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Caribbean Journal of Public Sector Management Volume XI Number I March 2014 SPECIAL ISSUE www.mind.edu.jm

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

Training for Public Service Excellence

Caribbean Journal of

Public Sector Management The Caribbean Journal of Public Sector Management (CJPSM) is a publication of the Management Institute for National Development (MIND). The Journal takes a multi-disciplinary approach to public sector issues and seeks to provide a platform for analysing and discussing matters pertaining to governance, public policy and public sector management, and for engaging the widest possible audience both locally and regionally. This special issue of the Journal is being produced in partnership with the HEU, Centre for Health Economics from the University of the West Indies (UWI), St. Augustine Campus. It focuses on matters related to public health in the Caribbean and addresses areas dealing with public health financing, challenges to the local and regional public health sector, and general issues pertaining to access and equity in particular.


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EDITORIAL STAFF Editor-in-Chief: Managing Editor: Line Editor: Copy Editor: Graphic Design:

Ruby Brown C. Andrea Bruce Erica Gordon Ann-Marie Smith Shawn McEwan

REVIEW BOARD The current volume was edited by a prestigious panel of reviewers from across the region, representing a multiplicity of disciplines. They are well-known and respected academics and practitioners engaged in the field of economics, health care, public sector management and policy development. •

Professor Karl Theodore, Professor of Economics and Director of the HEU, Centre for Health Economics, University of the West Indies, St. Augustine Campus, Trinidad and Tobago

• Professor Claremont Kirton, Professor of Development Economics, University of the West Indies, Mona Campus, Jamaica •

Martin Franklin, Head, Department of Economics, University of the West Indies, St. Augustine Campus, Trinidad and Tobago

• Dr. Anton Cumberbatch, Former Chief Medical Officer of Health, Trinidad and Tobago • Dr. Melody Ennis, Assistant Regional Technical Director at South East Regional Health Authority, Jamaica

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

The Publisher The Management Institute for National Development (MIND) is the Government of Jamaica’s public sector training and leadership development institute. It is charged with developing the human resource capacity of the sector to enable it to respond effectively to the priorities of the Government. MIND is seized with the importance of its role to national development which is highlighted by Vision 2030 Jamaica the “important role of the Management Institute for National Development (MIND) in building the capacity of public sector employees to deliver effective and efficient services”. MIND and its predecessor organisations have been providing training over 35 years and the Agency is registered with the University Council of Jamaica (UCJ) as a tertiary level institution. Its specific mandate is to provide effective leadership development programmes and management training appropriate to all levels and in line with the demands of a modern competitive public service (CD 32/93 of September 6, 1993). It is therefore required to contribute to public sector transformation by preparing public servants to be able to adapt to and inform the social, political, economic and technological changes that are transforming governance processes and the business of government.

Partner MIND is pleased to partner with the HEU, Centre for Health Economics, The University of the West Indies (UWI), St. Augustine Campus for the publication of this special issue of the CJPSLM. The Health Economics Unit (HEU) was first established in 1995, after which it was granted semi-autonomous status in 2008 and renamed the HEU, Centre for Health Economics. It is one of the research clusters in the Department of Economics at the University of the West Indies, St. Augustine. The HEU fills a regional need for continuity of research efforts in a number of areas that have a direct bearing on public sector policy formulation and implementation. Through the HEU, the efforts of governments are strengthened in bringing better health care within the reach of citizens. The Centre has responsibility for research, training and project-related activities in health economics and related areas, including social insurance, poverty, health and sustainable development, equity, health policy and management.

The Caribbean Journal of Public Sector Management is one of MIND’s key tools for sharing research information both internal and external to the sector, and to promote and encourage a more effective Jamaica and Caribbean public service.

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Table of Contents Preface

V

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

1

Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

13

Estimating Public Expenditure on Women’s Health Services In Jamaica: 1997 & 2007

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The Impact of Government Expenditure on Economic Growth in Developing Countries: A Literature Review

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Health Financing in The Caribbean: A Possible Role for National Health Accounts?

73

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Caribbean Journal of Public Sector Management, Vol. 2 No. 1, March 2014

Preface The Management Institute for National Development is pleased to present this issue of the Caribbean Journal of Public Sector Management. This special issue is in partnership with the HEU, Centre for Health and Economics at the University of the West Indies, St. Augustine Campus and focuses on health in the Caribbean. The remarkable acceleration of the rate of technological advancement and global economic growth in recent decades has transformed the development prospects of many countries, which has in turn transformed human potential and the quality of life. World averages for health, nutritional and educational status have improved markedly, infant mortality and poverty indices have fallen significantly, and life expectancy has increased from 47 years in 1950 to 66.4 years today, a 41% gain over the period. This has in turn helped to raise economic growth rates, as a population that is no longer handicapped by disease and nutritional deficiencies is far more economically productive. The 2001 Human Development Report noted the astonishing progress made in recent years1. In 1975 the majority of countries were defined as ‘low and medium’ human development, but by 2001 the majority of countries were defined as ‘medium and high’ development. The Caribbean nations score well on most of the health indicators, such as life expectancy and infant mortality, but the majority of them have not yet seen the economic returns. In this volume, Charmaine Metivier and KimberlyAnn Gitten-Baynes point to the many chronic non-communicable diseases (NCD) that have

significant economic impact on Caribbean economies. They use examples from across the Eastern Caribbean where public expenditure on diabetes ranged from US$1.8 million to US2.4 million annually. The team highlights the economic burden of NCD in four Caribbean countries and presents two approaches in Jamaica and Trinidad which have offered real gains. Althea La Foucade, Ewan Scott and Christine Laptiste narrow the focus by looking at women’s health and how much was spent on women’s health services in Jamaica in 1997 and 2007. This is an important area as the 2006 Jamaica Country Survey pointed out that 35.8% of poor households were headed by females. These findings have significant social and economic implications, particularly where women account for 45% of the labour force, with a labour force participation rate of 55%. Natalie Greaves addresses the matter of Palliative Care Services in Barbados by reviewing service models across the world. She recommends a system which provides equal access to all individuals while adopting a multidimensional capacity building thrust. Such a system will need to be funded and Patricia Edwards-Wescott and Prof. Karl Theodore examine the impact of government expenditure on economic growth. They identified varying levels of impact as a result of government expenditure but concluded that this was particularly important in developing economies like those of the English Speaking Caribbean.

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Preface

The final paper by Ewan Scott, Althea La Foucade and Karl Theodore examines the possible role for National Health Accounts (NHA) in the region. The Pan American Health Organisation (PAHO) has pointed out that the region is woefully deficient in public health leadership. With that, the team looks at the potential of NHA to strengthen health care systems by showing the channeling of resources. They argue that NHA can make it possible to provide more purposeful and targeted health care reform.

Each article provides an example of government decisions and their impact on health and/or the economy. Many individuals have contributed to the creation of this special issue. It is our hope that this issue will stimulate further discussion and additional research on health and its impact on national and regional development as we explore viable and sustainable solutions.

(Endnote) 1 United Nations Development Programme. 2001 Human Development Report (UNDP, 2001).

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

Acknowledgement

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CONFRONTING CHRONIC NON-COMMUNICABLE DISEASES: RESPONSE PROGRAMMES OF SELECTED CARIBBEAN COUNTRIES Charmaine Metivier and Kimberly-Ann Gittens-Baynes1

1

The authors acknowledge and thank Ms. Jocelyn Koma and Ms. Chantal Malcolm for research assistance provided.

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Management Institute for National Development

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries ABSTRACT Globally, countries have experienced a shift from infectious diseases to chronic noncommunicable diseases (NCDs). NCDs are sweeping through countries and lifestyle factors are one of the main drivers. In 2008, an estimated 36 million persons died from these diseases, of which 9 million were under the age of 60 years. Further, of the projected 64 million persons who will die in 2015, some 41 million will die of a chronic disease condition. Of concern for the Caribbean, is that the vast majority of the premature deaths (90%) in 2008 occurred in low and middle-income countries (World Health Organization, WHO, 2011). One in four persons in the Caribbean is affected, with varying levels of severity, by one or more NCDs (Caribbean Epidemiology Centre, CAREC, 2005). Limited access to medication and affordability concerns are major deterrents to effective and sustained NCD treatment and management. Where these situations exist, people tend to display poor health seeking behaviour. This paper examines the NCD response programmes of Jamaica and Trinidad and Tobago, which provide subsidized or free prescription drugs to persons with NCDs. The intention is to emphasize the importance of confronting NCDs with strategic intervention measures even when faced with fiscal and demographic challenges and resistance due to poor lifestyle choices by the population. Key Words: Chronic Non-Communicable Diseases, Response Programmes, Improved Access, Affordability, CDAP, NHF. 2

INTRODUCTION Chronic Non-Communicable Diseases (NCDs) are slowly progressing, noninfectious diseases. While individuals may be predisposed to NCDs due to genetic factors, lifestyle/behavioural factors are the major contributors to the epidemic. The four major behavioural factors of tobacco use, alcohol abuse, poor diet (low fruit and vegetable intake) and physical inactivity have been identified as risk factors related to hypertension, obesity, high blood sugar levels and high blood cholesterol (World Health Organization, WHO, 2003). According to the WHO, in 2008 cardio-| vascular diseases, chronic respiratory diseases, cancers and diabetes were the leading causes of mortality worldwide, accounting for 63% of all deaths. An estimated thirty six million persons died from these diseases in 2008, of which nine million were under the age of 60 years. The vast majority of these premature deaths, (90%), occurred in low and middleincome countries. Further, of the projected sixty four million persons who will die in 2015, some 41 million will die of a chronic disease condition (WHO, 2011). In the region of the Americas in 2008, the top three leading causes of death were ischemic heart diseases (9%), cerebrovascular diseases (8%) and diabetes mellitus (6%). In Latin America and the Caribbean, projections show that some 338 million persons will die from chronic diseases in the next ten years, with the Caribbean region facing a very heavy burden of NCDs (WHO, 2011). In the Caribbean, one


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

SCOPE OF THE STUDY This paper examines one aspect of the NCD response programmes of Jamaica and Trinidad and Tobago, namely the provision of subsidised or free prescription drugs to persons with NCDs. The intention is to determine the importance of confronting NCDs with strategic intervention measures even when faced with fiscal and demographic challenges and resistance due to poor lifestyle choices by the population. METHODOLOGY The study was a desk review of the existing literature on NCDs and utilized mainly secondary data in its examination of the topic.

FINDINGS Counting the Costs of NCDs The World Bank (2011b) notes that NCDs have economic consequences not just at the individual, household or community levels, but also at a level which extends to “employers, health care systems, and government budgets” (World Bank, 2007 p. 17). This is illustrated in Figure 1 below.

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

in four persons is affected, with varying levels of severity, by one or more NCDs (CAREC, 2005). In this region, the greater part of the NCD disease burden is due to cardiovascular diseases (heart disease, stroke, hypertension), diabetes, cancer and asthma. These conditions are mainly attributable to the lifestyle factors articulated above.

In the Caribbean, the burden of NCDs is already proving to be significant through the rising health care costs as the region’s sector re-adjusts to the increased demands for pharmaceuticals, inpatient care, equipment, human resources and the related challenges including the loss of mobility associated with diabetes and amputations in particular (Pan-American Health Organization, PAHO/WHO & Caribbean Community, CARICOM, 2011). The public health systems, which bear the brunt of health costs in the Caribbean, have to cope with the fact that the utilization rate of individuals

Figure 1: Costs of NCDs at the Macro and Micro Levels

Source: World Bank, 2011b.

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Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

with NCDs tends to be higher than that of the non-NCD population. In addition to the larger number of interactions with the health system due to the nature of NCDs, these interactions tend to be more expensive in terms of the human resources, physical space and quite often the technology required (World Bank, 2013). The costs of such frequent interactions with the health system associated with hypertension and diabetes in particular have proven to be quite significant. The World Bank (2013) found that in the Eastern Caribbean, public expenditure on diabetes ranged from a low of US$1.8 million (US$326 per diabetic patient) for St. Vincent and the Grenadines to a high of US$2.4 million (US$776 per diabetic patient) in Antigua and Barbuda. At the household level, NCD-related outof-pocket costs are also quite substantial. In St. Lucia, these costs amounted to 36% of annual household expenditure (World Bank, 2013). Figure 2 below highlights the economic burden of diabetes and hypertension in four countries of the CARICOM. It is easily seen that for Trinidad and Tobago and Jamaica, the costs of treating these two diseases over a decade ago were significant.

As a percentage of these four countries’ real Gross Domestic Product (GDP), the total cost of diabetes and hypertension was found to be 1.4% in The Bahamas, 5.3% in Barbados, 5.9% in Jamaica and 8% in Trinidad and Tobago in 2001 (PAHO/WHO & CARICOM, 2011). For countries that experience slow and even negative economic growth, including Barbados which saw negative real GDP growth (-2.6%) in 2001, such costs merely add to their fiscal challenges (Caribbean Centre for Money and Finance Database). Although this is a snapshot in time, if the chosen year is representative, then the implications for increasing rates of change in the cost of treating NCDs outstripping the rates of growth in GDP is of great consequence for countries. In this context, the concern expressed by Theodore (2011, p. 392) indeed has legitimacy. Theodore stated that, “Health system costs are increasing faster than national income in almost all nations and the main cause is the growing incidence of CNCDs and the diverse spill-over effects. The concern is that if this continues, there will come a time when the economic system will simply no longer be capable of coping with the burden of the CNCDs.”

Figure 2: Economic Burden (US$ Millions) of Diabetes and Hypertension in Four Caribbean Countries (2001)

Sources: PAHO/WHO & CARICOM, 2011.

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 population (IMF, 2009). Of the two financing options highlighted, general taxation is more likely to provide a reliable source of funding for health care as opposed to payroll/social security contributions because it provides a wider revenue base and, unlike the latter, is not as sensitive to passing conditions that may impinge on successful revenue generation (IMF, 2009). In the Caribbean region, the financing to tackle NCDs has come from various sources, such as taxation and government contributions. Financing has also come from contributions and out-of-pocket spending by individuals and from regional and international donor agencies such as the: • World Bank; • World Development Foundation; • Inter-American Development Bank; • United Nations Food and Agriculture Organization; • Government of Spain; and • Government of Canada (through the Canadian International Development Agency) (PAHO/WHO & CARICOM, 2011).

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

Financing of NCDs There is no universally agreed best financing option for health care programmes. These programmes need to be country-specific owing to differences in economic, cultural, institutional, demographic and epidemiological characteristics, as well as because of differences in political economy conditions. Whatever the chosen financing option, it is imperative that it is domestically based, sustainable, efficient, equitable and politically acceptable (International Monetary Fund, IMF, 2009). Furthermore, it is important to implement monitoring procedures and incentives that will curb incidences of system abuse, including the over utilization of services. The design of the financing mechanism should reflect the circumstances of the health system and should project alternative scenarios for providing services in a manner which ensures financial viability and sustainability. Rising health care costs have caused countries to put more attention on seeking out viable and sustainable ways of financing care for their populations. Universal health care is increasingly receiving considerable attention globally. It is known that universal coverage can be financed through mandatory payroll/social security contributions from the employed population as done in countries like Japan, France, Germany and Singapore or from general taxation as is done in the United Kingdom, Australia, Canada and Denmark. Some countries have opted for a combination of both of these methods (IMF, 2009). With regard to mobilizing financial resources for health care, it has been argued that taxation presents itself as the best source of financing because health care spending involves recurring expenses which are only expected to rise, partly owing to the increased burden of NCDs, as well as demographic changes that indicate a rapidly growing older

With the WHO estimating a cost of US$11.4 billion per year for a basic package of intervention strategies to prevent and treat NCDs in low and middle-income countries, bundled sources of financing are inevitable (GBCHealth, 2012). However, it is recommended that the source of financing for health care programmes should be largely domestic-based as opposed to donor/grant support, which can be unpredictable and intermittent owing to: • political and budgetary decisions by the donor; • administrative delays by donors; and • substantial bureaucratic procurement and reporting requirements that often result in noncompliance with conditionalities (IMF, 2009). 5


Management Institute for National Development

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

Responding to NCDs Until recently, at the global level and despite multilateral successes, such as the WHO Framework Convention on Tobacco Control, chronic diseases were not predominantly featured in international health and development planning. It is interesting that combating NCDs was not included in the global Millennium Development Goal (MDG) targets. However, there has been advocacy for its inclusion in Goal 1 (Eradicate extreme poverty and hunger) and Goal 6 (Combat HIV/AIDS, malaria and other diseases) (Witt, 2008). In the Caribbean, we have seen the CARICOM Heads of Government in a joint effort with PAHO/WHO in 2007, issue the Declaration of Port of Spain, “Uniting to Stop the Epidemic of Chronic NonCommunicable Diseases”. The Declaration of Port of Spain outlined the framework for policies and programmes to be designed across several government ministries, and encouraged collaboration with the private sector, civil society, media, academia and Non-Governmental Organizations (NGOs) in an effort to strengthen the fight against NCDs (PAHO/WHO and CARICOM, 2011). In response to the Declaration of Port of Spain, a regional strategic plan that identified five priority areas for action for the prevention and control of NCDs was developed for the period 2011-2015. The proposed annual budget for regional actions and support to countries was US$2.6 million (PAHO/WHO & CARICOM, 2011). Jamaica’s Response to NCDs Jamaica, like its CARICOM neighbours, has been grappling with the impact of NCDs, with hypertension, diabetes and asthma being the most common conditions. The Ministry of Health, through its Chronic Disease Unit, spearheads health promotion and prevention initiatives as part of the overarching 6

thrust of the Vision 2030 Jamaica: National Development Plan. These efforts support the national policy for the promotion of healthy lifestyles agenda of the Government of Jamaica. In 2003, the Jamaican Government established the National Health Fund (NHF) “to provide financial support to the national healthcare system to improve its effectiveness and the health of the Jamaican population…”(NHF, n.p.). The NHF serves two categories of beneficiaries, namely individuals and institutions. Individuals are served through the NHF card and the Jamaica Drug for the Elderly Programme (JADEP). The NHF card allows individuals to access over 1,000 drugs for 15 outlined conditions (breast cancer, prostate cancer, hypertension, ischaemic heart disease, major depression, high cholesterol, vascular disease, diabetes, epilepsy, rheumatic fever/ heart disease, glaucoma, psychosis, asthma, arthritis and benign prostatic hyperplasia) at a subsidized cost. The JADEP, which started in 1996, offers persons 60 years and over free access to a specific list of drugs for 10 chronic conditions (hypertension, cardiac conditions, high cholesterol, vascular disease, diabetes, arthritis, glaucoma, asthma psychiatric conditions and benign prostatic hyperplasia). Individuals can, as long as they qualify, register for both programmes (NHF, n.d.). Approximately 13% of the Jamaican population (350,000 persons) is enrolled in the NHF card programme (World Bank, 2011a). The institutional benefits are provided through two funds—the Health Promotion and Protection Fund and the Health Support Fund. The NHF offers grants to both public and private institutions that support activities directed at health promotion and chronic disease prevention through the Health Promotion and Protection Fund, while the Health Support Fund provides financial


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 to access health care. Results from a 2010 study on the NHF card programme found that 92% of the pharmacists surveyed (in 12 privately-owned pharmacies) attributed improved compliance of beneficiaries with their drug regimen to the NHF card programme. Further, 90% of the 178 beneficiaries interviewed believed that the programme facilitated better management of their NCDs (IDB, n.d.).

