations: Scope of Review

While it was pertinent to address the major stakeholders within theRHAs, due to the time constraints the Task Force grouped various categories



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

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

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



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3.0 THE HISTORICAL DETERMINANTS OF THEJAMAICAN HEALTH SECTOR

3.1 PRINCIPLES AND WATERSHEDS IN JAMAICA’S HEALTHSERVICE SYSTEM

The Task Force determined that a close look at the history of HealthCare in Jamaica would inform us of the core values which are embodied inour system over the years. These values have enabled the sustainability ofour system, and they should be revisited if we are to get clarity inunderstanding the Ministry’s mission and enable the conditions for asuccessful outcome.

The form and content of health service systems always reflect theprevailing social, economic, political, cultural and religious systems ofcountries. Every health service system is culture-bound and reflects theunique and particular characteristics of its society.

The direction, pace, quality and quantity of Jamaica’s health servicesystem have been determined, in the main, by the prevailing pattern ofdiseases (morbidity and mortality i.e. epidemiology) and conditions affectingthe system both at particular points in time and over different periods.

A brief summary of the two hundred and fifty year history of Jamaica’shealth service system gives evidence that epidemiological determinants haveprovided the context, conditions and circumstances for clinical interventionmeasures 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” andevery health service system must determine its unique interventionmeasures, adapted to the prevailing epidemiological patterns, conditions andcircumstances of the particular country.

Any change in the system, from a policy standpoint or from anorganizational standpoint must satisfy the fundamental criterion of beingevidence-based and having epidemiological justification.

Indeed the history of Jamaica’s health service system is characterizedby a number of watersheds. These have arisen from qualitative changes inthe epidemiological conditions, contexts and circumstances over the past 250years. One paradigm has endured: it is the essential core paradigm of



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“PATIENT / DOCTOR / DIAGNOSIS / TREATMENT”. It reflects theessence of the system’s long, enviable health development record.

Historical analysis also identifies the core paradigms at the centre ofthe health care delivery value-chain. It speaks to the relative importance andrelationships of different elements in the health care process delivery-systemand value-chain. Exaggerating any one’s importance in the system of valuesin the care delivery process is as dangerous as denying the importance of anyelement. We will examine to what extent each element has been predominantin the system.

In this Report, the system of values developed by the science ofepidemiology will inform the conceptual framework. If this is right, then therelative relationships among elements making up the delivery processes andvalue-chain will be right. This is the challenge which faces Jamaica’s healthcare system at this critical point.

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

Between 1658 and 1798, approximately 281,000 slaves were importedto Jamaica. Thousands died in the middle passage or became ill and diedafter arrival. The period of adjustment to plantation conditions known as“seasoning” took one to three years. This period was accompanied bymortality rates of 1/4 to 1/3 of the slaves being “seasoned”. Epidemics werecommon on plantations and as many as half the slaves died. At Worthy ParkEstates, of 181 slaves bought, one quarter died in one year from yaws anddysentery; and of 345 births, 186 children died in a five-year period. Slavesalso died from yellow fever, small pox, TB, worm infestations, maltreatment,over-work and starvation.

In 1792, passage in Britain of the Consolidated Slave Act called for theprovision of medical facilities and the submission of medical reports from thecolonies as to the numbers of slaves and the causes of death. This took place134 years after the beginning of the slave trade. Prior to that Act, the cause ofdeath of a slave was not required to be recorded. Medical officers wereemployed by plantations and had responsibility for the health of slaveowners, their families, and their indentured and house slaves. These doctorswere also responsible for general hygiene on the property, the control ofcommunicable diseases, and births and deaths. Field slaves were treated inmany instances in plantation “Hospitals” or “Hot Houses” and a number ofthese were manned by veterinarians.



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Comment: Although morbidity and mortality data for the plantationowners and their household and indentured serfs were not available,nevertheless the data speak to the early stratification of the health servicesystem based on a hierarchy of relative wealth. However, the idea of best carefor the wealthiest and not the neediest does not hold today as the healthsystem, in the majority of cases, has lost its wealth/hierarchy configuration.Although access to basic health services of Primary Care is universal ,remnants of the Jamaican class-structure are reflected in the organizationand structure of the health service system today,. The data also point to the250 year history of “The Physician” as having the central and leading roleat the core of the health care system in patient care, public and communityhealth and population medicine.

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

Slavery was abolished in 1838, and many plantations went out of business.The majority of doctors migrated, leaving only 50 doctors out of 200 doctorsprior to emancipation. Health and social conditions worsened. Ex-slaves hadno social protection, and jobs on the plantations were taken by indenturedlabourers (Indians & Chinese). By 1846 the Sugar Equalization Act waspassed which was the final act in destroying the plantation system.

Comment: Whenever there is a fundamental change in the social system,there are health consequences which may be good or bad. Highly trained andmarketable professionals will always be in demand. Their loss leads tonegative consequences in human development. These data provide earlyevidence of the close relationship between health and development. They alsopoint to the essential role of the physician in health service delivery.

3.4 COLONIAL POST-EMANCIPATION (CROWN COLONY)PERIOD 1846-1866

As the plantations closed down, worsening social conditions led to amassive epidemiological crisis in Jamaica. During this period, an outbreak ofcholera in 1850 caused 32,000 deaths; a smallpox epidemic in 1852, andepidemics of typhoid fever and cholera in 1853 resulted in deaths of a quarterof the population of Kingston, the victims being buried in mass graves. By1865, conditions were so poor that it led to the Morant Bay Rebellion.



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

Comment: The institutions of the colonial state broke down. Health carewas anarchic. Epidemiological conditions were worse than they had beenduring the plantation period. Death, destruction and rebellion wereinevitable.

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

In 1867, the Public Health Law was passed and it set up a Central Boardof Health. A Parochial (Local) Board of Health was established in the 14parishes. The Central Board was established as an Island MedicalDepartment with a Government Medical Service coming into being. TheseBoards endure to this day, albeit in a different form.

Greater emphasis on public health, better roads, safer water supplies, theenactment of quarantine measures and the provision of dispensaries occurredthroughout Jamaica. People, irrespective of income, were able to obtain drugsand medical supplies. The Kingston Dispensary was opened in 1870. Forsixty years it had only one doctor. By 1874, the 14 parishes were divided into40 medical districts and thirty-five District Medical Officers (DMO’s) wereallocated to 14 Parishes. Some Estate Hospitals were reopened and placedunder the administration of the DMOs.

Comment: The Central Board of Health dealt with health issues ofnational importance, whereas the implementation of the services toindividuals, groups and populations was the domain of the Local Board ofHealth in the parishes.

This change established the crucial relationship between health anddevelopment. Integration took place at the local level through the ParishCouncil mechanism, whereby public health, roads and communications, watersupplies, control of disease by quarantine and treatment of illness throughdispensaries were integrated under the auspices of the Parish (Local) Boardof Authority.

The management of the system was the responsibility of the medicaldoctor at both the field (parish) level and central level. This organization,structure and function represented the basis of the Government MedicalService of Jamaica’s health service system, the essence of which exists today.



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Financing the Health SystemDuring this period the District Medical Officer was paid a retainer by

the Government and allowed a restricted private practice not exceeding sixhundred pounds per year, using the scale of fees in Table 1 . DMOs wereexpected to perform any other duty designated by the Governor withoutcharge i.e. to paupers, the constabulary, prison inmates, and residents ofalms houses. They also supervised dispensaries did vaccinations and gaveadvice to government.

Table 1Fee Scale for Private Patients

Comment: In 1867 there was an element of fee-for-service (“patient pays”) inthe system, and a means test was introduced to assist the financing of thehealth service system. The principle of the means test which began in 1867 isstill used in our hospitals today. It has served the health services well. In ourthinking, there must be epidemiological justification for any change. One suchjustification would be the future capacity of the Government to fully fundhealth care delivery services. This is not a real possibility at this time giventhe low percentage of the national budget which is presently allocated forhealth care.

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

Patient Wages/- per week

Fee forService

Up to 12 Shillings No charge

12 to 25 shillings 1.5 shillings

25 to 50 shillings 2.5 shillings



26

THE TASK FORCE RECOMMENDS:The use of three criteria for monitoring consultants with geographic

private practice. These are: a) Service b) Teaching c) Research. Monitoringthese highly trained and experienced consultants only on the basis of thenumber of patients they are able to see per day is not utilising the vastpotential that these professionals have to contribute to the improvement ofpatient care.

3.6 THE NATIONAL HEALTH SERVICE SYSTEM 1900-1938

By 1900, there were 48 DMOs and 28 private practitioners serving apopulation of 640,000 Jamaicans. Thereafter, there was a steady increase inprivate practitioners, later overtaking the number of DMOs. Rapid expansionof hospital services, with the opening of three additional hospitals between1916 and 1926, led to a period of “hospitalization” of the health services to theneglect of the basic community health care preventive services.

In the 1935 report of the Hand Book of Jamaica, the public health reporttook up a mere paragraph compared to 10 pages of hospital statistics. Thisrepresented a complete reversal of the situation of the previous ten years.

Between 1918 and 1937, the Rockefeller Foundation supported theestablishment of the health departments and a new cadre “medical officers ofhealth” along with a new health cadre, the public health inspectors, who wereengaged in the control of communicable diseases such as malaria, hook worm,TB and yaws.

By 1945, two hospitals had more doctors than the total complement of allthe DMOs in the island. This undesirable proportion led to a shift in the coreparadigm of the health delivery system of the Government Health Service,which created some dysfunction in the delivery of health care. The 4 shillingsper head allocated for needy-cases was revoked and in 1904 a ticket systemwas introduced for patients to access the hospital services. This was the firstattempt to ration hospital services. It reflected a paradigm shift fromcommunity health services to hospital services.

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



27

tension between institutional and non-institutional clinical & public healthservices. This tension has persisted to this day. It is worse during times of scarceresources. Indeed this tension was further exacerbated by unprecedented allocationof resources to the hospital services system, in manpower, finance andadministrative support at the expense of the community / district health careservices. This was the first recorded period referred to as the “hospitalization” ofJamaica’s National Health Service system. The neglect of community clinical healthpractice in the district medical services continued, and led to an exacerbation ofnegative public health conditions on the ground.

The lack of prevention, early detection and clinical intervention measures dueto very low budgetary allocation to the Local Board of Health reduced access to basichealth service in the districts nearest to the homes of the population. On the otherhand, rationing of the hospital services because of overcrowding planted the seeds ofa national health crisis which was looming prior to 1938.

Table 2West Indian Mortality Rates 1928- 1938

1928 1930 1932 1934 1936 1937BarbadosDeath RateIMR

30.1331.0

23.1251.0

19.0198.0

23.0256.0

18.5198.0

18.5217.0

British GuianaDeath RateIMR

27.9185.0

23.0146.0

21.1139.0

24.7168.0

20.4120.0

21.9121.0

British HondurasDeath RateIMR

18.2 13.

19.2109.5

20.3104.8

19.2102.8

20.2152.7

18.5122.6

JamaicaDeath RateIMR

19.7157.0

17.0141.0

17.2141.0

17.0131.0

17.3130.0

15.3118.5

Leeward IslandsDeath RateIMR

31.4 24.8 20.693.0

19.7125.5

20.4111.2

20.6171.1

St. KittsDeath RateIMR

39.8308.3

37.2186.0

27.5166.7

30.7229.0

33.2164.1

36.5209.0

NevisDeath RateIMR

19.4286.6

24.2155.9

11.1102.2

12.3103.9

14.5177.4

14.9107.1



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A crisis and the failure of Colonial Governance methods throughout theWest Indies led to widespread riots in 1938. This resulted in the BritishCrown setting up a Commission of Enquiry chaired by Lord Moyne, known asthe “Moyne Commission”. The wide-ranging recommendations of thisCommission set the stage for far-reaching health policy changes throughoutthe Caribbean, most of which are still relevant today.

SOME CONCLUSIONS OF LORD MOYNE’S COMMISSION

• The cure of disease has received much more attention than itsprevention.

• Much ill-health arises from poverty; poverty of the individual, of themedical departments and of governments.

• Much ill-health is of a preventable nature and much arises fromignorance.

• The high rate of illegitimacy combined with large families, and a lack ofparental responsibility are serious factors in health.

• Housing accommodation for the poorer people in the West Indies isgenerally deplorable & general sanitation is primitive.

• Little improvement in the health of the people is expected no matterhow extensive the hospital facilities are.

• This will continue until such defects are remedied.• Relatively too large a proportion of the available funds and medical

efforts is expended on curative medicine and too little on prevention.• There is neglect of rural districts in favour of the urban areas.• The creation of at least one School of Hygiene with the training of

auxiliary medical personnel is recommended.• The centralization of medical institutions for the training of all classes

of medical personnel is recommended.• The reorganization of the medical services for the better balance

between preventive and curative medicine is recommended.• A minimum of ten percent of the National Budget should be spent on

health care services.



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Comment: The recommendations of Lord Moyne in 1938 identified theinextricable relationship among health conditions and poverty, illiteracy,available housing, provision of public health, availability of auxiliary medicalpersonnel, illegitimacy and irresponsible parenting, community development,and adequate funding of community health services. These linkages were tobecome the conceptual framework which informed the policy, organization,structure and function of Primary Health Care (PHC) services in Jamaica inthe 1970s.

3.7 PRE-INDEPENDENCE INTERNAL SELF GOVERNMENTPERIOD (1938-1962)

In 1939, World War 2 intervened and Lord Moyne’s recommendationswere put on hold.

The number of Medical Officers of Health increased from 7 to 17 andthey took over from DMOs at the parish level. In 1944, a New Constitutiongave the Jamaican people more rights with Universal Adult suffrage.

By 1957, internal self-government with Cabinet rule of locallyappointed Ministers of Government came into being. By 1959, Jamaicagained complete self-government. The problems of the Island Medicaldepartment were still the responsibility of the Colonial Governor.

By 1955, the Medical Department was incorporated into the Ministry ofHealth. Jamaica now had a Minister of Health, a Chief Medical Officer andPermanent Secretary.

A major epidemiological success was the eradication of malaria andyaws which took place in 1961, while hookworm and TB was reducedconsiderably. This was largely the result of the public health team working inthe parishes led by the Medical Officers of Health.



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Diagram 1

MINISTRY OF HEALTH ORGANISATIONAL STRUCTURE(Central Board: 1938-1962)

Source: W. Mendes Davidson 2007

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

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



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Diagram 2MINISTRY OF LOCAL GOVERNMENT

(Local Board: 1938-1976)

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

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



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Comment: The weakness in the organizational structure of the Ministry ofHealth became evident because of the separation of the parish health servicesfrom the central medical services at the end of Colonial Governance and thebeginning of internal self-government.The Central Ministry of Health was responsible for hospital services whileparish health services were under the jurisdiction of the Ministry of LocalGovernment. However the parish health services were better integrated withthe community development process in such sectors as water quality control,vector control, food hygiene, public hygiene in markets and restaurants etc.The strength of the local government process was to integrate health into thecommunity development.

The community participation model introduced in the development of theprimary health care services system in the 1970s was implemented to correctthis weakness of inadequate integration of health care services with thecommunity development process. Such integration was a critical factor inLord Moyne’s recommendations. 1Subsequent research done in Hermitageand August Town by Davidson (1973-1976) in the Department of Social andPreventive Medicine and replicated in Olympic Gardens established thevalidity of the concept in 1976. It must be noted that there was never anybreak in command in the medical services sector, a fundamental professionalprinciple which had been the policy of Jamaica’s Health Care Service since1867.

3.8 THE POST-INDEPENDENCE PERIOD (1962-1972)

After the 1961 referendum Jamaica seceded from the West IndiesFederation.In 1962, Cold War alliances deepened, with people voting out of fear becauseof the presence of Russian ships in the harbour. Independence in 1962 led tomembership in the United Nations. Prime Minister Bustamante declared “Weare with the West”.

The Ministry of Health then became preoccupied with hospitalinstitutional services which became the centrepiece of its policyimplementation. This policy alignment was in keeping with the Americanmodel of a hospital-centred health care system. It increased the tensionamong the non-hospital health services to the detriment of public health andcommunity health services; a repeat of the situation between 1900 and 1938.

1 Community Participation in Primary Health Care; W. G. DavidsonPublished 1978; Primary Health Care Jamaican Perspective



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This continued “hospitalization” of the Health Services in line with theAmerican model of a high- cost, hospital-centred health care delivery systemled to the commitment of the largest capital investment ever in the healthsector. This was the building of the Cornwall Regional Hospital.

Investment in this institution by the World Bank created very seriousdemands on the Jamaican Health budget as there were many design faultswhich had to be corrected. The institution became a mal-application ofEuropean hospital architecture funded by the Bank. The design placed theboiler under the Casualty Department to provide heating during the winter.Jamaica does not have a winter season and the heat of the Jamaican summerbecame so unbearable that the department had to be abandoned during thesummer. Subsequently, a Type 3 Health Centre was built on the hospitalpremises to carry out the work of the Casualty Department.

The Cornwall Regional Hospital consumed over 60% of the nationalhospital budget and this led to the gross under-financing of the other 28hospitals with the subsequent closure of a number of these institutions.

Chart 1Birth, Death, Marriage Rates 1880 -1930

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

0

10

20

30

40

1880 1900 1910 1920 1930

Death RateBirth RateMarriage rate



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consideration in attempts at service delivery designs for record linkages ofindividuals, families groups and communities.

Diagram 3

POPULATION EXPLOSION OF THE LATE 1960s

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

From an epidemiological standpoint, Jamaica had entered the stage of ademographic transition. Improvements in the health status of the populationresulted in lower death rates and greater birth rates with high dependencyratios, and demonstrated the inability of the economy to sustain the rapidrate of population increase.

The response to the situation was the development of family planningspearheaded by Dr. Lenworth Jacobs, whose pioneering work was



35

subsequently adopted as national policy by the Government with theestablishment of the National Family Planning Board in 1967.

Table 3

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

AreaBirthRatePer 1,000

DeathRatePer 1,000

Annual %Rate ofPopulationIncrease

World 34 14 2.0

Africa 47 21 2.6

West Europe 16 56 0.6

America N & S 29 32 2.1

Caribbean 35 35 2.2

Jamaica 35 7 1.6

Source: U.N. Demographic Year Book 1972

The Family Planning initiative was funded by the World Bank whichalso funded the Cornwall Regional Hospital which added another 400 beds tothe national hospital stock of beds.

Greater privatization was encouraged and the number of privatehospitals beds was increased during this period. There was continuedseparation between Central and Local Boards of Health, and health centresdid not receive any budgetary allocation but functioned essentially on an adhoc basis.

The Ministry of Health supply system was supported by theDepartment of Supplies located in the Ministry of Finance. Each hospital hada small group of artisans on staff but hospital maintenance was theresponsibility of the Ministry of Works.



36

Budgetary allocation did not reflect community activities in the field.The vast majority of health workers continued to be part of the hospitalsystem, and public health and community health care were neglected.

Results of a Knowledge/ Attitude/ Practice (KAP) study done by medicalstudents supervised by Dr. Davidson in the Dept. of S&PM in 1994, revealedthat as many as 78% of patients who were seen in the Casualty Departmentof the Kingston Public Hospital could have been adequately treated in ahealth centre, had the services been available in their own community. Thisstudy was part of the evidence which inspired the strategic development ofthe primary health care services in the 1970s.

Indeed, history is repeating itself in the current massive overcrowdingat the Bustamante Hospital for Children in the absence of a properlyorganized and structured national Primary Health Care system.

Diagram 4

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

Source: W. Mendes Davidson (1975)

By 1972 the organizational chart included the newly formed NationalFamily Planning Board. Two Principal Medical Officers (Medical; hospitals)and (Health; public health) were supported by Senior Medical Officers and



37

Medical Officers of Health. These PMOs reported directly to the ChiefMedical Officer who reported directly to the Political Directorate. The chain ofcommand of the central mission of the health services, the delivery of healthservices to the Jamaican people, was therefore unbroken.

This has been one of the most important principles in the delivery ofhealth care since 1867. The process begins with the patient / doctorrelationship, and diagnosis becomes the critical mission of this relationship.

3.9 MODERNISATION OF THE HEALTH SERVICES SYSTEM 1972-1989

Three unbroken periods of policies drove the development of the health sectorin the next 35 years: 1972-1980 (Michael Manley); 1981-1989 (EdwardSeaga); 1992-2005 (P.J. Patterson). Each period created both quantitative andqualitative changes which mainly resulted in positive outcomes.

Introduction of the Environmental Control portfolio in 1972 for thefirst time in the Ministry of Health was an important policy initiative whichcould have had a great impact on the development agenda of the country ifthe opportunities had been seized and sustained over the years. This period isseen as a preparatory step to enable the most far-reaching reforms to takeplace within the health service sector in 250 years.

3.10 HOSPITAL MANAGEMENT AND STANDARDIZATION

In 1972, the first task of the new Government was to complete theCornwall Regional Hospital and to commission its operations. The funds forthis project were approved and for the first and only time in 250 years theamount of expenditure on health care was 10.1 % of the National Budget(1972- 1973). World Bank consultants initiated new systems and protocols forhospital management, especially with regard to the larger hospitals. This ledto the classification of Hospitals into Type A, B, C, and D. The Type Ahospital was the benchmark for a Regional Hospital service system. This wasa precursor to the development of Centres of Excellence. The policy of theHospital Board structure was introduced. All hospitals were governed by aBoard of Management to satisfy international corporate practice standards.

The Minister announced the cancellation of all fees in hospitals. Therationale was that the revenue collected was far less than the administrativecost of collecting it. This declaration was underpinned by a politicaldeclaration that “health care was a right and not a privilege”. This was the



38

declared policy by the Government. The major challenge was theimplementing of this policy in concert with practical, evidence-baseddeterminants, and to translate this policy into affordable and sustainableactivities.

3.11 LEADERSHIP OF JAMAICA’S MODERN HEALTH REFORM AGENDA(1967 to 1980)

Jamaica’s modern health reform agenda began in earnest prior to 1967under the leadership of Professor Sir Kenneth Standard in the Department ofSocial & Preventive Medicine at the University of the West Indies. Heinfluenced the evidenced-based content of the 1974 Green Paper “The Healthof the Nation” presented to the House of Parliament. He was The ChiefTechnical Consultant / Advisor to the Ministry of Health (1972 to 1980) anddeveloped creative policies related to the delivery of health services inJamaica, the Caribbean and throughout the developing world. A pioneer andinnovator, he trained the first health auxiliaries, the Community HealthAides in the Hermitage August Town Research Clinic. Community HealthAides were introduced en masse to the Jamaican Health Service in the1970’s.

Sir Kenneth nurtured several young Public Health students, ( theParliamentary Secretary in the Ministry of Health from 1976 to 1980 Dr.Winston Davidson was one of them). In 1973, after Internship and CasualtyDepartment exposure, Sir Kenneth invited Dr. Davidson to do full-timeservice, research and teaching as head of the Hermitage August Town HealthClinic Unit in the Department of S&PM.

Research on Primary Health Care from a Jamaican perspective wasdone in the Hermitage August Town Clinic in the communities of Hermitageand August Town. Dr. Davidson won a seat as Local Government Councillorin 1975 and became the Deputy Chairman of the Public Health Committee ofthe Kingston and St. Andrew Corporation which is the largest LocalGovernment Jurisdiction in the country. He witnessed the problems of publichealth management which arose between the Central Board of Health andthe Local Board of Health. This exposure inspired the decision to unify theBoards of Health under one jurisdiction i.e. the Ministry of Health andEnvironmental Control between the years 1976 and 1977.

Dr. Davidson applied the Primary Health Care working modeldeveloped at the S&PM clinic at the Olympic Gardens Health Centre between1975 and 1976 at the request of the Government of Jamaica. This was



39

successful and the model became the precursor to the full implementation of“Primary Health Care: the Jamaican Perspective” at the national levelbetween 1976 and 1980.

Dr. Davidson recruited Dr. Christine Moody to head the newly formedPrimary Health Care Unit in 1977, which was one of the outcomes of theorganisational reform process.

The World Bank Project of the Cornwall Regional Hospital created theconditions for the organization of the non-institutional health services in theCounty of Cornwall as a regional pilot project. This was referred to as “TheCornwall County Regional Project” and was a pilot project of the Departmentof Social & Preventive Medicine at the University of the West Indies.

3.12 Health Administrative Office vis- a- visChief Medical Office 1955-1980

The Health Administrative Office, now Office of the Permanent Secretary(PS), was responsible for Administrative Support to ensure that theadministrative support systems were in place for the implementation ofpolicies, plans, norms, standards and technical support systems for all healthservices programs and projects. The area of service delivery with respect topolicies, plans, norms, standards and technical support for theimplementation of all health plans, programs and projects was theresponsibility of the Chief Medical Officer. The leadership of service deliverywas the domain of the Chief Medical (Technical / Advisory) Office and in thisregard had never been changed since 1867. The Permanent Secretary’s Officewas established when the Island Medical Department which was under thejurisdiction of the Governor and the Secretary of State for the Colonieslocated in London, became incorporated into the Ministry of Health in 1955.The Office of the PS maintained daily liaison with the Ministry of Finance(which controlled the supply management systems), and the Ministry ofWorks (which controlled the health maintenance systems) in order tocoordinate the financial, maintenance and supply management systems of theMinistry of Health, and to carry out the management of the budget of theMinistry of Health.



40

THE RELEVANCE OF THE 1974 GREEN PAPER TASK FORCERECOMMENDATIONS TODAY

The following are extracts from the recommendations.• The establishment of a Central Planning and Evaluation Unit

within the Ministry which would be responsible for theadministration and management of an integrated secondary andprimary health care service.

• T he estab lishm ent of a R egional M anagem ent team atthe county level consisting of a R eg ional M edical O fficero f H ealth , a R egional H ospita l M anager and a R egionalSenior M edica l O fficer.

• Primary Care services should be based at the Health Centres,which should be upgraded in keeping with their expanded rolein the delivery of comprehensive primary medical care.

• Health Centres should be demographically located, to serve aspecific population, the needs of who should be assessed.

• Para-medical personnel should be used in order to overcome theshortfal1 in medical personnel in delivering primary care.

• A special programme for the training of such paramedicalpersonnel should be established, with emphasis being placed onthe needs of the community e.g. Maternal and Child Health,Nutrition, clinical services.

• Greater emphasis should be placed on community medicine intraining programmes for physicians, nurses and other healthprofessionals.

• In view of the high cost of prod ucing a m edical grad uate ,new ly qualified Jam aican doctors tra ined at U W I shouldbe required to serve in the G overn m ent Service – e .g . tw oyears in a rural area ; th ree y ears in a n urba n a rea .

• Every effort should be made to retain qualified medical personnelby improving working conditions, providing adequateremuneration and providing more facilities for post-graduatetraining.