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

support for infrastructural activities for public sector health facilities including construction, renovations and equipment purchase. Since 2008, the NHF has received 20% of the revenue collected from a tax on tobacco and tobacco products, 5% of the revenue received from a special consumption tax on petrol, alcohol, motor vehicles and one half of a percent of revenue received from payroll tax on annual earnings paid by employees and employers (World Bank, 2011a). The NHF programme has had a positive effect on the lives of Jamaicans and has had success in achieving its primary goal of reducing out-of-pocket spending on pharmaceuticals by roughly 10% in 2006 and 2007 when compared to spending in 2000 and 2001 (World Bank, 2008). In a 2010 study on the NHF card programme, it was revealed that 41% of respondents/beneficiaries (n=178) stated that they experienced average savings of between J$1,400 and J$4,199 per month on prescription drug purchases, while 17% of this group had monthly savings of more than J$4,200 (IDB, n.d.). There has also been a noted decrease in the absolute difference in health expenditure between the rich and the poor since the implementation of the NHF. However, there still exists inequality among the socio-economic groups, with the rich benefiting more from the programme while the poor have limited and uneven access to it (World Bank, 2008). There has been an improvement in the number of people accessing treatment among persons suffering from NCDs, with the percentage of persons seeking care increasing from 3.8% in 1990 to 18% in 2007 (World Bank, 2008). Although it is difficult to prove that this improvement in health-seeking behaviour is as a result of the implementation of the NHF card programme, it is important to recognize that NCD patients are making greater effort

Trinidad and Tobago’s Response to NCDs In February 2003, Trinidad and Tobago implemented the Chronic Disease Assistance Programme (CDAP), which is a government-sponsored initiative established to supply free prescription drugs and other pharmaceutical items to citizens of Trinidad and Tobago. Although available to all nationals regardless of age, gender or socioeconomic status, the CDAP mainly targets the poor, vulnerable and the elderly with one or more chronic disease conditions. CDAP offers 53 pharmaceutical items through a network of 250 public and privately-contracted pharmacies located throughout the country. Coverage is for 12 health conditions, namely diabetes, asthma, cardiac diseases, thyroid diseases, arthritis, glaucoma, mental depression, high blood pressure, benign prostatic hyperplasia (enlarged prostate), epilepsy, hypercholesterolemia and Parkinson’s Disease (National Insurance Property Development Company Limited, NIPDEC, 2013). CDAP’s objective is to increase access to prescription drugs and reduce the financial burden experienced by some persons in purchasing the required medication to treat their chronic disease condition(s). Although the programme spends over TT$400 million annually (Government of Republic of Trinidad and Tobago, 2013) and faces several challenges related to efficiency, accountability and irregularities, it continues to be one 7


Management Institute for National Development of the main Government programmes that provide assistance to the impoverished and marginalized in Trinidad and Tobago.

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

Assessing Trinidad and Tobago’s Programme An IDB-commissioned study conducted in 2010 by The University of the West Indies, HEU, Centre for Health Economics examined the impact of the prescription drug programmes for Jamaica and Trinidad and Tobago over the period 2003 to 2009. For Trinidad and Tobago, the analysis of administered questionnaires to stakeholders (405 CDAP beneficiaries, 25 prescribing physicians, 27 private pharmacies in the provider network) provided qualitative results of their views on the performance of the CDAP (IDB, n.d.). Some of the findings are presented below: i) For the period 2008/2009, diabetes and hypertension medications were the top two most sought drugs by CDAP beneficiaries. ii) Some 65% of beneficiaries stated that they believed that their health improved since accessing CDAP drugs. iii) 25% of respondents said that they experienced no health improvements, which implies that 75% did experie- nce improvements. iv) In terms of financial benefits, 53% of respondents said that they experienc ed savings from accessing their medication under CDAP. v) Physicians noted that of the average number of patients seeking care per week, 46% were CDAP beneficiaries. vi) There was a high level of awareness (96%) of the CDAP, with 80% having knowledge of the conditions covered under the programme while 20% of patients were unaware. vii) Some 88% of physicians interviewed 8

related improvements in their patients’ health with the use of CDAP drugs. viii) Pharmacists said that they observed improvements by beneficiaries in complying with the quantities of prescribed medication. ix) Pharmacies expressed satisfaction (78%) with the programme and recommended that CDAP be expanded to offer a wider range of drugs for NCDs. Challenges Faced in Addressing NCDs Small Island Developing States (SIDS), in contrast to developing countries, face their own economic challenges and peculiar vulnerabilities and characteristics. Some of these vulnerabilities are related to their small size, geographic isolation from markets, risk of climate change and sea level rise and the intensity and frequency of natural and economic disasters. Now, NCDs are at the forefront of developing countries’ concerns and are posing severe threats to the populations’ health and economic wellbeing of these small island nations. This is to be noted in the context of the changing demographics that see increasingly ageing populations posing challenges for addressing NCDs in countries experiencing severe fiscal constraints. According to PAHO’s Collaborative Action for Risk Factor Prevention and Effective Management of NCDs (CARMEN) Network, developing countries are still behind in their data collection and quality use of timely epidemiological data. They are even more behind on gathering data to provide evidence on the outcomes of interventions and programme performance (PAHO/WHO & CARICOM, 2011). PAHO has been working at the sub-regional, multi-sectoral and governmental levels to strengthen NCD surveillance in the Caribbean and Central


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

CONCLUSION NCDs are a source of great economic burden in various regions of the world. Different programmes have varying approaches to the prevention and management of chronic diseases. However, a common objective of Governments is to stem the tide of the NCDs and in so doing, protect their populations and economies. Countries, such as Jamaica and Trinidad and Tobago have opted to provide subsidized and/or free prescription drugs to persons with NCDs. Such initiatives strive to widen access to medication and contain expenses by reducing the amount of out-of-pocket payments individuals have to make to treat these conditions. The intention of the Jamaica and the Trinidad and Tobago programmes is to improve disease management while looking for mechanisms that allow for sustainable financing of these

programmes. The Caribbean experience has shown that revenue from taxation (general tax, payroll tax or combination of both), complemented by funding from NGOs and international agencies can go a long way in generating the type of responses needed in the continued fight against NCDs. Is there strong evidence that suggests that countries like Jamaica and Trinidad and Tobago have had successes in controlling and preventing chronic conditions in their respective countries? Since both programmes are just a decade old and because of the limited databases available, it is not yet possible to tell the full story about the effects and outcomes of programmes such as NHF and CDAP. However, one study has pointed to real gains from these initiatives, including reductions in out-ofpocket spending on drugs, improvements in self-reported health status, reported adherence to medication regimes and compliance in self-management programmes. It would therefore be fair to state that the limited evidence available suggests that confronting NCDs in the Caribbean has had some measure of success, but that much more needs to be done.

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

America. The chronic disease registries being developed will have the potential to improve chronic disease management, provide support for programme follow-ups, and produce aggregate results on affected populations.

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Bibliography Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

Caribbean Centre for Money and Finance Database. (n.d.). Accessed online from http://www. ccmf-uwi.org/?q=statistical_data_and_charts. April 10, 2013 Caribbean Epidemiology Centre. (2005). Caribbean Health Situation Analysis. Working Paper— Caribbean Commission on Health and Development. Caribbean Community. (2001). Estimates of Economic Burden of Diabetes and Hypertension. CARICOM Summit on CNCDs. Accessed online from http://www.caricom.org/jsp/ community/ chronic_non-communicable_diseases/diabetes_hypertension.jsp. April 15, 2008 GBCHealth. (2012). NCDs in Latin America and the Caribbean. Government of the Republic of Trinidad and Tobago. Ministry of Health. (2013). Accessed online from http://www.health.gov.tt/sitepages/default.aspx?id=132. December 16, 2013. International Monetary Fund. (2009). Universal Health Care 101: Lessons for the Eastern Caribbean and Beyond. Accessed from http://www.imf.org/external/pubs/ft/wp/2009/ wp0961.pdf. May 18, 2013. Inter-American Development Bank. (n.d.). Comparative Analysis of the Impact of Chronic Disease Prescription Drug Programs in Jamaica and Trinidad and Tobago, 2003-2009. National Health Fund website. (n.d.). Individual Benefits. Accessed from http://www.nhf.org. jm/index.php/individual-benefits. November 14, 2013 National Health Fund website. (n.d.). Aims and Objectives. Accessed from http://www.nhf.org. jm/index.php/aims-objectives. December 18, 2013. National Insurance Property Development Company Limited. (n.d.). Pharmaceutical. Accessed November 2013. http://www.nipdec.com/site15/index.php?option=com_ content&view= article&id=12&Itemid=70. Pan-American Health Organization/World Health Organization and Caribbean Community Secretariat. (2011). Strategic Plan of Action for the Prevention and Control of NonCommunicable Dseases for Countries of the Caribbean Community 2011-2015. Accessed from http://www.caricom.org/jsp/community_organs/health/chronic_non_ communicable_ diseases/ncds_plan_of_action_2011_2015.pdf . Theodore, K. (2011). Chronic Non-Communicable Diseases and the Economy. West Indian Medical Journal 2011; 60 (4), 392 - 396. Accessed from http://caribbean.scielo.org/pdf/ wimj/v60n4/a07v60n4.pdf May 20, 2013.

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Witt, J. (2008). Why to Include Chronic Non-Communicable Diseases in the Next Set of Development Goals: “Globesity” and Jamaica. 12th EADI General Conference. Accessed from http://www.eadi.org/fileadmin/Documents/Events/General_Conference/2008/ Poverty/EADI_-_CNCDs_and_MDGs_-_JWitt_2008.pdf. December 18, 2013.

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World Bank. (2007). Public Policy and the Challenge of Chronic Non-Communicable Diseases. Washington D.C.: World Bank. World Bank. (2008). Non-Communicable Diseases in Jamaica: Moving from Prescription to Prevention. Accessed from http://www-wds.worldbank.org/external/default/ WDSContent Server/WDSP/IB/2012/03/26/000356161_20120326012648/Rendered/ PDF/620650WP0P11170UBLIC00JM0NCD0Report.pdf September 21, 2013 World Bank. (2011a). Non-Communicable Diseases in Jamaica: Moving from Prescription to Prevention. Washington D.C.: World Bank. World Bank. (2011b). The Growing Burden of Non-Communicable Diseases in the Eastern Caribbean. Washington D.C.: World Bank. World Bank. (2013). Non-Communicable Diseases in the Caribbean: The New Challenge for Productivity and Growth. Washington D.C.: World Bank. World Health Organization. Accessed from http://www.who.int/mediacentre/factsheets/fs355/ en/. November 26, 2013. World Health Organization. (2003). Surveillance of Non-Communicable Disease Risk Factors. Fact Sheet No 273. Accessed from http://www.who.int/mediacentre/factsheets/fs273/ en/index.html. July 12, 2013. World Health Organization. (2011). Global Status Report on Non-Communicable Diseases 2010 Description of the Global Burden of NCDs, their Risk Factors and Determinants

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Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

Values C H I L P R R R T

ustomer-focused onesty & Integrity

nnovation eadership rofessionalism espect esponsiveness esults-Oriented

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eamwork & Cooperation

The core values that guide the actions, transactions and behaviours of the MIND Team

Vision Statement To be the pre-eminent and preferred public service training, organisational and leadership development institution in Jamaica serving the Caribbean

Mission Statement To provide public servants with quality training and leadership development options, supporting services and outreach which sustain a culture of enterprise, efficiency and responsiveness to the publics they serve


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

Confronting Chronic Non-Communicable Diseases: Response Programmes of Selected Caribbean Countries

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DESIGNING PALLIATIVE CARE SERVICES: INSIGHTS FROM THE REVIEW OF SERVICE MODELS PROCESS OF THE BARBADOS PALLIATIVE CARE NEEDS ASSESSMENT PROJECT Natalie S Greaves MBBS, PhD1

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Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

Management Institute for National Development

Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project ABSTRACT Background: The Barbadian Public Health Care Sector has facilitated an evidence based approach to the development of Palliative Care (PC) on the island. This paper shares result of a review of global PC service models which was used to inform decision making. Design and Methods: A keyword search was performed of the following databases: MEDLINE, EMBASE, CINHAL, PSYCHINFO, and The Cochrane Library (Period: January 2005- January 2010: final update in April 2010). Five key peer reviewed palliative care journals were also hand searched (Period: January 2007- April 2010). All publications describing models of palliative care delivery were included; exceptions being single patient case studies and editorials. Data extracted included: type of palliative care service; extent of care offered; and implementation or usage challenges. Results:  331 publications were retrieved; 17 reports (12 countries) met the inclusion criteria. Nine reports described mixed models across tertiary, secondary and primary care levels. Fifteen reports included descriptions of home based care, which proved important for clients: in rural areas; and those with a diagnosis of HIV/AIDS.  Services were predominantly funded using existing mechanisms for health care, and were organized under one of five medical disciplines, including Public Health. Identified service challenges included lack of trained staff and variability inopioid supply. 

Conclusions: Models of palliative care exist that are relevant and perhaps adaptable to the Barbadian and wider Caribbean. Policy makers within the Caribbean Health sector should view the provision of palliative care as a necessary and achievable goal. Key Words: palliative care, models, developed country, review Palliative Care and its Relevance in the Caribbean The care of the dying and those who face the challenges associated with life threatening illness has historically been a consistent feature of human societies (Cowley, Young & Raffin, 1992; Weber 1997). More recently, in modern societies there has been an increasing level of interest and support for the improvement and integration of such forms of care into modern health care systems (Bosnjak, Milicevic, & Lakicevic, 2006; Clark, 2007, Sepulveda, 2002). In the Caribbean context, the last five years have seen an increasing level of interest in palliative care and the development of palliative care health services in the English Speaking Caribbean. There are now national palliative care organisations in Trinidad, Barbados and Jamaica; annual national conferences facilitated through regional and international collaboration1, and the inclusion of aspects of palliative care into the curriculum of all three campuses of the University of the West Indies2.

................................................................................................................................ 1

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Palliative Care Society of Trinidad and Tobago-http://pcstt.wordpress.com/-Accessed Jan 17th 2014, Barbados Association of Palliative Care-http://barbadospalliative.org/-Accessed Jan 17th 2014, Palliative Care Association of Jamaica-http://www.thewpca.org/ latest-news/palliative-care-association-of-jamaica/-Accessed Jan 17th2014


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an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illnesses, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (WHO, 2002, n.p emphasis added). This definition and its accompanying explanatory notes are now widely referenced

Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

At the national health policy level, the Ministers of Health of Barbados, and more recently Trinidad and Tobago, have voiced support for the palliative care movements in their respective countries with resources being made available for the design of appropriate socially acceptable health services to the populations of these countries3. However, it is important to note that at the regional policy level, palliative care is not firmly on the health care agenda but occurs indirectly through policies to address the needs of specific disease groups; for example, in the management of patients with endstage renal disease (Pan America Health Organization, 2013). This gap in policy is notable as more than a decade has passed since the World Health Organisation (WHO) formally recommended that its member states implement palliative care services, [perhaps initially] as part of their Cancer Control programmes (World Health Organisation, 2002). This use of the term, “palliative care”, by the WHO at that time was in the context of the 2002 definition of the term which states that palliative care is

and accepted in palliative care academic and policy academic literature and is the definition of palliative care (PC) used in this article. The WHO 2002 definition has resulted somewhat in a paradigm shift in modern palliative care, in that, it has sought to address inequalities and highlight the value of PC as a universal approach to improving the quality of life of persons around the world. The definition and its notes show that the principles of PC are applicable to persons with diagnoses of life threatening illnesses other than cancer, and that the principles of care are relevant in the non-terminal phases of a disease trajectory. For some, this scope is too broad and perhaps dangerously ubiquitous as it deviates from the historical narrow and clearly defined emphasis on the patient who is dying from a narrow subset of diseases (Randall & Downie, 2006). However, clinical and health services operational research in palliative care show relevance and benefit to patients and their families with the expanded and perhaps more equitable approach to service provision (Franks, 2005; Greaves, 2012; Theide, 2005; Watson, Lucas, Hoy & Back, 2005). The recognition of the applicability of the palliative care approach beyond the cancer clientele is especially important in the Caribbean context. The region has seen increased aging of its population, coupled with increasing mortality and morbidity associated with other CNCDs such as diabetes mellitus (DM), hypertension and other cardio vascular diseases such as ischemic heart disease (IHD) and chronic heart failure (CHF). Furthermore, the natural history of diseases such as HIV/AIDS has been altered (positively so) by medical advancements, particularly the availability

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Examples of the aspects of Palliative Care Education available at the University of the West Indies • Mona Campus- Programme/ Course-Doctorate in Public Health. Topic : An Introduction to Palliative Care- teaching delivered by Associate Lecturer Dr Dingle Spence- Programme Director –Professor Figuero • Cave Hill Campus- Programme/Course- Social and Preventative (4th year students in the MBBS Programme) Topic: General Palliative care in the community setting- teaching delivered by Associate Lecturer Dr Natalie Greaves-Course Director- Dr Natasha Sobers. • St Augustine Campus- Programme –Masters in Palliative Care- http://sta.uwi.edu/postgrad/documents/MScPallitiveCare.pdf 3 http://newsday.co.tt/news/0,185360.html Accessed Jan 17, 2014 http://www.barbadosadvocate.com/newsitem.as?more=local&NewsID=16139 Accessed Jan 17, 2014

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Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

Management Institute for National Development of highly active anti-retroviral therapies (HAART) (Karim, Karim & Detels. 2009). This has resulted in a “Prolongation of the chronic disease phase” and the development of “New HIV–related co-morbidities” (Harding et al., 2005 p.251) that make the need for palliative care likely. (Harding et al., 2005, p.255). The net result of the factors discussed above (namely: the aging population of the region; the increasing incidence of CNCDs and advances in medical treatment) is that the need for palliative care provision within the region is imminent, that is, if is not already here. It should be noted that internationally the provision of palliative care is increasingly being viewed as a public health and human rights issue. As stated by Hunt et al. (2009, p.335), obtaining “the highest attainable standard of health” may be seen as a legally binding human right in many modern countries. This may include Caribbean countries who are signatory to the International Covenant on Economic Social and Cultural Rights (particularly Article 12The right to health). Arguably the highest attainable standard of health may extend to the provision of palliative care. Therefore, research which could be used to inform the policy gap relating to the provision of palliative care in health systems in the Caribbean is timely and important. Chronic Non Communicable Diseases in Barbados as a Trigger for the Need for Palliative Care Like many countries across the region, the island of Barbados has seen the incidence and economic burden of CNCDs increase over the past 30 years (World Health Organisation, 2008a). Further it is expected that by the year 2030, 86.3% of all deaths on the island would be caused by this category of illness (Cancer 25.5%, Cardiovascular diseases 32.6%, Other Chronic disease 16

28.2%) (World Health Organisation, 2008b). International studies have demonstrated that within a given population, 2/3 of persons who would have died as a result of CNCDs of a non-malignant nature, would have benefited from receiving palliative care in their last year of life (Tebbit, 2004). In a 2007 mapping of the global level of palliative care development conducted on behalf of the Worldwide Palliative Care Alliance, Barbados was identified as a Group 3 country i.e. having localised provision (The maximum level of development being Group 4; in these countries, palliative care provision is found to be approaching integration into the health care system.) (Wright, Woods, Lynch & Clark, 2008). In addition, the Hospice-Palliative care service to population ratio for Barbados was recorded as being one service to serve a population of two hundred and seventy thousand (Wright, Woods, Lynch & Clark, 2008). In view of the potentially large number of Barbadians who are likely to benefit from palliative care, the Ministry of Health (MoH) of Barbados has recognised the public health and ethical importance of researching and detailing the need for such services (Greaves, 2008). Further, given the comparably high performance of the Barbados health sector, the achievement of integrated palliative care provision would represent a major aspect of modernization for the Barbadian Health Care System. However, local research was required to further specify the precise palliative health needs, and to serve as an input for priority setting. Therefore the MoH commissioned a needs assessment - The Barbados Palliative Care Needs Assessment Project (BarNap). The BarNap process included: • a comprehensive review of current evidence-based literature on models of palliative care delivery;


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One of the seven key recommendations from the BarNap process was that services in Barbados develop using a mixed model delivery system. One of the data sources informing this recommendation was a review of global service models. This was primarily combined with inputs on culturally appropriate forms of care and elements of economic evaluation to achieve the overall service design. While cultural and economic inputs may vary between the islands of the Caribbean, the data from the review of models may be valuable and relevant to policy makers in the public health sector in the Caribbean. Therefore, the review process and its findings are shared in this article along with some discussion on the relevance and potential use of this work. It is hoped that other insights and results from other aspects of the process will be shared in the future and that they will advance the palliative care work in the region.

Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

• an epidemiological needs assessment; • an estimation of human resource service cost; • and stakeholder consultation.

Literature Review of Palliative care Service Models The review presented in this paper aims to summarise the major models of palliative care service delivery being used globally. In particular, it seeks to describe service structure and the extent of care offered. The sub questions to be answered in the review with respect to each model of palliative care delivery identified are given in Box 1 below. Methods Primary Search Strategy As was stated previously, this review was concerned with obtaining relevant descriptions of service models of adult palliative care used globally. In January 2010, (with updates in March and April 2010), five (5) computerized databases were researched from 2005 to 2010; these were, Medline (1950- ), EMBASE, CINAHL4, COCHRANE Library5 and PsycINFO. The search terms used were chosen so as to capture: • those terms used in the description and evaluation of health services and health systems; • the variation in terminology used in palliative care provision globally;

Box: 1 Sub Questions to be Answered in Review

Service Structure: How was the care model: financed and staffed? What were the basic infrastructure components? What was the number of patients that could be cared for on a daily basis (what was the average daily service capacity?) The extent of care offered: What clinical interventions are generally offered? What activities are generally offered? Access and discharge pathways: How are patients referred? What are the referral criteria? What is the major need that has prompted referral to the service? How are patients discharged? Service implementation and usage pitfalls: Were there any challenges during the process of implementation of the service? If so what were they? Were there any identified barriers to service utilization unrelated to issues of access?

4

This database provides indexing for 2,960 journals from the fields of nursing and allied health. The database contains more than 2,000,000 records dating back to 1981

5

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Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

Management Institute for National Development and • data which might be particularly relevant to the developing country context. Given the above, the primary search strategy was as stated below: (service structure or care model or infrastructure or service capacity or organi*e or organi*ation or (organi*ation and administra*) or effect* or evalua* or benefit*) and (palliative care or hospice care or terminal care or supportive care or end-of- life*or end of life care or comfort care or hospice* or palliat*) and ( developi* countr* or developi*nat* or mid* income countr* or low* income countr*).kw. The search was not restricted to English speaking countries. However studies reporting on care services for a target clientele 18 years and under and case studies of single patients were excluded. In addition the following journals were hand (index) searched from Jan 2007- 2010 as a means of identifying any studies that were not identified using bibliographic databases: 1. American Journal of Hospice & Palliative Medicine 2. BMC Palliative Care 3. Journal of Palliative Medicine 4. Palliative Medicine 5. Journal of Pain and Symptom Management It has been noted that within palliative care, searches of grey literature have proven to be of limited usefulness; therefore this was not done (Davies & Higginson, 2005). Secondary Data The primary search strategy given above was used to identify literature which could potentially inform policy in Barbados within the context of lessons to be learnt from countries classified as being developing. However, it should be noted that over the past decade, the Human Development Index 18

of Barbados has been such that the island may be seen as a high performing developing country, and is listed by the World Bank as a high income economy (World Bank Classification 2011). In light of this, it was viewed that the systems of organisation and delivery of palliative care in developed countries would also be useful models for consideration, for informing the organisation and design of PC services on the island. To this end, a secondary search strategy was used to identify research which described and evaluated systematic models of palliative care in developed countries. A review was conducted in April 2010 in the Cochrane database of systematic reviews, Database of abstracts of reviews of effects, Health technology assessment database and the NHS economic evaluation data-base. The scoping search strategy (given below) was limited by time 20052010 but unlimited by language. (service structure or care model or infrastructure or service capacity or organi*e or organi*ation or (organi*a-tion and administra*) or effect* or evalua* or benefit*) and (palliative care or hospice care or terminal care or supportive care or end-of- life*or end of life care or comfort care or hospice* or palliat*). This resulted in seventy publications being identified of which two were relevant to this work. (The detailed results of this search are given in Table 3). The first was conducted in 2005 and focused on global PC day care services (Davies & Higginson, 2005 the other was a 2009 review of twenty two models of PC in the United States of America (Byock, Twohig, & Merriman, 2006). Although these reviews were intervention (day care) and country specific (USA) (Byock et al. 2006) they were recent; in view of this and the low yield of publications retrieved from the primary search strategy (Table 1) the primary search strategy was not re-executed in bibliographic


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Results Three hundred and thirty one publications were retrieved from bibliographic databases, of these five met the inclusion criteria. The remaining twelve reports were identified as a result of hand searching with a significant number of hand searching results being sourced from a special edition of the Journal of Pain and Symptom Management; (see Tables 1- Table 3). The occurrence of most relevant publications being found as a result of hand searching, has been noted in other palliative care studies (Davies &Higginson, 2005). The seventeen reports identified presented information from twelve countries: two low income economy: Nepal (Brown et al., 2007 ), Zambia (Mundia, 2008); two lower middle income economy: (India (Kumar, 2007; Mc Dermott et al., 2008); Jordan (Stjernsward et.al, 2007); three upper middle income economies: (Argentina (Wenk & Bertilino, 2007), Brazil (Lemonica & Barros, 2007) and South Africa (Defilippi & Cameron, 2007; Demmer, 2007) and four high income economies: Canada (Fasinsinger, Brenneis, & Fassbender, 2007); Ridley & Gallagher, 2008; Wowchunk et al. 2009); United Kingdom (Davies & Higginson, 2005); Spain (Hererra et al 2007; Gomez-Batiste et al., 2007); Norway (Kaasa, Jordhøy, & Faksvüg, 2007) and United States of America (USA) (Byock et al 2006). These studies provided descriptions of various acute hospital and community based service models used in palliative care. Nine studies provided descriptions of mixed models of care, with single model/ intervention reports being available on day care (Davies & Higginson, 2005), 24 hour PC

Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

databases. Instead major journals in palliative care were hand searched so as to find any publications not already summarized in the reviews.

telephone hotline (Ridley, 2008), and HBC (Brown et al., 2007; Kumar, 2007; Defilippi 2007; Demmer, 2007). Of note, HBC was described as a component in many of the mixed model reports (Brown et al., 2007; Kumar, 2007; Lemonica, 2007; Fainsinger et al., 2007; Gomez-Batiste et al., 2007). From the publications retrieved, data pertaining to extent of care offered, physical plant infrastructure, staffing resources, source of funding, access and discharge pathways and implementation or usage challenges was extracted. A summary of these is provided in the Barbados Palliative Care Needs Assessment Report, however, thorough descriptions of extracted data are provided below, and in Table 4 in the Annex. For easy referencing and reading, the studies in Table 4 have been labeled with unique numbers. These unique numbers are reproduced as exists in the original source used in the remaining text which describes models of care. Descriptions of Models of Care and the Extent of Care Offered General Palliative Care in the Community Setting General PC services were provided in most instances in the primary care community setting and were delivered via home hospice care, day hospice care, nursing home services, or home based care delivered by family friends or trained volunteers. Only a few studies described in detail the extent of general services offered [17, 21, 22, 28]. (The lack of this data, is a limitation of this work). The identified general palliative care activities included: supporting the daily living activities of patients such as, bathing, cooking, collecting clothing [21,22,28] as well as more medical and psychosocial interventions such as the distribution of medication and vitamin 19


Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

Management Institute for National Development supplements [21, 28], monitoring and assessing new symptoms [17], providing supportive counselling [17], physiotherapy, wound care, assessing new symptoms, chiropody, art and music therapy services [17]. Some generalist PC services which provided respite for carers were also identified [17]. General palliative care in the community setting was found to be an important way of ensuring access to care for rural populations [32, 34] and those persons with HIV/AIDS in the South African and Zambian context [21, 27, 28]. Community and health professional volunteers were sources of staffing for general palliative models [17, 20, 21, 22, 27, 28]; however, in rural and lower performing economic regions/countries volunteers were a major source of staffing [21, 22, 27, 28]. In other reports, other members of the general palliative care team were nurses, general practitioners/family physicians with further training in palliative care, as well as physiotherapists and social workers [20, 29, 32-34]. It is important to note that volunteers and professionals worked together using a multidisciplinary team (MDT) approach, and in some cases, community general PC services were not physician lead [17, 22]. Specialist Palliative Care in the Community Setting Specialist palliative care services in the community were explicitly *-reported in three of the seventeen reports. These included a unique 24 hour hotline providing specialist advice to physicians, nurses and pharmacist [30] and a home care services by palliative care specialist or specialist pain and symptom management team [26]. In both of these cases, the specialist palliative care, team which functioned in the community shared the same human resources as specialist inpatient facilities. In Botucatu, the palliative care team providing home visits, 20

was also involved in inpatient and outpatient clinic care at the tertiary hospital; while in British Colombia, the physicians providing specialist palliative care advice during the day (9:00-17:00) and after hours also had responsibility for the hospice and community hospice at home services during their shifts [26,30]. Physical Plant Infrastructure of General and Specialist Palliative Care in the Community The physical plant infrastructure for community based care, in many instances, used already existing structures e.g. patient’s homes, nursing homes, and outpatient community clinics [23, 32,33]. From the report, there was no identifiable ratio of number of community PC beds per population. However, in some mixed models, the number of community PC beds was notably larger than the number of acute care beds and in particularly the number of tertiary acute care beds [32, 34]. In the WHO demonstration project in Catalan 97.6% of PC beds were located in the community (excluding home care), while in Extremadurarural area also in Spain 95.7% of PC beds were also in the community. Additional physical resources for community home based care such as oxygen and medications were only mobilised in the presence of demonstrated need as determined by a HP [26, 31]. Access to Community Palliative Care Services Seven reports described guidelines for acceptance or use of the PC services (six services catered to patients or carers and one service to health professionals). Of significance, there were no clear descriptions of self-referral as a means of access. Patients were referred to PC after having their needs assessed by a health professional or comm-


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Specialist Palliative Care in the Acute Hospital Setting All mixed models provided specialist palliative care (SPC) in the acute hospital setting. Four main forms of SPC were identified acute inpatient care [20, 25, 3234], outpatient clinic [20, 25, 26, 33,34], pain management and/or symptom control outpatient clinics [26], and day care [26]. Of interest, the lead medical specialty providing SPC varied, and were as follows: Specialist Palliative care [29], Oncology [20], Anaesthesiology [26], Internal Medicine [19] or Family Physician with further training in Palliative Care [29]. Despite the variability in lead clinical specialty, all models used an MDT approach to staffing and care. At a minimum, teams included a physician and a nurse with further training in PC, oncology, internal medicine, or anaesthesia. The other health or allied health professionals in the MDT varied between reports but could include a social worker [24, 26], nutritionist [26], clinical pharmacist [19, 24], and psychologist [26, 32]. The number of staff members per SPC team was described in three reports; however, the staffing ratio per population for an SPC teams was described in only one report (WHO demonstration project in Catalan). In Catalan, there were 34 teams composed of 1 Full Time doctor, 1 nurse, 1 psychologist and 1 full/part time social worker. The number of HPs per100,000 were Doctors-2, Nurses- 3, Social Worker-1 [32]. SPC Infrastructure in the Acute Hospital Setting The number of SPC beds in acute hospital setting was consistently lower than the number of community care beds. It was

Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

unity volunteers [22]. Referral and acceptance routes were similarly restrictive for specialist palliative care services [25, 29, 26].

noted that none of the reports described achieving the recommended fifty beds per million population. In addition, there were explicit reports of inadequate numbers of inpatient beds [20, 25, 32], with this possibly resulting in unmet need [25]. In institutions where there were no dedicated palliative care beds, patients were admitted to beds controlled by a related service. Only one report described the physical infrastructure for a PC outpatient clinic. The Anaesthesia led Botucatu model provided outpatient pain management and symptom control using 4 consulting rooms, one dedicated intervention room, a waiting room with audio visual equipment for patient education and a meeting room [26]. Service Discharge Policy or Criteria Discharge criteria were not explicitly stated in any of the reports, although it was noted that in Nepal patients in acute care beds were sometimes not discharged because of insufficient family or palliative care support in the community [20]. Funding Funding for SPC in the acute hospital setting followed the normal funding pattern for hospital care in the particular country. In most cases, this was provided by the National Health System with contribution from NGO [25, 26, 33, 34]. Service Implementation and Usage Challenges From the data retrieved, some common challenges were found to occur with respect to implementation and usage of PC services. The most prominent of these was the lack of education and training programmes for health professionals and volunteers. This lack of local education was seen as a contributor to the inadequate staffing levels experienced in some models [24, 25, 27, 21


Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

Management Institute for National Development 32-34]. In addition, education programmes would be a potential way of reducing community and health professional misperception of what palliative care involved [33]. Other challenges identified related to: • the need to have legislation and funding which would ensure that a consistent supply of opioids and other pain medication were available for use [ 24-26, 33]; • the need for increased funding to support increased staffing levels, given service demand [29], and mechanisms of funding to reimburse health professionals providing care [19,33]; • inadequate numbers of inpatient beds [20,26]; • challenges with correcting geo-graphic inequalities in service provision, especially serving rural and scattered populations [25,34,33]; • funding for PC research to inform local service development [33,34]; • developing standardized quality and evaluation measures for PC, given variability in services delivered across the respective local systems [17, 27, 29, 32]. Symptom Control or Health Related Quality of Life Though not a specific aim of this literature review, it was noted that in the reports which commented on symptom control or related quality of life of PC users, the service was seen as being an important contributor to improvement in symptom control, and of quality of life of patients and their carers [17, 19, 24, ]. Discussion: Summary of Findings From the seventeen reports reviewed, it can be seen that a mixed model was the dominant model used for delivering palliative care. Though it appears that some reports focused 22

on describing a single model of PC delivery, such as day care, or home-based care, these may in fact be best understood by considering them as single interventions in an overall mixed model delivery system. This is exemplified by considering involving the ICHC programme in South Africa which, though reported as a single model homebased programme, operates in a framework in which there is monitoring by in patient hospices. The mixed model care used in the countries studied was found to have a dual emphasis of palliative care being provided both in the community and the acute hospital setting. Importantly, specialist palliative care services were not restricted to the acute care setting, but was also found to be a core component of community care. Providing specialist community services to facilitate the management of acute crisis, has been noted as an important step in reducing hospital admissions, and facilitating families whose preferred place of care and death is the home or community setting (e.g. local hospice, or nursing home). The precise care packages offered by individual mixed models reflected the holistic approach advocated in the current WHO definition. No two service models offered the same package of PC interventions; however, the management of pain physical and psychological symptoms management was core aims in all models. There was no evidence suggesting access to PC services by self-referral, and no reports described discharge criteria. The service implementation and usage challenges highlighted the importance of educating and training health professionals and the community as a part of the capacity building process. Education and training activities served as a means of increasing staffing resources, both paid and voluntary. In addition, educating the general public and


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Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

potential referring professionals about the principles of palliative care was identified as having the capacity to increase use of the service. Funding for PC services followed the normal methods of funding for health services in the individual countries, notable exceptions were the UK and South Africa. In these countries, PC is funded primarily by the voluntary sector. The funding model in these two countries perhaps reflects the historical development of their PC services. In the UK, modern PC has its origins in religious charitable organizations, with the funding base being charitable giving by local communities in which hospices were established (Lewis, 2007). In South Africa, very early in its development, PC services became linked care with care of those with HIV/AIDS. This condition is heavily stigmatized in the SA context, and health care services for addressing the needs of these patients and their relatives are known to lack government and political will as well as the necessary financial government support (Lemonica & Barros, 2007; Defilippi, 2007). In both the UK and SA context, the staffing of PC is heavily supported by volunteers (Davies & Higginson, 2005; Lemonica, 2007; Defillipi, 2007). An important finding, which probably functioned as a cost saving measure, was the sharing of human resources and physical infrastructure between community and hospital-based PC services (Lemonica, 2007; Ridley, 2008). In addition, acute hospital and nursing home PC services were housed in existing functioning facilities within the health system (Stjernsward et al 2007; Gomez-Batiste, 2007). It should be noted that besides the potential cost savings, having shared human resources facilitated continuity of care for patients and possibly smoothed transitions between community and hospital care (McDermott et al., 2008).