• Streamline the management and pharmaceutical services, usingmodern techniques and expertise, to ensure obtaining drugs at themost competitive prices, thus maintaining adequate supplies.



41

• Establish a Central Drug Testing Laboratory to monitor drugsimported into the Island as well as those manufactured inJamaica.

• Restrict the use of proprietary drugs with few exceptions andimport mainly generic drugs.

• Institute a nom inal charge for drugs (i.e. 20 or 30 cents) tohe lp defray the cost w hich would apply only to thoseearn ing over $20 per w eek .

• Special emphasis should be placed on health education of thewhole community especially the areas of Nutrition, FamilyPlanning, Maternal and Child Health, and CommunicableDisease Control, stressing the need for immunization.

• Make maximum use of manpower available in the community, bysetting up committees at each Health Centre, who would be ableto help in the launching and implementation of specialprogrammes in Health Education, Environmental Control, andNutrition etc.

3.13 POLITICAL INFLUENCES ON PUBLIC HEALTHMANAGEMENT IN JAMAICA

The national discussions on the Green Paper occurred in Jamaica at atime when there was heightening of Cold War global politics. Prime MinisterMichael Manley had just declared the PNP’s political philosophy ofdemocratic socialism and positioned his country in the domain of the non-aligned movement, a movement in which he subsequently became a worldleader. The impact on the health sector was immediate as the philosophy ofinclusion informed the declaration that health care was “a fundamentalhuman right of all Jamaicans” and the ultimate responsibility lay on theGovernment to manifest this right.

The consequences of this declaration of democratic socialism unearthedthe spectre of communism which had plagued the political landscape inJamaica in the 1962 general elections. This condition immediately placedJamaica yet again at the centre of east west cold war political tensionsinvolving the USA and The Soviet Union and Cuba. These internal andexternal political tensions affected Jamaica adversely and led to a flight ofhealth personnel, almost reminiscent of the 1838 flight of Doctors from



42

Jamaica. This necessitated the development of bilateral support agreementsfor health personnel from Cuba in order to prevent a collapse of the nationalhealth care system. These agreements further exacerbated the climate oftensions within the public health sector.

By 1976, the Parliamentary Secretary translated the PNP philosophy ofDemocratic Socialism into a coherent set of principles which were formulatedinto a new set of health policies referred to as 2Primary Heath CareJamaican Perspective. A number of these documents written by theParliamentary Secretary between 1975 and 1976 were informed by evidencefrom the research project in S&PM. These were made available in a documentwhich was published in time for the world conference on Primary Health Carein Alma Ata in the Soviet Union in 1978. This historical record confirms thereality of the influence of national and global political ideas, events andcircumstances on public health policy and action. Public health practitionersignore these conditions at their peril if they are to function with optimumprofessional integrity and efficiency in the interest of the population.

There is no fundamental difference between a hospital in Cuba andthat in the USA. Neither is there any difference in the treatment of streptonsillitis in Europe or China. Ideological difference does not determine publichealth practice; however, it does influence it.

The challenge of good public heath practice is to respect all ideologicalstreams and to work closely with the prevailing political ideas focusing at alltimes on the interest of the population, by constantly engaging in policyformulation, thereby creating the context, circumstance and condition tointroduce practical evidence based solutions on behalf of the people. In thisregard the formulation of policy must take its cue from the prevailing realpolitical ideas from which the conceptual frame-work is derived. Policies mustalways be in a constant state of upgrade as the evidence of scientific findingspermits.

If the political conceptual framework is irreconcilable with standardpublic health practice then the exercise of good judgement must be theattempt to engage policy makers, relentlessly presenting very clearlyunderstood scientific evidence to support the position to the contrary. Inthe final analysis, it is not about the interests of the public healthpractitioner but fundamentally about the peoples’ interests. Policyformulation as a public health tool is without doubt a necessity for successful

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



43

public health practice especially in a global marketplace of diverse anddisparate ideas.

3.14 IMF CONDITIONALITY AND ITS IMPACT ON PRIMARY HEALTH CAREINITIATIVES OF THE 1970s

The IMF conditionality in 1979 was very harsh and immediately PublicHealth became the first casualty. The West Indies School of Public Healthwas closed down. This school was commissioned in the late 1940s (in responseto the recommendation of the Moyne Commission) as an essential institutionfor capacity development for the health sector in the West Indies.

The School of Public Health trained Public Health Inspectors, PublicHealth Nurses and other members of the Primary Health Care team. Theother training programmes involving other categories of auxiliaries such asCommunity health aides, pharmacy technicians, and entomologic assistantsfor vector control; nurse practitioners were either drastically cut back orclosed.

The Cornwall School of Nursing was closed and this left a very largegap in human resource and capacity for health development which thecountry has not fully recovered from even after thirty years. The rates ofimmunisation decreased, the momentum of the Primary Health Careprogramme faltered, and the surveillance of communicable disease becameweakened.

There was cutback in the Primary Health Care budget, out ofproportion to its relative epidemiological significance and we suffered thepublic health consequences of this when Jamaica had an out-break ofpoliomyelitis, in the mid 1980’s after the disease had been eradicated twentyfive years before. This outbreak threatened the tourist industry and aftermany deliberations on the question of confidentiality vs. transparency a massimmunisation programme against polio was put in place and the mobilisationof communities led by the Public Health team effectively controlled theoutbreak.

Primary Health Care as a fundamental strategy for the delivery ofhealth services to the community lost its policy pre-eminence and as aconsequence lost much of its budgetary support. The institutionalisation of anumber of primary health care components in the Jamaican health servicesystem continued not-withstanding the set-backs and this led to performancelevels way below its potential or its capacity.



44

The IMF conditions also negatively affected the Secondary Health Caresector as Type D hospitals became easy prey for closure. This reality wasmade worse because sixty percentage (60%) of the national budget forhospitals was spent on Cornwall Regional Hospital, which had majorconstruction and design faults, some of which have yet to be fixed.

As a matter of Government policy, Secondary Health Care took centrestage after the change of Government in 1980, and the Inter-AmericanDevelopment Bank (IDB) became a very important player in funding theHospitals improvement project against the background of the slowing down ofthe regionalisation process started in the 1970s. There was, however,continuity of the Health Care Reform process in the area of the SecondaryHealth Care services by the new government and this was an importantpolitical statement since it demonstrated that the determining factor forhealth development was not political expediency but evidence-basedepidemiologic criteria. The hospital improvement project of the 1980s had avery positive outcome which laid the basis for the modernisation of Secondaryand Tertiary Health Care services in Jamaica.

Summoning the political will to close the Type D hospitals was animportant step in the right direction by the Government of the 1980s since itwas difficult on epidemiological grounds to justify the existence of Type Dhospitals nor could these non-viable facilities be financially justifiable.

In fact these “hospitals” should have been converted to ambulatory daybed facilities to address the large back-log of ambulatory surgical proceduresand other follow-up outpatient services of the larger hospitals. This wouldhave been an excellent differentiation of the existing Primary Health careservices. Once again the historical tension between the Hospitals Servicesand the Public Health Services was rearing its ugly head.



45

3.15 ORGANISATIONAL REFORMS PRIOR TO THE RHAs

By the end of 1970s, the organisational reform was in full flight, withthe integration of the Local Board of Health with the Central Board of Healthand the transfer of the maintenance division from the Ministry of Works tothe Ministry of Health and the Supply Division located in the Ministry ofFinance transferred to the Ministry of Health and Environmental Control.

The Ministry of Health was now fully in charge of the levers of decisionmaking and this enabled rapid changes to be made in the foundations of theorganisational reform process.

As a matter of policy, reorganisation of the health services wasestablished on the basis of levels of Care into Primary, Secondary andTertiary Health Care Services.

For the first time since 1867 Primary Health Care became a line itemon the budget of the Ministry of Health, the scope, content and extent ofpopulation coverage for comprehensive health services for the Jamaicanpeople became a reality.

The rationale for reorganisation into levels of care was not merely forthe health services to become more efficient but also to enable the fullintegration of the fragmented non institutional services on the ground fromthe most basic form to the most complex cutting edge service, from non-institutional to institutional and from the field level in communities to thecentral level in the Head Office of the Ministry. Integration must enableseamless interrelated functions of all levels of the Ministry led by a singleHead Office.

By streamlining the technical and administrative functions, intoCentral and Field responsibilities of the Ministry it would therefore bepossible to put in place a health information system to monitor, evaluate andtrack the process in the delivery of services and would also enable the fullintegration of all the elements and functions of the Ministry whether thesefunctions are at the Field level or at the Central level.

After the unification of the Central and Local Boards of Health underone 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 electedGovernments), policy determination, policy formulation, national strategicplanning, norms and standards, monitoring, consultative and supportfunctions to the Field level. The Field level would be responsible for PolicyImplementation and the Implementation of all service delivery, programmes



46

and projects. All service implementation functions would therefore bedecentralised to the Field level.

The principle was the separation of the policy formulation anddetermination, national epidemiologic and strategic planning, norms,standards and support functions to be the core functions of the Ministry’shead office and that these functions be separated from the implementation ofall services (unless in unique circumstances e.g. National EpidemiologicEmergencies), programs, plans, and projects which are the domain of theField level.

In so doing the Ministry of Health would function as one fullyintegrated organisation with clearly defined roles and responsibilities for itsthree fundamental organisational components:

a) The Head Office

b) The Regions

c) The Parishes.

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

The review and evaluation of the Jamaican Health Service System over250 years provided overwhelming evidence to confirm the definition of therelative roles and responsibilities and interrelationships of the serviceproviders to the bottom-line i.e. Patient Care.

Introduction of the Environmental Control portfolio in 1972 for the firsttime in the Ministry of Health was a very important policy initiative whichcould have had a great impact on the development agenda of the country ifthe opportunities were seized and sustained over the years. This period isseen as a preparatory step to enable the most far reaching reforms to takeplace within the health service sector in 250 years.



47

Diagram 5

CORE ORGANISATION OF THE HEALTH SERVICE (1972-1976)

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

3.16 TASK FORCE CONCLUSIONS FROM HISTORICAL REVIEW:

• That the chain of professional command in service delivery leadingdirectly to the political directorate was NEVER broken and this was aprinciple which characterised the development of the health servicesystem for over 150 years.

• This feature of an unbroken chain of professional command did notcompromise the supportive role of the administrative managementsystems during those 150 years.

• That patient care requires a complex set of MANAGEMENT principleswhich are evidence based and which require a unique set of clinicalmedical training and collegial consultative culture honed and cultivatedas a medical professional. This must be a prerequisite for being part ofthe command leadership of the clinical professional diagnostic valuechain.



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• Any category of health worker or member of the health team mayqualify himself or herself to function as an administrative manager butthe role as administrator cannot take precedence over the fundamentalcore value of patient/ doctor / diagnosis encounter and the consequentialintegrity of the value- chain. Indeed the ethical and medico- legalconsequences may result in cost implications which a number ofjurisdictions have experienced to their peril.

• Such consequences may result from spurious legal challenges andimplications for compromises of professional integrity. The outcome ofsuch ill-advised change of paradigm may render the practice of clinicalmedicine so contentious and so expensive as to becomecounterproductive to patient care and epidemiologic outcomes.

• Any change of these time honoured principles MUST only be consideredif there is overwhelming and irrefutable evidence to support theintroduction of such a new paradigm.

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

Diagrams 6 and 7 capture the essence of the relative elements determiningand ENABLING the sustainability of Jamaica’s Health service system andthe process driving its basic elements.



49

Diagram 6

The Conceptual Framework Outlining the Relative Levelsof Importance of Elements Determining the

Jamaican Health Sector 1867-1972

(W. Mendes Davidson Nov. 2007)

This diagram represents the logic of the core competences of theMinistry of Health. It represents the system of values and their relativeimportance without which there would be no logic in the process of delivery ofhealth care to the Jamaican people. At the centre is “patient care” where thepatient encounters his/her doctor who establishes the diagnosis which thenforms the epidemiological (scientific) basis on which patient management,plans, programs and projects for service delivery would take place.Administrative support is derived as a consequence of service delivery whichis derived from the evidence of epidemiology determined by the diagnosiswhich arises from the Patient / Doctor Encounter / Diagnosis / Program. Seealso Section 5.3.2.



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The next diagram demonstrates the logic of a modern efficient healthservice system.

Diagram 7

THE PROCESS AND LOGIC OF EFFICIENTHEALTHCARE SERVICE SYSTEMS

Source: W. Mendes Davidson December (2007)

Diagram 7 demonstrates the inextricable link and sequential relationshipbetween patient care diagnostic management and administrative support.

To invert this process and put administration at the centre of thesystem in health is to undermine the health care delivery mission andprocess. Further this channels scarce resource into areas which satisfy non-health care agendas to the detriment of patient care. The world is repletewith evidence of the consequences of such a reversal. In some jurisdictions thecosts of health care become prohibitive. An analogy could be that of a fightingarmy having its chain of command broken by the military officers reporting tocivilians during a war- a prescription for certain defeat!



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DISCUSSIONThe Ministry of Health became preoccupied with hospital institutional

services, which became the focus of policy implementation. This was inkeeping with the American model of a hospital-centred health care system.The public health agenda was secondary, seen as adjunctive to hospitalservices in the health care delivery process. Once again, the error is made onthe question of the institutional vs. non-institutional relationship. As LordMoyne pointed out thirty years before: “The cure of disease has received muchmore attention than is given to its prevention” and that “Little improvementin the health of the people is expected, however extensive the hospitalfacilities, until these serious defects are remedied”. Moyne also wrote“Relatively too large a proportion of the available funds and effort is expendedon curative medicine and too little on prevention”.

This observation was made not only by Lord Moyne in 1938, but also in1867 as a finding of the Royal Commission after the Morant Bay rebellion.Ignoring this reality plagued the health sector for over 150 years, but itbecame a fundamental principle in shaping the organizational reform effort ofthe 1970s. The conceptual framework locates and defines the patient / Doctor(health team relationship) as the essential value in the Jamaican health caredelivery system throughout its 250 year history. This is both a philosophy anda fundamental principle for service delivery.

Adopting this paradigm will enable rational and optimal relationships,support mechanisms and systems necessary to create the conditions for asustainable health care delivery system. Such a paradigm is the frameworkwhich will enable the vision of the Minister of Health and Environment: “A21st Century Modern Health Service System that addresses the healthproblems of the Jamaican people in a comprehensive and sustainableway”.

4.0 THE REGIONAL HEALTH AUTHORITIES (RHAs)

4.1 INTRODUCTION

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



52

• Policy making• Programme formulation• Programme execution.

The challenges that existed was due in part to the absence ofinstitutional knowledge which lead to the needs for organizational reform andimprovement in service standard.

We again quote from the 1974 Green Paper

• High degree of centralisation of the MOH decision making functionsleading to frustration, stagnation and inefficiency.

• Desperate need to decentralise the management of the services toallow for decision making at the local level, prevent undue delay,facilitate problem solving and bypass unnecessary bureaucracy.

• Need to integrate the health services under the jurisdiction of oneMinistry (Ministry of Health) rather than the division of healthservice authority between the Ministry of Health (Central Board ofHealth), and the Ministry of Local Government (Local Board ofHealth).

• Supply management and maintenance services were located in theMinistry of Finance and the Ministry of Works respectively, whichalso compounded the problem of undue delays, bureaucraticmismanagement and waste of resources.

• The need for this reform to begin from the bottom up using thehealth centre in communities as the basic essential entity inbuilding comprehensive Primary Health Care services for allJamaicans.

• That any reform must be sustainable and improve the efficiency ofthe Health Service system.

The new players in the health sector would have had an insight into thefactors causing the problem and would have been able to arrive at a moreinformed analysis and made a more accurate assessment.

Indeed the conditions in 1989 posed much greater challenges than the1970s because of the greater responsibility of the Ministry to deliver servicesnow that the levers of power such as the unification of the Boards of Healthunder one Ministry and the supply and maintenance divisions were handedover to the Ministry of Health.



53

There was no third party to blame for delays, frustration, stagnation andunnecessary bureaucratic inertia. This build up of frustration anddesperation resulted in the call for drastic action. Three Ministers within theshort space of five years attempted to grapple with these endemic challenges.

The public health fundamentals are clear, that there are still only twofundamental organisational streams in the health services sector:

• Health Care Service Delivery (Technical/Professional)• Administrative Support (Administrative / Managerial)

Both are inextricably linked by the following paradigm:3“Health care service delivery determines the content and form of its

administrative support, while, administrative support influences theoutcome of service delivery”

Both fundamental categories possess inherent management systems;service delivery is essentially a clinical management system andAdministrative support is a non clinical management system. The science ofepidemiology is the basis on which decisions are made for health servicedelivery systems and epidemiology and public health organisationalprinciples should inform the form and content of the administrative supportmanagement system.

4.2 CONDITIONS PRIOR TO THE ESTABLISHMENT OF THE PRESENT RHAs

The concept of 4Regionalisation is not a new one in Jamaica, and has much torecommend it. However the major challenge has always been the conceptualframework, policies and organisational forms which are to be put in place tojustify its introduction.The outcome of the National debates and consultation on health care between1974 and 1976 overwhelmingly justified the need for organisational reform ofthe Ministry of Health. Some of the factors which arose in the debates andconsultations were the following:

• High degree of centralisation of the MOH decision making functionsleading to frustration, stagnation, inefficiency.

3The Process of Health Care delivery Diagram 6“ A Healthy Jamaica In a Healthy World” Davidson et al

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



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• Desperate need to decentralise the management of the services to allowfor decision making at the local level, prevent undue delay, facilitateproblem solving, bypass unnecessary bureaucracy.

• Need to integrate the Health Services under the jurisdiction of oneMinistry (Ministry of Health) rather than the division of health serviceauthority between the Ministry of Health (Central Board of Health),and the Ministry of Local Government (Local Board of Health).

• Supply management and maintenance services were located in theMinistry of Finance and the Ministry of Works respectively, which alsocompounded the problem of undue delays, bureaucraticmismanagement and waste of resources.

• There is need for this reform to begin from the bottom up using thehealth centre in communities as the basic essential entity in buildingcomprehensive primary health care services for all Jamaicans.

• Any reform must be sustainable and improve the efficiency of theHealth Service system.

Prior to the unification of the Central Board of Health ( in MOH) and theLocal Board of Health (in MLG) between 1976 and 1980, the supply divisionfor the Ministry of Health was located in the Ministry of Finance and theMaintenance Division for the Ministry of Health was located in the Ministryof Works.

The Ministry was driven my its core mission which was service deliveryunder the leadership of the Chief Medical Officer and role and responsibilitiesof the Permanent Secretary was as chief accounting officer andadministrative support manager to the health services delivery systemlocated under the professional command of the Chief Medical Officer.

Unification of the Central and Local Boards of Health brought with it agreater scope of service delivery for the Chief Medical Officer and thisrequired the reorganisation of the service delivery sectors at the Ministry ofHealth into levels of care (Primary Secondary and Tertiary Health Care).This required the most far reaching health manpower / health teamreconfiguration of the Ministry of Health in its history.

For the first time there was a budget for Primary Health Care. This couldnot have taken place prior to unification of the health boards under oneMinistry. This new situation required new scope of work for the CMO and thereconfiguration of ALL service delivery programmes.



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While this was taking place in the service delivery area, for the first timethe Permanent Secretary was confronted with new direct responsibility fordesigning administrative systems to support the parishes and the addedresponsibilities of supply management and maintenance of ALL healthinstitutions. These two areas, maintenance and supply management havebeen 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 hadtraining in engineering to lead the process of a reconfigured administrativemanagement and support system in light of the new areas of responsibility ofboth supply and maintenance management was not coincidental.

The scope of administrative management was therefore expanded andthe Office of the Permanent Secretary became larger than ever before in thehistory of the development of the Jamaican health service.

This new situation however, did not change the fundamentals of thedeeply embedded core value chain of command of the relative roles of theleadership between the services delivery area and the administrativemanagement and support area.

The beginning of tensions between these two offices is seen in thediagram prepared by the collaborative efforts of Permanent Secretary and theChief Medical Officer in 1980.



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Diagram 8CORE ORGANISATIONAL REFORM MINISTRY OF HEALTH 1980



57

Source Dr. Sonia D. Davidson: Dissertation:“The future of Doctors in the Delivery of Primary Health Care 1980”

Key to figure:PMO: Principal Medical Officer; SMO: Senior Medical OfficerMO: Medical Officer of Health; PNO: Principal Nursing OfficerANO: Assistant Nursing Officer; PDS: Principal Dental OfficerDPS: Director Pharmaceutical ServicesDECS: Director Environmental Control ServicesDHES: Director Health Education Services

The organisational chart (Diagram 8) by no means exhaustivelyrepresents all the elements of the Ministry of Health in 1980. The areas to beadded include: Project Management (Capital Works), Prison Services, HealthLegislation, Sanitary Engineering Services, Education & Training Servicesi.e. Physiotherapy School, School of Public Health, Bureau of HealthEducation, In-service Nursing Education, Dental Auxiliary School,Government Chemist Department, Registrar Generals Department,Laboratory Services, Personnel and Establishment Division, UniversityHospital, National Family Planning Board, Hospital Boards’ ProfessionalCouncils, Bellevue Hospital, Quarantine Services, Central Medical Stores,Child Feeding Programme, Transport Management.

The administrative management and support functions also hadweaknesses e.g. lack of personnel with formal training in HospitalManagement, Financial Analysts and Health Planners.The rapid changes and development of the Ministry of Health during 1976 to1980 was unprecedented. New categories of workers were trained for Primary



58

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

Flight of Health and Medical personnel from Jamaica because ofheightened “Cold War” tensions led to the acceleration of the grave shortagesof medical personnel. This need led to greater bilateral cooperation with Cubaand (Socialist European) countries and the acceleration of the training ofmedical and dental personnel to fill this gap in the long term.

The introduction of Cuban Medical personnel to man the PrimaryHealth Care facilities and rural hospitals in general and the BellevuePsychiatric Hospital in particular resulted in more efficient andcomprehensive service delivery to the Jamaican people.

The organisational reform process enabled and supported as a matter ofpolicy, the revolutionary changes in the Bellevue Hospital from a custodialcare psychiatric hospital which it had been for over 100 years to a thedecentralised therapeutic hospital with a strong and vibrant communitypsychiatry programme. The Bellevue hospital changed from a custodialinstitution of approximately three thousand beds to a therapeutic communityoutreach institution of just over 1000 beds during the period of five years.This development took place under the leadership of the SMO of the BellevueHospital, Professor F. W. Hickling, supported by his Cuban counterpart.Professional leadership in all spheres of service delivery was strong and theunbroken service delivery value-chain was intact.

Administrative management support of the rapid service deliverychanges taking place in the Ministry was excellent and the Director of HealthServices Administration the late Ms Xenia Ellington was a shining exampleof best practice in the efficiencies which she brought to bear in administrativemanagement support systems in the Ministry of Health. She was a loyalmember of the health team and gave support far in excess of the call of duty.

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



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Compulsory immunisation was introduced as a prerequisite forattending primary school in 1978. The fall in the rates of infectionspreventable diseases i.e. diphtheria, whooping cough, tetanus and polio andtuberculosis in children was unprecedented.Jamaica was the first Caribbean country to develop a National Formularywhich was implemented under the leadership of Dr. Peter Figueroa whoworked in tandem with the Director of Pharmaceutical Services Mr LesterWoolery between 1977 and 1980.

“Primary Health Care for All by the year 2000” was the “Declaration ofAlma Ata” in the Soviet Union in 1978 at which forum the Jamaicandelegation led by the Parliamentary Secretary were honoured withmembership of the drafting committee. Jamaica’s achievements of globalleadership in this area went almost unnoticed although it has been said byreliable sources that this goal was achieved in Jamaica before the end of themillennium 2000.

Preserving the integrity of the health services sector delivery value-chain is a precondition for evidence-based health care delivery and thereforesustainability.

This professional value-chain is reflected in the preservation of theintegrity of the services by utilising the most appropriate organisationalcontext and form based only on epidemiological criteria and evidence.

Indeed these successful programmes of the 1970s were grounded in principlesderived from tried and proven public health practice and which were craftedaround the long term needs of the patients in their communities.The public health principle of developing the services designed to meet theneeds of the patients as close to their homes as possible is a very importantenabling strategy for effectiveness and efficiency in the delivery of publichealth services.

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



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This factor sometimes leads to an exacerbation of the tension betweenthe two roles of Permanent Secretary and Chief Medical Officer. Just as theintroduction of Primary Health Care services also increased the tensionbetween the Hospital and non-Hospital services throughout our history.

The cause of this phenomenon is linked to the fact that they are competinginterests for scarce resources.

The role of the health team is of vital importance in this regard and themost important tool or measure which should be used to establish thepriorities for resource allocation in the health services sector is the science ofepidemiology.

In the absence of the application of epidemiological methods, thedevelopment of territorialism and cronyism will develop among healthpersonnel and may lead to a further deepening of the crisis of management ofand within the system. If these phenomena become institutionalised, thechange-management techniques must be applied within context.

Change management as a methodology is a vital and necessary componentof the reform process. Greater depth of analysis and evaluation of questionsrelating to conceptual framework, policies and organisation, structure andfunction coupled with fundamental reforms is the only way of breaking out ofthis type of institutionalised dysfunctional culture.

The history of Jamaica’s Health Services sector demonstrates that PublicHealth / Primary Health Care services are always the immediate victims ofcutbacks in resources, and perhaps that is why a culture of creativity hasdeveloped in public health.



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Diagram 9

THE SCOPE AND CONTENT OF COMPREHENSIVEPRIMARY HEALTH CARE 1980-2000



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

This caused setbacks in the possibilities for even greater health servicedelivery, the impact of which is still felt thirty years after its introduction.

The experience confirms the public health dictum that mistakes inpublic health practice may take a generation to be recognised and even longerto be corrected.



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The organisational chart reflected the thinking with regard to the scopeand content of comprehensive Primary Health Care with minor modifications.The scope and content of primary health care is exhaustive and eachsubcategory requires coherent national policy guidelines. Strategic planningand development requires the most rigorous participation and collaborationwith the implementation of services in the field and necessary administrativesupport.

The institutional framework of the clinical component of primaryhealth care services is the network of health centres throughout the island.This is partly documented in the 5Goffe / McCartney report. The reportoutlines the health centre network and takes into consideration thedemographic shifts in the system. This is indeed a viable framework as astarting point in rebuilding the clinical component of the National PrimaryHealth Care Programme.

It adequately deals with the institutional (Hospital) integration of PHCclinical services with the hospital system, but is woefully inadequateregarding the non-institutional public health component and its backwardlinkages in the community development process. Epidemiological principlesare involved here and must be clarified.