Implications: Policy, Clinical Practice and Research There is little debate regarding the need for palliative care in modern health systems (Clemens et al., 2007). However, as indicated by the development of palliative day care in UK, even in the presence of public support and a source of funding, implementing services without adequate assessment of population need and comprehensive service development policy can result in: 1. variable standards of care (Davies & Higginson, 2005); 2. fear and under-utilization of services (Greaves, Dale & Ong, 2008); 3. and at worst, inequalities of access to care (Greaves, 2012). From this review of palliative care models, it was seen that using the WHO PC implementation strategy served to reduce the likelihood of some of the negative outcomes mentioned above (Stjernsward, 2007, Hererra et al. 2007, Kaasa et al, 2007). In the Barbadian and wider Caribbean context, it is therefore vitally important that palliative care services be developed in a structured way as opposed to a piece meal approach. To this end, there would be benefits in the development of national palliative care programmes with an end point of full integration of PC into health services. Key development steps in such a programme should include: 1. The performance of an epidemiological-based needs assessment to inform resource allocation (physical infrastructure and human); 2. The performance of economic evaluations to guide resource allocation; 3. The development of a training undergraduate and post graduate programme for palliative care education; 23


Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

Management Institute for National Development 4. Continuing medical education activities to inform potential referrers to the principles and scope of palliative care; 5. Implementing frameworks to ensure that essential medications for palliative care are consistently available and in the formulations most needed by the population (De Lima et al., 2007); 6. The development of national plans for diseases with recognized palliative phases such as HIV, Cancer, Renal Failure and Heart Failure plans (where these do not exist) and the integration of palliative care policy into these; 7. Building an academic and policy palliative care research environment to inform local service planning and development. Fortunately, in some Caribbean countries the building blocks for many of these developmental steps are already present (Greaves, 2010; Pan American Health Organization, Health Systems Profile Barbados). In addition, postgraduate training in medical specialties closely allied with palliative care are already delivered in the region through the medical faculties of the three campuses of the University of the West Indies (Anesthesiology, Internal Medicine, and Family Medicine). What is needed now is advocacy and coordinated efforts to pull these pieces together for the good of the population.

24

Conclusion From the literature review it is evident that there are a number of models for consideration that may inform the development of palliative care services in Barbados and other Caribbean islands with similar health care sectors. However, as indicated by the evidence, a viable service to which patrons have equitable access would be enhanced by following a capacity building process that simultaneously develops clinical care, education, research, monitoring and evaluation. Acknowledgements

This study was facilitated by Mr. Grantley SealyFormer Deputy Chief Health Planner (European Development Fund) and Mrs. Roxanne BecklesWhite- Health Planner of the Ministry of Health, Barbados.


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Bibliography Bosnjak, S., Milicevic, N. & Lakicevic, J. (2006). Palliative Care in Serbia and Montenegro: Where are We Now? Archive of Oncology, 14 (1-2), 8-10. Brown, S., Black, F., Vaidya, P., Shrestha, S., Ennals, D., LeBaron, V. (2007). Palliative Care Development: the Nepal Model. Journal of Pain and Symptom Management, 33 (5), 573-577. Byock, I., Twohig, J. & Merriman, M. (2006). Promoting Excellence in End of Life Care: A Report on Innovative Models of Palliative Care. Journal of Palliative Medicine, 9 (1), 137-146. Clark, D. (2007). From Margins to Centre: A Review of the History of Palliative Care in Cancer. Lancet Oncology, 8 (5), 430-438. Clemens, K.E., Kumar, S., Bruera, E., Klaschik, E., Jaspers, B. & De Lima, L. (2007). Palliative Care in Developing Countries: What are the Important Issues? Palliative Medicine, 21,173-175. Cowley, L.T., Young, E. & Raffin,T. A. (1992). Care of the Dying: an Ethical and Historical Perspective, Critical Care and Medicine, 20 (10), 1473-1482. Davies, E. & Higginson, I. J. (2005). Systematic Review of Specialist Palliative Day-Care for Adults with Cancer. Supportive Care in Cancer, 13 (8), 607-627. De Lima, L., Krakauer, E.L., Lorenz, K., Prail, D, MacDonald, Doyle., D. (2007). Ensuring Palliative Medicine Availability: The Development of the IAHPC list of Essential Medicines for Palliative Care. Journal of Pain and Symptom Management, 33 (5) 521-526. Defilippi, K. & Cameron, S. (2007). Promoting the Integration of Quality Palliative Care – the South African Mentorship Program, Journal of Pain and Symptom Management, 33(5) 552-557. Demmer, C. (2007). AIDS and Palliative Care in South Africa. American Journal of Hospice and Palliative Care, 24: 7-12. Detels, R., Beaglehole, R. Lansang, M. A., & Gulliford, M. (Eds.). (2009). Acquired Immuno Deficiency Syndrome Section 9.13. In Oxford Textbook of Public Health (5th Ed.). (pp.1193-1212). New York: Oxford University Press.

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Management Institute for National Development Fainsinger, R. L., Brenneis, C. & Fassbender, C. (2007). Canada: A Regional Model of Pallia tive Care Development. Journal of Pain and Symptom Management, 33(5), 634-639. Franks, P.J., Salisbury, C., Bosanquet, N., Wilkinson, E.K., Kite, S., Naysmith, A. & Higginson, I.J. (2000). The Level of Need for Palliative Care: A Systematic Review of the Literature. Palliative Medicine, 14 (2), 93-104. Gomez-Batiste, X., Porta-Sales, J., Pascual, A., Nabal, M., Espinosa, J., Paz, S., et al (2007). Catalonia WHO Demonstration Project at 15 years (2005). Journal of Pain and Symptom Management, 33(5), 584-590. Greaves, N.S, Dale, J. & Ong, P. (2008). The Term “Hospice” and its Potential Impact on Access to Adult Palliative Day Care: Mis-messages, Meta Messages and Marketing. Palliative Medicine 2008; 22: 582 (Research poster presented at the 7th Palliative Congress, Glasgow, Scotland 29th April-1st May 2008). Greaves, N. S. (2008). Barbados Palliative Care Needs Assessment Project Proposal; 1-10. Greaves, N. S. (2010). Barbados Palliative Care Needs Assessment Project: Models of Palliative Care Delivery. Commissioned by the Ministry of Health, Barbados. Greaves, N. S. (2012). Adult Palliative Day-Care Services: An Investigation of the Factors Influencing Access to Services Using the Case of a Cancer Network in the United Kingdom. The University of Warwick, Coventry, United Kingdom (unpublished thesis June 2012 available by personal correspondence). Harding, R., Easterbrook, P., Higginson, I. J., Karus, D., Raveis, V. H. & Marconi, K. (2005). Access and Equity in HIV/AIDS Palliative Care: A Review of the Evidence and Responses. Palliative Medicine, 19 (3): 251-258. Hunt, P., Backman G., Bueno de Mesquita, J., Finer, L., Khosla, R., Korljan, D. & Oldring, L. (2009). The Right to the Highest Attainable Standard of Health. In R. Detels, R. Beaglehole, M.A. Lansang & M. Gulliford (Eds.). Oxford Textbook of Public Health (pp. 335-350). New York: Oxford University Press. Hererra, E., Rocafort, J., De Lima, L., MHA, Bruera, E., Garcia-Pena, F. & Fernandez-Vara, G. (2007). Regional Palliative Care Program in Extremadura: an Effective Public Health Care Model in a Sparsely Populated Region. Journal of Pain and Symptom Management, 33 (5): 591- 598. Kaasa, S., Jordhøy, S.M. & Faksvåg, D. (2007). Palliative Care in Norway: A National Public Health Model, Journal of Pain and Symptom Management, 33(5) 599-604.

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Karim, S. S. A., Karim, Q. A. & Detels, R. (2009). Acquired Immunodeficiency Syndrome. In R.Detels, R. Beaglehole, M.A. Lansang, M.Gulliford (Eds.). Oxford Textbook of Public Health (5th ed.). (pp.1193-1212). New York: Oxford University Press. Kumar, S. K. (2007). Kerala, India: A Regional Community-Based Palliative Care Model. Journal of Pain and Symptom Management, 33(5), 623-627. Lemonica, L. & Barros, G. A. M. (2007). Botucatu, Brazil: A Regional Community Palliate Care Model. Journal of Pain and Symptom Management, 33(5), 651-654. Lewis, M. (2007). Medicine and the Care of the Dying. New York: Oxford University Press. Ministry of Health. (2009). Terms of reference. Barbados Needs Assessment Project Palliative Care. McDermott, E., Selman, L., Wright, M. & Clark, D. (2008). Hospice and Palliative Care Development in India: A Multimethod Review of Services and Experiences. Journal of Pain and Symptom Management, 35 (6), 583-593. Mundia, M. (2008).The Changing Landscape of Home Based Care Services in the Era of Widely Accessible ART in Zambia. Canadian Journal of Public Health, 99: Supplement 1: S20-2. National Cancer Control Programmes: Policies and Managerial Guidelines. (2002). World Health Organisation. Accessed online from http://www.who.int/cancer/media/en/408.pdf. September 6, 2013 Pan American Health Organization. (2008). Health Systems Profile Barbados. Monitoring and Analyzing Health Systems Change/Reform. December 2008, Washington D.C.: PAHO. Pan America Health Organization. (2013). Strategic Plan of the Pan American Health Organisation 2014-2019. Championing Health: Sustainable Development and Equity. September 2013, Washington D.C.: PAHO. Randall, F. & Downie, R.S. (2006). The Philosophy of Palliative Care Critique and Recon struction. New York: Oxford University Press. Ridley, J. Z. & Gallagher, R. (2008). Palliative Care Telephone Consultation: Who Calls and What do they Need to Know? Journal of Palliative Medicine, 11(7), 1009-1014. Sepulveda, A.C., Marlin C., Yoshida, T., Ullrich A. (2002). Palliative Care: The World Health Organization’s Global Perspective. Journal of Pain and Symptom Management, 24(2), 91-96.

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Management Institute for National Development Stjernsward, J., Frank D. F., Samir N. K., Walid J., Imad M. T., Mohammed M., et al. (2007). Jordan Palliative Care Initiative: a WHO Demonstration Project. Journal of Pain and Symptom Management, 33 (5), 628-633. Tebbit, P. (2004). Population Based Needs Assessment for Palliative Care. National Council for Hospice and Specialist Palliative Care Services. Thiede, M. (2005). Information and Access to Health Care: Is there a Role for Trust? Social Science and Medicine , 61 (7), 1452-1462. Watson, M., Lucas, C., Hoy, A. & Back, I. (2005). Oxford Handbook of Palliative Care, First Edition. New York: Oxford University Press. Weber, S. J. (1996). Ancient Answers to Modern Questions Weath Dying and Organ Transplants a Jewish Perspective. Journal of Law and Health, 11 (13), 13-44. Wenk, R. & Bertilino, M. (2007). Palliative Care Development in South America a Focus on Argentina. Journal of Pain and Symptom Management 33(5), 645-650. World Health Organisation. (2008a). World Bank Country Classification: The Impact of Cancer in your Country. Accessed online from http://data.worldbank.org/about/ country-classifications/country-and-lending-groups#Low_income). March 31, 2008 World Health Organisation. (2008b). Stop the Global Epidemic of Chronic Diseases. Accessed from http://www.who.int/infobase/report.aspx?iso=BRB&rid=119&goButton=Go. March 18, 2008. World Health Organization. (2002). WHO Definition of Palliative Care Accessed online from http://www.who.int/cancer/palliative/definition/en/. January 17, 2014. Wowchuk, S.M., Wilson, E.A., Embleton, L., Garcia, M., Harlos, M. & Chochinov, H.M. (2009). The Palliative Medication Kit: An Effective Way of Extending Care in the Home For Patients Nearing Death. Journal of PalliativeMedicine, 12(9),797-803. Wright, M., Woods, J., Lynch, T. & Clark, D. (2008). Mapping Levels of Palliative Care Development: A global view. Journal of Pain and Symptom Management, 35(5), 469- 485.

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Annex Table 1: Results of Primary Search Strategy (duplicate report of the same study n= 2)

Database

Electronic search results based on key heading words

Results after application of full exclusion criteria (major limits noted)

Post Abstract review- number of articles with content relating to review questions and sub questions

Post Article reviewnumber of articles covering scope of review

126

limited to 13 by date of article publication- 20052010

1

0*

EMBASE

112

limited to 39 by date of article publication -20052010 limited to 38 by age of participant-18yrs+

1

1

CINHAL

17

Limited to 15 by age Limited to 11 by date of publication-2005-2010

2

2

PschyINFO

12

Limited to 9 by date of publication 2005-2010 Limited to 8 by study type

5

1

1

1

0

0

Medline

Cochrane Library

Table 2: Results of Hand Searching (Jan 2007- April 2010)

Journal

Number of relevant articles found(developing countries)

Number of relevant articles found (developed countries)

American Journal of Hospice & Palliative Medicine

1

0

BMC Palliative Care

0

0

Journal of Palliative Medicine

0

2

Palliative Medicine

0

0

Journal of Pain and Symptom Management

7

2

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Designing Palliative Care Services: Insights from the Review of Service Models Process of the Barbados Palliative Care Needs Assessment Project

Management Institute for National Development Table 3: Results of Secondary Search Strategy (Duplicate report of the same study n= 5)

Database

Number of hits

Number of relevant articles post title+/-abstract review

Cochrane database of systematic reviews

5

0 (5 removed by tile)

0

Database of abstracts of reviews of effects

11

3 (8 removed by title)

1

Health technology assessment database

3

2 (1 removed by title)

0

NHS economic evaluation database

51

8 (39 removed by title, 4 removed by abstract,)

1

Table 4: Summaries of Retrieved Reports Describing PC Models

Inpatient hospice; Hospice at homeby HPs; Acute Hospital Beds at Cancer Hospital, both Private and Public; and Outpatient clinics

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Number of relevant articles post full text articles reviewed


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Management Institute for National Development

There was an initial need to develop national standards for care. Initially insufďŹ cient numbers of mentors & mentor surveyors given the presence of an increasing number of hospices and a large geographic area

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Management Institute for National Development

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Management Institute for National Development

MIND Profile The Management Institute for National Development (MIND) is the Government of Jamaica’s pre-eminent and preferred public service leadership development and management training institute in Jamaica, serving the Caribbean. The role of MIND is crucial to the transformation of the public service in Jamaica and the Caribbean region. The MIND Mission is to provide public servants with quality training and leadership development options, supporting services and outreach which sustain a culture of enterprise, efficiency and responsiveness to the publics they serve. MIND offers an exclusive focus on programmes, supporting services and outreach that are strategically developed to respond effectively to enhancing the professionalism and performance quality of public sector professionals; and transform the public sector into one “which puts the public’s interest first, and in which valued and respected professionals deliver high quality services efficiently and effectively.” MIND encourages collaborations and partnerships with local, regional and international learning organisations and donor agencies, to strengthen its capacity to provide a coordinated and integrated approach to deliver first class management training and leadership development to public service professionals. MIND Consultancy also responds to the call from public sector organizations, to provide a dynamic range of professional expertise and organisational development services. MIND Outreach services and programmes include Conferences, Public Lectures, Quarterly Policy Forums, and the publication of the Caribbean Journal of Public Sector Management, which stimulate public awareness of issues of national, regional and global importance and provide a forum for the exchange of information and ideas that result in improved quality of thought and behaviours. The Management Institute for National Development (MIND) is committed to developing the knowledge base required for globally competent and ethical public sector professionals to advance the fulfillment of their organization’s mandate, in the interest of creating and sustaining national and regional growth and development and evolve into becoming world-class exemplars of good governance in the global community.

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ESTIMATING PUBLIC EXPENDITURE ON WOMEN’S HEALTH SERVICES IN JAMAICA: 1997 & 2007 Dr. Althea Dianne La Foucade, Dr. Ewan Scott and Ms. Christine Laptiste

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Management Institute for National Development

Estimating Public Expenditure on Women’s Health Services In Jamaica: 1997 & 2007 Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

ABSTRACT The authors employ utilization-based and expenditure-side approaches to measure trends in demand for and supply of womenspecific health services in Jamaica. Estimates show that total expenditure on female reproductive health care for 1997 and 2007 was 8% and 7% of the secondary and tertiary health care budget, respectively. Additionally, there was an increase in total expenditure on women’s health programmes from US$12.3 million in 1997 to US$16.5 million in 2007, both figures representing almost 7% and 5% of total recurrent health expenditure, respectively. One trend observed is the decrease in the utilization of services by women at all levels—primary, secondary and tertiary. Given the reduction in utilization, there is need for further research to ascertain the cause(s) of this trend. Key Words: women’s health; public health expenditure, utilization of health services INTRODUCTION Governments in the Caribbean have traditionally played a leading role in providing health care services at every level. As evidenced by the estimates, public health expenditure in the Caribbean Community (CARICOM) accounted for approximately 60% of total health expenditure and an average of 6% of Gross Domestic Product (GDP) between 1997 and 2007 (World Health Organization, (WHO), 2010; 2006). 38

This study focuses on public expenditure specifically as it relates to the provision of women’s health services in Jamaica. Two distinct components of public expenditure on the basket of women’s health services—spending on women’s health programmes and spending on women’s health, are identified. The former refers to services that are solely consumed by women (and their children); the latter refers to general spending on health services from which women as members of the general population also benefit. Women’s health programmes typically refer to activities aimed at Maternal and Child Health (MCH) and female reproductive health. MCH services provided by the state most often consist of first level programmes for maternal health, family planning services and child health, including nutrition surveillance and breast-feeding. We attempt to get a sense of the extent to which the relevant services are provided and utilized, in the context of a comparative analysis of public spending on women’s health and service utilization for the years 1997 and 2007. There are two main reasons for using 2007 as a cut-off point for this analysis. Firstly, extrapolating the 1997 cost estimates more than a ten-year period may lead to accuracy issues and secondly, the most recent approved Annual Report of the Ministry of Health at the time of writing reflects data for 2007.


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Literature Review The first strategic objective for women’s health adopted by The Platform for Action at the Fourth World Conference on Women in Beijing, 1995, sought “to increase women’s access throughout the life cycle to appropriate, affordable and quality health care, information and related service” (United Nations, 1999, p.2). Further, the

fundamental importance of women’s health is embedded in the Millennium Development Goals (MDGs). MDG 5—Improving Maternal Health—addresses a key aspect of women’s health but is also directly linked to the achievement of the other MDGs: reducing poverty, reducing child mortality, curbing HIV and AIDS, providing education, promoting gender equality, ensuring adequate food, and promoting a healthy environment (Women Deliver, 2009). In fact, the author goes on to say that, “…none of these goals can be achieved without more progress in promoting women’s reproductive rights and protecting maternal and newborn health” (p. 2). Investments in women’s health and women’s health programmes promote extensive intergenerational benefits, economic efficiency and equity (World Bank, 1994). Several of the programmes that are considered as critical components in a package of essential services for women are cost-effective, and the related benefit yield to outlay ratio is quite high. World Bank (1994) highlighted these services as: • Prevention and management of unwanted pregnancies; • Safe pregnancy and delivery services; • Prevention and management of sexually transmitted diseases; • Promotion of positive health practices, such as safe sex and adequate nutrition; • Prevention of practices harmful to health, such as less food and health care for girls than boys and violence against women (p. xiii).

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Problem Statement The importance of ascertaining the expenditure on the health of women in Jamaica can be justified on different grounds. A review of the landscape in Jamaica shows that 40% of women have been pregnant at least once before the age of 20 (Ekundayo et al., 2007). Further, according to the Planning Institute of Jamaica (PIOJ, 2007), data coming out of a 2006 survey indicate that 35.8% of poor households were headed by females. In situations where the health of the head of household may be compromised, in this case women, there is a clear realization of the possible negative fall-outs on women themselves, as well as on the entire household, since in most cases, they are the principal caregivers in the home. Another point to be considered is that women account for 45% of the labour force and register a labour force participation rate of 55% (International Labour Organization, 2013). As such, it is important for Jamaica that its investments in women’s health contribute to a healthy labour force, which has been associated with significant productivity gains. Because the quantum of spending on women’s health services is likely to be reflective of the nature of the services offered/supplied, it is important that financial allocations to such services be placed within the context of (a) the volume of services provided by type; and (b) the extent of the health problem/issue to be addressed.

Two significant externalities attached to women’s health are that (i) women are the main contributors to children’s wellbeing at both pre- and post-natal stages and (ii) women are the principal caretakers of 39


Management Institute for National Development

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

children and others, who may be sick in the home (Levine, Glassman & Schneidman, 2001). Even if we do not consider these two factors by themselves, the critical need for adequate and quality services for women is in itself extremely important. According to the United Nations Population Fund (UNFPA, 2000, p.7), the “demographic bonus” derived from spending on women’s health care leads to economic growth. They assert that approximately one-third of the yearly economic growth of the Asian “tiger” countries can be attributed to spending on women’s health care. The argument being, that investments in services like family planning and safe childbirth allow women to make better reproductive choices, which lead to declines in fertility rates and a reduction in the ratio of dependent children to the productive working population, ultimately resulting in increased economic growth. Global data reveal that women account for 40% of the labour force worldwide and as such, are important contributors to the world economy (Grépin and Klugman, n.d.). On average, they put an estimated 90% of their earnings back into the family; while men contribute 30-40% (Department for International Development, UK, 2013). Further, estimates are that the world loses US$15 billion annually in productivity due to maternal and newborn mortality (Women Deliver 2009, p.2). WHO (2012) sums it up concisely by stating that, “…women’s health is the foundation for social and economic development” (p. 1). While the reproductive health of women is only one aspect of women’s health, statistics indicate that globally, between 350,000 to 500,000 girls and women die from pregnancy-related conditions, almost all of which occur in developing countries among the vulnerable and poor (Women Deliver, 2009). The authors also pointed out that between15 to 20 million girls and women 40

suffer from maternal morbidities annually. In Latin America and the Caribbean (LAC), women are the main recipients of health services since they undertake more intensive usage (Levine et al., 2001). Based on their study of 7 countries in LAC in 1997, it was revealed that public expenditure on women’s health programmes accounted for 24% of all health expenditure and averaged 1.4% of GDP. Additionally, public health expenditure per woman ranged from US$25 to US$151. Large funding deficits (ranging from 25% to 50%) in women’s health programmes, were found in two countries, Peru and Guatemala, impacting on both the provision (access) and demand (utilization) of these services. Almeida, Dubay, & Ko (2001) analyze the access and utilization of health care services by low-income women in the United States based on 1997 survey data. They found that women who were uninsured accessed fewer services overall, and more importantly, fewer preventive health care services, than women who were insured. This finding is supported by Taylor, Larson & Correa-de-Araujo (2006) in their study of women’s utilization of health services in the United States in 2000. In such a context, the state can provide access to these basic services by financing them and advancing gender-sensitive policies to enhance the provision of women’s health programmes as well as women’s health - another important component in poverty reduction (World Bank, 1994). This is especially the case in countries where private or national health insurance coverage is minimal. In the Caribbean, even in the face of widespread provision of ‘free’ health care services by the state, access to these services by the poor as well as the range of services offered must still be considered.


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 the step-down methodology for activitybased costing to derive average cost estimates for three (3) hospitals: Cornwall Regional Hospital (Type A); Spanish Town Hospital (Type B); and Princess Margaret Hospital (Type C). These hospitals were considered to be fairly representative of the hospitals in their individual categories – Type A, Type B and Type C. Over the decade 1997 to 2007, the manner in which inputs and resources are combined to produce services, as well as the cost generation processes at the various health facilities, have not changed significantly. Given this fact, the use of the La Foucade and Theodore estimates as a baseline is valid since they intrinsically reflect these services and processes. Since the financial year of the government runs from April to March, for the purposes of this paper, expenditure for the years 1997/8 and 2007/8 is referred to as 1997 and 2007, respectively. All figures have been adjusted for inflation.

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Research Methodology In Jamaica, both the public accounting system and the Ministry of Health’s database do not present data in a sufficiently disaggregated manner to allow all the necessary components of spending on women’s health to be explicitly captured. Public expenditure on these services is largely embedded within the state’s spending on the public health sector. As a result of this, a number of areas critical to women remain hidden in the estimates as reported by the Ministry of Health (MoH). For example, a substantial feature of the primary health care network is its focus on the delivery of maternal, child and reproductive health care services. Expenditure data for the primary health care system is presented by regions, without reference to the relative allocations to the various clinics or service types. Consequently, antenatal and postnatal health expenditure at the primary level is not readily identifiable within the budgetary estimates. The same is true to some extent of spending at the secondary and tertiary levels. With the exception of the budget for the Victoria Jubilee Hospital — a specialist maternity hospital — it is impossible, at a glance, to identify how much of the spending at public hospitals was utilized in the provision of reproductive (women’s) health services since the hospital budget is not broken down according to specialty. As such, the information contained in the Government Estimates of Expenditure in conjunction with average cost estimates based on previous studies of the Jamaican health system were used. More specifically, we have combined the women’s health services utilization data from the Planning and Evaluation Branch of the MoH, with the average cost estimates computed by La Foucade (1996) and Theodore (1997). La Foucade cited Drummond and Maynard (1993) in utilizing

Scope of Study and Contextual Overview The study provides an overview of the structure of the Jamaican health care system and highlights the services that are accessed by women. Comments on health status indicators of women’s health as well as a comparative analysis of utilization patterns in the two years under examination are also undertaken. Public expenditure on these services by type and level are then estimated. Both the public and private sectors are involved in the provision of health care in Jamaica. The MoH is the main provider of care, owning and operating primary, secondary and tertiary health care facilities. Three hundred and twenty two health centres facilitate the delivery of primary health care (PHC) along with ten dental and two family planning clinics (MoH, 2007a). Type V defines the largest and most sophisticated health centre, and Type 41


Management Institute for National Development

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

I, the most basic. Services range from basic maternal and child health services to curative, dental and specialist services, as well as laboratory support. Given its important role, the PHC network is designed to ensure access to services by the entire population, especially the poor and vulnerable. This is achieved by making PHC as inexpensive as possible and by operating a spread of facilities geographically distributed across the island’s four administrative units or Regional Health Authorities. Secondary and tertiary care services are delivered through 23 hospitals as well as the teaching hospital of the University of the West Indies, with a bed complement of 4,736 (PAHO, 2012b). Approximately 90% of all acute hospital beds are housed in public hospitals. The private for-profit sector in Jamaica provides services mainly through private pharmacies, doctors’ offices and in the area of diagnostic services. There are eight private hospitals on the island with a total bed capacity of approximately 300 (PAHO, 2012a). Non-governmental or non-profit institutions also provide health services, which include support or counseling as well as the actual delivery of care especially with respect to chronic illnesses. According to PAHO (2012a) close to 38% of Jamaicans use the public health sector for ambulatory care services, 57% use private sector services, and 5% straddle both sectors.

The public sector is the main provider of inpatient care, accounting for as much as 95% of all inpatient days (PAHO, 2012a). All tertiary facilities are financed and operated by the public sector. About 75% of outpatient curative care is provided by the private sector with approximately 81% of expenditure emanating from private sources. Although there are user charges at health facilities, patients who are poor are still able to access care through applications for fee exemptions and waivers. However, the reality is that many poor patients do not access care because they (i) are unaware they could apply for a waiver and therefore cannot afford care; (ii) want to avoid the stigma attached to a fee waiver, and (iii) found the process too difficult (PIOJ, 2003). Like most Caribbean territories, the Jamaican health sector features prominently in the government’s budgeting and planning. The Jamaican government’s commitment to the health sector remained relatively steady during the late 1980s to early 1990s, even as the country was experiencing the adverse effects of what has become known as one of the most stringent structural adjustment experiences in the region (Le Franc, 1994). As revealed in Table 1, in 1997/98, the MoH’s recurrent expenditure consumed J$6.7 billion 9% of the state’s recurrent budgetary resources of J$71.7 billion, while in 2007/8 it accounted for eight percent or J$20.9 billion.

Table 1: Public Sector Recurrent Expenditure on Health 1997 & 2007 ($J ’000)

Year

1997/98 2007/08

Total Recurrent Recurrent Health Expenditure Expenditure 71,654,413 6,676,646 252,900,000 20,937,266

Recurrent Health Expenditure as a % of Total Recurrent Expenditure 9.3 8.0

Recurrent Health Expenditure as a % of GDP 2.47 2.00

Sources: Ministry of Finance and Planning, Estimates of Expenditure, (2001); WHO, Jamaica National Expenditure on Health 1995-2008, (n.d.); Ministry of Health, (2007a); Selected Indicators, 2005-2010 (n.d.).

42


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 is also carried out among the antenatal population. In 1997, 18.6% of pregnant women tested at public facilities were found to be anemic—hemoglobin level of below 10 g/dl. This figure declined to 14.8% in 2007. In 1997, 5% of pregnant women tested at antenatal clinics were positive for syphilis; by 2007 this figure was one percent. Female mortality data for 1997 revealed that the five leading causes of death in public hospitals were diseases of the circulatory system, malignant neoplasm, infectious and parasitic diseases, neuro-psychiatric and accidents and injuries, in that order. By 2007, cerebrovascular diseases were the main cause of female mortality (PAHO, 2012b).

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Health Status of Women in Jamaica Table 2 gives an overview of some of the leading indicators of women’s health for 1997 and 2007. The maternal mortality rate was 9.5 per 10,000 live births in 2007. This represented a decrease from the 1997 level of 11.0. The leading causes of maternal deaths are attributed to hypertension, haemorrhage and death from infection. A specific goal of the MOH continues to be the further reduction of the maternal mortality rate to below 10 per 10,000 live births. A number of strategies have been identified to achieve this. These include the identification of high risk cases; increasing the antenatal attendance rates to 90% of pregnant women; ensuring at least five antenatal visits per pregnancy; increasing the number of pregnant women initiating care before sixteen weeks; increasing the general quality of antenatal and intra partum care; and tetanus inoculation during the prenatal period to prevent deaths from tetanus neonatorum. Jamaica’s contraceptive prevalence rate, which is influenced by clinical and surgical family planning services provided at the primary and secondary level, stood at 64% in 1997 and 69% in 2007. The corresponding total fertility rates for those years were 2.8 and 2.5 respectively. Anemia screening

Analysis of Utilization of Women’s Health Services At the primary level, maternal and child health clinics are provided at all primary health facilities. The estimated percentage of the pregnant female population utilizing antenatal care before 16 weeks stood at 21.8% in 1997 (PIOJ, 2001), increasing to 29.8% in 2007 (MoH, 2007a). The proportion of mothers receiving postnatal care in 1997 was recorded at 69.5% (PIOJ, 2001), falling slightly to 66.8% in 2007 (MoH, 2007a). Overall, the throughput at primary health care institutions as it relates to services targeted to

Table 2: Women’s Health Status Indicators: 1997 & 2007

Indicators

1997

2007

Maternal Mortality rate (per 10,000 live births)

11.0

9.5

64

69.01

Contraceptive prevalence rate (%) Total fertility rate

2.8

2.5

Percentage of pregnant women tested and found to be anemic (%)

18.6

14.8

Percentage of pregnant women tested, found positive with syphilis

4.9

1.1

Life Expectancy (All)

74.7

74.13

Male

72.5

71.26

Female

76.9

77.07

Sources: Planning Institute of Jamaica, (2001); PAHO, (2002), Ministry of Health, (2001 & 2007a)

43


Management Institute for National Development

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

women decreased (on average 20%) between 1997 and 2007 as depicted in Table 3. The secondary health sector also provides inpatient and outpatient services for maternal health and for the treatment of diseases and conditions specific to women. It is important to note that the Victoria Jubilee Hospital is the only specialist maternity institution and thus accounts for all of the maternity admissions recorded for specialist facilities. This hospital services the Kingston

area and as such, women’s inpatient services are provided there and not at the Kingston Public Hospital. In 1997, the obstetric specialty accounted for 39% of all admissions to secondary level facilities. (Table 4 provides details). This figure fell to 31% in 2007. At Type A facilities, it accounted for 24% and 17%, at Type B facilities 40% and 41%, at Type C hospitals 39% and 29% and at Specialist institutions, 59% and 46% in 1997 and

Table 3: Number of Visits to Health Centres by Targeted Female Services - 1997 & 2007

Type of Service

1997

Antenatal Postnatal Family Planning* Total Visits

2007

158,102 41,537 253,593 453,232

(%) decrease 1997-2007

122,935 32,220 205,286 360,441

22 22 19 20

Source: Ministry of Health (1997a & 2007a) Note: *1996 figure

Table 4: Total Admissions for Women’s Health Services by Specialty, 1997 & 2007

Hospital

All

All Specialties Male & Female 2007

1997

General Medicine General Surgery (Female) (Female) 2007

1997

2007

Obstetrics

2007

1997

2007

1997

180,438

154,015

23,811

29,102

24,149

36,531 28,178

27,588

56,617 59,871

Type A

59,050

43,563

11,688

11,231

10,398

18,023

3,578

3,785

10,156 10,524

Type B

53,425

45,689

5,317

7,763

7,342

11,763

7,537

7,699

21,769 18,464

Type C

39,262

36,643

6,642

9,229

4,803

6,590

5,638

6,544

11,397 14,280

Specialist

28,701

28,120

164

879

1,606

155 11,425

9,560

13,295 16,549

All (%)

100

100

100

100

100

100

100

100

100

100

Type A

33%

28%

49%

39%

43%

49%

13%

14%

18%

18%

Type B

30%

30%

22%

27%

30%

32%

27%

28%

38%

31%

Type C

22%

24%

28%

32%

20%

18%

20%

24%

20%

24%

Specialist

16%

18%

1%

3%

7%

0.4%

41%

35%

23%

28%

Source: Ministry of Health (1997b & 2007b)

44

1997

Paediatrics


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Apart from the activities of hospitals and health centres, the MoH also supports international policy initiatives relating to women. The Mother/Baby Friendly Initiative introduced by the UNICEF, and the WHO/PAHO for example, which is a global infant feeding campaign, has been adopted by the Government of Jamaica. Additionally, early detection strategy as a means of treating cancer is embraced and encouraged by the health ministry. Cancer screening is provided at the Family Planning Association (FPA), the Jamaica Cancer Society, and at primary and secondary public institutions. Self-examination as an early detection method for breast cancer is an integral aspect of the ministry’s public education campaign.