The “Prevention Model” developed by Public Health Specialists Leavel& Clarke from the USA 1940s and revised by Mendes-Davidson 1975, belowclarifies the epidemiologic fundamentals related to the principles ofprevention and the relative roles of primary, secondary, and tertiary healthcare intervention services. The organisational assignment of primary healthcare to the secondary and tertiary system violates these principles.

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



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Diagram 10

The Prevention Principles & The EpidemiologicalBasis For Primary, Secondary And Tertiary Health

Care Intervention Services.

PreventionMaintainHealthyLifestyle(Wellness)

COMMUNITY

State of Health The HealthCentre The Hospitals

COMMUNITY

PrimaryHealthCare Services

Secondary& Tertiary

HealthCare

Services

PrimaryHealthCare Services

Prevention

Rising Costs:

Rehab

Source: Leavel & Clarke; Revised W. Davidson. 1999. (copyright)

PRE-PRIMARY PREVENTION(Maintain Health & Wellness)

PRIMARY P REVENTION(Decrease Incidence)

SECONDARY PREVENTION(Decrease Prevalence)

TERTIARY PREVENTION(Avert Chronicity)

The HealthCentre

Treatment

Diagram 10 illustrates the evidence which confirms the fact of theviolation of both prevention and epidemiological principles when the clinicalinstitutional component of Primary Health Care (the Health Centres) islocated under the command of the hospitals organisational structure.The Health Centre is a vital and necessary community based clinicalinstitution of Primary Health Care. This is taken to mean health promotion,health risk reduction, early detection, early ambulatory treatment,community based rehabilitation averting “chronicity” and communityparticipation.

There is therefore no scientific justification for locating Health Centresunder the command of the hospital services system as is presently the case.The rationale to attempt justification of this change is the need forintegration of services. This is a vital and necessary outcome but this mustalways be placed within the context of sound epidemiological principles,otherwise the service interventions will be unsustainable.

Health Centres must always be located under the public healthcommunity based Primary Health Care services.

These were the conditions which preceded the establishment of theRegional Health Authorities.



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It is convenient at this stage to consider an organisational chart whichwas prepared in 1990 under the leadership of George A Briggs. Diagram 11.reflected the new thinking arising from the organisational tensions betweenPermanent Secretary (Administrative support) and Chief Medical Officer(Service delivery).

Although that structure was not implemented, nevertheless all itsessential elements were put in place. These changes resulted in a shift in thepolicy and paradigm of the Ministry of Health from the patient centredservice delivery system of over 150 years to an administrative managementcontrol centred system.

This is the essence of the policy dysfunction of the present RHAssystem, and one of the focal points of this comprehensive review andevaluation process. Without addressing this fundamental question, themission of this task force would be a pointless exercise.

The rationale is that the Chief Medical Officer should no longer reportdirectly to the Minister of Health but through the Permanent Secretary. Ifthis became the standard, then the new paradigm would have organisational“justification”, therefore, for all health and medical professionals in the areaof service delivery to report to administrators. Implementing this policy in anumber of areas in the RHA has had the most far reaching dysfunctionaleffect on service delivery in the history of the health service sector in Jamaicaand is at the heart of the dysfunctions of the present Regional HealthAuthorities.

Diagram 114.3 PROPOSED ADMINISTRATIVE MANAGEMENT CENTRED SYSTEM (1980)



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4.4 PROFILE OF THE RHAs

The RHAs were established under The National Health Service Act of1997 and implemented through an instrument of delegation.



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It is referred to as an “Act which repealed the Hospital (Public) Act”.The Instrument of Delegation highlights:“The rationalization of the administration within a decentralized structurewill improve efficiency and accountability in the use of resources,organizational communication and facilitate decision making with locallybased managers responsible for the operation of each region. The autonomy ofeach region within a given framework will eliminate delays which have hitherto adversely influence the efficiency with which healthcare has been madeavailable to the public……..

The Regions were determined by examination of and analysis of geography,proximity of facilities in several parishes, the traditional patterns ofutilization of health facilities, the transportation flows, as well as feasibilitystudies undertaken” (George A. Briggs, Instrument of Delegation, March1998). The four Authorities are:

• South East Regional Health Authority (SERHA)• Southern Regional Health Authority (SRHA)• Western Regional Health Authority (WRHA)• North East Regional Health Authority (NERHA).

Table 4

Population and Geographical Extension ofHealth Regions in Jamaica, 1999

REGION EXTENSION(Km²)

POPULATION DENSITY (p/km²)

JAMAICA

North East

South East

Southern

Western

10,991

2,637.1

2,387.7

3,238.8

2,726.9

2,590,400

356,000

1,214,700

562,300

457,400

236

135

509

174

168

Source: Planning and Evaluation Unit-MOH, StatisticalInstitute of Jamaica (1999)

Table 5STAFF STATUS OF THE RHAs- Jan 2008



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REGION E P P S SAP As. Vac. U Vac. Temp S U S O C XS

SERHA 2,326 217 926 73 668 40

SRHA

WRHA 917 104 2 268 11 498 355 62

NERHA 1,503 791 64 333 34 238 16 368

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

4.4.1 SOUTH EAST REGIONAL HEALTH AUTHORITY

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

In terms of people coverage, it is the largest Regional Health Authoritywith responsibility for 47% of the total population.

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

.

Table 6Hospital Profile- SERHA



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Institution Type BedComplement

OccupancyRate

Remarks

A B C

Kingston Public ü 505 89.4% National Referral Hospital

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

*Bassinet

Spanish Town ü 242 132%

BustamanteHospital forChildren

ü 253 60% National Referral Hospitalfor paediatrics

Princess Margaret ü 122 70%

Linstead ü 50 55%

Bellevue ü 900 90% Specialist – PsychiatricHospital

National Chest ü 98 37% Cardio-thoracic/Pulmonaryfacility

Sir John Golding ü 70 68% Rehabilitative facility

Hope Institute ü 44 58% Oncology facility

Table 7Health Centre Profile -SERHA



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Parish Type1

Type 2 Type 3 Type4

Type5

Satellite Total

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

Health Care is delivered through a network of ten (10) hospitals andEighty one (81) Health Centres. There were also eight (8) satellite clinics.Five (5) of the ten (10) hospitals within the region are also specialist orNational Referral Hospitals. (See Table 7) Some of these institutions alsoaccept patients referred from other Caribbean islands.

SERHA employs approximately 5,000 individuals from a variety ofmedical and non-medical groups. These include staff directly involved withhealth care delivery, for example nurses, doctors, technologists, pharmacists,health record administrators, attendants and public health inspectors.

There are other staff members who work to ensure that the health caredelivery system functions at an optimal level and give support to thosecharged with the direct delivery of health care. These include among othersthe Management Information staff, Maintenance Teams, Human Resource,Administrative and Accounting staff.

SERHA is managed by a team of directors led by the Regional Directorwho reports to a Board, which is appointed by the Minister of Health. Theregion is funded by allocations from the Ministry of Health and User Feescollected at its institutions, project support and donations.

4.4.2 NORTH EAST REGIONAL HEALTH AUTHORITY

The NERHA comprises the Parishes of St. Ann, St. Mary and Portlandwith 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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general population and makes it the least populous of the four RHAs. Locatedon the northern coast of the island the North East Region houses some of themost important tourist resorts and attractions. It received the smallest shareof the MOH Grant.

Table 8Hospital Profile- NERHA


OccupancyRate Remarks

A B CSt. Ann’sBay Hospital ü 249 85%Annotto BayHospital ü 95 57.1%

Hospital beingupgraded to a Bfacility.

Port MariaHospital ü 60 50%Port AntonioHospital ü 95 49 %

Table 9Health Centre Profile - NERHA

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

St. Ann 11 8 4 1 - 24

St. Mary 18 8 4 - - 30

Portland 12 3 1 1 - 17

Total forRegion

41 19 9 2 - 71

NERHA has responsibility for a health network of seventy-five (75) HealthCentres with different degrees of resolution capabilities. There are four (4)General Hospitals, one (1) Type B, the regional referral Hospital in St. Ann’sBay, St. Ann, and three (3) Type C hospitals one (1) in Port Antonio Portland,and one (1) each in Annotto Bay and Port Maria in St. Mary.



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4.4.3 SOUTHERN REGIONAL HEALTH AUTHORITY (SRHA)

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

Table 10Hospital Profile-SRHA


OccupancyRate

Remarks

A B CMandevilleRegional

ü 220 95%

May Pen ü 150 70% Hospital beingupgraded to a Bfacility

Black River ü 97 77.5%Percy Junior ü 121 60%Lionel Town ü 45 36%

Table 11Health Centre Profile (SRHA)

Parishes Type 1 Type 2 Type 3 Type 4 Type 5 TotalClarendon 13 11 8 - - 32Manchester 12 5 6 1 - 24St. Elizabeth 8 7 6 1 - 22Total for Region 33 23 20 2 - 78

4.4.4 WESTERN REGIONAL HEALTH AUTHORITY

WRHA serves a population of 467,461 (1999 estimates) in four parishesdistributed as below:

Westmoreland - 143,042



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Hanover - 68,978St. James - 180,728Trelawny - 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 12Hospital Profile- WRHA


OccupancyRate

Remarks

A B C

CornwallRegional

ü 342 86.3%

Savanna-laMar

ü 140 88.4% Two (2) privatebeds included.

Falmouth ü 60 73.4%

Noel Holmes ü 38 51.1%



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Table 13Health Centre Profile- WRHA

Parish Type1

Type2

Type3

Type4

Type5

Satellite Total Remarks

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 forRegion

40 25 12 3 1 1 82

4.5 THE NEW STATUTORY RHA AND ITS INSTRUMENT OF DELEGATION

The literature reveals that the creation of the 6Regional Health

Authorities was signed off in March, 1998 by George A Briggs, Permanent

Secretary in the Ministry of Health. This document created the deepest

departure from the fundamentals of the Health Service delivery system that

has taken place in the 250 year history of the Jamaican health service

organisation. Review indicated a conceptual flaw in both organisation and

structure of the RHAs. This has caused serious concerns for the effective

functioning of the Jamaican Health service system.

Fundamental conceptual flaws of the document are now outlined.

6Instrument of Delegation George Briggs Permanent Secretary Ministry of Health, March1998.



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There are four, semi-autonomous Statutory Regional Authorities with

their respective corporate structures creating the conditions for five Health

Authorities (if the Head Office of the Ministry of Health is taken into

account).

Each of the five entities is carrying out roles of policymaking,

programme formulation and programme execution. This breaches the

fundamental principles of good health service management, which ought to

have clearly defined roles and responsibilities specific to levels of function

within the health service matrix. This is a major point of departure from the

historic principles and practice of public health in the development of the

Jamaica’s health service system.

There is a noticeable absence of documented justifiable evidence to

support such a fundamental change

The balkanisation of the health care delivery system into five semi-

autonomous parts while at the same time asserting that “integrated health

care” is the objective is a contradiction.

The imposition of Administrative Management as the core-value of each

health service system and not “Patient care”, inverts patient care at the

centre of the health services delivery process. This paradigm contradicts 250

years of time-honoured principles governing the evolution of the health

service delivery process in Jamaica.

There is an absence of epidemiologically justifiable evidence coupled

with contradictions of fundamental principles of public health practice in

service delivery. The dysfunctional outcomes are therefore not surprising.

The delegation of “policies, resources and management objectives,

within which the local authorities will have greater freedom to manage”,

without a careful analysis of the epidemiological contexts, circumstances and

conditions of the Ministry as a whole, defies the most basic principles of

management of health services.



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

principles governing medical professional practice e.g. peer review, peer

consultation, peer advice and supervision, peer reporting, collegial referral,

patient care / health team coordination; medical ethical principles governing

patient / doctor relationships, patient / doctor rights and responsibilities,

medico legal issues governing patient care and service delivery.

Breaking the chain of professional command in patient care by having

medical professionals reporting to administrators who may have neither

knowledge of nor competence in patient care nor population medicine is not

recommended. This could creates serious problems in health service delivery

with medico-legal consequences.

Destroying the corporate board structure of Jamaica’s hospitals by

removing all the Boards of Management and replacing them with a system

where the Senior Medical Officer of the institution and the Director of

Nursing Services of the hospital reports to a CEO who may not have nursing

or medical knowledge, is also flawed. The CEO then reports to a Health

Committee chaired by an administrator. In a litigious jurisdiction such

hospitals operating without a Board of Management and therefore without an

universally acceptable corporate structure would be closed down without

recourse. The implications for medico- legal consequences are far reaching.

Role misrepresentation, poor communication, contradictory policies,

gaps in service delivery, fragmentation of service delivery, overlapping of

functions, exacerbation of resource challenges, are a few of the outcomes.

Results from the findings of the historical review of the Jamaica’s health

service confirm the validity of the foregoing analysis.



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5.0 FINDINGS OF STAKEHOLDERS5.1 ORGANISATIONAL STRUCTURE

Responses from the Focus Groups, Interviews and AdministeredQuestionnaires highlighted the following structural issues, which impactnegatively on staff performance and the service delivery:

THE MINISTRY (Head Office)

• Roles and functions at the MOH overlap. For example, HealthProtection and Promotion and Health Systems Integration.

• Too much bureaucratic humbug.

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

• Make all top posts contractual - e.g. 5 years with possibility ofrenewal conditional on satisfactory performance.

THE RHAs

• The lack of decentralisation of some roles and responsibility.

• Bureaucratic structure delays decision making, slows thecommunication process and causes inefficient use of resources.

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

• The technical structure at the Regions needs to be broadened toaccommodate technical experts to coordinate the implementation ofprogrammes.

• All three structures (Ministry of Health, Regional Health Authority(Regional Office) and Parish need to be reviewed bearing in mind thatthe goal is to provide patient centred care.

• Inconsistency in the region and parish structures, this is attributed tothe lack of an approved structure “signed off’” by the MOH.

.



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• Lack of corporate structure for hospital management which facilitatesdecision making. Currently the CEO decision making powers arelimited. For example, to purchase critical pharmaceutical items such asdrugs, the request has to be sent to the Parish Manager who supportsthe request then sends the request to the Region for processing. Thestep in the process of reporting to the Parish Manager should beomitted.

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

• The lack of parish administrators to manage the day to dayadministrative support operations of the parish.

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

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

PARISHES

• Lack of standardisation of structure.

• Technical officers of the professions supplementary to medicine,working without supervisors.

• Dysfunctional reporting relationships between the technical and non-technical staff; for example, Medical Officer of Health reporting to aParish Manager, and the professional nurse chain of command to non-technical persons.

Summary of Suggestions from Interviews(1) Create a structure with a ratio of Administrators to Technical Staff

relevant to the delivery of service.(2) More input by technical staff.(3) Revision of parish structure and standardize structures

across regions.(4) Review parish managers’ role and function – abolish role of Parish

Manager.(5) Effect Organizational changes within the RHAs



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including making all top positions contractual (5 years with renewal).(6) Health is a technical Ministry and must be led by technical people.(7) Re-orientation of the Permanent Secretary, Regional Directors and

Administrators to recognize their role as supportive and facilitatoryand change the “I am in charge” mentality.

(8) Align resources with programs and technical director determiningresource allocation within the health policy and priorities.

Task Force Recommendations1) Head Office of MOH&E should focus on its primary role of

policy formulation, policy determination, setting norms and standards,monitoring and maintaining support functions for strategic healthdevelopment.

2) Reorganise service delivery on the core functions of Primary, Secondaryand Tertiary Health Care.

3) The RHA must be changed from a semi-autonomous authority to beinga regional coordinating and enabling organizational system. In sodoing, it will be an integral part of the organization and structure of theMinistry and a strong link between head office and the parish, enablingand supporting the function of implementation.

4) Develop a HR system which recognizes the relative roles of themembers of the health team in service delivery and the supportingrelationship of the administrative teams and systems.

5) Ensure that there is a national standard for the establishment of theoperations of organizations and structures at the regional and parishlevels.

6) Redefine the role of the Parish Manager to become the leader of theadministrative support team and system; facilitating, enabling andsupporting the efficient implementation of health service delivery at theparish level.

7) Reinstitute the health team approach as the basic managementstandard for service delivery both in the hospitals and the non-hospitalsectors. This approach will enable the coordination of technicalfunctions necessary for the efficient management of service delivery.

8) Re-establish the corporate structure to all hospitals with each hospitalgoverned by a Board of Management and not a Health Committee ofthe region or parish. The reporting relationship to the Board would bethe triumvirate of the Executive Manager, the Senior Medical Officerand the Director of Nursing Services. This must become part of a



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national standardized corporate structure which becomes part of theprerequisite for public/private partnerships and other communityalliances including international recognition and accreditation.

9) Each Hospital Board must have representation from the region or theparish as indicated in order to enable the coordination and integrationof the levels of care in service delivery.

.

Diagram 12

TASK FORCE RECOMMENDATION(RELATIONSHIP BETWEEN HEAD OFFICE, REGION AND PARISH)

Source: W. Mendes Davidson (2007)

Diagram 12 highlights the integrated and interrelated role and

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



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Diagram 13TASK FORCE RECOMMENDATION - MOH&E

(HEAD OFFICE)ORGANISATIONAL CHART



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All Statutory Agencies and Departments not included in the diagrammust have a direct line reporting relationship with the PermanentSecretary who is the Ministry’s Accounting Officer.

The Task Force recommends the organisational framework at

Diagram 13 which identifies the very essential directors and principals

in the critically necessary areas to be given leadership of a reorganized

MOH&E. There are many other portfolios which are not represented in

the diagram the details of which are to be decided according to

epidemiological and resource capabilities. These portfolios we regard as

very essential and necessary to achieve the objectives of a modernised

Jamaican Ministry of health which will be equal to the challenges of the

twenty first century. This is by no means exhaustive but will evolve as

the conditions change and the situation demands.

What is important is the development of multidisciplinary

decision making teams at the Central Level in order to fully integrate

policies, norms, standards, and support functions for the Regional and

Parish Levels service delivery and administrative support functions

and operations.

This is vital for successful execution of the respective portfolio

responsibilities at Head Office.

The health team approach MUST be an important factor in the

annual performance appraisal of all staff, including principals and

directors. Use the contract terms to ensure satisfactory performance.

5.2 RECOMMENDED CHANGE IN POLICY FRAMEWORK FOR REGIONS

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

Diagram 14, to a fully integrated Regional Health Organization System as in

Diagram 15. The integration would be both vertical i.e. with the Head Office

and Parishes and also Horizontal, i.e. with the other Regional Organisations.



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Diagram 14SEMI-AUTONOMOUS (RHA) STATUTORY BODY

Diagram 15

FULLY INTEGRATED REGIONAL ORGANISATION SYSTEM



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Diagram 16Reporting Responsibilities between Structures

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

The Regions would then have the following responsibilities for:

1. Health services development, coordination, facilitation, review,monitoring and support systems and processes for program andproject planning and implementation at the Parish level.

2. Coordinating the implementation of national health policies withand between the Parishes at the FIELD level.

3. Functioning as nodal points in a National Health InformationSystem linked to a Ministry of Health, national networkinfrastructure, located, directed, and managed from the HUB(Network Operating Data Centre) of the National Health Fund.

4. Health Information Systems and resource allocation (Manpower,Materials and Money) to the parishes.

5. Forming the bridge between the Ministry (Head Office) and theParishes, which are the responsible entities for MOH&E healthservices implementation.

6. Inter-regional coordination. All systems and processes withinregions adhering to national standardized systems of practice andinteroperability enabling the free movement of resources betweenregions as the need arises.

7. Determination of needs unless in cases of national emergenciesand vertical mission critical programmes.

Chief Medical OfficeMOH&E

Principal Medical OfficerRegional Technical Administrators

Senior Medical OfficerParishes



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8. Physical resources of the region which belong to the MOH&Ealthough the Regions hold these in trust and must account forthem. Periodic audits must be mandated.

5.3 TASK FORCE RECOMMENDATIONS FOR ESSENTIALFUNCTIONS OF REGIONAL HEALTH ORGANISATIONS

5.3.1 Essential Functions of Regional Health Organisation: Field levelenabling and supporting mechanisms for health serviceimplementation

Ø Oversee National Policy implementation within the Region.Ø Facilitating Health Care Strategic Planning and enabling its

implementation.Ø Giving direction to the parishes and charting the course to be taken in

the Region to achieve improvements in population health within thenational policy and plan.

Ø Facilitating intersectorial coordination within the Region and enablingthe integration of health programs with other social sectors incommunities.

Ø Coordination of Health Care Delivery implementation within thefollowing field institutional framework and contexts: Primary HealthCare; Secondary & Tertiary Health Care; Other Public Health &Environmental Related Healthcare Delivery systems and programs.

Ø Coordination and Support of National Emergency and Centralised(Vertical) Programmes Implementation at the field level

Ø Technical Support and coordination especially for Epidemiology /Surveillance which is of National and Global significance.

Ø Enabling Clinical and Non-clinical Governance / Quality Assuranceand ISO standards for all Health Institutions and programs.

Ø Monitoring of Service Level Indicators (SLIs) at the parish levels,whether these resources are related to clinical or non-clinical services.

Ø Management of the resources available to the parishes through strongand efficient administrative support systems regarding manpower,materials and money (HR, Finance, Information Technology, Operationsand Maintenance, Projects and Audits).

Ø Advocacy role for all health facilities / parishes; that is, strongrepresentation of the issues, constraints etc to the national level forsupport.

Ø Establish and coordinate the health information systems deploymentand utilisation in the region



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Ø Inter Regional collaboration, consultation, communication andexchange to foster inter regional integration to enable national servicedelivery synergies in both primary, secondary and tertiary health care.

5.3.2 LOCATE PATIENT CARE AND SERVICE DELIVERY AT THE CENTREOF THE HEALTH CARE DELIVERY VALUE-CHAIN

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

LEVEL 2Diagnostic support systems: Laboratories, Diagnostic Centres, Otherinvestigative modalities.

LEVEL 3Technical and Institutional contexts, circumstances and conditions:

(Organisation i.e. Levels of Care, Structures and Collegial professionalrelationships, Related Institutional entities and the Application ofEpidemiologic scientific methods of analysis).



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

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

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

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

A change in paradigm from Service Level Agreements (SLAs), operablebetween independent corporate entities, to Service Level Indicators asbetween inter-related organisational entities, which would then be used asreference indicators to map out qualitative and quantitative benchmarks andstandards during service delivery of programmes and projects in all Primary,Secondary & Tertiary Health Care services and administrative supportsystems.

By changing this paradigm we will achieve the following objectives:

(i) Putting service level operations in epidemiological contexts; in sodoing we would be able to match clinical and non-clinicalstandards to epidemiological reference points and thereforemeasure project and program outputs region by region, parish byparish, institution by institution and community by community ina standardised way.

(ii) Fully integrating and standardising the functions of the HeadOffice, Regions and Parishes into a single organised andinextricably related entity.

(iii) The implementation process would become more precise andobjective since it has become more indicative and therefore datadriven rather than subjective and relationship driven.

(iv) These indicators are derived from the collaborative work betweenthe regions the field and the head office. The subculture ofsubjectivism and cronyism which has reared its ugly head in theRHAs would gradually become a thing of the past.



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1. We recommend that in order for the process of decentralization to bemeaningful, it must go hand in hand with a measure of regionalautonomy in the following areas in accordance with National standardsand operational guidelines:

§ Independence in the recruitment of manpower with freetransferability of contract to any region subject to releasefrom and acceptance by of the respective Region.

§ Independence in the procurement of material resources,maintenance and supplies with the power to outsourcewhere justified.

§ Management of its own budget.§ Autonomy in personnel management functions.§ Reporting to the central administration by way of

management and financial audits and epidemiological normsand standards.

§ Involvement in the national strategic planning processduring a specified calendar period every year.

2. Re-institution of Hospital Management Boards is a vital precondition ifthere is going to be the possibility of public / private partnerships tobuild Centres of Excellence and to attract private investments in thehospitals to rebuild capacity. Further this is necessary to enabletraining of health personnel for accreditation purposes, and for thesustainability of the network system of Secondary and Tertiary HealthCare.

3. Establish a triumvirate of reporting relationship to the Board ofManagement of all hospitals. These include a) SMO b) Director Nursingc) CEO.

4. Line item budgets MUST be established for Primary Health Careservices at every level of function of the health services system; Policy,Region and Field.

5. The Hospitals will account for their budgets through their respectiveBoards of Management. These are Secondary and Tertiary Health Carecategories.

6. At the Head Office or policy level the Secondary and Tertiary HealthCare unit will also have portfolio regulatory responsibility forlaboratories, diagnostic centres and other service delivery relatedentities as well as health research and development entities. Theplacing of Primary Health Care under the direction of the personresponsible for Secondary Health Care was a grave error.



89

Diagram 17 presents the current structure of the RHAs. Diagram

captures the organisational structure being recommended by Task Force.

Note the fundamental paradigm change that is being recommended:

from an administration / management centred health

system where the diagnostic chain of command is

broken with technical personnel reporting to and

supervised by non-technical administrative personnel

to a patient centred delivered service delivery.



90

Diagram 175.4 EXISTING REGIONAL HEALTH AUTHORITY

ORGANISATIONAL STRUCTURE

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

Regional HealthAuthority (Board)

RegionalDirector

ParishCommittee

RegionalTechnicalDirector

(Med. Officer)

Director ofFinance

Director, HR&

IndustrialRelation

Director ofOperations &

Dir. Mgmt.Information

Systems

ParishManager

MedicalOfficer of

Health

CEOHR Manager OperationsManagers



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Diagram 18TASK FORCE RECOMMENDATION FOR THE NEW

REGIONAL ORGANISATION STRUCTURE



92

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

It is recommended that the posts of Regional Technical Director and RegionalDirector should be combined to become one Senior Technical post at the PMOlevel and should be designated Regional Technical Administrator. Thequalifications of that individual must satisfy the following:

This leadership must embody the following characteristics:

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

b) Must have public health training and practicec) Must have had a successful operational (service delivery) field

experience for at least five years.d) Must have acceptable certification in administrative management.

Administrative Support WeaknessesThere are three areas of fundamental weaknesses in the National Health

Service system:• Human Resource Management• Maintenance• Supplies

The Task Force recommends that these Administrative support functionsare given priority and targeted for special attention in the organisationalframework of the Regional Organisation.

Regional autonomy in these areas is vital, although every Region mustconform, from a policy standpoint, to a uniform set of National Standards,without compromise.



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Diagram 19

TASK FORCE RECOMMENDED CORE FUNCTIONSOF THE PARISH ORGANISATION



94

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

service delivery system and MUST be designed in keeping with the public

health and epidemiological demands of communities within the parishes and

the Institutions (Hospitals) in the Parishes and the Regions. In so doing the

intervention measures will be targeted specifically to the needs of the

patients in communities and within the hospitals system.

The management of the health care delivery process is best carried out

by disaggregating the functions of the clinical and non-clinical components

drilling down to its most basic unit. This will facilitate the proper auditing of

the service to enable the measurement of cost per unit output of Primary

Health Care service; a vital and necessary activity for budgeting purposes.