2007, respectively. However, alongside these reductions, there was a significant increase in the percentage of general surgical procedures performed at the Victoria Jubilee Hospital. For 1997 and 2007, the volume of obstetrics and gynecology cases that were being attended to in outpatient clinics was 22% and 19% of the total volume of clinic cases, respectively (Table 5). Despite the overall reduction in total women’s cases and the fact that there were no reported cases for Type C and Specialist hospitals in 1997, Gynaecology cases increased by 18% in 2007. In 2007, obstetric conditions were the leading cause of discharges (29%) overall, while surgeries for obstetric conditions numbered 8,398, which represented an increase over the previous year of 3 percent (MoH, 2007b). Table 5: Outpatient Clinics by Specialty (1997 & 2007)

Hospital

All Cases

Obstetrics

Gynecology

No. of Clinics

Total Women’s Cases

Women’s Cases as % of all Cases

No. of Clinics

Total Cases

Total Cases

1,270

73,280

625

26,830

100,110

22 20

1997 All Hospitals 453,258 Type A

264,550

432

36,253

340

15,631

51,884

Type B

82,325

331

18,584

285

11,199

29,783

36

Type C

38,815

252

303

0

0

303

0.8

Specialist

67,568

255

18,140

0

0

18,140

27

2007 All Hospitals 480,022

1,107

57,727

858

31,692

89,419

19

Type A

229,800

387

23,164

307

11,968

35,132

15

Type B

123,038

362

19,535

325

11,306

30,841

25

Type C

38,564

151

2,604

80

1,882

4,486

12

Specialist

88,620

207

12,424

146

6,536

18,960

21

Source: Ministry of Health (1997b & 2007b); 0: no clinics/cases recorded

45


Management Institute for National Development

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Findings The data in Table 6 reveal that on average, women tend to account for a higher percentage of inpatient days in Type B hospitals than in Type A and C hospitals. However, with the exception of the specialist maternity hospital, Victoria Jubilee, the Linstead Hospital which is a type C hospital recorded the highest percentage (40%) of Obstetric Gynaecology (OBGYN) patient days in

1997. This doubled over the decade to 80% in 2007. Excluding spending on Victoria Jubilee Hospital, total spending on inpatient OBGYN care amounted to J$135.5 million in 1997 and J$309.7 million in 2007. OBGYN clinics were conducted in 10 and 11 of the nation’s 19 public hospitals in 1997 and 2007, respectively. Details are given in Table 7. According to our estimates,

Table 6: Spending on Inpatient Care for Women at Public Hospitals (1997 & 2007) J$ millions Hospitals

Women’s Services No. of Inpatient Days

Average Cost Per Day (J$) 1997 2007

Type A Cornwall Regional University Subtotal

1997

2007

22,407 18,355 40,762

16,666 16,530 33,196

1,655.43 1,655.43

4,234.50 4,234.50

37.1 30.2 67.3

Type B Mandeville St. Ann’s Bay Savanna-La- Mar Spanish Town Subtotal

11,620 10,969 6,975 31,655 61,219

15,243 14,285 9,841 23,229 62,598

651.07 651.07 651.07 651.07

1,665.40 1,665.40 1,665.40 1,665.40

Type C Annotto Bay Black River Falmouth Linstead Lionel Town Maypen Noel Holmes Percy Junor Port Antonio Port Maria Princess Margaret Subtotal

2,599 3,075 1,207 3,995 2,354 4,412 2,387 1,566 1,911 2,886 4,002 30,394

3,208 3,589 1,664 3721 241 6,576 1,278 958 1,429 958 3,721 27,343

928.05 928.05 928.05 928.05 928.05 928.05 928.05 928.05 928.05 928.05 928.05

Specialist Victoria Jubilee

46,590

44,229

na

178,965

167,366

GRAND TOTAL

1997

2007

70.6 70.0 140.6

20 16

15 16

7.6 7.1 4.5 20.6 39.8

25.4 23.8 16.4 38.7 104.3

22 24 16 28

26 21 23 28

2,373.90 2,373.90 2,373.90 2,373.90 2,373.90 2,373.90 2,373.90 2,373.90 2,373.90 2,373.90 2,373.90

2.4 2.9 1.1 3.7 2.2 4.1 2.2 1.5 1.8 2.7 3.7 28.3

7.6 8.5 4.0 8.8 0.6 15.6 3.0 2.3 3.4 2.3 8.8 64.9

12 13 7 40 24 24 18 5 9 21 15

17 17 10 80 4 17 16 4 9 9 13

na

na

na

100

100

135.4

309.7

na: not available Sources: (La Foucade, 1996, Theodore, 1997; Authors’ calculations).

46

Total Expenditure (J$ million) 1997 2007

Women’s Inpatient Days as % of Total Inpatient Days


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 2007—an increase of 73%. Of the 1997 figure, 3,007 were done at Type A hospitals, 6,253 at Type B hospitals, 2,019 at Type C hospitals and 3,650 at the specialist Victoria Jubilee Hospital. For 2007, the largest increase in surgeries (4,805) occurred at Type B hospitals. Our estimates show that total expenditure on female reproductive surgery amounted to J$32.0 million in 1997; (see Table 8). The comparative figure for 2007 stood at J$149.5 million.

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

exclusive of the Victoria Jubilee Hospital, approximately J$15.67 million and J$34.2 million was spent on the provision of OBGYN outpatient clinic services to the women of Jamaica in 1997 and 2007 respectively, having more than doubled in nominal terms. Data from the MoH indicate that 14,929 operations related to the female reproductive system were performed in public hospitals in 1997 while 25,842 were performed in

Table 7: Spending on Outpatient Care for Women at Public Hospitals (1997 & 2007) J$ millions

Hospitals

Type A Cornwall Regional Kingston Public University Subtotal

No of Outpatient, Visits 1997 2007

Women’s Services Average Cost Per Visit (J$) 1997 2007

Total Expenditure (J$ millions) 1997 2007

15,577 5,762 30,545 51,884

19,071 22,177 41,248

264.74 264.74 264.74 264.74

677.19 677.19 677.19 677.19

4.1 1.5 8.1 13.7

12.9 15.0 27.9

Type B Mandeville St. Ann’s Bay Savanna-La- Mar Spanish Town Subtotal

11,293 2,598 2,140 13,752 29,783

9,315 4,349 4,334 12,843 30,841

64.42 64.42 64.42 64.42 64.42

164.78 164.78 164.78 164.78 164.78

.7 .2 .1 .9 1.9

1.5 0.7 0.7 2.1 5.0

Type C Annotto Bay Black River Falmouth Linstead Lionel Town Maypen Noel Holmes Percy Junor Port Antonio Port Maria Princess Margaret Subtotal

282 21 303

478 2,855 785 368 4,008

112.21 112.21 112.21

287.03 287.03 287.03 287.03 287.03

.03 .002 .03

0.14 0.82 0.23 0.11

na

na

-

-

15.6

34.2

Specialist Victoria Jubilee GRAND TOTAL

18,140

18,960

100,110

95,057

1.3

na: not available Sources: La Foucade, (1996); Theodore, (1997); Authors’ calculations

47


Management Institute for National Development Table 8: Spending on Surgeries for Women at Public Hospitals (1997 & 2007)

Hospitals

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

No. of Operations

Women’s Services/Surgery Average Cost Per Operation 1997 2007

Total Expenditure (J$ millions) 1997 2007

Type A Cornwall Regional Kingston Public University Subtotal

1997

2007

2,152 173 682 3,007

3,106 0 2,513 5,619

4,502.66 4,502.66 4,502.66 4,502.66

11,517.57 11,517.57 11,517.57

9.7 .8 3.1 13.6

35.8 28.9 64.7

Type B Mandeville St. Ann’s Bay Savanna-La- Mar Spanish Town Subtotal

1,239 1,342 1,014 2,658 6,253

2,905 2,385 1,330 4,438 11,058

2,466.77 2,466.77 2,466.77 2,466.77 2,466.77

6,309.87 6,309.87 6,309.87 6,309.87 6,309.87

3.1 3.3 2.5 6.6 15.5

18.3 15.0 8.4 28.0 69.8

Type C Annotto Bay Black River Falmouth Linstead Lionel Town Maypen Noel Holmes Percy Junor Port Antonio Port Maria Princess Margaret Subtotal

290 32 203 43 0 196 46 474 270 97 368 2,019

757 364 250 0 0 1,315 95 206 336 0 670 3,993

1,469.53 1,469.53 1,469.53 1,469.53 1,469.53 1,469.53 1,469.53 1,469.53 1,469.53 1,469.53 1,469.53

3,758.98 3,758.98 3,758.98 3,758.98 3,758.98 3,758.98 3,758.98 3,758.98 3,758.98 3,758.98 3,758.98 3,758.98

.4 .05 .3 .06 .3 .07 .7 .4 .1 .5 2.9

2.8 1.4 0.9 4.9 0.4 0.8 1.3 2.5 15.0

Specialist Victoria Jubilee

3,650

5,172

na

14,929

25,842

GRAND TOTAL

na

na 32.0

149.5

na: not available; 0: no surgeries recorded. Sources: (La Foucade, 1996; Theodore, 1997 ; Authors’ calculations).

Because of the variance in both inflation and the exchange rate over the period, total expenditure on women’s programmes has been converted into US dollars. An estimated J$358.4 million (US$10.2 million) or (eight percent) of the total secondary and tertiary health care budget was used to provide

48

female reproductive health care services in 1997. Comparatively, in 2007, expenditure in this category was J$1,004 million (US$14.5 million). Overall, there was a US$4.3 million (42%) increase in expenditure on hospitalbased women’s programmes (Table 9).


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Table 9: Total Secondary and Tertiary Spending on Women’s Health in the Public Sector (1997 & 2007)

Hospitals Total Hospital Expenditure on Women’s Care

(US$ millions) 1997 2007

50.9 2.3 41.5 94.7

119.2 114.0 233.2

1.4 0.1 1.2 2.7

1.7 1.7 3.4

Type B Mandeville St. Ann’s Bay Savanna-La- Mar Spanish Town Subtotal

11.3 10.6 7.2 28.1 57.2

45.3 39.6 25.5 68.8 179.2

0.3 0.3 0.2 0.8 1.6

0.7 0.6 0.4 1.0 2.6

Type C Annotto Bay Black River Falmouth Linstead Lionel Town Maypen Noel Holmes Percy Junor Port Antonio Port Maria Princess Margaret Subtotal

2.8 2.9 1.4 3.8 2.2 4.4 2.3 2.1 2.1 2.8 4.3 31.1

10.5 9.9 4.9 8.9 0.6 21.4 3.6 3.2 4.7 2.3 11.4 81.4

0.1 0.1 0.0 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 1.0

0.2 0.1 0.07 0.1 .008 0.3 0.05 0.05 0.07 0.03 0.2 1.2

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Type A Cornwall Regional Kingston Public University Subtotal

(J$ millions) 1997 2007

Total Hospital Expenditure on Women’s Care

Note: US$1=J$35.59 (1997);

Specialist Victoria Jubilee

175.4

510.6

4.9

7.4

GRAND TOTAL

358.4

1,004.0

10.2

14.5

The state also allocated public resources to the provision of primary care and other services for these programmes in Jamaica. Data from Table 10 show that there has been a decrease in utilization of primary health care services with a 22% fall in both antenatal and postnatal visits and a 19% fall in family planning attendance. Further, assuming an average cost per visit at a level comparable to a visit in the outpatient clinic of the Spanish Town Hospital (excluding Accident & Emergency and Casualty), and further

US$1=J$69.06 (2007) Authors’ calculations

assuming that average cost would not have changed considerably between 1996 and 1997, the results of the average cost estimates for that hospital in 1996 (La Foucade, 1996), were applied. With the appropriate adjustments made for inflation, expenditure on women for primary services was also calculated for 2007. With the exclusion of Family Planning Services, expenditure on primary health care services for women was J$4.8 million and J$9.6 million in 1997 and 2007, respectively. 49


Management Institute for National Development Table 10: Cost of Primary Care Services Targeted at Women’s Health 1997 and 2007

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Type of Service

Visits

Estimated Expenditure

Visits

Expenditure

1997

1997

2007

2007

J$

US$

J$

US$

millions

millions

millions

millions

Antenatal

158,102

3.8

.1

122,935

7.6

0.1

Postnatal

41,537

1.0

.03

32,220

2.0

0.03

Family Planning+

253,593

-

-

205,286

-

-

Total

453,232

4.8

0.13

360,441

9.6

0.13

Note: US$1=J$35.59 (1997); US$1=J$69.06 (2007) Authors’ calculations : + Family Planning expenditure subsumed under other public sector spending (Table 11)

In addition to the above areas of expenditure, a review of Jamaica’s Estimates of Expenditure as prepared and presented by the Ministry of Finance, indicated at least three other categories of spending, presented in Table 11, that are applicable to women’s health. These are: (i) Training of Midwives; (ii) Family Planning; and

(iii) Contribution to Planned Parenthood Federation. The entire budget for Family Planning and Contribution to Planned Parenthood Federation has been included under spending on women. This was done based on the fact that the majority of family planning services are accessed by women.

Table 11: Other Public Sector Spending on Women’s Health 1997 & 2007

Function/Sub Function Programme RECURRENT Training - training of midwives Family Planning - grants for direction and administration - grants for information, education and communication - grants for delivery of family planning services - grants for training - grants for evaluation and research Contribution to Planned Parenthood Federation TOTAL

1997 2007* J$ millions

1997 2007 US$ millions

15.8

27.3

0.4

0.4

17.2 19.2 13.2 4.1 4.3

29.7 33.2 22.8 7.1 7.4

.01

na

0.4 0.5 0.3 0.1 0.1 0.0 na

73.8

127.5

0.5 0.5 0.4 0.1 0.1 0.0 2.1

1.8

Source: Ministry of Finance and Planning, Estimates of Expenditure, (2001 & 2004) *: The “Family Planning Services” functions of the board have been decentralised and administered by the Regional Health Authorities – 2007 figure estimated as average increase (7.27% per annum) of other family planning grants (not including evaluation and research).

50


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

indicated that a funding deficit does not exist in Jamaica and women’s health status was among the best in the seven countries they examined. Our findings also point to some measure of underutilization of services (Tables 3, 4, 5 and 10), which suggests that sufficient services are being provided. What is beyond the scope of this paper though is the assessment of the quality of the services being provided, which may or may not be a contributing factor to the decline in utilization.

Of a total recurrent health expenditure of J$6,676.6 million in 1997, an estimated total of J$437 million (6.5%) was spent on women’s health programmes (Table 12). Of this, 82% was utilized at the secondary and tertiary care level. In 2007, out of a recurrent budget of J$20,937 million, J$1,026 million (5.5%) was spent on women’s health programmes with 88% of that amount allocated to hospital-based services. Over the period, therefore, the share of the recurrent health budget allocated to women’s health programmes fell by 1% point. With the acknowledgement of differences in methodology, a tentative comparison with the Levine et al. (2001) study is made. This study estimated average public expenditure on women’s health at 24% of public health expenditures in 7 LAC countries, inclusive of Jamaica. While there is an over 17% differential in the findings between both methodologies, Levine et al. reported that spending on health in Brazil is 147 times what it is in Jamaica. The average they arrive at therefore will be heavily influenced by expenditures on health in the larger countries included in their study. It is important to note however, that they

Discussion and Analysis One of the main trends observed from the comparison of women’s health programmes in 1997 and 2007 is the decrease in the utilization of services at all levels, primary, secondary and tertiary. However, it appears that at the primary level, the fall-off in utilization is not due to a lack of resources to fill the needs of women requiring reproductive health services. Data show that between 67% and 72% of mothers use ante- and postnatal services. Indications are that at the primary level, maternal health services are under-subscribed, hinting that there may be excess capacity.

Table 12: Summary of Total Public Sector Spending on Women’s Health (1997 & 2007)

Secondary and Tertiary Care Inpatient Outpatient Surgery Victoria Jubilee Subtotal Primary Care Primary Care (Less Family Planning) Other (including all Family Planning) Subtotal TOTAL

Expenditure (J$ millions) 1997 135.4 15.6 32.0 175.4 358.4

2007 309.7 34.2 149.5 510.6 1,004

Expenditure (US$ millions) 1997 2007 3.8 4.5 0.4 0.5 0.9 2.2 4.9 7.4 10.1 14.5

Percentage Distribution (%) 1997 2007 31.0 27.1 3.6 3.0 7.3 13.1 40.1 44.7 82.0 88

4.8

9.6

0.1

0.1

1.1

0.8

73.8

127.5

2.1

1.8

16.9

11.2

78.6

137.1

2.2

2.0

18.0

12.0

437.0

1,141.1

12.3

16.5

100

100

Note: US$1=J$35.59 (1997); US$1=J$69.06 (2007)

Authors’ calculations

51


Management Institute for National Development

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

At the secondary and tertiary levels, resource constraints do not appear to be a major reason for the decrease in utilization. With the contraceptive prevalence increasing from 64% to 69% over the period and the total fertility rate falling from 2.8 to 2.4, there are indications that this may be a factor in the decline in utilization. Additionally, it may be that the private sector is attracting more clients for reproductive services. It is important though that research be undertaken to ensure that access problems due to poverty are not contributing to the decline in usage. With the methodology for the costing of services inextricably tied to utilization and even in the face of inflationary pressures, the total expenditure on women’s health programmes increased from US$12.3 million in 1997 to US$16.5 million in 2007. However, based on our calculations, the share of expenditure on these programmes of total recurrent health expenditure, fell from 7% to 5%, in 1997 and 2007, respectively. Given the level of resources that are being allocated to women’s health programmes, there is need for continuous assessment of the cost and range of health

services targeted to women’s health. There is also need for a consistent methodology to facilitate more accurate identification of gaps that may exist. Important too is the need for continuous research to provide analysis and dissemination of the latest information that will have real time effect on policy decisions. Implicit in this is the need for adequate monitoring and evaluation of both the efficacy of spending on women’s health as well as the reach and effectiveness of the programmes themselves. Conclusion This study also pointed to the large role of women in the household in Jamaica and some of the poverty issues that may impact health seeking behaviour of women. Given the foregoing, there is need to ensure, at the policy level, that services are accessed by those who need them most. This raises the very real issue of the necessity for an increased awareness of the role of women in both the promotion of health and also in the context of the wider role of human development.