95

Diagram 20

TASK FORCE RECOMMENDED SCOPE AND CONTENTOF PRIMARY HEALTH CARE IN THE PARISHES

Diagram 20 outlines the scope and content of the sub-categories whichcomprise a comprehensive Primary Health Care system and portfolio whichmust be the portfolio responsibility of the PMO, Primary Health Care.



96

The institutional framework of the Primary Health Care systemrevolves around the network of Health Centres (in the communities, districts,and the parishes) and the parish Public Health Departments. TheseDepartments function as the hub for coordination and integration of clinicaland non-clinical functions of Primary Health Care delivery services. Withouta proper functioning electronic health information system, the qualitativeleap needed to modernise Primary Health Care will never take place.

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

The present practice of combining Primary, Secondary and TertiaryCare under one Director at the Head Office demonstrates a very serious gapin knowledge of public health principles and practice and the scope andcontent of Primary Health Care. This criticism must also be levelled at theother technical directorates at the Head Office where the combination ofportfolio responsibilities bear no relationship whatsoever to epidemiologicprinciples or public health logic.

Diagram 10 (the prevention model see page 62) puts the respectivedomains of responsibilities in both public health and epidemiologic contextsfor clarification. It identifies four interconnected and interrelated stages ofPrevention:

The first stage Pre-Primary Prevention is a state of healthmaintenance and wellness. This is the primary context of the HealthPromotion intervention strategy. Health promotion however may be appliedright across the prevention spectrum.

The second stage is Primary Prevention, which is represented in anepidemiologic context as measures designed to decrease the incidence (theoccurrence of new cases) of disease. This is the domain of Primary HealthCare intervention measures and is comprised entirely of community baseddelivery services. Primary Health Care services may be applied right acrossthe prevention spectrum and health promotion is only one of its many pillars.



97

The third stage is Secondary Prevention which is represented in anepidemiologic context as intervention measures designed to decreaseprevalence (all cases old and new) of diseases. This is the domain ofSecondary and Tertiary Health Care and is institutional care which isrepresented as Non-Community Based services. However Secondary andTertiary Health Care services are organically connected, overlap and areinterrelated to Primary Health Care both at the Health Centre and publichealth management levels as the diagram describes.

The fourth stage is Tertiary Prevention which is represented in anepidemiologic context as averting “chronicity” or rehabilitation i.e. re-motivates, retrain, re-socialise, reintegrate. This is essentially a communitybased intervention service of chronic disease management and is the domainof Primary Health Care in close collaboration with the Secondary Carereferral system.

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

It is evident that much work needs to be done in acquiring institutionalknowledge of the scope and content of Primary, Secondary and TertiaryHealth Care. In so doing, this would correct obvious errors in organisational,structural and functional configuration.



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6.0 THE HEALTH INFORMATION SYSTEM

6.1 Stakeholders’ Key Issues

• There is no standardization of the very limited management

information system being used across the regions. The more rural

parishes lack connectivity from the network providers of the country.

• There seem to be consistency across regions in terms of software usage.

The major software in use are HRMIS, MAXIMO, PAS, Free Balance

and Great Plains. NERHA has however developed computer software

“in house” to satisfy its needs.

• Interconnectivity is done through LAN and WAN.

• Patient Administrative System (PAS) for the management of patient

records is implemented in few hospitals and clinics.

• There is limited use of the PAS; there are some modules that are not

being used.

• The Human Resource Management Information System (HRMIS) is

linked to payroll in all regions; however the capacity for human

resource management is not being maximized.

• The software MAXIMO does not work. It was highlighted that the

system was non-functional for six (6) months in 2006 and currently is

not working.

• Most of the software being used though insufficient are providing basic

information. However, collectively most stakeholders suggest

improvements are needed in the system.

• Majority of the MIS staff including those at leadership level do not have

the capacity for managing the system.

• Funding for the purchase of computer equipment is inadequate.



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.

In order to achieve a modern health service delivery system the HealthInformation System must achieve the following outcomes:

• Real time access to patient information.• Reliable connectivity.

• Greater efficiencies in the management of information.

• Greater efficiencies in processing of patients and patient /health care

provider encounters.

• Ability to monitor service delivery in every health facility in real-time.

• Better and more efficient access online to morbidity and mortality data

from the parishes and regions.

• Ability to quickly and more accurately establish norms and standards

for service delivery.

• Referral of patients and their information to other facilities in real-

time.

• Saving time in enabling the integration of Primary, Secondary and

Tertiary clinical services.



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• Enabling integration of clinical services between Health Centre and

institutions such as hospitals, public health departments, the regions

and head office.

• Enabling the referral of patients between the public and private

sectors.

• Saving time in patient management and therefore saving lives.

• Better accountability of drug utilization in clinics hospitals and

pharmacies in the public and private sectors.

• Real-time access to hospital service delivery statistics for monitoring

and evaluating service delivery in these institutions and follow up in

the communities.

• More efficient data mining for greater capabilities in strategic health

planning capacity at the MOH Head Office in collaboration with the

Regions and the Parishes.

• More efficient use of professional resources in Tele-Radiology, Tele-

Dermatology, Tele- Pathology, Tele-Consultations, Home Health, Tele-

Mental Health, Tele-Mentoring etc.

• The use of web-based video conferencing for meetings and coordinating

functions of the Regions Parishes and Head Office.

• More efficient management of emergency medical conditions.

• Greater capability in the coordination of service delivery and

administrative support systems especially in the supply chain and

maintenance systems.

To achieve the outcomes listed above the two most important requirements

are:

(i.) A modern web-based electronic patient health record system

which meets the requirements of international standards of

interoperability and sits as the core of the health information

technology software application system for service delivery.



101

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

infrastructure (Tele-Health network) dedicated to the unique

specifications of the Ministry of Health clinical service delivery

system.

These two criteria represent the core of the Health Information System

which provides the platform for the integration of other information system

such as supply management systems, human resources management

systems, financial management systems and maintenance management

systems. All of these represent the administrative support systems in the

health sector.

Significant capacity building work is necessary in order to ensure that the

Ministry of Health and Environment achieve these outcomes. This point was

made by different categories of staff.

The reasons are the following:

(i) The PAS system which Ministry of Health has deployed does not have the

capability of a modern web-based electronic health record system

necessary to meet the requirements of international standards of

interoperability and portability (HL7 compliant) for the National Health

Service System.

(ii) MIS unit at the Ministry of Health does not have the professional

expertise or the resources or to build a Multi-service IP network

infrastructure capable of running a mission critical Tele-Health network.

6.2 TASK FORCE RECOMMENDATIONS

The Ministry of Finance, when faced with a similar challenge developed

Fiscal Services which is an independent entity with a professional

management structure and an adequate budget subject to monitoring and

oversight by the Ministry.



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The Task Force recognizing the critical and urgent need to satisfy the

requirements of a National Health Information System recommends that:

• National Health Fund (NHF) should be the executing agency for the

immediate, short term, medium term and long term Information

Technology needs of the Ministry of Health and Environment.

• NHF should further develop its IT division into a department and

continues to develop the IT professional capacity to do the following:

a) Implement the deployment of a modern web-based

electronic patient health record system which meets the

requirements of international standards of

interoperability and sits as the core of the health

information technology software application system for

service delivery of the patient health information system.

b) Implement the building and deployment of a robust multi-

service Internet protocol (IP) network infrastructure (Tele-

health network) dedicated to the unique specifications of

the Ministry of Health service delivery system.

c) Recruit, train, and deployment of all IT personnel and

development of systems throughout the MOH&E and

Environment.

7.0 MANPOWER

7.1 HUMAN RESOURCE MANAGEMENT

Key Issues- Stakeholders

1) Shortage of staff particularly specialist nurses (critical care, dialysis, theatre

nurses, ophthalmic, nurse midwives), midwives and enrolled assistant

nurses.

2) Non-appointment of staff acting in clear vacancies.

3) Size of the workforce is insufficient for the various administrative and



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 ofemployment, and leave.

8) Limited training programmes exist for Artisans - Plumbers, Carpenters,and Biomedical Technicians.

9) Insufficient incentive schemes / programs that may be used as tools toimprove staff morale.

10) Remuneration packages are not justified by years of employment andtraining.

11) Lack of transparency in the management of human resource issues.

12) No clear human resource appeals process.

13) Inadequate funding for staff development.

14) Lack of comprehensive Manpower plan.

15) Poor working conditions.

DISCUSSION

When the scope of Primary Health Care is laid bare, and the epidemiological

trends of the next thirty (30) years are assessed, the manpower needs of the

categories of workers required for successful health care delivery services are

protean. All categories of staff interviewed reported that the HR performance

at every level of the health service system was very poor in areas of

recruitment, selection, promotion, appointments, training and communication.

The current size of the workforce is insufficient for the various

administrative and support functions. A shortage was reported in almost

every speciality area of employment: Nursing, Medicine, Midwifery,

Pharmacy, Health Records, Cashiers, Leave Clerks, Parish Auditors, Social

Workers and Dieticians. With “no post”, “unclear vacancies”, and a category

described as “excess”, the current health care cadre situation is unrealistic.



104

The lack of a comprehensive orientation programme for all levels of

staff of the Regions, and lack of posts, low remuneration packages, high staff

turnover and in some instances poor working conditions have resulted in a

strain on the system.

The general consensus among all level of workers is they are frustrated

and de-motivated when they cannot do what they are trained to do. NERHA

and SRHA staff were disgruntled with the number of years individuals have

been working in some cases ten (10) to twenty five (25) years without being

appointed.

Of approximately thirty recommendations of the Ying report in 1996,

the first one called for the establishment of a Centralized HRD Planning Unit

and the development of a National Manpower Master-Plan. Ten years have

elapsed and the Central Office HRM Division/Department does not possess

the capability of addressing core manpower issues of policy analysis,

forecasting and planning. Moreover, the database to achieve this is non-

existent.

7.2 TASK FORCE RECOMMENDS THAT:

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

packages, welfare and incentive schemes must be quickly addressed by

a special multi-disciplinary group in order to improve staff morale.

• A National Human Resource Management Strategic Plan be

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

epidemiologic principles.

• The leadership in the service delivery and administrative support areas

together with the epidemiologist in charge of strategic planning must

be involved in the design, development and final documentation of all

National Human Resource Development Plans.



105

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

disciplinary approach that relates to clearly defined functions of service

delivery and administrative support.

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

develop an appropriate National Human Resource Manpower Plan” for the

sector in general and each specific Regional Health Authority in particular.

The Task Force agrees with this recommendation but emphasizes that the

effort must be one of priority but must take place simultaneously with the

organizational reform and reclassification exercise currently being undertaken

by the Ministry of Finance and Planning.

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

necessary, based on the epidemiological requirements in each Region

and in every parish.

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

organization structure and functions at the central, regional and parish

levels.

• The projected 2014 Proposals (Goffe / McCartney 2007 Report) related

to the classification of staffing for Primary Health Care and Mental

Health Staffing by Regions be given the highest priority. These services

are important for the largest and most vulnerable sections of the

Jamaican population.

• The RHAs should institute training for maintenance personnel at all

levels, in collaboration with UTECH, NCTVET, and MIND and like

organizations with special emphasis on Artisans and Bio-Medical

Technicians.

• A systematic approach must be developed for international recruitment

and for training and certification of local staff.



106

• International recruitment must be the domain and sole responsibility of

Head Office and not the Regions, while local recruitment must remain

the prerogative of the Regions and Parishes. This should foster greater

transparency in the management of Human Resources matters.

• The appeals procedure for disgruntled workers MUST be swift,

transparent and impartial.

• The Ministry of Health and Environment should establish very close

cooperation and collaboration with our universities, especially the

University of Technology. This is necessary to accelerate the education

and training not only of the traditional health sector personnel but also

the non-traditional such as

those persons in the areas of new technologies required by the

diversified global health sector.

8.0 SUPPLIES MANAGEMENT AND PROCUREMENTKey Issues by Stakeholders

8.1 Pharmaceuticals• Health Corporation Limited, the Government Agency which

supplies drugs to the RHAs usually supplies approximately 60%

of the Institution’s order; the gap has to be filled by purchasing

drugs on the open market.

• Unavailability of credit facilities within regions for the

procurement of drugs on the open market.

• Inadequate budgetary support to purchase pharmaceuticals from

the open market

• Inadequate inventory control system to facilitate ordering, and

distribution of drugs.



107

Suggestion from Focus Group

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

pharmaceuticals.

• Review procurement guidelines to make it easier to reorganize andcapitalise HCL to increase efficiency.

7Undercapitalization of Health Corporation Limited (the Government

importer and distributor of pharmaceuticals and medical supplies) and

inadequate budgetary provisions for the RHAs results at times in stock outs

of drugs and medical supplies.

As a result, hospitals end up having to supplement shortages with emergency

purchasing from local private sector distributors at higher prices. The

situation is further compounded by the fact that at the end of September

2007, HCL sales to RHAs represented an average service level of 50 percent

and an average service level of 76 percent for critical drug items.

On the other hand, the amounts collected by HCL on behalf of the RHAs, as

at September 30th, 2007 were still inadequate to deal with the overhang in

amounts owed, with $225.6 million still being owed to HCL, with an average

aging of nearly two months.

Unfortunately, the Drugs and Therapeutic Committees (a useful

mechanism for monitoring drug usage in hospitals) do not appear to be

meeting or are meeting irregularly in most hospitals. Hence, there is no

timely feedback mechanism to inform HCL’s procurement unit when there

are changes in therapy.

8.2 OTHER SUPPLIESKey Issues from Stakeholders

7 A Review of the Performance of the Regional Health Authorities By: Paul S. Ellis,(Lecturer – UTech &Management Consultant) November 21, 2007



108

• Shortage of supplies impacting negatively on patient care.

• Inadequate funding to purchase supplies.

• Delay in the procurement process which hinders efficiency. For

example, the practice of getting three quotes before the decision is

taken to purchase.

• Lack of a management information system for supply

management.

• Currently, management is not making use of economy of scale inpurchasing supplies.

8.3 THE TASK FORCE RECOMMENDS THAT:• The Health Corporation Limited (HCL) be reorganised and capitalised

to improve its capacity and its efficiency.

• HCL be transferred to the NHF as a Department and be fully

integrated into the NHF procurement system.

• All HCL systems be fully computerised for procurement, inventory

control, supply and distribution.

• Health Corporation Limited should expand the Drug Serve Pharmacies

in hospitals throughout the Regions. All reports confirm this to be a

“best practice”.

• Drug Serv Pharmacies to be included in Primary Health Care Facilities

in all Regions.



109

8.4 EQUIPMENT

Key Issues from Stakeholders

• Non-Functional Equipment.

• Inadequate Maintenance.

• Lengthy procurement procedure for approval of requests for equipment

e.g. Three quotes are needed for purchase of an item yet only one or two

places possess licences for the specific equipment.

• Special donations to purchase equipment when paid into the Regions

are held by the Region and is not released to be applied for the intended

purchases (SERHA and NERHA).

• Maintenance of specialised equipment should be out-sourced.

• Establish mobile maintenance teams in each parish.

• Increase training of Artisans, Electricians and Biomedical Technicians.

• Procurement of equipment is being affected by inadequate financing

and limited capacity of procurement officers.

8.5 THE TASK FORCE RECOMMENDS THAT:

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

Stocks and Supplies, etc.) be set up and maintained up-to-date, in every

Region as a matter of priority.

• Policies must be developed for the standardisation of all categories of

machinery and equipment, especially with regard to energy

conservation and replacement parts.

• Outsourcing of maintenance of specialised equipment.

• Increase training opportunities for Maintenance personnel.

• Equip a Mobile Maintenance team for each parish.

9.0 FINANCE AND THE RHAs

Next follow a series of Tables and Charts derived from financial data supplied

by the RHAs and MOH&E.



Total 2003/04% of Total

Income% of Total

Expenditure$M

INCOME:

MOH Grant 8,292.79 88.2%Fee Income 1,043.88 11.1%Other Income 60.34 0.6%Donations 0.0%Total Income 9,397.01 100%

EXPENDITURE:

Salaries etc. 7,899.57 84.1%Travelling 534.31 5.7%Rental 23.46 0.2%Salaries,Travelling, Rental etc. 8,457.34 90.0%Utilities 402.79 4.3%

Purchase of Other Goods and Services 1,770.74 18.8%Purchase of Fixed Assets 37.36 0.4%Total Expenditure 10,668.22 113.5%

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

MOH&E - RHAsAnalysis of 2003/04 Income & Expenditure for Combined RHAs

TABLE 14

Source: Data submitted by MOH&E, RHA



Total 2004 /05% of Total

Incom e% of Total

E xpen ditu re% of M O H

G rant M th ly. Avg.$M $M

IN C O M E:

M O H G ran t 8,633 .12 87.5% 81.8% 100.0% 719.43Fee In com e 1,140 .17 11.6% 10.8% 13.2% 95.01O th er Incom e 57.65 0.6% 0.5% 0.7% 4.80D on ation s 38 .79 0.4% 0.4% 0.4% -Total In com e 9,869 .73 100.0% 93.5% 114.3% 819.25

E XP E N D ITU R E:

Salaries etc. 7,616 .93 77.2% 72.2% 88.2% 634.74Travelling 536 .54 5.4% 5.1% 6.2% 44.71R en tal 27 .23 0.3% 0.3% 0.3% 2.27Salaries,Travelling, R ental etc. 8,180 .69 82 .89% 77.51% 94.76% 681.72E lectricity 241 .79 2.4% 2.3% 2.8% 20.15W ater 163 .01 1.7% 1.5% 1.9% 13.58Teleph one 77.85 0.8% 0.7% 0.9% 6.49U tilities 482 .65 4.9% 4.6% 5.6% 40.22

D ru gs 726 .85 7.4% 6.9% 8.4% 60.57M edical gases 125 .42 1.3% 1.2% 1.5% 10.45D ietary 112 .11 1.1% 1.1% 1.3% -Secu rity 167 .93 1.7% 1.6% 1.9% 13.99C lean in g an d Porterin g 244 .37 2.5% 2.3% 2.8% -Toiletries 33 .87 0.3% 0.3% 0.4% -Laun dry E xpen ses 23 .91 0.2% 0.2% 0.3% -Food & D rin k 97.66 1.0% 0.9% 1.1% 8.14M ain tenan ce - B u ilding 34 .64 0.4% 0.3% 0.4% 2.89M ain tenan ce - E qu ipm en t 67 .23 0.7% 0.6% 0.8% 5.60M ain tenan ce - V eh icles 38 .79 0.4% 0.4% 0.4% 3.23O th er 199 .62 2.0% 1.9% 2.3% 16.63P urchase of O ther G oods an d Services 1,872 .41 19.0% 17.7% 21.7% 121.51P urchase of Fixed Assets 19 .28 0.2% 0.2% 0.2% -Total E xpen ditu re 10,555 .03 107% 100% 122% 843.46

Su rplu s/(D eficit) (685 .30)$ -6.9% -6 .5% -7.9% (24 .21)$

M O H & E - R H A s

A n alysis of 2004/05 In com e & E xpen ditu re for Com b ined R H A s

TA B LE 15





Income% of Total

Expenditure% of MOH

Grant Mthly. Avg.$M $M

INCOME:MOH Grant 5,802.82 82.1% 82.1% 100.0% 483.57Fee Income 912.81 12.9% 12.9% 15.7% 76.07Other Income 60.44 0.9% 0.9% 1.0% 5.04NHF Grants 287.40 4.1% 4.1% 5.0% 23.95Donations 2.68 0.0% 0.0% 0.0%Total Income 7,066.15 100.0% 100.0% 121.8% 588.62

EXPENDITURE:Salaries etc. 5,033.48 71.2% 71.2% 86.7% 419.46Travelling 396.59 5.6% 5.6% 6.8% 33.05Rental 15.80 0.2% 0.2% 0.3% 1.32Salaries ,Travelling, Rental etc. 5,445.88 77.1% 77.0% 93.8% 453.82Electricity 179.20 2.5% 2.5% 3.1% 14.93Water 116.78 1.7% 1.7% 2.0% 9.73Telephone 46.02 0.7% 0.7% 0.8% 3.84Utilities 342.01 4.8% 4.8% 5.9% 28.50

Drugs 470.62 6.7% 6.7% 8.1% 58.93Medical gases 68.68 1.0% 1.0% 1.2% 9.72Dietary 74.56 1.1% 1.1% 1.3% 10.75Security 101.70 1.4% 1.4% 1.8% 14.25Cleaning and Portering 156.74 2.2% 2.2% 2.7% 22.48Toiletries 27.22 0.4% 0.4% 0.5% 3.70Laundry Expenses 13.53 0.2% 0.2% 0.2% 1.87Food & Drink 69.59 1.0% 1.0% 1.2% 9.58Maintenance - Building 52.39 0.7% 0.7% 0.9% 6.56Maintenance - Equip 37.03 0.5% 0.5% 0.6% 4.50Maintenance - Veh 17.16 0.2% 0.2% 0.3% 2.14Others 159.29 2.3% 2.3% 2.7% 20.97Purchase of Other Goods and Services 1,248.49 17.7% 17.7% 21.5% 165.45Purchase of Fixed Assets 33.09 0.5% 0.5% 0.6%Total Expenditure 7,069.46 100% 100% 122% 647.77Surplus/(Deficit) (3.31)$ 0.0% 0.0% -0.1% (59.15)$

MOH&E - RHAsAnalysis of 2005/06 Income &Expenditure for Combined RHAs

TABLE 16

Source: Financial Data supplied by MOH&E, RHA




Income% of Total

Expenditure% of MOH

Grant Mthly. Avg.$M $M

INCOME:MOH Grant 11,487.28 86.9% 84.5% 100.0%Fee Income 1,605.09 12.1% 11.8% 14.0%Other Income 106.05 0.8% 0.8% 0.9%NHF Grants 23.49 0.2% 0.2% 0.2%Donations 4.56 0.0% 0.0% 0.0%Total Income 13,226.48 100.0% 97.3% 115.1% 1,101.83

EXPENDITURE:Salaries etc. 9,929.57 75.1% 73.1% 86.4%Travelling 770.01 5.8% 5.7% 6.7%Rental 34.23 0.3% 0.3% 0.3%Salaries, Travelling, Rental etc. 10,733.81 81.2% 79.0% 93.4%Electricity 342.46 2.6% 2.5% 3.0%Water 176.93 1.3% 1.3% 1.5%Telephone 66.58 0.5% 0.5% 0.6%Utilities 585.98 4.4% 4.3% 5.1%Drugs 852.75 6.4% 6.3% 7.4%Medical gases 118.97 0.9% 0.9% 1.0%Dietary 114.84 0.9% 0.8% 1.0%Security 194.36 1.5% 1.4% 1.7%Cleaning and Portering 266.48 2.0% 2.0% 2.3%Toiletries 60.40 0.5% 0.4% 0.5%Laundry Expenses 26.41 0.2% 0.2% 0.2%Food & Drink 128.07 1.0% 0.9% 1.1%Maintenance - Building 78.41 0.6% 0.6% 0.7%Maintenance - Equip 46.90 0.4% 0.3% 0.4%Maintenance - Veh 25.35 0.2% 0.2% 0.2%Others 301.23 2.3% 2.2% 2.6%Purchases of Other Goods and Services 2,214.19 16.7% 16.3% 19.3%Purchase of Fixed Assets 54.36 0.4% 0.4% 0.5%Total Expenditure 13,588.34 103% 100% 118% 1,121.65

Surplus/(Deficit) (361.86)$ -2.7% -2.7% -3.2% $

MOH&E - RHAsAnalysis of 2006/07 Income & Expenditure for Combined RHAs

TABLE 17




CHART 2AMOH&E – RHAs

INCOME FOR THE COMBINED RHAs BY YEAR & SOURCE (J$M)

Com position of T otal Incom efor 2003/04 Y ear

M O H G rant8,293

F ee Incom e1,044

O ther Incom e60

C om position of T otal Incom efor 2004/05 Y ear

O ther Incom e

F ee Incom e1,140


M OH G rant5 ,803

F ee Incom e913

O ther Incom e60

N H F G rants287 D onations

3

C om position of Total Incom efor 2006/07 Y ear

F ee Incom e1,605

O ther Incom e106


O ther Incom e60F ee Incom e

1,044

M O H G rant8,293

C om position of T otal Incom efor 2004/05 Y ear

F ee Incom e1,140

O ther Incom e




CHART 2BMOH&E – RHAs

INCOME FOR THE COMBINED RHAs BY YEAR & SOURCE (%)

Total Incom e 2003/04 Year ($M )

Other Incom e1%Fee Incom e

11%

M OH G rant88%

Com position of Total Incomefor 2004/2005 Year

M O H G rant87.47%

D onations0.39%

F ee Incom e11.55%

O therIncom e0.58%

Com position of Total Incom efor 2006/2007 Year

Fee Incom e12.14%

O therIncom e0.80%

C om position of T otal Incom efor 2003/2004 Year

M OH G rant88.25%

Fee Incom e11.11%

Other Incom e0.64%

Com position of T otal Incom efor 2005/2006 Year

Fee Incom e12.92%

O therIncom e0.86%




CHART 3AMOH&E – RHAs

EXPENDITURE FOR THE COMBINED RHAs BY YEAR & TYPE (IN J$M)

Source: Financial Data supplied by MOH&E, RHACHART 3B

Composition of Total Expenditurefor 2003/04 Year

Salaries, travel,rental etc.

8,457

Fixed Assets37Other Purchases

1,771

Utilities403


Dietary, Food &Drink210

Security &Maintenance

309 Clean/Portering244

Utilities483

Drugs & Med.gases852

Toil/Laundry


Utilities342


Sal, travel, rentaletc.

5,446

Others159

Toil/Laundry41

Fixed Assets33

Clean/Portering157


208

Drugs & Med.Gases539


Toil/Laundry


Drugs & Med.gases972

Clean/Portering266


345

Utilities586



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

Source: Financial Data supplied by MOH&E, RHACHART 4

MOH&E – RHAs

Com position of Total Expenditurefor 2003/04 Year

Salaries,travelling, rental

e tc.79.3%

Fixed A ssets0.4%O ther Purchases

16.6%

U tilities3.8%

Com position of T otal Expenditurefor 2004/05 Year

Toil/Laundry0.5%

D rugs & M ed.gases8.1%

U tilities4.6%

Clean/Portering2.3%

Security &M aintenance

2.9%D ietary, Food &

Drink2.0%


Utilities4.8%

D ietary, Food &D rink2.0%

Sal, travel, rentale tc.