Bibliography Almeida, R. A., Dubay, L. C., Ko, G. (2001). Access to Care and Use of Health Services by LowIncome Women. Health Care Financing Review, 22, (4), 27-47. Department for International Development, UK. (2013). Why is Reproductive, Maternal and Newborn Health Important? Accessed from DFID website: http://consultation.dfid. gov.uk/maternalhealth2010/why-is-maternal-and-reproductive-health-important/. November 29, 2013. Ekundayo, O. J., Dodson-Stallworth, J., Roofe, M., Aban, I. B., Bachmann, L. H., Kempf, M. C., Ehiri, J. & Jolly, P. E. (2007). The Determinants of Sexual Intercourse Before age 16 Years among Rural Jamaican Adolescents. The Scientific World JOURNAL, 7, 493–503. 52


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Grépin, K. & Klugman, J. (n.d.). Closing the Deadly Gap between What we Know and What we do: Investing in Women’s Reproductive Health. Washington, D.C.: The World Bank. International Labour Organization. 2013. Jamaica: Key Labour Market Indicators for Jamaica. Accessed from ILO website: http://www.ilocarib.org.tt/index.php?option=com_content &view=article&id=1175&Itemid=1244. November 18, 2013.

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

La Foucade, A. (1996). Estimating the Cost of Selected Hospital Services in Jamaica, 1994/95. A report submitted to the Ministry of Health, Health Reform Unit. Kingston: Ministry of Health. Le Franc, E. (1994). Consequences of Structural Adjustment: A Review of the Jamaican Experience. Kingston: Canoe Press. Levine, R., Glassman, A. & Schneidman, M. (2001). The Health of Women in Latin America and the Caribbean. Washington, D.C.: The World Bank. Ministry of Finance and Planning. (2001). Estimates of Expenditure. Kingston. Ministry of Finance and Planning. (2004). Estimates of Expenditure. Kingston. Ministry of Health. (1997a). Annual Report. Kingston: Policy, Planning and Development Division, Policy and Evaluation Branch. Ministry of Health. (1997b). Hospital Monthly Statistics. Kingston: Planning and Evaluation Branch. Ministry of Health. (2001). Annual Report. Kingston: Policy, Planning and Development Division, Policy and Evaluation Branch. Ministry of Health. (2007a). Annual Report. Kingston: Policy, Planning and Development Division, Policy and Evaluation Branch. Ministry of Health. (2007b). Hospital Monthly Statistics. Kingston: Planning and Evaluation Branch. Pan American Health Organization. (2002). Core Health Data Selected Indicators, Jamaica 2002. Accessed from PAHO website: www.paho.org/English/DD/AIS /cp_388.htm. March 24, 2013 Pan American Health Organization (2012a). Pharmaceutical Dituation in Jamaica: WHO Assessment of Level II - Health Facilities and Household Survey. Technical Series: Essential Medicines, Pharmaceutical Policies, Nº 5, September. Washington, D.C. Pan American Health Organization (2012b). Health in the Americas, 2012 Edition: Country Volume. Washington, D.C.

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Planning Institute of Jamaica. (2001). Economic and Social Survey. Kingston. Planning Institute of Jamaica. (2003). Economic and Social Survey. Kingston. Planning Institute of Jamaica. (2007). The Poverty-Environment Nexus: Establishing an approach for determining special development areas in Jamaica. Kingston. Selected Indicators 2005-2010. (n.d). Received from the Ministry of Health, Jamaica, 2011.

Estimating Public Expenditure on Women’s Health Services in Jamaica: 1997 & 2007

Taylor, A., Larson, S. & Corea-de-Araujo, R. (2006). Women’s Health Care Utilization and Expenditures. Women’s Health Issues 16, 66 –79. Theodore, K. (1997). Cost Analysis of Secondary Health Care Services in Jamaica. A Final Report Submitted to Ministry of Health, Health Reform Unit. Kingston: Ministry of Health. United Nations. (1999). Follow-up to the Fourth World Conference on Women: Implementation of Strategic Objectives and Action in the Critical Areas of Concern. Thematic Issues before the Commission on the Status of Women. Accessed from the United Nations website: www.un.org/womenwatch/daw/csw/thematic99.htm. June 12, 2013. United Nations Population Fund. (2000). The State of World Population: Lives Together, Worlds Apart: Men and Women in a World of Change. UNFPA. Accessed from UNFPA website: http://www.unfpa.org/swp/2000/pdf/english/chapter1.pdf. May 12, 2013 Women Deliver. (2009). Focus on 5: Women’s Health and the MDGs. Accessed from UNFPA website: http://www.unfpa.org/webdav/site/global/shared/documents/ publications/2009/Focus-on-5.pdf. June 16, 2013. World Bank (1994). A New Agenda for Women’s Health and Nutrition. Washington, D.C.: The World Bank. World Health Organization. (n.d.). Jamaica National Expenditure on Health 1995-2008. World Health Organization. (2006). World Health Report 2006. Working Together for Health. Geneva. Accessed from WHO website: http://www.who.int/whr/2006/annex/06_ annex2_en.pdf. November 20, 2014. World Health Organization. (2010). World Health Statistics 2010. Geneva. World Health Organization. (2012). Addressing the Challenge of Women’s Health in Africa. Report on the Commission on Women’s Health in the African Region. WHO Regional Office for Africa.

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THE IMPACT OF GOVERNMENT EXPENDITURE ON ECONOMIC GROWTH IN DEVELOPING COUNTRIES: A LITERATURE REVIEW Patricia Edwards-Wescott and Professor Karl Theodore1

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The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

The Impact of Government Expenditure on Economic Growth in Developing Countries: A Literature Review INTRODUCTION The standard neoclassical growth model suggests that government expenditure has no effect on economic growth (Solow, 1956). In this model, economic growth depends mainly on increases in the capital stock, the labour force and the speed of technological progress. Endogenous growth models (Romer, 1986; Lucas, 1988) on the other hand, show that there are both short-term and long-term effects of government spending on economic growth. These models show that in addition to factors suggested in the standard neoclassical growth theory, other factors could affect the production function and improve economic growth. This means that public expenditure on education and health can positively influence growth by enhancing both the stock and flow of human capital (Mankiw et al., 1992). Aschauer (1989) also found that public spending on infrastructure positively impacts on economic growth. Hence, government expenditure on human capital accumulation and public infrastructure are said to play the part of an output-promoting control variable with constant returns to scale in the economy (Arghyrou, 1999). A number of explanations have been given for the intervention of government in an economy. Economic theories identify the occurrence of market failure or the inability of the market mechanism to arrive at an efficient allocation of resources and to produce socially-desirable outcomes, as the main basis for state intervention. This means that in order to solve the many problems caused by market failure, governments 56

are forced to play a number of economic roles such as identified by Musgrave (1959). These roles include the allocation, distribution, stabilization and regulation of resources and markets. These areas of economic activities require certain levels of government expenditure. Wagner (1890) postulated that as an economy grows in its level of economic activity and urbanization, the level of government expenditure will also need to grow. The ultimate objectives of public expenditure therefore are to improve resource allocation, ensure equitable income distribution and provide stabilization in the economy. Wahba and Smith (1995) contended that the state of the market in developing countries increases the need for government intervention. They note that in some developing countries the market mechanism is under-developed and in some instances markets may not even exist and therefore the state is needed to ensure their existence and optimal operations. Furthermore, the need to achieve economic growth and development increases the expenditure demands placed on developing countries’ governments. Here the state is often called upon to significantly enhance the human capital capacity through state provision of merit goods, especially education and health care. In addition, the level of basic infrastructure development required by developing countries for structural transformation is tremendous and is again generally undertaken by the state. Developing countries are also plagued by chronic and adverse macroeconomic


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Problem Statement Generally, the empirical evidence on the impact of government expenditure on economic growth has been inconclusive. The fact is that in many developing countries, like those in the English speaking Caribbean, government expenditure is substantial, but little is known about its impact on growth. Given the dearth of information on this relationship in the Caribbean, this review of the literature is undertaken to unearth what are the methodological, theoretical and policy issues that must be considered when trying to determine the impact of government expenditure on growth in the Caribbean region. Methodology This paper draws widely on an array of secondary sources of data to determine what has been discovered about the impact of government spending on economic growth both from the theoretical and empirical perspectives. The literature review revealed that while some empirical studies have been conducted in developing countries

on this topic, only a few have been done in the English speaking Caribbean. In spite of this limitation, exploration of the various methodologies and variables used in the literature and the results of those studies reviewed can assist in identifying the best methodological approaches, components of expenditure and efficiency guidelines that can be used in similar research in the Caribbean . Following the introduction and a description of the problem this section explains the methodology used. An extensive review of the literature follows. It reviews the theoretical arguments about the involvement of government in an economy beyond its core functions. Some empirical evidence of the impact of government spending in different developing countries follows. A discussion of the different definitional and methodological issues which arise in the literature and may account for variations ensues. Following that, is a case study of the use of government expenditure in Malawi, where the positive impact of government expenditure on the economy is observed. The final section gives some recommendations and the conclusion.

The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

disequilibria affecting employment, foreign exchange rates and earnings, public debt and government budget balance. High poverty levels and notably high income inequality are characteristics which increase the redistributive role of the state in developing countries. State interventions to correct some of these problems and deficiencies have been widely accepted as direct growth enhancing government interventions, but these are not costless. The achievement of economic growth is an objective of every government and given the importance and level of government spending in developing countries it is necessary to find out the answer to the question, What impact does public expenditure have on economic growth, especially of developing countries?

Literature Review Early theoretical literature on economic growth did not articulate an active role for the state in achieving this objective. These theories are often described in the literature as exogenous growth models. Included in the exogenous models are the post-Keynesian Harrod-Domar model which is based on the Keynesian ideas of incomplete markets and the failure of markets to bring about full employment, and the neoclassical model developed by Solow and Swan. Even though earlier writings of Marx (1867) did not outline a theory of economic growth nor an explicit role of the state in achieving growth, it is clear that the role of the state in Marxian type economies is central. 57


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The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

Keynesian Theory of Economic Growth The Harrod-Domar model, also known as the Keynesian theory of economic growth, developed independently by Harrod (1939) and Domar (1946), did not include any active role for the state in determining economic growth. The model considered a closed economy where households saved and consumed and firms invested. Hence, economic growth depended on the level of investment which depended on the level of savings and the capital-output ratio or efficiency of investment. In other words, given the efficiency of investment, higher levels of investment led to higher levels of capital accumulation then to economic growth. The Harrod-Domar model identifies an equilibrium growth path where there would exist no deviation of the warranted growth rate (the rate of growth at which the capital to output ratio remains constant) from the actual growth rate. However, this equilibrium rate of growth is not always achieved and any deviation makes the growth path unstable. The model concludes that full employment and equilibrium growth rates cannot be guaranteed in an economy. A government, in such circumstances, is required to intervene to ensure that the warranted rate of growth is achieved. Empirical evidence has shown that the theory’s emphasis on capital accumulation to attain economic growth was misplaced. This is particularly true in developing countries. These countries are often plagued by low levels of savings and investment, especially private savings and investment, under-developed financial and transport systems and a large pool of mainly unskilled labour. Evidence has also shown that other countries have experienced growth without achieving high levels of savings but because of factors such as labour productivity and technical innovation. The evident weaknesses and instability problem of the Harrod58

Domar model led to the development of the neoclassical model of economic growth. The Neoclassical Theory of Economic Growth The Solow-Swan model (Solow, 1956; Swan, 1956) of economic growth also outlined no role for government spending in influencing the rate of economic growth. Like the Harrod-Domar model, the neoclassical model assumes a closed economy but disregards the exogenous nature of the capital-output ratio of the Harrod-Domar model. In fact, the model identifies the capital-output ratio as the adjusting variable that could bring the economy to the steady state path of growth. The theory outlines a production function with inputs - capital and labour - which are used to produce an output. Given the assumptions of the model, the economy moves towards steady state equilibrium. An economy achieves steady state equilibrium when per capita income and capital are equal. The steady state levels of output and capital occur where savings and required investments are also equal. However, it is technical progress which brings about long run economic growth when an economy is in the steady state equilibrium. The rate of population growth and the rate of technical progress affect the steady state rate of aggregate output. Hence, as far as the neoclassical theory is concerned, long-run economic growth is caused by exogenous factors such as technical progress and population growth but not by government spending. Marxian Theory Unlike the Harrod-Domar and the SolowSwan models, Marxian theory articulated an active role for the state in the capitalist society. Marxian ideology stands on the pillar of Marx’s labour theory of value which


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 growth. Researchers have sought answers to a number of questions such as: What is the relationship between government expenditure and growth? Is the relationship consistent with Keynesian theory? Is it reflective of Wagner’s Law? How efficient and effective is government expenditure? Other questions often asked include: What is the optimal size of government expenditure? Which components of government expenditure are productive and which are nonproductive? However, for this paper, the focus will be on the impact of government expenditure on growth. On the issue of causality, some researchers reveal that public expenditure leads to economic growth and therefore support Keynesian theory (Aschauer, 1989; Khan and Reinhart, 1990). Others support Wagner’s Law and contend that growth stimulates the expansion of government expenditure (Islam 2002. Several studies find bidirectional causality (Ram, 1986; Cheng & Wei Lai, 1997), while there are those which find no relationship between the two variables (Bagdigen & Cetintas, 2004 Singh & Sahni, 1984). The body of literature on the effect of government expenditure on economic growth continues to reveal contrasting views and results both on the theoretical as well as empirical levels. In economic theory, we can distinguish between two views. A group of theorists believes that state intervention should be limited to some core or basic functions which essentially enhance economic efficiency and thereby foster growth in the economy. One aspect of these core functions casts the government in the role of protector of private property. This involves the provision of law and order and the protection of individuals and their right to property. Another aspect concerns government provision of public goods such as national

The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

was proposed in his writing, Capital (1867). Marx used his version of the labour theory of value to attack the economic system of capitalism and its supporters. The Marxian view of the state evolved from the need to resolve the cycle of conflict which existed in the capitalist economy. According to Marx, the demise of capitalism was inevitable because the system was proned to internal conflicts caused by exploitation, injustice and uncertainty. The exploitation of the majority working class by the minority capitalist class and the private ownership of the productive resources of societies would come to an end. Marx therefore saw the birth and expansion of the state as the means to solving the periodic crises of economic slump and unemployment which occurred in capitalist economies (Elliot, 1981). The function of the state in such a society was to quell all the antagonism and conflicts in the society and to facilitate economic growth. Marx postulated that as capitalism developed, the economic role of the state would grow; but, eventually this power of the state would fall into the hands of the majority working class who would become the ruling class. Hence, a fundamental belief of the followers of Marx is that the productive heights of the economy must be managed and controlled by the state. For Marxians, the institutional characteristics of this centrally controlled economy include the state ownership of property and resources and central economic planning. Essential to achieving these goals is the nationalization of privately owned industries. In reality, for Marxians, the role of the state in ensuring economic growth is critical (McConnell & Brue, 1996). However, economies which have followed the Marxian ideology have not enjoyed sustained economic growth. A large number of researchers have undertaken studies on the relationship between public expenditure and economic

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The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

defense, roads and public affairs because the market may be unable to provide any of them or may be unable to provide them adequately (Gwartney, Lawson & Holcombe, 1998; Gallaway & Vedder, 1998). Two studies have also identified a number of reasons for the negative impact of increasing government spending on growth in an economy. They note that government expenditure is generally financed from taxes and/or from borrowing, two activities which are associated with imposing burdens on the economic system of a country. Higher taxes mean less after tax incomes for households and firms. The reduction in incomes dampens the desire of firms to invest and take risks and of householders to work. On the other hand, government borrowing results in higher interest payments for private investors and the government itself. This higher cost crowds out or reduces the level of private sector investment in the economy and also leads to the possibility of higher taxes in the future. These disincentive effects, caused by growth in the size of government in the economy, exert a negative impact on economic growth. In addition, the continued expansion of government beyond its core functions eventually results in diminishing returns as the government’s contribution to growth becomes less and less even in the presence

of more and more government activity. This occurs because as government grows it eventually undertakes activities for which it has little expertise such as food production and housing construction (Gallaway & Vedder, 1998). The Public Sector is also less responsive than the private sector to market signals and opportunities which require the discovery and use of new technologies. Thus the value of goods and services produced by the private sector, using the limited resources of the economy, is often of greater value than that produced by the government sector (Gwartney, Lawson & Holcombe, 1998). An illustration of the relationship between government spending and economic growth can be explained using the Rahn Curve (Figure 1). The curve illustrates that low levels of government expenditure spending on core activities facilitate growth. This is shown by the rising part of the curve. However, beyond a particular level of expenditure, also known as the optimum size of government, the contribution to growth of additional government expenditure declines. Recall that the decline is caused by factors such as ‘crowding out’, disincentive to work caused by government social programmes and government bureaucracy. For these activities the cost of government exceeds the benefit of the expenditure.