77.0%

O thers2.3%

Toil/Laundry0.6%

Fixed A ssets0.5%

Clean/Portering2.2%


2.9%

D rugs & M ed.G ases7.6%


U tilities4.3%


2.5%

Clean/Portering2.0%

D rugs & M ed.gases7.2%

D ietary, Food &D rink1.8%

Toil/Laundry



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


MOH&E – RHAs

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

MOH Grant Fee Income Other Income Donations Total Income

Source of Income

Inco

me

(J$

M)

Eas

y P

DF

Cre

ator

is p

rofe

ssio

nal s

oftw

are

to c

reat

e P

DF.

If y

ou w

ish

to re

mov

e th

is li

ne, b

uy it

now

.


Analysis of 2004/05 Income by Amount (J$M) and by RHA & Source

0

2000

4000

6000

8000

10000

12000

M OH Grant Fee Income Other Income Donations

Source of Incom e

Inco

me

(J$

M)


CHART 6MOH&E - RHAs



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

0

2000

4000

6000

8000

10000

12000

14000

M OH G rant Fee Income Other Incom e N HF G rants D onations

Source of Income

Inco

me

(J$

M)


CHART 7



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

-200

0

200

400

600

800

1000

1200

SERHA WRHA SRHA NE RHA ALL RHAs

Regional H ealth Authority

Col

lect

ions

(J$M

)


MOH&E - RHAs



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

-200

0

200

400

600

800

1,000

1,200

1,400

SERHA NERHA WRHA SRHA TOTAL

Regionial Health Authority

Col

lect

ions

(J$M

)


MOH&E - RHAs



Analysis of 2006/07 Collections by Regional Health Authority

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

SERHA WRHA SRHA NERHA ALL RHAs

Regional Health Authority

Col

lect

ios(

J$M

)




COSTCENTRE BUDGETED ACTUAL BUDGETED ACTUAL$ $ $ $

Regional Office 111,251,957 72,982,000 129,482,905

KingstonPublic Hospital 1,456,555,636 1,424,915,551 1,739,832,932

VictoriaJubilee Hospital 354,035,850 341,685,349 426,767,398

Sir JohnGolding RehabilitationCentre 101,921,935 515,666,069 585,110,263

BustamanteHospital for Children 548,751,825 168,539,575 169,069,798

National Chest Hospital 169,702,294 30,755,694 32,397,724

Hope Institute 32,154,172 668,198,832 738,442,936

SpanishTownHospital 674,822,913 78,095,944 72,796,826

Linstead Hospital 65,568,876 216,731,188 204,287,008

Princess Margaret Hospital 183,697,363 643,148,122 633,079,768

Kingston&St. AndrewHealthDept. 530,414,997 334,494,078.00 320,994,311

St. Catherine HealthDepartment 292,094,408 171,994,597.00 161,046,911

St Thomas HealthDepartment 136,422,369

TOTAL EXPENDITURE 4,657,394,595 4,667,206,999 5,213,308,780

TOTAL ALLOCATIONRECEIVED 3,914,299,028 3,865,116,999 4,248,304,258

TOTAL FEECOLLECTED 503,800,000 433,726,009 578,000,000 616,400,815

OTHERINCOME 52,426,424 216,885,044 243,134,332

DONATIONS 4,414,253 4,158,643

TOTAL CASHDONATIONRECEIVED 4,404,865,714 4,660,002,043 5,111,998,048

2004/2005EXPENDITURE 2005/2006 EXPENDITURE

TABLE18MOH&E- RHAs

SERHA EXPENDITURE 2004-2006 BY COSTCENTRE




CHART 10MOH&E - RHAs

South East Regional Health Authority2004/05 Actual Expenditure (in J$M) Analysed by Cost Centre

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

Regional O

ffice KPH

Victoria Jubi

leeHsp

Sir JGoldin

g Rehab

Bustamante

Hsp

National Ch

est Hsp

HopeInsti

tute

SpnshTwnHsp

LinsteadHsp

Princess

Marg Hsp

K&SAHthDept.

St. CathHthDept

St Thom

as HlthDept

Cost Centre

Exp

endi

ture

-J$M





South East Regional Health Authority2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by Cost Centre

0

1,000

2,000

3,000

4,000

5,000

6,000

Regional

Office KPH

Victoria Jubil

eeHsp

Sir JGoldin

gRehab

Bustamante

Hsp

National Ch

estHsp

HopeInsti

tute

SpnshTwnHsp

Linstead

Hsp

Princess

MargHsp

K&SAHlthDept

St. Cath.

HlthDept

StThom

asHlthDept

Cost Centre

Exp

endi

ture

-J$M

Budgeted Expenditure Actual Expenditure





South East Regional Health Authority2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by Cost Centre

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Regional O

ffice KPH

Victoria Jubil

eeHsp

Sir JGoldingRehab

Bustamante

Hsp

National Ch

estHsp

HopeInsti

tute

SpnshTwnHsp

Linstead

Hsp

Princess

MargHsp

K&SAHlthDept

St. CathHlthDept

StThom

asHlthDept

Cost Centre

Exp

endi

ture

-J$M





COSTCENTREBUDGETED ACTUAL BUDGETED ACTUAL

$ $ $ $

MandevilleHospital 326,433,538 522,876,570 492,299,303 652,448,742

MayPenHospital 207,687,113 267,841,841 390,998,733 369,304,018

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

BlackRiver Hospital 131,808,891 135,191,578 151,292,921 159,939,424

Percy Junor Hospital 139,112,608 146,349,718 135,693,999 184,657,880

ClarendonHealthDepartment 179,994,732 197,502,083 178,762,176 230,862,893

St. ElizabethHealthDepartment 138,440,570 134,009,459 129,727,014 152,855,904

Manchester HealthDepartment 119,511,052 130,298,456 113,455,503 145,091,252

Regional Administration 54,032,480 108,376,969 68,929,303 139,600,337

TOTALEXPENDITURE 1,351,960,000 1,690,440,664 1,711,890,001 2,101,690,181

TOTALCASHDONATION

RECEIVED 233,717

TABLE19MOH&E- RHAs

SRHA EXPENDITURE 2004-2006 BY COST CENTRE

2004/05EXPENDITURE 2005/06 EXPENDITURE





Southern Regional Health Authority2004/05 Budgeted vs. Actual Expenditure (in J$M) Analysed by Cost Centre

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Mandeville

Hsp

May PenHsp

Lionel T

own Hsp

BlackRiver

Hsp

Percy Juno

rHsp

Clarendon

HlthDept

St. Elizab

ethHlth Dept

Mancheste

rHlthDept

Regional A

dmin

Cost Centre

Exp

endi

ture

-J$M






Southern Regional Health Authority2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by Cost

0

5 0 0

1 ,0 0 0

1 ,5 0 0

2 ,0 0 0

2 ,5 0 0

Mandevill

e Hsp

May Pen Hsp

Lionel To

wn Hsp

BlackRiver

Hsp

PercyJun

or Hsp

Clarendon

Hlth Dept

St. Elizab

ethHlth Dept

Mancheste

r Hlth Dept

Regional A

dmin

C ost C e n tr e

Exp

endi

ture

-J$M

B ud ge ted E xpe nd itu re A c tua l E xpe nd itu re





Southern Regional Health Authority2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by Cost Centre

0

5 0 0

1 ,0 0 0

1 ,5 0 0

2 ,0 0 0

2 ,5 0 0

Mandeville

Hsp

May PenHsp

Lionel T

own Hsp

BlackRiver

Hsp

Percy Juno

r Hsp

Clarendon

HlthDept

St. Elizab

ethHlth Dept

Mancheste

r HlthDept

Cost Centre

Exp

endi

ture

-J$M

Budgete d E xpend itu re Actual E xpenditure




COST CENTRE BUDGETED ACTUAL BUDGETED ACTUAL BUDGETED$ $ $ $

Regional Office 69,056,193 82,555,953 68,749,262 73,445,124

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

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

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

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

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

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

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

TOTAL EXPENDITURE 1,202,580,983 1,408,756,307 1,320,110,000 1,443,647,081 1,442,104,000

CASH DONATION RECEIVED 1,208,756 151,340

MOH&E - RHAsTABLE 20

NERHA EXPENDITURE 2004-2006 BY COST CENTRE

2003/ 2004 EXPENDITURE 2005/2006 EXPENDITURE





North East Regional Health Authority2003/04 Budgeted vs. Actual Expenditure in (J$M) Analysed by Cost Centre

0

200

400

600

800

1,000

1,200

1,400

1,600

Regional

Office

St. Ann's

BayHsp

PortMaria

Hsp

AnnottoBay

Hsp

PortAnton

ioHsp

St. AnnHlthDept

St.MaryHlthDept

Portland

HlthDept

Cost Centre

Exp

endi

ture

-J$M

Budgeted Expenditure $M Actual Expenditure $M





North East Regional Health Authority2005/06 Budgeted vs. Actual Expenditure (in J$M) Analysed by Cost Centre

0

200

400

600

800

1,000

1,200

1,400

1,600

Regional

Office

St. Ann's

BayHsp

PortMaria

Hsp

AnnottoBay

Hsp

PortAnto

nioHsp

St. AnnHlthDept

St.MaryHlthDept

Portland

HlthDept

Cost Centre

Exp

endi

ture

-J$M






North East Regional Health Authority2006/07 Budgeted vs. Actual Expenditure (in J$M) Analysed by Cost Centre

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Regional

Office

St. Ann's

BayHsp

PortMaria

Hsp

AnnottoBay

Hsp

PortAnton

ioHsp

St. AnnHlthDept

St. MaryHlthDept

Portland

HlthDept

Cost Centre

Exp

endi

ture

(J$

M)






2004/05 Expenditure Ratios by Regional Health Authority

0

10

20

30

40

50

60

70

80

90

100

Sal as % of TE S&T as % of TE S&T as % of MOH Grant S&T as % of TI

Expenditure Ratio

Perc

enta

ge(%

)





Analysis of Payables (J$M) at 2005 March 31 by RHA & by Creditor

0

500

1,000

1,500

2,000

2,500

Statutory Deductions Utilities Drugs Others

Creditor

Paya

bles

(J$

M)





Analysis of Payables at 2007 March 31 by RHA & by Creditor

0

500

1,000

1,500

2,000

2,500

Statutory Deductions Utilities Drugs Others

Creditor

Paya

bles

(J$

M)





Analysis of April - Nov. 2005 Income (J$M) for Combined RHAs by Source

0

200

400

600

800

1,000

1,200

April May June July Aug Sept Oct

Inco

me

(J$

M)





Analysis of April - Nov. 2005 Expenditure (J$M) for Combined RHAs by Type

0

200

400

600

800

1,000

1,200

Sal etc.

Travel&

Rental

Utilities

Drugs

MedGases&Dietar

y

Security&Mtnce

Clean&Port

ering

Toil&Laun

dry

Food&Drink Others

FixedAssets

Type of Expenditure

Exp

endi

ture

-J$M




141

9.1 MOH GRANT

The MOH grant continued to be the most significant source of income

for the Regional Health Authorities, averaging $8.55 billion over the last four

fiscal years. For the years examined this grant was 82% to 88% of the total

income of all the RHAs, individually and combined. In 2005/2006 it was down

to 82% but hovered at 86%-88% for fiscal 2003/04, 2004/05 and 2006/07.

The pattern was erratic as shown in Table 14 to Table 17. There was a slight

increase (4%) of the 2004/05 Grant over the 2003/04. But in 2005/06 there was

a significant 33% reduction, followed by 97% increase of 2006/07 over

2005/06. (See also Charts 2A, 2B and Charts, 4, 5 and 6.)

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

which was of the order of 5 % of GDP. Given the competing calls on the

national budget and the prognosis for its growth during the next few years, it

is clear that in the absence of a radical change in the financial policy, the

RHAs will have to access other funding sources to maintain viability. This

will have to be done if they are to acquire the assets and technology necessary

to upgrade their service delivery to achieve the level required to attain

recognition in keeping with international standards. The annual income

currently covers staff emoluments, utilities and drugs, with very little left for

asset maintenance and the other vital necessities.

9.2 USER FEE INCOME

Over the last quadrennium, except for fiscal 2005/06, the User Fee

income grew from $1 billion to $1.6 billion. This remained at 11% to 12% of

the MOH Grant. This is also illustrated in Tables 14 – 17 and Charts 2A and

2B.



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9.3 NHF GRANTS

The NHF made grants in 2005/06 and in 2006/07. The first of these

was for $287 million. The second was much less - $23 million. This

precipitous fall was partly due to the lack of capacity of the Regions to

implement projects in a timely manner, due in no small part as we were

informed to the cumbersome and bureaucratic procurement system and

procedure.

9.4 FIXED ASSETS

The financial data supplied hardly mentioned the Fixed Assets,

(buildings, plant, machinery and equipment) which, from observation, are of

significant value. If these are not owned by the RHAs then there is no need

to include them in the financials. The RHAs do not pay rental/leases so the

preservation of these assets and their replacement and upgrading are not

directly or indirectly their responsibility. This does not augur well for the

preservation or maintenance of the assets.

This point was stressed by the 8Auditor General when he met with the

Task Force. He stated that there was great difficulty in getting information

on the identification and the value of the Assets from the RHAs. Further that

there was a failure on the part of these RHAs to adhere to the Public Bodies

Management and Accountability Act. In addition, when posts are classified

and emoluments attached the RHAs did not comply with procedures. There

was a disconnect between the level of services and the resources.

Actual purchases of Fixed Assets by the RHAs were relatively minor; at less

than 0.5 % of annual income.

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



143

9.5 EXPENDITURE

Altogether, the RHAs spend more than their annual income. The gap is

met mainly by delayed payment of Statutory Deductions and Pension Scheme

contributions. These late payments are to the detriment of the staff whose

National Housing Trust, National Insurance Scheme, and Pension

entitlements are at risk. This is not a fiscally satisfactory method of funding

the budgetary shortfall.

The Task Force was advised that the statutory deductions are now being

taken out at source by the Ministry of Finance to offset the practice of delayed

payment to Inland Revenue and NHT. This is a welcome change.

As expected, given the nature of the service, the staff emoluments bill was the

most significant expenditure each year. In excess of 80% of the annual income

was absorbed by staff costs. Purchase of other goods and services constitute

the remaining 20%. Surprisingly utilities were less than 5% of the income.

The RHAs gave analyses of their expenditure by Cost Centres. The hospitals

were allocated the larger amounts in each case (63% to 66% overall).

There are gaps in the financial accountability.

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

health sector is not adequate, given the demand for services. The call for the

Government to spend no less than 10% of the National Budget on Health

Care since 1938 was only realised in fiscal year 1972/3. There was no other

period in Jamaica’s history when the expenditure in the health sector has

been more than single digit as a percentage of the National Budget. The

range of expenditures is between 4.5% to 7.5% over recent years.

Given the present budgetary challenges, any call for no less than 10% of

the National Budget is not anticipated to yield any significant change in

budgetary allocation to the RHAs in the short term. Of course, with a new



144

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

resource allocation would be quite premature.

9.6 USER FEES

The reduction in User Fees which was introduced in 2007 (for children

18 years and younger) will negatively impact on the financing of the RHAs

budgets unless there are other initiatives to increase collections. Over 95% of

stakeholders who were interviewed strongly recommended that User Fees be

continued at this time and that those who have the ability to pay should pay

but that provision should be made for the indigent, the infirm, the

handicapped and the elderly with relief through targeted programs such as

PATH.

The total amount of fees collected in both the Hospitals and the Health

Centres account for approximately $1.6 billion dollars per year. If there is a

cessation of User Fees collected in the hospitals the replacement cost to the

National budget would amount to approximately $3.2 billion dollars in fiscal

year 2007 to 2008. This amount would have to be found to maintain the

health status quo (of fiscal year 2006/2007), in fiscal year 2007/2008.

The $1.6 billion accounts for approximately 12% of the Health Budget.

From our analysis this amount was not disaggregated from Health

Centre User Fees and therefore we could not precisely establish the amount

of fees which were collected from the Health Centres as compared with the

Hospitals. However, based on our knowledge of the average costs per patient

using the hospital services versus the Health Centre the ratio of 8:1 or 10:1

would give a guesstimate of the relative incomes from User Fees in the

Hospitals vs. the Health Centres.

On average, less than 20% of persons who are ill will justify a place in a

Hospital while greater than 80% of patients can be managed quite well in a

Health Centre. Hence the most important need of the Jamaican people is

Primary Health Care where over 90% of the population will seek health care

if high quality services are available and there is a good consultation and



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



146

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

$8.2 billion dollars. This Task Force is not required to supply exact estimates

of this consequential shortfall of income to the RHAs. We merely mention

this in passing.

9.7 PUBLIC/PRIVATE PARTNERSHIPS

Finally, the Hospital management system which is currently

functioning without a corporate structure or Board of Management will have

to be radically changed, if it is to play the critical role in the public / private

partnership arrangement for investments in the sector to lead the anticipated

Health Tourism development and to grow the service for regular population

access..

Abolishing User Fees in hospitals at this time would weaken the

Government’s bargaining position for public / private partnerships as it would

undermine investor confidence with respect to return on investments in a

business climate where the health services are essentially free. It would be

very difficult to justify the need for public / private partnerships and for

creating investments for Centres of Excellence as a business venture located

within designated hospitals in a situation in which the policy in reality

provides free hospital care.

Medical “Health Tourism” as a Jamaican niche market would be very

difficult to implement in this context.

This is, therefore a mountain of epidemiologic, public health and health

economic evidence to warrant caution in the application of this policy on cost

sharing.

However, the following proposal is recommended in keeping with a

more viable and sustainable policy option which is epidemiologically

justifiable on the question of relieving the cost of the disease burden on the

Jamaican population and exercising the principle of compassionate relief.



147

9.8 TASK FORCE RECOMMENDS

Abolition of User Fees for Primary Health Care in every community as

the first step to fulfil the commitment of the Government in their Election

Manifesto.

In the absence of accurate primary data on the amount of User-Fees collected

at Health Centres, we have estimated that some eight to ten percent of $1.6

billion dollars could be accounted for was being derived from Health Centres.

This would be an approximate figure of $200 million annually.

A gap of approximately $200 million as compared with $1.6 billion in the

health budget would be more manageable at this time. From an epidemiologic

standpoint better access to Primary Health Care would lead to earlier

detection, diagnosis and treatment of diseases closer to the patients’ homes.

This would create lesser burdens on the hospitals because of less

complications and more preventive and successful curative care. The cost

savings would be significant bearing in mind that the health centres system

which functions well will serve eight to ten times more patients than those

seen in hospitals at less costs in a much shorter time.

Another step : Primary Health Care services should be improved almost

immediately by utilising Primary Care physicians and specialists in a night

shift (say, between six to ten p.m.) in communities distributed right across

the island. Remote districts could be served by Mobile clinics. This

recommendation is in keeping with the findings of the Goffe / McCartney

Report.



148

Possible sources of required additional income are the following:

(1). Grants from the National Health Fund.

(2). Savings as a result of the application of information and

communication technology to the health service system.

(3). Public / Private partnerships resulting in new investments in the

health sector to implement an aggressive Health Tourism Industry

and extend the services for the citizens. The charges (for tourists and

nationals) would have to incorporate economic costs as well as

funding for asset maintenance, replacement and upgrade.

(4). Bilateral or Multilateral Grant funding.

10.0 PROJECT MANAGEMENT10.1 PROJECT PLANNING AND IMPLEMENTATION

Key Issues from Stakeholders

• The cycle time for contracts and tender become lengthy given the nature of

the competitive bidding process.

• The Head Office has not been involved in the scope of work and does limited

monitoring for Projects in progress.

• There is a lack of Project Management staff.

• Inflation affects the timeliness of projects and their completion.

• There is a lack of procedures to address additional funding for project

overruns.

• Projects that are approved for a particular RHA are sometimes routed to

other projects across other regions.

THE PROJECT PROCESS

The project process for the RHAs has a framework that has result-chain

logic and social mapping that is used in the management of projects, though

when regionalization was introduced project management was not a part of

the regional structure.



149

Projects are conceptualized in the RHAs and the cycle time for contracts

and tender can become lengthy. Under the guidelines, proposals are

developed within the regions and forwarded to the Project Management and

Implementation Unit (PMIU) in the Ministry of Health. Technical projects

are sent to the Chief Medical Officer for input, then to the Permanent

Secretary for approval. Once approved by Head Office, projects are sent to

the funding agency (NHF) Institutional Benefits Committee for

considerations.

Smaller projects are reviewed for correct specifications by PMIU and

sent to the National Health Fund for funding. After that there is no

communication between the RHAs and the MOH PPU except for a monthly

report. A reporting relationship exists between the NHF and the RHAs, and

the RHAs with the contractors. Although a monthly progress report is

requested, there is limited monitoring by the PMIU of projects and variations

from the scope of work. The regions are obligated to report to the NHF and

for large projects the NHF has a representative onsite.

NHF has a monitoring system varying according to the project size.

For all incomplete projects it was the reporting mechanism is non-

existent. The Technical Directors approve the additional scope of work

without knowledge of the source of additional funding. It was reported that

funds for projects not yet started or routed to other regions within a given

timeframe are placed in non-interest earning accounts at financial

institutions. Project Management is a dynamic field and given the low

remuneration packages in the public sector, the persons in this field are

wooed by the private sector.



150

DISCUSSION

The project process as described did not seem to develop within a

national strategic planning framework. The process seems to be more in

keeping with an ad hoc needs responsive framework. Because of the

weaknesses in the Regional management system, from a policy,

organizational, structural and functional standpoint there can be no

immediate change in the process of project management until there are

changes in the areas outlined. There is no organizational logic between the

Head Office and the RHAs to permit a rational and efficient project

management system, because there is a fundamental disconnection between

the head office and the field level from a project planning, programming and

implementation standpoint. There is duplication, overlapping and omission of

functions, between RHAs and Head office with little capacity to monitor,

establish norms and standards or to efficiently harness the resource capacity

to effectively and efficiently implement projects.

The fact that there have been many instances of successful outcomes

speaks to the high calibre of achievement of a number of functionaries who

persist in spite of the awesome obstacles.

10.2 TASK FORCE RECOMMENDATIONS

The Task Force recommends that every RHA should have within its

organizational structure, a Project Management and Implementation Unit.

This should be complemented by a vibrant planning and evaluation process at

the Region and Parish Levels. (See diagram on Regional Organisation).

The Task Force recommends that the MOH&E determines the appropriate

measures to modernise the guidelines for the tender process.

Project overruns are sometimes unavoidable because of the

unpredictable nature of the health service delivery process which has to

respond to disease complications and diagnostic discoveries which change

costs assumptions. This is particularly prevalent during emergencies and

national outbreaks of diseases and epidemics.



151

The Task Force recommends that the appropriate policy be developed

to deal effectively with cost over-runs which may be justified by

epidemiologic determinants rather than human error or deliberate under

pricing.

11.0 PUBLIC / PRIVATE PARTNERSHIPS

11.1 HEALTH TOURISM, A CONSEQUENCE OF GLOBALISATION

“Medical Tourism, broadly defined, is travel undertaken for the purposeof availing cost effective health care”.

Global analysis indicates that the global medical tourism marketcomprised over 19 million trips in 2005, with a total value of $20 billionexperiencing double-digit growth in medical tourism, which is forecast togrow to 40 million trips, or 4% of global tourism volume by 2010(Source: International Travel Trade market).

Thailand attracts 600 000 medical tourists per year and is projected to attractone million foreign patients. (Source: Medical Tourism Assoc. Inc).

Medical tourism is a rapidly growing industry with countries likeMexico, 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 thatforeigners account for 10 to 12 per cent of all patients in top Mumbaihospitals despite roadblocks like poor aviation connectivity, poor roadinfrastructure and absence of uniform quality standards.



152

Diagram 21

CLASSIFICATION OF HEALTH TOURISM

This classification in Diagram 21 is very important. It is very useful forplanning a coherent national strategy that could accurately inform thedevelopment of sustainable business models for Health Tourism.

This classification of Health Tourism consists of three distinct butinterrelated categories:

v The First is WELLNESS HEALTH TOURISM which is estimated to be amultibillion dollar global business of which a small part is the spa industry.Jamaica’s ethnic medicines can become a vibrant niche industry in thisimportant category. This industry demands a large number of workersespecially in the complementary and alternative medicine area.



153

v A national policy which addresses the issues relating to complementary andalternative medicine in Jamaica is needed urgently. The standards andregulatory branch in the Ministry of Health must be given the support toproceed with this as a matter of priority. This is particularly important asthere needs to be documentation of the modes of complementary medicine aswe seek to establish a registry for this unregulated industry which has grownexponentially. A registry of practitioners of complementary medicine inJamaica is needed urgently.

v The Second is MEDICAL HEALTH TOURISM which has attracted anumber of investors to Jamaica. The conditions for medical health tourism inJamaica are favourable when we compare not only prices but other criticalfactors of our Jamaican people’s history and culture with regard to theirfunction in the services industries. There are however some structuralorganisational and policy constraints which must be addressed before we canhope to be part of this global $50 billion dollar market growing in countrieswhich are much less endowed or capable than Jamaica at rates of 15% to 20%per annum.

v There is a need for the development of Hospital Centres of Excellence,additional investment, a partnership of public health and the private sector,and a National Tele-health multi-service internet protocol networkconnecting broadband to all components of the health sector whether privateor public. A Universal web-based patient electronic health record systemintegrated with IP voice, video and data services is needed.

v Jamaica presently has both the know-how and the resources to develop theseinitiatives.

v Central to this, is the organisational reform of the MOH&E which is aprecondition for this advance to take place with least cost and in a sustainedway.

v The Third component is CONVALESCENT OR RETIREMENT VILLAGEHEALTH TOURISM . This industry is estimated be the most lucrative of allthe categories and growing at a phenomenal rate globally. Jamaica is poisedto be a significant player in this industry. In order to have an excellentsustainable Retirement Village Health Tourism industry one ought to havean excellent Medical Health Tourism industry and a vibrant and sustainableWellness Health Tourism industry.

v All three components of this industry are interconnected.



154

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

In order to jump start the Development of Health Tourism Services inJamaica, the Task Force recommends the following model.

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

Ø Allow Private investor entities to manage existing beds where possible ifthere are no opportunities to build.

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

Ø Provide Physical resources if available (Operation Theatres, diagnosticfacilities etc. to increase capacity of the Centres of Excellence makingavailable bed spaces in the Centres of Excellence.

Ø Provide “Doctor-On-Call” and emergency services coverage to Hotels andretirement villages for both pre-operative and convalescence Health tourismpatients and clients.

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

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

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

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



155

Diagram 22

THE BOOT: PUBLIC / PRIVATE PARTNERSHIP

Source: W. Mendes Davidson & S. Kumar 2008

This model creates a golden opportunity for developing long termrelationships with partners and trusts, in keeping with global trends in thedevelopment of the health service system. Health Tourism is also a best fitindustry for Jamaica and indeed the Caribbean as the tourism industry is anembedded industry in the vision, culture and practice of the Jamaican andCaribbean peoples.

The Task Force is mindful of the critical importance of itsrecommendations, but more importantly the urgent need to follow up on thevital changes to make this model a reality.

CENTRES OF EXCELLENCEPrivate entities with state of theart facilities: built, owned,operated and managed byinvestor group; to be transferredback to the Government afterlong term (30 to 50 year) lease(BOOT)

RESORTS & HOTELSPatients have pre-operative (2-3 days)stay in resort facility; Return to hotelafter treatment and being stabilised toremain for extended vacation, ifnecessary

EXISTING GOVERNMENTHOSPITAL SERVICES GovtTeams of High level ProfessionalClinical staff e.g. (ConsultantsDoctors, Specialist Nurses etc)



156

Table 21

Country Health Expenditure Per Capita Per Year& Male / Female Longevity; W.H.O Estimates-2000

United States $4187 73.7M/79.7F

Germany $2713 73.8M/80.1F

Switzerland $2644 75.6M/83F

Luxemburg $2580 74.5M/81.4F

Denmark $2574 72.9M/78.1F

Japan $2373 77.6M/84.3F

France $2369 74.9M/83.6F

Jamaica $149 75.2M/77.4F

Table 21 illustrates the strategic position Jamaica holds in terms of costper capita per year of health care and the qualitative return it receivesmanifested by its life expectancy. Jamaica has the potential for a highlycompetitive Health Tourism product and there is every justification toparticipate fully and without reservation in this very important GlobalIndustry.

Below are the results of the interviews with Corporate Personnel andPrivate Groups who are currently significant investors of large amount ofcapital over many years in the Jamaican health sector. They have takenmajor risks with no special incentives.

11.3 PROPOSALS FOR PUBLIC / PRIVATE PARTNERSHIPS BYPRIVATE ENTITIES

113.1 Representatives from the AIC Group

Conditions for a vibrant Public Private partnership in the Jamaicanhealth sector.Based on this type of information and the nature of health care, a prudentinvestor traditionally looks at the types of products & services offered i.e. the



157

price of entry, the market that is being serviced, and the expected returns orrevenue streams.

Barriers to investment are traditionally related to the following:• Low return on investment concerns• Capacity• Pricing• Volume of business• Utilization• Ability to Pay• Taxes• Technology• Infrastructure• Support• Restrictions

The private sector investors seek risk mitigation and predictability ofprofits. This can only be achieved in an environment of predictable capacity,costs and ability to pay.

Focus should be placed on developing a framework that would achievethese conditions.

The primary areas that the Jamaican government might need to focus onin order to attract investors are:

(i) Clinical Service Strategies which clearly define theboundaries between the public, private and public/private areas.

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

a) Government (MOH) certified product offerings to potential partners.b) Controls on specialization.c) Limiting entrance to those areas in which certified partners have

invested.

(ii) Clinical Service Compensation Scheme and anAttainable Return on Investment:

The current system endorses market pricing with limited governmentsupport or control and yet the cost of entry is yielding unprofitable results.

Examples of incentives that would attract investors would be:



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• Mandate Insurance companies to design full health care products thatare affordable;

• Pass legislation to mandate employers to carry these insurance policiesto cover their employees;

• Managed pricing of services certified by MOH;• Tax incentives for both the investor and participants.

(iii) Entry into the Defined Clinical Services should haveProtective Barriers:

There is no control over who enters the various markets on the Island; assuch it is all based on the availability of capital. They recommend that thefollowing incentives would assist:

Government guaranteed loans and / or initiatives for funding;Allow a 10 year moratorium on the health care environment to allowthe system to rebuild itself;Remove barriers related to duties, licenses and withholding taxes for aperiod of 10 years.

(iv) Infrastructure and Support:

Hospitals on the island are all starting to age, are space challenged, needingrepair, upgrading or expansion due to constantly growing demand. Inaddition, 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 todevelop, install / build and rollout any investment related to the healthsector;

• Endorsed tracking / reporting and IT systems that would enable easyaccess to funds for payments without barriers;

• Establish certified training centres for technical support related tohospital equipment servicing.

(v) ACCREDITATION AND IMPORTING / EXPORTING RESOURCES:

There appears to be no controls over the quality of service or standardizedmonitoring over the level of service provided at the various hospitals. Inaddition, the hospitals are always faced with staff shortages while certain



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

• Legislate compliance with international standards;

• Establish standardized quality of services with regular monitoring;

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

• Offer initiatives to partner with educational institutions for developingand training health professionals;

• In developing this mandate, a partnership needs to be formed with theprivate sector and there has to be a beneficial reason for thisinvestment;

• If an incentive is derived for the investor and in turn the Jamaicanpeople benefit, then only would the Government have achieved itsobjectives.

11.3.2 ACHIEVING A SUSTAINABLE WORLD CLASS DIAGNOSTICIMAGING SECTOR IN JAMAICA – IMPERATIVE FOR NATIONALDEVELOPMENT- Presentation by THE RADIOLOGY GROUP

INTRODUCTIONThe impact of imaging technology on the achievement of best-practice

standards in modern health care is incontrovertible. Despite limited publicresources, Jamaica has been blessed with a very high standard of imagingcapacity and diversity due to the vision and entrepreneurship of a small bandof private radiologists. However, the Government has an important role toplay in ensuring the sustainability of this very important health sector and toestablish similar high quality in the public hospital system. To achieve thisgoal will require a unique brand of private/public sector partnership to ensurethe best possible health care for every single Jamaican and also to open thedoor for developing a viable health tourism market.



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The Radiology group recommends:

(i) INCENTIVES NEEDED FOR GROWTH IN THE PRIVATE DIAGNOSTICIMAGING SECTOR

• Abolition of all tax regimes on the importation of diagnostic imagingequipment and related ancillary supplies.

• Provision of special low interest US Dollar loans for the purchase ofequipment.

• Granting of special tax credits or tax holidays for establishing imagingcentres in the underserved rural Jamaican communities.

• Regional and international government to government discussions toopen a window of opportunity for Jamaican radiologists to provide offshore Tele-Radiology services to other countries that may benefit andbe in need of such services.

• Government support and collaboration with the Jamaica Association ofRadiologists in enabling and charting a course towards entry into therapidly growing worldwide Health Tourism market.

(ii) PRIVATE SECTOR/PUBLIC SECTOR COLLABORATION & UTILIZATION OFPRIVATE RADIOLOGISTS IN GOVERNMENT HOSPITALS

Given the inadequate quality and diversity of diagnostic imagingservices in the public hospital system, it is time to consider a new paradigm ofinitiatives to induce private radiologists to participate in the provision ofimaging services at public hospitals. Because of the shortage of radiologists inthe country, this can only be achieved by a radical departure from thetraditional film-based radiology system to one that is completely digital andamenable to networking through a comprehensive island wide Picture andArchiving Communications System (PACS).

The concept is that once the network is in place, private radiologistscould be contracted to remotely interpret and issue reports on line in a timelyfashion on all imaging studies performed on government hospital patientsfrom a computer console located in their office, their home or even if they areon vacation on a specially configured lap top computer.

The initial cost of purchasing the necessary hardware would be quiteconsiderable but would be recoverable over time by the tremendous savingsfrom the eventual abandonment of utilizing very expensive X-ray film.



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(iii) DIVESTMENT OF GOVERNMENT HOSPITAL RADIOLOGY DEPARTMENTS

The concept outlined in the preceding paragraph could actually betaken one step further in which private radiologists could be actually invitedto completely take over and manage on a lease basis, the entire operation ofradiology departments in Government Hospitals.

Special arrangements would naturally have to be entrenched in orderto ensure that all patients would receive the same level of service, regardlessof their personal financial capacity or incapacity.

It would also be worthy of consideration to establish individual Centresof Excellence in different imaging modalities. For example, the NationalChest Hospital, unencumbered as it is by the high level of trauma cases seenat the Kingston Public Hospital, could be transformed into a designated highend National Interventional Radiology Centre, to which patients from all overthe island could be referred for the more sophisticated biopsy, drainage andvascular interventional procedures.

(iv) TRAINING OF RADIOLOGY PERSONNEL

For imaging services in Jamaica to take the necessary quantum leaptowards world class standards, it will be necessary to increase the cadre ofradiologists, radiographers and ultra-sonographers graduating from theUniversity of the West Indies training system. It may even be necessary toconsider setting up parallel training programmes for radiographers at theUniversity of Technology and Northern Caribbean University, so that theyearly output of radiographers can be increased exponentially.

(vi)IMPACT OF NEW TAX MEASURES ON THE DELIVERY OF MEDICALSERVICES IN JAMAICA

The Radiologists noted the historical development of imaging services inJamaica under the following three headings:

(a) Availability of high technology equipment.(b) Accessibility of services in a reasonable time period.(c) Cost of services.

(a) Availability of High Technology EquipmentThe record shows that practically all of the major technological innovations indiagnostic imaging have been first introduced by private sector radiologistsand not the University Hospital. The history is now tracd:

• Mammography for the early detection of breast cancer was introducedin the early 1980’s by Dr. Freddie Clarke.



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• The University Hospital and KPH did not obtain mammography unitsuntil 20 years later.

• Diagnostic ultrasound was introduced by Dr. Freddie Clarke in theearly 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 mid1990s.

• To date, neither The University Hospital nor KPH can perform bonedensitometry.

• The first state of the art Linear Accelerator for radiation therapy wasinstalled by Dr. Freddie Clarke and Dr. Venslow Greaves in 2002.

• The public sector continues to use outdated Cobalt radiotherapy unitsat Kingston Public Hospital and Cornwall Regional Hospital.

(b) ACCESSIBILITY TO SERVICES IN A REASONABLE TIME PERIOD

Sophisticated technology is of little value to a society if the servicesprovided are not available on a consistent and timely basis. The record willshow that it is far easier to access services on short notice in the privatesector compared to the public sector.

This is mainly due to three reasons.• The endemic culture in public sector institutions lends itself to

inefficiencies and a reluctance to “go the extra mile” in stepping uppatient throughput beyond an arbitrary standard level.

• The clogging of the system at the University Hospital and KingstonPublic Hospital by referrals from public sector hospitals and clinicsisland wide of those patients who cannot afford private health care.

• The private sector is more responsive to urgent medical situations forthe following reasons:

Ø The more experienced radiologists are in the private sector andnot the public sector.



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Ø The entrepreneurial risk involved in setting up private imagingcentres mandates a “turn back no patient” approach even beyondnormal closing time.

Ø The staff who work in private imaging centres are usually betterpaid and more highly motivated.

Ø The absolute need to offer quality service and achieve patient andreferring physician satisfaction in a highly competitive privatepractice environment.

Ø The public imaging sector is therefore unable to cope with themassive work load which would ensue if private radiologists wereforced out of the system by repressive tax measures.

(c) COST OF SERVICES

Prior to the budget presentation of 2003, a radiologist was faced thefollowing harsh realities in establishing a private imaging centre:• The equipment is very expensive, running into hundreds of thousands

of US dollars, and in the case of an MRI scanner, in excess of onemillion dollars (US$ 1M).

• Financing cannot be secured from a Jamaican dollar loan because ofprohibitively high local interest rates.

• US dollar financing must therefore be obtained at the risk of lossesfrom devaluation of the Jamaican dollar such as what is beingexperienced at the present time.

• A 10% import duty requirement on medical equipment has been inplace since the 1980’s.

• The former administration permitted a “Payment in Kind”arrangement whereby services are provided to patients in publichospitals in lieu of the dollar amount owed for import duty.

• This has eased the burden of having to borrow extra money to pay theduty in a lump sum.

• The 10% import duty applies not only to landing the equipment itselfbut also to imported spare parts which may be required from time totime, even during the free warranty service period or in cases where theRadiologist has a prepaid service agreement with the manufacturer.

• The unfair competition scenario in which although not pioneering aparticular service, the University Hospital will eventually obtainsimilar equipment and can afford to under price the service because asa Government entity, it is not personally liable to repay any loan and isnot subject to any duty regime on purchases of equipment or supplies.



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(vi) IMPACT OF NEW TAX MEASURES

The proposed implementation of a 15% GCT and 2% Import Cessregime on imaging equipment and supplies, inclusive of even X-rayfilm, will over time, completely wipe out private imaging centres forthe following reasons.

The increase in operating costs in tandem with the need for moreJamaican dollars to purchase the same number of US dollars for overseasdebt service will have to be passed on to the patient. However, exempt as it isfrom all import duties and taxes, the University Hospital will have no need toincrease its fees. More patients requiring CT and MRI scans will thereforehead to the University Hospital thus clogging up the University Hospitalsystem beyond its ability to cope.

The de facto increase in the purchase price of equipment will make itimpossible for the private Radiologists to retool and upgrade their equipmenton a timely base thus “trifling with Jamaica’s health services” and making itimpossible for us to maintain “world class” standards.

A practical example of the “cost push” effect of the proposed taxmeasures on the cost of equipment retooling and upgrading is illustrated inAppendix 11.

(vii) CONCLUSION-PRIVATE RADIOLOGISTS

There was a time not too long ago when patients requiring MRI scansand other sophisticated imaging procedures had to go to Miami, if they hadmoney and a US visa. Those that had the money but not the visa had to makedo with less than “world class” medical care because the necessary tests werenot available in Jamaica. Over the past twenty years, the brave men andwomen of the private radiology sector have propelled Jamaica to the pinnacleof imaging quality and diversity in the English speaking Caribbean.

The proposed new tax measures will turn back the clock on thetremendous gains we have made and encourage radiologists in training tomarket their skills in more practitioner-friendly overseas markets.

We urge the government not to be “penny wise and pound foolish”. Thecountry cannot function without a viable private imaging sector. TheUniversity Hospital and KPH have never been and will never be able to copewith the heavy work load left behind by a decimated private imaging sector.



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The 15% GCT must be rolled back in order to safeguard the health of ourchildren and our children’s children.

History will not judge us kindly if we fail to convince the governmentthat the medicine they have prescribed will not only sound the death knell forprivate imaging centres but will also sound the death knell for a countlessnumber of poor Jamaican sick people who will die because the overburdenedpublic hospital sector will not be able to respond to their needs in time to savetheir lives.

TASK FORCE RECOMMENDATIONS:

• Proposals to give protection or preference to the new players in themarket place go counter to existing Government open market policy.Given GOJ commitment to improving population access to high qualityhealth care, the proposal for abatement/relief of import duties onmedical equipment is worthy of consideration. Access to DiagnosticImaging equipment, Dialysis Machines, MRI, Laboratory Equipmentand related ancillary supplies should be opened up for locals all overthe island.

• The Ministry of Health should develop and implement a policy tofacilitate a support mechanism for the establishment of Public/PrivatePartnerships in Health Care delivery. This should includestandardisation of service quality, monitoring and compliance withinternational standards.

• Government guaranteed loans and or initiatives for US$ funding wouldhelp to encourage other professionals to enter the market for servicesthat require expensive, high tech diagnostic equipment.

• Allow tax holidays on Health Tourism investments similar to theincentive regime that applies to infrastructure plant, machinery andequipment for ordinary tourism.

• All investments in Health Tourism must satisfy internationalstandards and should enhance Brand Jamaica.

• GOJ to establish certified training centres for technical support relatedto hospital equipment servicing. Partnerships with educationalinstitutions to develop programmes for identified health and allied



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professionals, to ensure sufficient personnel for continuation anddevelopment of the services

• Training, Research and Development Allowances to be added to supportmedical service delivery .

.• Regional and International Government to Government discussions to

open a window of opportunity for Jamaican Diagnostic Facilitiesincluding Diagnostic Radiology, Laboratories, Telemedicine Systemsexperts in Medical information technologies to provide off shoreTelemedicine services including Tele-Radiology, Tele-Pathology, Tele-Dermatology Tele-Consultation, Surgical and Medical Procedural Tele-Mentoring, Tele-Home Dialysis Health Services etc, to other countriesthat may benefit and be in need of such services.

• Government to continue to support and collaborate with SpecialistAssociations (e.g. Medical Association of Jamaica and JamaicaAssociation of Radiologists) in enabling and charting a course towardsentry into the rapidly growing worldwide Health Tourism market.

11.3.3 THE NATIONAL HEALTH FUND

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

Health Fund (NHF) has developed and maintained a very high level of efficient

management. It has carried out its mandate faithfully and is a model of corporate

efficiency and propriety. The impact of the NHF individual benefits plan on the

epidemiology of chronic disease in Jamaica is being evaluated. Preliminary

indications are pointing towards a positive outcome.

The NHF model was developed in Jamaica by Jamaicans using the principles

of prevention embodied in the science of epidemiology to determine the policy

framework, its organisation, structure and function. The policy framework targets

the most epidemiologically prevalent condition in the Jamaican population i.e.

chronic diseases. The NHF functions as a strategic health financing institution

utilising prevention principles embodied in wellness, mitigating the development of



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

Secondary and Tertiary prevention.

The NHF has been a very important source of project funding for the RHAs;

the problem has been the inability of the Regions to execute their projects because

of lack of capacity or the inordinate cumbersome nature of the procurement process.

Financing is targeted within that framework. This demonstrates that

whenever epidemiologic criteria are used as the basis for the financing of public

health service delivery, the main beneficiaries are the patients and the system will

benefit from greater efficiency, accountability and sustainability.

The financial independence of the NHF has been critical to its operational

success. To maintain good governance, whilst ensuring the NHF is able to pursue

its mandate efficiently and provide the assurances required in the provision of

benefits, it is recommended that the CEO be designated an Accounting Officer by

the HMOF&P under Section 16 of the Financial Administration & Audit Act.

Executive Agency status is not recommended as the NHF is a statutory

organisation with administrative and financial guidelines provided by the NHF

Act. The CEO shall then be responsible to the HMOH under the NHF Act for the

operations of the NHF and to the HMOF&P under the FAA Act for its financial

administration.

It is further recommended that more creative measures further increase the

funding of the NHF to offset the decline in revenues as a result of the decrease in

the prevalence of cigarette smoking. The effect of the consequences of alcohol use on

traffic accidents and the disease of alcoholism have an impact on the disease burden

and cost to the health service.

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

Statutory financial institution which accounts for the turnover billions of taxpayer

dollars must have been an oversight since it is a necessary responsibility in keeping



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with proper corporate standards and practice that the responsibility of the CEO in

accounting to the Board of management of the NHF for every expenditure of the

institution must never be in question.

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

accounting officer be made with very soon.

11.3.4 HEALTH INFORMATION SYSTEM

The NHF has successfully implemented an electronic patient adjudication

system for the use of drugs by patients suffering from any one or more of the fifteen

most prevalent chronic diseases in Jamaica using a network of pharmacies across

the island.

Since March 2007 the NHF has successfully built up its technological

capacity in preparation to deploy a National Electronic Health Record System

developed for the use of all doctors universally and institutions throughout the

Jamaica. This software is presently being beta tested in preparation for its

deployment throughout the National Health Service System during the second

quarter of 2008.

The present status of the National Health Information System at the head

office of the Ministry of Health is flawed and has been a source of much concern by

every category of health personnel. The findings of the Task Force review and

evaluation confirm this.

In light of the urgency of the need of the MOH&E to deploy a national Tele-

health network infrastructure as a pre-requisite for Health Tourism and in order to

deploy its electronic health record system, which represents the core of the Health

Information System it is recommended that the health information system

requirements of the health sector be administered by the National Health Fund

which has a track record of an efficient organisation geared to provide these services

to the healthcare providers.



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The NHF would be responsible for providing the required technology

platform and supporting infrastructure to implement a national Health Information

System. This system would ensure that patients and the public would have

available the facilities needed for modern comprehensive care that can only be

achieved through systems that allow health practitioners to access and share

patient information in a timely manner. The source of funding for building such an

infrastructure has already been approved by the Ministry of Health.

This source of funding is derived from a bilateral agreement between the

Government of Jamaica and the Government of the Peoples Republic of China. The

bilateral agreement has been in an advanced state of planning and preparedness

and may be implemented before the end of the second quarter of 2008.

The Task Force recommends that these funds be made available to the

National Health Fund with the mandate to build a national Tele-health network

infrastructure to connect all institutions of the MOH&E for an integrated voice,

data and video service to begin the process of modernising the Jamaican health

service system and to build a viable Health Tourism industry.

This would ensure that the basic infrastructure for Heath Tourism would

be in place and the way paved for vast opportunities for new business in Health

Tourism in the global marketplace.



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12.0 CONCLUSIONS AND RECOMMENDATIONS

The Task Force Review was welcomed by the various segments of the health

service sector. The RHAs have been in existence for a decade and the

Stakeholders are not fully cognisant of their roles and functions. Critical

concerns were HR issues; lack of appropriate information technology; supplies

management and financing. The link between the Regions and the Ministry

and existing reporting relationships came in for a lot of criticisms. The

professional groups are very sensitive to the dysfunctions in the

organisational structures of the RHAs.

In this Report specific recommendations are dealt with under the topics as

outlined in the Terms of Reference and presented to the stakeholders. For

the sake of completeness we now list all our recommendations together. It

will be noted that a number of these are exactly as made by the stakeholders

in the Review.

The Task Force Recommends the Implementation of the Following :

POLICY , ORGANISATION & STRUCTURE

1. The RHAs must be changed from semi-autonomous authorities tobecome Regional Coordinating and Enabling Organizations. In sodoing, each will be an integral part of the organization and structure ofthe Ministry and a strong link between head office and the Parish,enabling and supporting the function of implementation – which is thedomain of the Parishes

2. Head Office of Ministry of Health and Environment should focus on itsprimary role of policy formulation, policy determination, setting norms andstandards, monitoring and maintaining support functions for strategichealth care delivery.

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



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4 Reorganise service delivery on the core functions of Primary,Secondary and Tertiary Health Care

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

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

the health team in service delivery and the supporting relationship of the

administrative teams and systems.

6. Ensure that there is a national standard for the establishment of the

operations of organizations and structures at the regional and parish levels.

7. Redefine the role of the Parish Manager to become the leader of the

administrative team and systems; facilitating, enabling and supporting the

efficient implementation of health service delivery at the parish level.

8. Reinstitute the health team approach as the basic management standard for

service delivery both in the hospitals and the non-hospital sectors. This

approach will enable the coordination of technical functions necessary for

the efficient management of service delivery.

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

governed by a Board of Management to which will report the Executive

Manager, the Senior Medical Officer and the Director of Nursing Services.

Each Hospital Board must have representation from the Region or the

parish in order to enable the coordination and integration of the levels of

care in service delivery.

.



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MANAGEMENT INFORMATION SYSTEM

10. The National Health Fund (NHF) be the executing agency for the

immediate, short term, medium term and long term Information

Technology needs of the Ministry of Health and Environment.

11. The NHF further develops its IT division into a department and

continues to develop the IT professional capacity to do the following:

i. Develop and implement a modern web-based electronic

patient health record system which meets the

requirements of international standards of

interoperability and sits as the core of the health

information technology software application system for

service delivery of the patient Health Information

System.

ii. Implement the building and deployment of a robust

multi-service Internet protocol (IP) network

infrastructure (Tele-health network) dedicated to the

unique specifications of the Ministry of Health service

delivery system.

iii. Recruitment, training, and deployment of all IT

personnel and development of MIS throughout the

MOH&E.

MANPOWER

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

salary packages, welfare and incentive schemes must be

immediately addressed by a special multi-disciplinary group in

order to improve staff morale and efficiencies.



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13. A National Human Resource Development Strategic Plan be

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

epidemiologic principles.

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

approach that relates to clearly defined functions of service delivery

and administrative support,

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

develop an appropriate National Human Resource Manpower Plan” for

the sector in general and each specific Regional Health Authority in

particular. The Task Force agrees with this recommendation but

emphasizes that the effort must be one of priority and should take

place simultaneously with the organizational reform and

reclassification exercise currently being performed by the Ministry of

Finance and Planning.

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

necessary to deliver the quality care based on the epidemiological

requirements in each Region and in every parish.

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

new organization structure and functions at the central, regional and

parish levels.

18. The RHAs should institute training programmes in collaboration with

UTECH, NCTVET, MIND and like organizations for maintenance

personnel at all levels, with special emphasis on Artisans and Bio-

Medical Technicians.

19. International recruitment must be the domain and sole responsibility

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



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and Parishes. This should foster greater transparency in the

management of Human Resources.

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

PHARMACEUTICALS

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

to improve its capacity and its efficiency. A good fit would be to

absorb it fully as a department of the NHF to benefit from its

fully computerised for procurement, inventory control, supply and

distribution management.

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

Reports confirm this to be a SRHA best practice and could be expanded

to selected Primary Health Care facilities.

EQUIPMENT

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

Fixtures, Vehicles Stocks and Supplies ) must be established in

every Region as a matter of priority and maintained up- to- date.

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

equipment, especially with regard to service and maintenance, energy

conservation and replacement parts.

25. Outsourcing of maintenance of specialised equipment.

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



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FINANCES

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

community as the first step to fulfil the commitment of the

Government.

28. Retain User Fees for Secondary and Tertiary Care with

appropriate , sensitive system for exempting the indigent.

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

minimum of 10% of National Budget.

PROJECTS

30. Establish a Project Management and Implementation Unit in

every Region.

31. MOH&E should determine the appropriate measures to

modernise the guidelines for the tender process. These should

address situations where over-runs are caused by the changes in

epidemiologic determinants rather than human error.

HEALTH TOURISM

32 The BOOT model is offered as a method that would jump startthe development of Health Tourism Services in Jamaica Refer tosections 11.2. to 11.6. A national Tele-health networkinfrastructure is needed to connect all the institutions to theMOH&E. Funds identified from the Peoples’ Republic of Chinashould be channelled through NHF which has demonstrated itsability to successfully operate a national health record system.



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PUBLIC /PRIVATE PARTNERSHIP

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

NATIONAL HEALTH FUND (NHF)

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

HMOF&P under Section 16 of the Financial Administration & Audit Act.

More creative measures be utilized to capitalise the NHF to offset the decline

in revenues as a result of the decrease in the prevalence of cigarette smoking

in the country.

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

administered by the National Health Fund which has a track record of an

efficient organisation geared to provide these services to the healthcare

providers.

36. The NHF utilize funding derived from bilateral agreement between the

Government of Jamaica and the Government of the Peoples Republic of

China for building a National Tele-health Network infrastructure to connect

all institutions of the Ministry of Health for an integrated voice, data and

video service to begin the process of modernizing of the Jamaican Health

Service system and to build a viable Health Tourism industry.



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APPENDICES

APPENDIX 1 - LIST OF STAKEHOLDERS

LIST OF PARTICIPANTS INTERVIEWED

Senior Medical Officers

Name Institution

1. Patrick Bhoorasingh Kingston Public Hospital (KPH)2. Nadine Bourg (for Ray Fraser) Annotto Bay3. Winston Dawes May Pen4. Bradley Edwards5. Sonia Henry Bustamante Hopsital for children6. Yumkalla Kamara Falmouth7. Jeremy Knight PC, Portland8. John McRae Black River9. Maureen Irons Morgan Bellvue Hospital10. Onyema Njoku Hanover11. Dingle Spence SMO(H) Hope Institute12. Gregory Thomas Cornwall Regional Hospital13. Mikael Tulloch-Reid National Chest Hospital14. Peter Wellington Mandeville

CEOsName Institution Region1. Everton W. Anderson Cornwall Regional Hospital2. Helen Brooks Linstead Hospital SERHA3. Diana Brown Black River Hospital SRHA4. David Coombs Princess Margaret SERHA5. Beverly Douglas Lionel Town Hospital SRHA6. David Dobson Spanish Town Hospital SERHA7. Paulette Elliot M. R. Hospital SRHA8. Gary Francis Annotto Bay Hospital NERHA9. Eon Jarrett St. Ann's Bay NERHA10. Brent Nation Port Antonio NERHA11. Nadia Nunes-Howe May Pen Hospital SRHA12. Stanhope Scott Percy Junor Hospital SRHA13. June Tyme Port Maria Hospital NERHA14. Hazel Waite NCH/HI/SJGRC SERHA15. Lorene Whinstanley Sav-La-Mar Western



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Technical Focus GroupName Institution Post1. Yvonne Amair Cornwall Regional Hospital (CRH) Registered Pharmacist2. Rosalee Brown CRH/WRHA Registered Dietician3. Dianne Campbell Stennett Westmoreland Health Department Medical Officer (Health)4. Diahann Dale WRHA Reg. STI/HIV Prog. Coord.5. Denise Forsythe CRH/Physiotherapy Charge Physiotherapist6. Bancroft Haughton CRH Radiographer7. Kevin Johnson CRH Senior Medical Physicist8. Denise Malcolm Noel Holmes Hospital Director of Nursing Services9. Basel McFarlane WRHA REHO10. Rae Ponnada St. James Health Department Medical Officer (Health)11. Alicia V. Smith Sav-La-Mar Hospital Pharmacist12. Gregory Thomas CRH SMO

SRHAName Position Parish1. Desmond Brenniton DMOII Clarendon2. Sonia Copeland MO(H) Clarendon3. L. Darbon R.E.H.O. SRHA4. John Falconer FNA Clarendon5. Cislin Hall Registered Midwife St. Elizabeth6. Marcia Harris Lawrence PHN Clarendon7. Zeen Lalor C.H.A. St. Elizabeth8. D. A. Ledford MO(H) St. Elizabeth9. Faith Lylle HEO Clarendon10. Errol McLean Pharmacist St. Elizabeth11. J. Nation Dental Nurse Clarendon12. Carlton Nichols PPO Clarendon13. Charmaine Palmer-Cross DCPHI Clarendon14. Carlisa Pearson HEO Clarendon15. K. Pate-Robinson DMOI MHD16. C. Ramsay Dental Nurse Clarendon17. Valene Reid-Wright PHN St. Elizabeth18. George Sloley CPHI Manchester

SRHA - Group 2Name Position Institution/Parish1. Denise Brown-Anderson Dietetic Assistant Clarendon

2. Lorna Harold GrayChief Radiographer/Ultrasonographer Manchester

3. Donovan Leon Chief Medical Technologist SRHA4. Shaureal Llewellyn-Johnson Nursing Supervisor Manchester5. Keith Lowe Director Technician May Pen6. Ruby E. Melville Social Worker Manchester7. Jacqueline Pennicook Matron Lionel Town Hospital8. Verda N. Richards Regional Dietitian SRHA9. Michele Shaw Parish Pharmacist Manchester10. Inez Sunamon Matron Lionel Town Hospital11. Juliet Y. Vaughan-Mason Acting Deputy Matron Clarendon



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12. Saidie Williams-Allen Ward Sister ManchesterAdministrative Group - SRHA

Name Job Title Institution/Parish1. Yvonne Alexander-Gayle Health Records Administrator St. Elizabeth2. Bueretta Beckford Acting Operations Manager Mandeville Regional Hospital3. Hyacinth D. Bromley Matron St. Elizabeth4. Sandia Chambers Parish Administrative Officer Manchester

5. Eugena Clarke-JamesParish Administrative Officer(Acting) Clarendon

6. Verrol Ebanks Parish Accountant (Acting) St. Elizabeth7. Angella Henry Personnel Officer Manchester8. Jacqueline Jackson Parish Administrative Officer St. Elizabeth Health9. Etinel Locke Operations Manager May Pen Hospital10. Keitha O'Gilvie Personnel Officer St. Elizabeth11. Norman W. Rose Parish Accountant Manchester12. Pauline Rose-Campbell Parish Health Records Tech. Manchester M.H.D13. Beverton Roye Deputy C.P.H.I. St. Elizabeth14. Vivienne Wallace Health Records Administrator Mandeville Regional Hospital15. Nadene Williams Acting Accounting Mandeville Regional Hospital

Parish Managers

Name Region1. Michael Bent Southern Clarendon

2. Godfrey BoydSERHA - Kgn & St. And. HealthServ.

3. Carmen M. Foster Western4. Claudette Lewis South East5. Verlie James WRHA - Hanover6. Alwyn Miller Southern - St. Elizabeth7. Valencia Pearson-Maponya Western / St. James8. Yvonne Pitter Southern - Manchester9. Beulah Stevons SERHA10. Tatlin Tider Western

Nursing Associations

Name Position / Instititution

1. Beverly Bryan-Maragh Jamaica Enrolled NursesAssociation (JENA)

2. Aseta Edwards-Hamilton Jamaica Midwives Assn(Secretary)

3. Allan Jeffrey JENA President4. Ilene Murray JENA5. Carmen Walker Sutherland Jamaica Midwives Assn (President)6. Carmelita Wheeler Jamaica Midwives Assn (1st V.P)



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SERHAName Job Title Institution/Parish1. Jean Allen Parish Accountant St. Catherine Health Services2. Henry Anglin Administrator BHC3. Judy Creary Telecom Dept. KPH4. Joan Golding Personnel Manager St. Catherine Health Services5. Maureen Golding Personnel Officer Bellvue Hospital6. Junett Hayle Health Records Victoria Jubilee Hospital7. Dwight Holtham Accountant K.S.A.8. Evlin Hyatt-Beckford Administrator S.T.H. Medical Records9. Carol Hussey-Myers Budget Cash Flow Officer10. Karlene Taylor McKenzie Parish Administrative Officer K.S.A.11. Regent Walker-Smith Personnel Officer S.T.H. D12. Lorna Watson Health Records Primary Care13. Diana Williams Health Records K.S.A.14. Colleen Wright Operations Manager S.T.H.D.

Name Institution/Parish1. Dianne Campbell-Stennett Westmoreland2. Sandra Chambers KSA3. Diahann Dale WRHA4. Tamu Davidson SERHA5. Hurbert Elliot KSA6. Dawn Graham Padilla KSA7. Lambert Innis A.G.M.C.8. Yvonne Munroe MOH9. RamachondrayNaragomatharty SERHA, St. Thomas10. Heather Reid Jones SERHA, St. Catherine11. Andrew Salmon St. Catherine12. P. L. Weir KSA13. Yasmin Williams MOH

Technical Group – KPHName Job Title Institution/Parish1. Leeford Bennett Chief Medical Tech. II CHC2. Diane Buckley-Smith Registered Nurse KPH3. Patsy Gilling Acting Dept. SR S.T.H.4. Muslaw Gooden Registered Nurse PMH/St. Mary5. Khaleela Henry Registered Nurse Midwife V.J.H.6. Daphne Hutchinson Medical Technologist Spanish Town7. Angella Jennison Ward Assistant KPH8. Angella Lee-Grant Ward Assistant / Public Health Insp. Princess Margaret, St. Thomas9. Vera Morgan Nurse Anaesthetist Princess Margaret10. Norell-Lee Morrison-Ramsay Senior Physiotherapist KPH11. Ruth Nash Chief Pharmacist S.T.H.12. Dayanand Sawin MOH Orthopaedics BHC/KSA

13. Basil WalkerMedical Technologist/UnionDelegate St. Thomas

Western Regional Health Authority



181

Name Position1. Maung Aung Regional Technical Director (Acting)2. Raymond Kitson-Walters Finance Director

3. Cladius RamsayOperations and MaintenanceDirector

4. Anthony Smikle Procurement Manager5. Nadine Stewart MIS Director6. Arthur Warren Human Resource Director

Technical Focus Group - NERHA

Name Post Institution/Parish1. Judith Atkinson Linton Pharmacist SABH2. Deon Barrett Dietitian St. Ann's Bay Hospital3. Christine Buchanan Med. Tech. SABH4. Barbara Burke D.N.S. Port Antonio Hospital5. Caroll DaCosta EN St. Ann's Bay Hospital6. Nichole Dawkins Emergency Physician St. Ann's Bay Hospital7. Primrose Edwards W/A St. Ann's Bay Hospital8. Colita Fraser-Howard RN St. Ann's Bay Hospital9. Yi. Han Radiographer St. Ann's Bay Hospital10. Jeremy Knight Medical Officer (H) Portland11. Paulett Long Carr Matron St. Ann's Bay Hospital12. Arlene L. McGill rep. S.M.O. SABH13. Jean Rowe D.N.S. Annotto Bay Hospital14. Barbara Sinclair Ward Sister Port Antonio Hospital15. Linda D. Sutherland-Hines D.N.S. Port Maria Hospital16. Debra Treasure Physiotherapist SABH17. Patrick Wheatle Medical Officer (H) SAH Dept

Administrative Group - NERHAName Position1. Nordia Campbell Assistant Internal Auditor2. AnnMarie Davidson Reg. Health Records Administrator3. Leon Francis Chief Porter4. Patrice Gavin Systems Administrator5. Caroline Grant Bassan Cashier6. Rowena Hayle CCO/Regional Office Manager7. A. Higgins Accounting Clerk8. Cordelyn Jackson Secretary9. Lenworth Jones Driver10. Horesa Martin Acting Parish Administrator11. Desmond Matthews Accounting Technician12. Jeannette Parris Senior Accountant13. Joy Ridley Cashier14. L. Badre Singh Accounting Clerk15. R. Taylor Parish Administrator16. Patrice Thompson Accountant - SABH17. Doreen Wilson Human Resource Officer (Acting)Primary Health CareName Position Institution/Parish



182

1. Beverly Bisasor-Richards D/N St. Ann2. Maxine Blake-Hylton C.I. St. Ann3. A. Paul Brown DCSHI St. Mary4. Aylete Brown Hall F.N.P. St. Ann5. Charmaine Clarke Secretary Portland Health Department6. Jennifer Gilmore SPHN Portland7. Arthur Green DMO STHC8. Meris Hopkins Regional Nutritionist St.Mary Health Department9. Valrie McLeary HEO Portland10. Vinnette Mitchell-Forrester P.D.A.C. (D/N) Portland11. Dorrett Norrine C.I. Portland12. Sabrina Palomino Nutrition Assistant St. Mary13. Joan Robinson-Mcpherson VPHI (Acting) Portland14. Desrene Strachan D/A St. Ann15. Beverley Samuels SPHN (Acting) St. Mary16. George Wilson C.H.A. Portland

DentistsName1. Winston Grey3. Sandra Hill-Cameron4. Irving McKenzie

Region Board ChairmenName1. Mr. Kenny Benjamin Bustamante Hospital for Children2. Mr. W. Levy, J.P. May Pen Hospital3. Mr. Lyttleton Shirley SERHA4. Mr. Whilston Taylor KPH & VJH5. Mr. Michael Whittingham NERHA

Ministry of Health - Head OfficeName Position1. Dr. Grace Allen Young Permanent Secretary2. Dr. Peter Figueroa Chief Epidemiologist

3. Mrs Gail HudsonDirector, Human Resource Mgmt &Corporate Services

4. Mr. Lincoln Walters Director, Systems & InformationTechnology Unit

5. Nigel Logan Principal Financial Officer6. Dr. Leila McWhinney-Dehaney Chief Nursing Officer

7. Dr. Eva Lewis FullerDirector, Health Promotion andProtection

8. Dr. Denise Duncan-GoffeDirector, Health Services Planning& Integration

9. Mrs Princess ThomasOsbourne Director, Standards & Regulation10. Dr. Earl Wright Director, Mental Health



183

National Health FundMr. Rae Barrett Director

Auditor General's DepartmentMr. Adrian Strachan Auditor General

Office of the CabinetHon.Dr. Carlton Davis Cabinet Secretary

Administrative GroupName Position Institution/Region

1. Jacquelinie Allen-Blake Health Records Technician Trelawny Health Dept.2. Nezlyn Bowen Hospital Administrator CRH3. Margaret Clarke-Thompson Accounting Clerk Trelawny Health Dept.4. Henviella Harrison Regional Health Records Admin.5. Dawn Harvey Senior Hospital Administrator CRH6. Celia Huggan Personal Manager Regional Office7. Angella Lumley Powell Assessment Officer Falmouth Hospital8. Geneve McCulloch Medical Records Administrator Sav. Hospital9. Maria McGhie Checking Officer WRHA Accounts10. Orlain Nembhard Patient Affairs Manager (Acting)11. Patricia Pennycooke Telephone Operator Supervisor Sav. Hospital, WRHA12. Myrna Scott Medical Records Technician Lucea Hospital13. Kirkland Simms Records Officer St. James Health Dept.14. Darion Smith Assistant Internal Auditor15. George Thomas Parish Administrator St. James Health Dept.16. Marcellen Wheatle Health Education Officer17. Charmaine Williams- Parish Administrator Hanover

Private Hospitals Association of JamaicaPatrick Rutherford President, CEO Andrews HospitalBill Poinsett CEO NuttallDr. Neville Graham Chairman Winchester MedicalFaith Williams Administrator Winchester Medical

Private Sector GroupJoe Sterazza AICRoshan Sapra AIC



184

APPENDIX 2 - REFERENCES

(1) Allen-Young G. E. (2006). Ministry of Health Regional Health AuthoritiesHuman Resources Policies and Procedures Manual.

(2) Annual Report 2004. (2005). Ministry of Health. Policy Planning &Development Division.

(3) Belvett O. Decentralisation of Health Services. A success Story. Presentationto the Permanent Secretaries Board.

(4) Briggs G. (1998). Regional Health Authorities. Instrument of Delegation.Ministry of Health.

(5) Cabinet Submission (2003). Appointment of Members to Parish HealthCommittee and Hospital Committees.

(6) Change Management Consultation Report.(7) Civil Service Establishment Act (2006). Jamaica Printing Press(8) Corporate Strategic Planning Work Plan: Ministry of Health.(9) DAH Consulting Inc. (2004). Consultancy to Evaluate the Implementation of the

Health Sector Improvement Programs in Jamaica: Bitran y Asociados,Health Care Organizers and Advisors.

(10) DAH Consulting, Inc. (2004). Evaluation of the Scope, Process and Impact ofthe Health Sector Reform Programmes.

(11) Daniel H. S. (2004). Service Level Agreement discussions in January 2005:Letter.

(12) Decentralisation of the Ministry of Health. A Green Paper (MAJ).SWOT Analysis Dr. Shiela Campbell-Forrester CMO

(13) Department of Operations & Maintenance. (2007). North East Regional HealthAuthority. Regional Maintenance Plan 2007-2008 (Draft).

(14) Duncan-Goffe D. & McCartney T. (2005). Redesigning the Health System inJamaica. A Proposal.

(15) Executive Summary of Organisational Structures and Staffing of the four RHAsJamaica Social Policy Evaluation (JASPEV) Project. Jamaica 2015.

(16) Government’s Response to the Annual Progress Report on National SocialPolicy Goals 2003. Office of the Cabinet Government of Jamaica.

(17) Exemption Process for all Health Centres except Montego Bay Type V.(18) Figueroa P. (2007). Interview with Professor Figueroa re Health Reform.(19) Graham S. (2007). Report on Change Management Meetings with Senior

Directors. Ministry of Health.(20) Institutional Benefits Project Status Report October 2007. Approved Projects that

are in Progress (MOH and RHAs).(21) Interim Report by the Sub-Committee on the Development of Reorganization

Proposals for the Ministry of Health and Environmental Control. 14 th

July 1977.(22) Junor J. A. (2006). Human Resource Council Submission. (Draft).(23) Management Services Branch. (2000). Ministry of Health South East Regional

Health Authority. Proposed Organisational Structure Human ResourceDevelopment.

(24) Ministry of Finance & Planning. (2002). The Financial Administration and AuditAct. Instructions.

(25) Ministry of Health. Major Health Reform Programmes.



185

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

(27) Ministry of Health. (1996). Report of the Task Force on Health SectorManpower Education and Training.

(28) Ministry of Health. (1997). Technical Services Head Office. Detail Functionsand Staffing Patterns of Technical Units.

(29) Moyne L. (1930’s). Moyne Commission Report.(30) National Health Services Act, 1997.(31) North East Regional Health Authority. Human Resource Department Business

Plan 2007/08.(32) North East Regional Health Authority. Job Specification and Description

National Health Fund. (2007). Projects Achievements – 2006 April to2007 May. Objectives 2007 April to 2008 December. North EastRegional Health Authority Projects.

(33) Operations and Maintenance Budget (2005-2008).(34) Oral Health Services Level of Care Document(35) Organisation of the Statistics & Information Services Division(36) Osbourne, P. (2006). A Summary Description of the roles and function.

Ministry of Health: Standard and Regulation Division.(37) Osbourne P. Standards and Regulations Division Annual Report January –

December 2005.(38) Osbourne P. (2007). - Expected Outcome of “Short Term” Consultancy to the

Ministry of Health on Matters Related to Complementary andAlternative Medicine (CAM) 2008/2010. Terms of Reference.

(39) P. A. Consulting Group. (2007). Public Sector Reform Unit. Ministry of HealthChange Management Final Report Incorporating.

(40) P. A. Consulting Group. Public Sector Reform Unit. Ministry of Health ChangeManagement Programme: Draft Final Report. Focal Point Consulting.

(41) PIOJ (2007). 2030 National Development Plan Jamaica Health Chapter.(42) Policy Analysis of HSRP & the Decentralisation Programme.(43) Prince L. A. (2001). A Comparative Review of the Cost and Benefits of

Centralisation Vis-à-vis Decentralisation of Health Benefits and Costs.(44) Public Bodies Management and Accountability Act (2001).(45) Public Services Regulations (2006). Human Resources Policies and Procedures.

Staff Orders for the Public Service.(46) Purvis. G. P. (2002). Strategic Planning for Accreditation Standards and

Regulation Division (Final Report): Ministry of Health.(47) Ramsay C. (May 10, 2007). Maintenance Restructuring – Staff Promotion and

Recruitment.(48) Ramsay C. (October 16, 2007) Project Unit the Way Forward. (Memo).(49) Ramsay C. (2006). Standard Operating Procedures (SOP) for Vehicles

involved in an Accident. WRHA.(50) Regional STI/HIV/AIDS Programme Management Meeting. 14 September 2007

at SRHA Board Room.(51) Regional Technical Services Document (1998).(52) Reid U. V. (1999). Regional Technical Functions and Staffing. A Working

Document. Report. PAHO/WHO/Ministry of Health Report.(53) Report of the Complementary Medicine Committee or the Ministry of Health



186

Advisory Panel (Volume 1). December 2001 – May 2003.(54) Service Level Agreement. (2005). North East Regional Health Authority. 3 Year

Agreement. 2005/2006 – 2007/2008.(55) Service Level Agreement. (2005). South East Regional Health Authority. 3 year

Agreement. 2005/2006 – 2007/2008.(56) Service Level Agreement. (2005). Southern Regional Health Authority. 3 Year

Agreement. 2005/2006 – 2007/2008.(57) Service Level Agreement. (2005). Western Regional Health Authority. 3 year

Agreement. 2005/2006 – 2007/2008.(58) South East Regional Health Authority 3rd Quarter Performance Review (2006).(59) St. James Public Health Services (Health Department).(60) St. James Public Health Services (Health Department) Standard Operating

Procedure (SOP) Complaints.(61) St. James Health Department Standard Operating Procedure. Protocol for seeing

Walk-In Clients at Montego Bay Type V Clinics.(62) Standard Operating Procedure (SOP) Patient Billing and Exemption Reporting.(63) Standards and Regulation Division Annual Report. (2005).

(64) Stanhope S. A Review of Decentralization of the Health Care Services in theSouthern Region - Jamaica. The Health Workers Perspective.

(65) Summarized report on the Performance of Portland Parish Health Committee- 2007.

(66) Terms of Reference for Consultant to develop a Corporate Plan for the Ministryof Health.

(67) Thomas N. (2007). Western Regional Health Authority Maintenance MonthlyReport.

(68) Ward E. & Grant A. (2005). Epidemiological Profile of Selected HealthConditions and Services in Jamaica 1990 – 2002. Report of the HealthPromotion and Protection Division. Ministry of Health.

(69) Western Regional Health Authority. Acceptable use Policy.(70) Western Regional Health Authority. Hardware and Software Policy.(71) Western Regional Health Authority. User Password Policy.(72) Western Regional Health Authority. Human Resource Department Annual

Report 2006-2007.(73) Western Regional Health Authority. Organisation Chart.(74) Western Regional Health Authority Transport Department Status.(75) Williams H. A. (2007). Project to Document Organisation Structures and

Staffing for North East Regional Health Authority. Appendices showingOrganisation Structures and Excess Listings.

(76) Williams H. A. (2007). Project to Document the Organisational Structures andStaffing of the North East Regional Health Authority. Report.

(77) Williams H. A. (2007). Project to Document Organisation Structures andStaffing for South East Regional Health Authority. Appendices showingOrganisation Structure and Excess Listing.

(78) Williams H. A. (2007). Project to Document the Organizational Structures &Staffing of the South East Regional Health Authority. (Report).

(79) Williams H. A. (2007). Project to Document the Organisation Structures andStaffing for Western Regional Health Authority. Appendices showingOrganisation Structures and Excess Listing.



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(80) Williams H. A. (2007). Project to document the Organizational Structures &Staffing of the Western Regional Health Authority. (Report).

(81) Wright E. Mental Health Reform. The Development of Community MentalHealth Services & Deinstitutionalization.

(82) ZTE Corporation (2005). Telemedicine System in Jamaica.



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APPENDIX 3

FOCUS GROUPSRegion: Western RegionGroup: Admin, TechnicalReports To:Role:

POLICIES STRUCTURE FINANCIALPOLICY DEVELOPMENT§ Some policies were not

discussed e.g. MGD, A&E,MOH expectations wereunrealistic

§ PHI had input in the SolidWaste policy. Groups whosaid input was sought-Physiotherapy, PHI.

§ Physicist-Policies not backedby Legislation- X-ray policymanual but no legislationabout the effects of radiation.

§ MOH has not adopted amonitoring role.

POLICY COMMUNICATION§ Consultation required in

changes of policies for e.g.- Human Resource- Fees for Service- Stand By On Call Allowance

for Nurses.(interpreteddifferently by each Region)

POLICY IMPLEMENTATIONSLA

§ Unfunded mandate sent tothe region for implementation

§ Try to implement policies ifpressured.

§ A&E policy not reviewed toinclude suggested changes.

§ Policies are ambiguous- Leadto various interpretations.

Challenges in PolicyImplementation§ Lack of Resources (MMF),

Procurement procedures ,Forexample, staff workshops,materials.

MONITORING

ORGANIZATONALSTRUCTURE§ Too many Regions.§ Top Heavy (A,T)§ Some functions can be

merged.§ Unclear functions/

duplications (A,T)§ Technical Structure is

still in draft form(Technical staff at theRegional level is weak)(Admin is strong).

§ Ratio of Admin. toTechnical Staffshould be of relevanceto the delivery ofService. Comment:

§ Decentralization wasdesigned foradministrative staff tocontrol delivery ofService

§ Chief Pharmacist forCRH also has theresponsibility ofRegional Officer

PARISH STRUCTURE§ Overlapping of Role of

Parish Manager andMedical Officer

§ Parish /Regional rolescompeting

§ Technical officerswithout immediatesupervisors.

HUMAN RESOURCE§ HR and maintenance

the two biggestdisappointments.

§ Region lacks strategicplanning.

§ Problems with

FINANCIAL RESOURCES§ Inadequate funding

PROPOSED STRATEGIES

USER FEES§ Should not be abolished:Exemptions:§ <18 years except for

pregnant clients belowthe age of 16 years.

§ Age 60 years§ Indigents.



189

§ Lack of Monitoring by theMOH. Needs competentpersons to give guidance.

§ Audit from the MOH isinfrequent.

§ Two (2) Auditors in WesternRegion.

Recommendation:§ Independent monitoring

Body (Sanctions).

performance appraisal§ Cadre inadequate§ No accommodation for

new positions§ Non-appointment of

staff (A, T, PC.)§ Chief Pharmacists

CRH also works asRegional Pharmacist.

§ Pharmacists – 64vacancies.

PROPOSED CHANGES§ Region: Need for a

Nursing position tointegrate Secondaryand Primary Care.

Parish:§ Overlapping of roles

and functions.

SUPPLIES MANAGEMENT INFORMATIONSYSTEM

Best Practices

PROCURMENT PRACTICE§Major problem with HCL

unable to supplypharmaceuticals so Regionhas to purchase on the openmarket). No line of Creditwhen supply is out of stock.

Recommendation:§ Reorganize HCL (debts need

to be written off) and theentity recapitalized.

§ Poor quality of paper used forprinting medical records

§ Delay in getting requestedmaintenance equipment andsundries because ofprocurement procedures of

getting 3 quotes.

Recommendation:§ Outsource Maintenance of

Equipment§ Each Parish should have a

maintenance team§ Training of Artisan Plumbers,

electrician carpentersNCTVET Certification

§ Manual – Majority ofHospitals andhealth centres.

USAGE§ Only Two hospitals

have PAS.§ The system is

inadequate and not§ User friendly.(Needs

upgrading as it relatesto STI& HIVprogrammes).

§ HR System linked topayroll at RegionalHealth Authority

§ Parish HR System isoperated manually.

§ Patient affair System ismanually operated ineach parish.

§ Medical Doctor asRegional Director

§ Hospital on the samebuilding as RegionalHealth Authority.RD understands

All these enhance theproblem solving process.

21ST CENTURY JAMAICA Concerns



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§ Computerization (A,T,P)§ Efficient Transportation

System( preventive maintenance)§ General upgrading of

infrastructure (A,T,PC)§ Modern Communication

System (A,T,PC)§ Increase cadre of Health

workers (A,T,PC)§ Increase training of Technical

and para-medical staff,pharmacists, physiotherapists,radiographers. (A,T,PC)

§ Increase compensation for staff§ Introduction of Welfare

programme for staff withemphasis on OccupationalHealth and Safety (OH&S).

§ More Autonomy for region.§ Customer Service.§ Expansion of Emergency

Response Service.§ Expansion of the Services at

Health Care Facilities.§ Quality Assurance.§ Clinical Governance.§ Standardization of RHAs

processes at the RHA andparish Level. (Apply sanctions)

§ Upgrade facilities at FalmouthHospital to match with the newA&E department.

§ Stop self referral to hospital.§ Attract and retain Staff.§ Training of Administrators in

Technical field.§ Improve infrastructure of

Health Centres.§ Projectise programmes.§ Programme plans and

budgeting need to be donesimultaneously.

§ Need for Psychologists, SocialWorker for staff. (OH& S)

§ Staff Welfare.§ Policy for staff to Access

health care.§ Increase the # of facilities for

social cases.§ Staff representative to be

accommodated on Board.

§ New graduates have ‘no’clinical skills.



191

FOCUS GROUPRegion: WRHAGroup: Primary Care Group

(Public Health Inspector, Driver, Midwife, Community Health Aide, DentalNurse, Pharmacist, Health Education Officer, Lab Tech., Senior Public HealthNurse, Family Nurse Practitioner, Secretary)

POLICIES STRUCTURE FINANCIALPOLICY DEVELOPMENT§Top Down

POLICYIMPLEMENTATION§Use of creativity§Apply a shift system

CHALLENGES§ Manpower supply§ Office Space§ Structure of building

OVERVIEW§ Overlapping in

management functions.§ Top heavy.§ Lack of communication

between regions – noteam approach.

§ Lack of monitoring of regions§ Proposed changes CI position§ No autonomy§ Inconsistency in

processes vs. practices§ Lack of focus on Primary

Care§ Proactive not reactiveHUMAN 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

CAPABILITIES§ Lack of funding§ Potential exists for Dental

services§ Patient needs are not met§ Quality of work reduced

USER FEES§ Should not be abolished§ Rationale: Money needed,

unaware of cost recoveryby region

§ Overcrowding

SUPPLIES MANAGEMENT INFORMATION SYSTEM 21ST CENTURY JAMAICAPROCURMENTPRACTICES§ Pharmaceutical (3)§ Sundries (3)§ Maintenance Supplies (2)§ Equipment

TYPE§ Manual

CAPABILITIES§ Inadequate§ 1 printer: 5 computers§ OverloadingCHALLENGES§ No relatedness of IS§ Inadequate computer

§ Greater autonomy to PCmaking them moreindependent.

§ Build fully equipped Type 5in all parishes with a team.

§ Improve infrastructure§ Standardization of processes§ Improve investor relations.§ Include mandate for

development.§ Better monetary incentives

for PC.§ Better MIS system.§ Increase equipment supplies.



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Region: SRHAGroup: Primary Care Group

(Dietetic, Nursing Supervisor, Chief Radiographer, Parish Pharmacist, SocialWorker, Matron, Ward Sister, Chief Medical Technologists)

POLICIES STRUCTURE FINANCIALPOLICY IMPEMENTATION§ Top Down§ Sonographers –

International Code ofEthics, Training Register

§ Social Workers initateActions.

§ Lab Techs – operate onown standards.

§ Nurses – meeting andseminars, educationworkshops and regionalworkshops.

POLICYIMPLEMENTATION§ Use of creativity.

CHALLENGES§ Allied health profession

Disregarded.§ Decision is left to people

on the ground.§ Board composite.§ Reactive approach by

management to problems.

OVERVIEW§ Concept is good§ Regions need to be

monitored§ No equity in the region§ No autonomy§ Disparity with knowledge

base in region.

HUMAN RESOURCEMANAGEMENT

§ No new post.§ Staff motivation.§ Retirement benefits.§ Radiographer – high

turnover due toinsecurity.

§ Quality of workstemming from HRissues.

§ Lack of standards forcontractors esp. nursingassistant.

COMMUNICATION§ Meetings§ Face to face

CAPABILITIES§ Lack of funding§ Patient needs are not met§ Quality of work reduced

USER FEES§ Should not be abolished§ Rationale: Money needed

to supply the regionsneeds.

SUPPLIES MANAGEMENT INFORMATION SYSTEM 21ST CENTURYJAMAICA

PROCURMENTPRACTICES§ Pharmaceutical (4)§ Sundries (2)§ Maintenance Supplies (2)§ Equipment

TYPE§ Manual

CAPABILITIES§ Inadequate

CHALLENGES§ No relatedness of IS§ No computer

§ Improve infrastructure§ Standardization of

processes§ Improve human resources

capabilities§ Improve equipment§ Better Procurement

practices§ Staff participation in the

decision making/policydevelopment

§ Staff facility – nurses§ Improved funding§ Appropriate funds§ Better MIS system

FOCUS GROUP



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Region: AllGroup: Senior Medical OfficersReports To: Parish Manager, CEORole: Supervise technical and clinical services.

POLICIES STRUCTURE FINANCIALPOLICY DEVELOPMENT§ Bottom Up approach§ Crisis approach§ Lack of communication of

how policies aredevelopedο Parish+ Regional

Boardsο Central governmentο Regionsο Technical +

Management staffο Hospital Management

Committee (SMO,senior nurses, Admin.Staff)

§ Lack of involvement inthe policy process

§ Developed guidelines forpatients and technicalstaff.

POLICYCOMMUNICATION§ No/minimal

communication.§ Adhoc with no set

standards§ Review and develop

policies with team (HopeInst.)ο SLAο Meetingsο Develop patient care

guidelinesPOLICY IMPLEMENTATION§ Rationalization for new

policies.§ Educate staff on

institutional policies§ Wider policy is

problematic§ Procedures manuals act

as guides.

CHALLENGES§ Change management

ORGANIZATONALSTRUCTURE§ Top Heavy§ Good idea but needs a

team approach andmore technicalinvolvement

§ Current structure toobureaucratic andinefficient

§ Inverted§ Cumbersome§ Imposed without

understanding service

PROPOSED CHANGES§ Change in reporting

structureο SMO should not

report to the ParishManager.

ο Establish positionsin the parish.

ο Include aMaintenanceSupervisor for eachparish.

Meetings§ Abolish role of Parish

Manager§ More input needed by

technical staff§ SMO to report to region

MODES OFCOMMUNICATION§ Emails§ Meetings§ Face to Face§ Indirect – go through

PM or CEO§ Difficulty with HR§ RTD*

MONITORING§ More dialogue with

FINANCIALRESOURCES§ Poor, under-budgeted§ Improve allocation of

funds across region§ Unaware of the budget

allocation for hospital.§ Financial liabilities for

medication, utility bills§ Limited fundraising

PROPOSEDSTRATEGIES§ Collaboration

(private/public)§ Fundraising§ Emphasis should be on

accountability§ Lack of standards to

monitor for shortfalls§ Increase fee collection§ Better Billing§ Better Payment options§ More autonomy over

budget§ Improve capacity (MIS)§ Increase budget

USER FEES§ Should not be abolished.§ Rationale:ο Misuse of privilegesο Hospitals need the

Money.ο Over utilization of

services.ο Should be tailored.



194

issues with staff.§ Adapting to policies from

central government.§ Institutions capacity is

inconsistent with policygoals.

§ Methods of policydevelopment – project/team driven forsustainability.

§ Communication withadministrativebureaucrats.

§ Technocrats andbureaucrats relationships.

§ Medical staffing issues§ Underdeveloped cadre of

workers (para-medical).§ Lack of resources.§ Define job description.

policymakers.§ More ongoing monitoring

by central government.

SUPPLIES MANAGEMENT INFORMATION SYSTEMPROCURMENTPRACTICES§ Poor, under-budgeted§ Unaware of the budget

allocation for hospital.§ Financial liabilities for

medication, utility bills§ Limited fundraising

USAGE§ No IS§ Manual IS or retrieval

areο Timelyο Accurate

21ST CENTURYJAMAICA§ Proper Infrastructure

(equipment).§ Adequate Staff (Medical,

Nursing).§ Financial sufficiency.§ Developed defined

standards nationally.§ SMO to recommend and

follow hiring of staff.§ Private partnership in

Medicare.§ Extensive investigations to

be contracted out.§ Communication network

with RHAs.§ Developed system of

accountability.§ Decrease administrative

staff in the region.§ Abolish PM posts.§ Give more power to the

SMOs’ and CEOs; +Administrators



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§ Public/Private Partnership§ Electronic Integrated records§ Clinical Research§ Improve Transport systems§ Retool Radiological

Laboratory services in thehospitals + PC

§ Strengthen PHC to reduceload on hospitals.

§ Public/Private Partnership.§ Develop training

opportunities in the sub-specialties and distributingthem evenly in the country.

§ Develop all islandcommunication systems.

§ Proper and efficientprocurement systems(centralize)

§ Reviews allocation ofHealth Budget.

§ Implement a functioninglaboratory system.

§ Simplification +rationalization of regionalstructure.

§ Redefine role of SMO/MOHin management structure.

§ Redefine role CMO withrespect to PS.

§ Separation of training vs.non training posts forregistrars/residents.

§ Incorporate clinicians inMOH structure.

§ Create centres of excellenceoutside the UniversityHospital.

§ Preventative maintenanceprogram.

§ Excellent Customer Service§ Excellent HR (teamwork,

staff perception)§ Frequent Audit and Review



196

FOCUS GROUPRegion: AllGroup: Chief Executive OfficerReports To: Parish ManagerRole: Manage day to day operations of the hospital.

POLICIES STRUCTURE FINANCIALPOLICYDEVELOPMENT§ Through RHA with inputs

from the parish (5)§ Developed by HR (1)§ Done by MOH (10)§ Inputs from mgmt team

(3)

POLICY COMMUNICATION§ No Participation (2)§ Little Participation (1)§ Submission of documents§ Discussions in meetings§ Contribute via interaction

with PHRO duringdesign.

POLICYIMPLEMENTATION§ Staff workshops,materials§ Consultations§ Face to face interaction§ Budgets, time based

action sheet§ Circulation of draft

documents to seniormanagers

§ Change managementmeetings

§ Audits§ Approval/input from the

PM and ensure consensus§ Staff Meeting§ Training sessions§ Programme Planning

CHALLENGES§ Recommendations are

never implemented orconsidered.

§ Change managementissues with staff.

§ Clinical staff may identifygaps not previously

ORGANIZATONALSTRUCTURE§ Structures are not

uniformed acrossregion§ Top Heavy (1)§ PM does not interface

with hospital CEO§ Inverted§ Cumbersome§ Imposed without

understanding service

PROPOSEDCHANGESRegion§ Yes (4)§ No (§ Greater autonomy§ Lengthiness ofresponse

time§ Increased Budgetary

allocation§ Reduce the number of

managers at HOD andestablish PA to

managethe day to day

operations.Parish§ Yes (4)§ No (1)§ Parishes to be more in

charge of PHC§ Increase autonomy of

PM§ Change in reporting

structureο SMO should not

reportto the Parish

Manager.ο Establish positions

in

FINANCIAL RESOURCES§ Poor§ Most day to day needs are

satisfied§ Weak and counterproductive§ Possibility to collect 50% of fin.

Needs§ Improve allocation of funds across

region§ Ability to manage but not

given the responsibilities.§ Unaware of the budget

allocation for hospital.§ Give the hospital the

responsibility to manage theimprest a/c

§ Budget is inadequate

PROPOSED STRATEGIES§ Collaboration (private/public)§ Fundraising§ Emphasis should be on

accountability to UnitManager

§ Provide more autonomy tolarger hospitals

§ Payoff existing debt§ Provide realistic budget

based on operational plancoupled with user fees andfundraising.

§ Develop a development plan§ Inclusion of experienced

MOH personnel who areproficient in GovernmentAccounting.

USER FEES§ Should not be abolished.§ Rationale:ο Misuse of privilegesο Hospitals need the moneyο Country cannot afford “free”

health care



197

discovered.

§ Parish Managers areoften

invited to represent theviews of hospital

personneland may not be wellequipped to do so.

§ Lack of financialresources

in adequate forimplementation.

§ Lack of manpower.§ Resistance to change.§ Lack of participation.§ Lack of interest by some

groups.

the parish.ο Include a

MaintenanceSupervisor for eachparish.

ο Meetings§ Abolish role of Parish

Manager

§ More input needed bytechnical staff

§ SMO to report toregion

MODES OFCOMMUNICATION§ E-mails§ Memo§ Letters§ Fax§ Internet§ Meetings§ Face to Face§ Indirect – go throughPM

or CEO§ Difficulty with HR§ RTD*MONITORING§ More dialogue with

Policymakers.§ More ongoingmonitoring

by centralgovernment.

o It supplements thebudget

o Infrastructure needs tobe upgraded first.

SUPPLIESMANAGEMENT

INFORMATIONSYSTEM

PROCURMENTPRACTICES

POOR (2)FAIR (8)GOOD (4)EXCELLENT (0)

P F G EPh 2 6 3Sun 1 2 5 3MS 2 5 2 2Eq. 6 2 4

§ Supervisors need more

USAGE§ Electronic§ Manual§ Limited PAS.§ Can be timely when

everything works.§ Verbal has someamount

of inaccuracies.§ Standardization need

across region.§ Manual IS or retrieval

are fairly:- Timely- Accurate



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training in procurementPractices.

§ A procurement officer isneeded to coordinatepurchases for the entirehospital.

21ST CENTURYJAMAICA§ Proper Infrastructure

(equipment)§ Adequate Staff (Medical,

Nursing)§ Financial sufficiency§ Developed definedstandards

nationally.§ SMO to recommend and

follow hiring of staff§ Private partnership in

Medicare§ Extensive investigationsto

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/PrivatePartnership§ Electronic Integrated

Records§ Clinical Research§ Improve Transportsystems§ Retool Radiological

Laboratory services in thehospitals + PC.

§ Strengthen PHC to reduceload on hospitals.

§ Public/PrivatePartnership§ Develop training

opportunities in thesubspecialties anddistributing them evenly

inthe country.

§ Develop all islandcommunication systems



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§ Proper and efficientprocurement systems(centralize)

§ Reviews allocation ofHealth

Budget.§ Implement a functioning

laboratory system§ Simplification +

rationalization of regionalstructure.

§ Redefine role ofSMO/MOH

in management structure§ Redefine role CMO with

respect to PS.§ Separation of training vs.

non-training posts forregistrars/residents.

§ Incorporate clinicians inMOH structure.

§ Create Centres ofExcellence

outside the UniversityHospital.

§ Preventative maintenanceprogram.

§ Excellent CustomerService§ Excellent HR (teamwork,

staff perception)§ Frequent Audit andReview



200



201

Focus Group:SERHAParticipants: AdministratorsDate:

Policy Structure Human Resource§ Developed from the

Ministry of Health andhanded down.

§ SLA unrealistic.

RHA§ Top heavy (ineffective)§ High attrition rate in the

Civil works department§ Region attracts qualified

Engineers but do notretain them because ofinadequate compensation

§ Inadequate posts for:- Records Clerks and

Cashiers- Limited promotional

opportunities for thesegroups.

Parish§ Inconsistency in Structure

across parishes.§ Artisans without paper

Qualifications.§ Need for reclassification of

posts (Electrician trainedby HEART classified asTS1)

Recommendations:§ Partnership with

HEART for trainingand certification.

Supplies Management FINANCIAL RESOURCES§ Regularise Impress

account and makeManager Accountable

§ Impress Account (Inadequate)

Sir John Golding $10,000;Hope Institute $10,000;National Chest Hospital$20,000.

MODERNIZATION CONCERNS RECOMMENDATIONS



202

REQUIRED

§ Decentralization was fordecision making to be donecloser to service delivery –- This is not happening, all

decisions are made at theRHA

- It takes a long time to makethe decision, when it is doneit is outdated.

§ Written recommendationsare not considered.

§ When financial irregularitiesare uncovered steps are nottaken to address them

§ Reduce RHA staff andincrease parish staff.

§ Take decision making closerto service delivery.



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APPENDIX 4

MEDICAL OFFICERS OF HEALTH

Policy:- The policy and the beginning was flawed.- The Ministry of Health is a technical one and yet the technical personnel is

usually ignored.- There is a deterioration in the standard of care.- There is a clear lack of standardization with respect to the SLA. E.g.:

environmental health.

Recommendation:- There is a need to revisit the post of parish manager with a view to name these

persons administrators.- There is a need to merge the regions, the question is whether there is a need for

all of 4 regions.

Structure:- Structures across the regions are not uniform- in accordance with each regions

requirements. An example is the KSA where the structure at the BustamanteHospital 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 theRegions.

- 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.

Role of the Parish Managers:- Parish mangers are too involved in operational details.- Reporting responsibility should be re-evaluated.- There needs to be a clarity of the roles of the Parish Manager as distinct from the

Medical Officer of Health, as it relates the levels of authority.- There are clerks at the regional offices taking technical decisions, this is serious

cause for concern.

Communication- There is a need to establish a clear policy.- There is a need for an effective and efficient MIS.- Information flow is seriously lacking.- Systems of communication now in place in deficient.- MOH are not regarding enough to be allocated a computer while all clerks at the

region is equipped with computers.- The poor communications stifles any prospects for benefits for staff.

Finance:- Region was never adequately financed at start up.- Funds when generated at the parish all go to the Region and never redistributed.- An example of lack of support is where BHC had to independently solicit services

privately and where doctors are paying for the internet services in areas such asthe intensive care unit.

Procurement- The system of procurement needs to be reviewed.



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APPENDIX 5 -

POLICY ISSUES –ALL GROUPS

§ Key Issues/Challenges

(1) Need for greater participation in overall process, to replace thepredominantly top-down approach.

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

(3) Lack of capital budget.

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

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

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

(7) A need to encourage greater partnership and inter-relation between regionsand M.O.H. as well as stakeholders.

(8) Technicians - Artisans, biomedical, plumbers, carpenters are required ineach parish.

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

(10) Need to establish effective Patient Administrative System which isinteractive and interoperable across the regions/parishes.

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

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

(13) Establish system to encourage greater “e” communication to reduce paperand save money.

(14) Need flatter structure.

(15) CEOs should be only in regional hospitals.



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APPENDIX 6 - Organisation/Structure

ALL GROUPS

Ø Key Issues

§ Ministry of Health

(1) The lack of decentralization of roles and responsibilities.(2) Overlapping of roles and functions.

§ RHA

(1) Top heavy; need for merging some functions; current structure toobureaucratic and inefficient

(2) Unclear functions / duplications.(3) Draft form of technical structure.(4) Weak technical staff at the region.(5) Dysfunctional reporting relationships (technical to non-technical)(6) Lack of corporate structure for hospital management.(7) RHAs have created four ministries in one.(8) Reduction in the number of Regional Health Authorities.

§ Parish Structure

(1) Dysfunctional practice of Medical Officers reporting to Parish Managersrather than to SMOs, and the absence of professional nursing managementsystems.

(2) Technical officers of the profession being supplementary to medicine withoutimmediate supervisors

(3) Lack of standardization among regions.

Ø Suggestions

(1) Create structure with a ratio of Administrators to Technical Staff relevant to thedelivery 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



207

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



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APPENDIX 7 - HUMAN RESOURCE MANAGEMENT

ALL GROUPSKey Issues/Challenges

(1) The Ministry of Health Human Resource Management System is dysfunctional.(2) The size of the staff cadre needs to be reviewed in order to relieve the strain on the

system and to improve morale.(3) Improved incentive schemes/programs are needed.

(4) A comprehensive harmonisation programme is needed which would include all theregions.

(5) More emphasis must be placed on the recruitment process to ensure bettermanagement of staff replacement processes.

(6) More emphasis to be placed on a comprehensive orientation process.(7) More emphasis to be placed on staff development with the requisite awards and

compensation given after training.(8) There is need for comprehensive H.R. software to adequately manage the task.

(9) H. R. to facilitate/lead an effective communication channel/process is needed.(10) Improvement in remuneration packages should be considered.(11) More consideration should be given to the rotation process.(12) Industrial Relations process must be better managed.(13) Greater emphasis is needed on effecting change of culture to improve work/attitude

and efficiency.(14) Greater relationship-building among unions and management staff should be

encouraged.

(15) Improvement in processes of accountability must be sought.(16) Systematic approach to the appraisal system is needed.

(17) Improvement in the process of responding to staffing, replacements, etc is needed.(18) A realistic cadre needs to be established.(19) End overlap and duplication of functions.

Suggestions

(1) Develop manpower plan.(2) Appoint staff working in clear vacancies.(3) Encourage training and certification of staff (NCTVET)

Artisans – plumber, carpenter, biomedical technician



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APPENDIX 8 - Supplies Management and Procurement Practices

Ø Key Issues

Pharmaceuticals

• Health Corporation, the Government Agencies which supplies drugs tothe RHAs usually supply approximately 60% of the Institution’s order, thegap has to be filled by purchasing drugs on the open market.

• Inadequate budgetary support to purchase pharmaceuticals from the open market

• Lack of systematic approach to the procurement process.

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

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

• Unavailability of software to facilitate purchasing process.

• Need for improved stock levels and repair materials for equipmentmaintenance.

Suggestions

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

adequately staffed.



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APPENDIX 9 - Supplies Management and Procurement(Regions)

SERHA SRHA WRHA NERHA

Pharmaceuticals •Major problemwith HCL(unable to supplypharmaceuticalsso Region hasto purchase onthe openmarket).

•Poor – HCLsupplies only60% of order.

•Regionpurchasesdrugs on theopen market athigher prices.

•Gifts ofpharmaceuticals.

•No line of creditwhen supply isout of stock.

•Poor quality ofpaper used forprinting medicalrecords.

• Inadequate• Paperless

Parishprocurementprocess.

• Softwaredevelopedin-house forpurchasing.

• interconnectedEquipment •Limited

shopping forX-rays. Placeorders inaccordance withdemand.•Hospitals and

HD receive 2deliveriesmonthly.

•Facilitateemergencydelivery.

•Hospitals aregiven “cut-off”dates monthlyto meetscheduleddelivery.

•Delay in gettingrequestedmaintenanceequipment andsundriesbecause ofprocurementprocedures ofgetting three (3)quotes.

•Non functional•Money donated

for equipmentcannot besourced/used

•ProcurementCommittee andthe length oftime it takes toapproverequests forpurchases.

MaintenanceRecommendations

•Reorganize HCL(debts to bewritten off) andrecapitalize theentity.

•Outsource

• Increasebudget

•Procurementguidelines tobe reviewed to



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maintenance ofequipment.

•Each parishshould have a

maintenanceteam.

•Training ofartisans(plumbers,electricians,carpenters) -HEARTNCTVETCertification

includeessential andnon-essential.

HCL Principal FinanceOfficer

Pharmaceuticals •RHA terms ofpurchase 30 days

•Credit policyimplementation isfutile.

•MOH advises HCLsupply RHAsregardless ofcurrent debt.

•Buying process is notproperly financed.

• Internationalcompetitive tender(18 months.)

•Ranges from good topoor depending on theinstitution.

•There have beenconcerns aboutinternal control.

•Procurement practicesneed to be automated.

Supplies Equipment •Procurement ofequipment ischallenged byfinances and lack ofskilled procurementpersonnel.

Maintenance •Lack of funds toensure adequatemaintenance.

•HCL needs moreworking capital toensure timely andadequate supplies.

• HCL deliveryschedule needs to berevised.

•GOJ budget cover70% of needs for



212

procurement.

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



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APPENDIX 10

PATIENTS’ FOCUS GROUP

SERHA SRHA WRHA NERHA

ComprehensiveHealth CentreType V

Montego BayType V

St. Ann’s BayH. C.

Access toCare

§ They were ableto gettransportation tohealth centre.

§ Nointerviewsconducted.

§ They were ableto gettransportation tohealth centre.

§ At the St. Ann’sBay HealthCentre somepatientscomplainedof inability tofind bus faresand sometimesmissed theirappointments.

Environment § Cleanenvironmentbut overcrowded

§ Cleanenvironmentbut overcrowdedwith limitedspace for staffto work and forpatients’ seating.Patientssuggested thatmore signs areneeded to pointpatients to thedifferenttreatment areas.

§ At this clinicthere are 200 to300 walk-insdaily.

§ Over crowdedwith limitedseating.

.

StaffAttitude

§ Generally good. § Generally good.§ Complained a

about attitude ofrecords clerkand security.

§ Complainedaboutinappropriatebehaviour ofsecuritypersonnel andrecords clerk.



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WaitingTime

§ Patients weredissatisfied withthe waiting time.

§ Patients weredissatisfied withthe waiting time.

§ Patients saidthey had to waitup to 4 hoursto be seen by thedoctor. althoughthey hadappointments(chronic diseaseclinics).

§ More doctors andnurses areneeded totreat patients.



Pharmacy § Patients statedthat they wereunable to get allthe prescribedmedications atthe pharmacy,therefore it’s anincreased costto them.

§ The waiting timeis very long andpatients statedthat they had tohand in theirprescriptions forassessment ofcost of drug,then wait fortheir names tobe called, collectthe prescription,go to the cashierin anotherlocation, pay forthe medication,return to thepharmacy, handin the

§ Patients statedthat they wereunable to get allthe prescribedmedications atthe pharmacy.Therefore it’s anincreased cost tothem.

§ Satisfied withthe service atthe pharmacy.



215

prescription andwait. Thisprocess takes up

to 3 hours tocomplete andsometimes themedications arenot dispensed,they are asked toreturn thefollowing day.

Quality ofService

§ Patients statedthat the servicewas good andworth thewait.

§ Patients statedthat the servicewas good andworth the wait.

§ Patients statedthat the servicewas good andworth the wait.

User Fees § Those who canpay should pay.

§ Those who canpay should pay.

§ Those who canpay should pay.



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APPENDIX 11

Source: Public Private Partnerships –Radiology Group.

IMPACT OF NEW TAX MEASURES ON THE COST OF EQUIPMENTUPGRADING

Example

A quotation was received by a Radiologist from General Electric in February2003 for several new pieces of imaging equipment, including a high techdigital system not yet available in Jamaica or the English speakingCaribbean. Lease financing was approved by an overseas leasing company.

General Electric Invoice US$1,000,000.0010% Import Duty US$ 100,000.00TOTAL US$1,100,000.00



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The Effect of New Tax Measures on Viability of EquipmentUpgrading Project

General Electric Invoice US$1,000,000.0010% Import Duty US$ 100,000.0015% GCT US$ 150,000.002% Import Cess US$ 20,000.00TOTAL US$1,270,000.00

NET RESULT

The Radiologist is unable to come up with the additional US$170,000.00 andthe equipment upgrading project may have to be shelved because the leasingcompany requires a bank guarantee for this amount which may beunobtainable in light of the devaluation of the Jamaican dollar.



regional health authority report

Documents