Figure 1: The Rahn Curve Figure 1: The Rahn Curve GDP Growth

Optimum size of Gov’t

Gov’t outlays percent of GDP

Source: Prosperitas (2007) Vol VII, Issue III. Center for Freedom and Prosperity Foundation

Source: Prosperitas (2007) Vol VII, Issue III. Center for Freedom and Prosperity Foundation

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 remove output gaps where they exist. The government can redistribute purchasing power from one group to another to bring about greater equity (Wahba & Smith, 1995). FINDINGS Empirical Evidence The empirical evidence from studies done in various countries on the impact of government expenditure on economic growth also shows contrasting results. In a number of studies, Aschauer (1989, 2000), Ram (1986, 1996) and Knoop (1999), the results showed a positive relationship between government expenditure and economic growth. However, in studies conducted by Landau, (1983, 1986); Sunders, (1985), Grier and Tullock, (1989), and Barro, (1990, 1991), the results were negative. These studies mainly examined the impact of total government expenditure on economic growth in the long run. In general, most of these studies use different econometric models and specifications in arriving at these conclusions. Another feature of the literature is the presence of studies which incorporate the relationship between the composition of government expenditure and economic growth. Some studies which focus on the link between various components of government expenditure and growth include, Aschauer, (1989); Odedokun, (1997); and Easterly and Robelo (1993). Aschauer (1989) found that ‘core infrastructure’ consisting of streets, mass transit , airports, highways and other public capital positively impact private-sector productivity in the United States between 1949 and 1985. In a similar vein, Easterly and Robelo (1993) found that public investment in transport and communications positively impact economic growth in developing countries. Odedokun (1997) focused on 48 developing countries over the period 1970-1988 and found that infrastructural public investment promotes

The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

Growth is often restricted because expansion of government activities can lead to increases in rent-seeking ventures by individuals who aim to gain income from government transfers rather than from engaging in productive activities (Folster & Henrekson, 1997). Rent-seeking is an activity which provides gains to those receiving the transfers but losses to the economy and to the growth process (Sjoberg, 2003). Hence, the conclusion is that growth in government beyond providing the basic tools required for the functioning of the market economy and the provision of some public goods, leads to economic decline and eventually negative economic growth (Gwartney, Lawson & Holcombe, 1998). Another school of thought comes from those of the Keynesian persuasion who postulate that the effect of government expenditure on economic growth is mainly positive and that government spending is a key policy instrument to stimulate growth and development (Singh & Sahni, 1984; Ram, 1986). The positive effect is identified on the grounds that increasing government expenditure on investment activities directly and indirectly increases the efficiency of private sector allocation of resources. In addition, government spending on production, once done with a certain level of efficiency in the public sector, can enhance aggregate output (Lindauer & Velenchik, 1992). Therefore, government expenditure, both directly and indirectly, promotes economic growth. Governments can therefore intervene in a number of ways into economies: Governments can become producers of goods and services. They can use taxes and subsidies to orchestrate private sector production. Through regulation, they can control the behaviour of the private sector. Government can also use fiscal policy to influence the level of national income and

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The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

economic growth. Of note is the finding of Greene and Villanueva (1991) senior economists with the IMF, which revealed that public investment in developing countries had a crowding in effect on private capital. Chakraborty (2002) explained that the complementary relationship between public capital and private investment stems from the fact that public expenditure impacts on aggregate demand which in turn increases the demand for private investment. In addition, there is the positive impact of publicly provided infrastructure on investment returns of firms. As previously stated, some studies reveal that government expenditure on physical infrastructure can affect the output of firms and therefore act as an inducement to firms to invest. Aschauer (1989) found that both the productivity of private investment and production are increased by government infrastructural investment. Albala-Betrand and Mamatzakis (2001) also showed that for Chile, public expenditure on infrastructure had positive and significant effect on output between 1960 and 1995 because of a positive crowding-in effect on private capital over the period. Empirical data also show that studies conducted in developing countries with respect to the impact of the various components of government expenditure on growth produce a range of contrasting results. Devarajan et al. (1996) arrived at a negative and significant relationship between capital expenditure and economic growth as measured by per capita real GDP growth but a positive and statistically significant relationship between the current component of government expenditure and growth. This study was conducted for the period 1970 -1990 for 43 developing countries. It decomposed government expenditure to determine which component was productive or unproductive, by monitoring the impact of changes in each on long term economic 62

growth. This result, they explain, occurs because public capital expenditure is often misallocated in developing countries and results in capital expenditure being unproductive at the margin. Gregoriou and Ghosh (2006), also arrived at similar results to Devarajan et al. for 15 developing countries over the period 1972 to 1999. The findings of both Devarajan et al. and Gregoriou and Ghosh are interesting as both differ from the findings of, Easterly and Robelo (1993), and Gupta et al. (2005). The study conducted by Gupta et al. (2005) in 39 low income countries between 1990 and 2000, found capital expenditure to be growth-enhancing and current expenditure to adversely affect per capita real GDP. It must be noted that studies which show that government’s current expenditure play a major role in promoting growth in developing countries can lead to recommendations that go against the popular view about the composition of government expenditure, and the much touted policy prescription of reducing current expenditure and expanding public capital expenditure to achieve long run growth. Relatively recent studies undertaken by Fan and Rao (2003) for 43 countries and Fan and Saukar (2006) for 44 developing countries across Africa, Asia and Latin America also produced mixed results. The study by Fan and Saurkar used government expenditure by types for the period 19802002. The major findings of the research were that in Africa, public expenditure in the agricultural and education sectors significantly improved economic growth. In Asia, spending on agriculture, education and defense were observed to impact positively on economic growth. Government expenditure in Latin America on agriculture, infrastructure and social security had positive growth-enhancing impact. What is certain is that there is growing


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Empirical Evidence: English Speaking Caribbean In the English speaking Caribbean, few studies have been done on the relationship between government expenditure and economic growth. However, it is important to analyse the impact of government expenditure on growth in the Caribbean because of the major involvement of these governments in the economic life of each economy. Preliminary research conducted in the Organization of Eastern Caribbean States (OECS), by Douglas & Williams (1997) on the short run to medium term impact of government expenditure on economic growth, showed results which are broadly consistent

with the traditional view. This follows that while capital expenditure and total expenditure increase growth, government recurrent expenditure reduces growth. The study showed that expenditure on education, roads, law and order are growth enhancing but social security expenditure, such as welfare programs and pension payment, are growth retarding. Note that the impact of social security on growth differs between Latin America as measured by Fan and Saurkar (2006) and the English Speaking Caribbean. Another study, done by Belgrave and Craigwell (1995) in Barbados, showed how the composition of public expenditure affects growth. Similar to Douglas and Williams in the OECS, these researchers found that expanding capital expenditure positively impacted growth. The positive relationship was also found for health, housing, agriculture and road expenditure. However, as with many other studies, a negative relationship was derived between current expenditure and growth.

The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

evidence to show that spending on specific components of expenditure is productive. While the IMF (2005) noted that there was no clearly observed relationship between public investment and growth in a number of developing countries and that the impact of public infrastructural spending on growth was even less certain, the World Bank (2007) identified studies which show that this situation has changed since 2000 and recent studies have found mainly positive growth impacts with respect to transport, communication, education and health care spending. Furthermore, Ram (1986) employed both cross section estimates and timeseries estimates in developing countries and concluded that not only does government size positively impact on economic performance and growth but also made an interesting observation that for most of the 115 countries included in the study, there were indications of positive externality effect of government size on the rest of the economy. Moreover, there appears to be a stronger positive impact of government size on the growth performance of the economies in developing countries than in developed countries.

DISCUSSION AND ANALYSIS Empirical Evidence: The Role of Definition and Methodology There are few preliminary observations which are worth further investigation. First, what seems to emerge from the literature is that the negative relationship between government spending and economic growth appears to occur more often in studies involving developed countries (Landau, 1983; Grier & Tullock, 1989, and Saunders, 1985) than in those related to developing countries. Further observation reveals that studies which show negative results usually utilize the neo-classical framework. A third observation is that estimations of these models which exhibit negative relationships between the variables are often based on relationships that seem to be more definitional than behavioural. 63


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The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

Note also that some studies which report a negative impact of government expenditure on growth specify both variables in such a way that could only result in a predictable outcome. For example, Landau (1986) found that an increase in government consumption significantly reduces GDP. However, that study defines government consumption as a ratio of GDP (G/Y) and real output as an average rate of growth in real per capita GDP (Y/N). By using the same variable as part of the definition of both the dependent and independent variables, the results obtained may simply be a reflection of this definitional link. Yasin (2003) observed that the empirical results depend on the specification of government expenditure. He notes that when government expenditure is defined in the estimating equation as a percent of GDP, its impact on economic growth is mainly negative, but when it is specified as an annual percentage change, the outcome is usually positive. A further review of the literature reveals that while some researchers undertook case studies of specific countries utilizing timeseries data sets, most used cross-country analysis and panel datasets. Among those studies which used panel data are Grossman, (1990); Devarajan et al., (1996); Gupta et al., (2005); Bleaney et al., (2001); and Gregoriou and Ghosh, (2006). In spite of the similarity in the use of cross section analysis, these models still produced mixed results on the impact of government expenditure on growth. King and Levine (1993) noted that a shortcoming of cross country data is the failure to account for characteristics unique to each country. Studies which have used time series analysis include Albatel, (2000); Khan & Reinhart, (1990) and Ram (1986). These results were also inconclusive but these were not unexpected because of the differences in the political and economic characteristics of the various countries. 64

What must be of great concern to developing countries are the reasons for the negative growth impacts of government expenditure and therefore, what must be done to change or improve the performance of government expenditure in developing countries. The empirical studies provide the evidence that different categories and components of government expenditure have different impacts on economic growth and development. Therefore, it is essential to discover the specific components which contribute to growth to avoid generalized statements such as, “Government spending enhances growth.� Identification of these specific components will facilitate better interventions and policy prescriptions. Informed interventions can improve efficiency of government spending by rearranging how government resources are allocated to the different sectors. For example, in response to their finding that government expenditure on agriculture and specifically production-enhancing investment such as research and development is growth enhancing for Africa, Asia and Latin America, Fan and Saurkar (2006), recommended that all regions should increase spending in this type of activity. Furthermore, they suggested that spending in unproductive sectors such as defense and excessive subsidies should be reduced. Such reallocation would reduce poverty and generate employment because the poor in developing countries rely on agriculture. In addition, Wahba and Smith (1995), reiterated the need to determine which components are growth promoting and which are not, but also underscores the need for governments to carefully plan expenditures while considering how the expenditure will be financed. According to Nuta (2008), all of the methods used to finance government expenditure are costly. Taxes often act as a disincentive to labour and government


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 weaker governance. The World Bank (2003) identified poor budget management as a source of less than positive growth outcomes in developing countries. Government spending aimed at achieving growth is also affected by corruption and the rent seeking behaviours of different interest groups (Shonchoy, 2010). Corruption is reported as being a major barrier to growth in developing countries. Sasmal (2011) noted that achieving maximum growth may not be the objective of most governments. Therefore, they may seek to maximise political gain (re-election) by using government revenues to finance short-term populist measures and resort to distributive policies at the expense of long term growth. Such actions reduce or limit the effectiveness of public spending. Furthermore, while the level of government spending on capital stock is important, it is the flow of services from the capital stock that contributes to growth (Herrera, 2007). Herrera also noted that the impact of public expenditure on growth could be further strengthened if more emphasis is placed on economic efficiency. Busatto (2011) reminded us that not only is the quantity of public expenditure important for growth, but also the quality (composition of spending and effectiveness of public policies) of the expenditure. Acosta-Ormaechea and Morozumi (2013) noted that given the financial state of most economies, increasing government expenditure may not be possible, but what may be required is a reallocation of spending.

The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

borrowing ultimately crowds out private investment. Galbraith as cited in Nuta (2008), identified three groups into which government spending can be placed. First there are those activities with no visible present or future purpose such as overstaffing and expenditure undertaken in response to political or economic interests. Second, there are those activities which protect or enhance the current economic or other social conditions, such as the day to day expenses of the state. Finally, activities exist which bring or allow for an increase in future income, production and general well-being. Certainly for the first and second groups of activities, borrowing is not recommended, but these could be covered by taxation. However, for the third category of expenditure, borrowing can be justified. The growth impact is compromised when the cost of government expenditure exceeds the benefits derived from the expenditure (Herrera, 2007). Rajkumar and Swaroop (2007, p.97), in addition to identifying “crowding out” as a possible reason for the weak or negative impact of government spending on growth, also identified “poor targeting and/or institutional inefficiencies such as leakage in public spending and weak institutional capacity”, as other contributors. They also showed the importance of good governance (reducing the level of corruption and bureaucracy) in achieving effective government capital spending in developing countries. Their research showed that good governance will cause allocations of government spending on primary education, to result in higher primary enrollment levels and education attainment (Rajkumar & Swaroop, 2007). These researchers found that a 1% increase in public spending in GDP on education lowers primary failure rate by 0.70% in countries with good governance. No change was observed with

Case Study: Malawi The following case study seeks to illustrate how government spending can be used to improve economic performance in developing countries. In addition to supporting the findings of some researchers, that government spending in Africa on agriculture impacts positively on economic 65


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The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

performance, it also shows that proper targeting and monitoring are essential to ensure the right outcomes. Moreover, it shows that in developing countries, governments are required to provide more than the basic functions as suggested by some theorists. This case, involved the government spending on maize production in Malawi. Though this programme faced strong opposition from economists and multilateral donor agencies, on the grounds that subsidies would increase budget deficits, create dependencies, lead to abuse by those with political and economic power and affect the workings of the free market, the Malawian government persisted1. However, such spending contributed to an approximate tripling of Malawi’s maize production between 2005 and 2007/20082. Maize production rose from 1.2 million tonnes in 2005 to 3.4 million tonnes in the 2007/2008 agricultural season (AfricaFocus Bulletin, 2009). In addition, not only did its impact result in falling food imports and rising export sales, the programme also realized revenues three or four times in excess of the cost of subsidies. In fact, Fleshman (2008) notes that the subsidy programme has more than covered its cost to the government of Malawi. In 2005, the country spent approximately US$120 million importing food aid (AfricaFocus Bulletin, 2009), but by 2007/ 2008 the government was able to feed itself and export about 300,000 tonnes of maize to Zimbabwe, generating more than US$120

million. Malawi also sold about 400,000 tonnes to the World Food Programme (WFP) and donated 10,000 tonnes of maize to the WFP for people infected by HIV/AIDS (Fleshman, 2008). This once aid-dependent nation has become a net exporter and a donor of maize. Denning et al. (2009), noted that when the cost of the programme per person is compared with the cost of importing food and donor aid, the programme is fiscally manageable and responsible3. The continued success of such a programme requires careful monitoring to ensure that those who are politically and economically powerful do not benefit at the expense of the intended beneficiaries. Therefore, the government saw it fit to intervene as soon as any irregularities were sighted. This resulted in the dismissal of a senior government official who sold coupons to wealthy farmers, and the strengthening of eligibility requirements and oversight procedures4 (Fleshman, 2008). There has been opposition to the use of agricultural subsidies in Malawi and other African nations which followed this example. Opposition came from donor organizations located in rich countries where commercial farmers are the beneficiaries of expensive subsidies (AfricaFocus Bulletin, 2009). Input subsidies have been challenged on the following grounds: high costs, the absence of clear time-bound exit strategies, crowding out of commercial interests, targeting problems, and the possible scope for corruption.

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A senior Malawian Official, in response to objections from a representative of a donor country, stated, “We are going to do it. It is our programme and we’re going to do it.” Development Industry (2009) 2 Doward et al. (2008), note that all the credit for increased output cannot be attributed to the subsidy programme but good rains and good climatic conditions also contributed. 3 The subsidy programme cost less than 7% of the national budget in 2005-2006 (US$5/person /year and about 5% in 2006-2007. 2004-2005 food import cost about US$8 per person and donor aid in 2005 was US$44 per person (Denning et al., 2009; Dorward et al., 2008). 4 The subsidy programme began in 2005 and included both maize and tobacco producers. The authorities distributed coupons for maize seeds and maize and tobacco fertilizers in proportion to maize and tobacco acreage in each Malawian district. Coupons were distributed by the Ministry of Agriculture of Malawi to district traditional authorities who likewise distributed them to Village Development Committees. These committees had to identify farmers who could not afford 1 or 2 bags of fertilizer at the current prices and provide them with coupons. Though identifying the right beneficiaries has always been a problem, the system has improved. In 2006/07 the procurement and distribution of fertilizer were undertaken by both private and public retailers who were awarded contracts based on tenders submitted. Financial management of the programme is done by the Logistic Unit. This Unit verifies coupon authenticity and also makes payments to input suppliers when the need arises (SOAS.MSU and ODI 2008).


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Conclusion This paper explored the literature on the impact of government expenditure on economic growth. What has been revealed is 5

that both from the theoretical and empirical perspectives the impact of government expenditure on growth is largely inconclusive although recent studies have been able to identify components of spending which are yielding positive growth in a number of developing countries. This has been observed both in developed and developing countries. Based on empirical results on the relationship between growth and government expenditure a number of reasons have been proffered for these differences. These include the variation in methodology and differences in the definition and specification of variables used by researchers. The literature also identify that differences in size, composition, quality and management of government expenditure also contribute to the differences in the impact on growth in different countries. More so in developing countries the negative effect of government expenditure on growth is often attributed to crowding out, bureaucracy, poor targeting and governance issues. In spite of the differences in impact observed, what is clear is that government expenditure has the potential to stimulate every economy and is especially essential in developing countries. However, developing countries are not homogenous and government expenditure decisions are influenced by several factors that are country specific. Therefore, if government expenditure policies are not well designed to fit the specific economy then the desired effect on growth may not be realised. This holds true for the English speaking Caribbean for which much research in this area has not been undertaken. The next step forward would be to use the knowledge gained from this study to guide the collection of data and the methodological approach to be used in quantifying the impact of government spending in selected countries.

As a result of the removal of government support through subsidies along with other environmental factors, Africa moved from a net exporter of food in the 1970s to being dependent on food imports and emergency food aid in this decade (AfricaFocus Bulletin, 2009) 6 Subsidies can also be used to provide financing and training for importers and distributors, train and educate farmers and to supply small demonstration packs (AfricaFocus Bulletin, 2009)

The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

The World Bank and other donor countries have argued against the state-led involvement in economic activities including the granting of input subsidies since the 1980s. They stipulated expenditure control as part of their stabilization packages offered to developing countries. Governments in Africa and other developing countries adhered to their recommendations and reduced expenditure in their respective countries. However, when they were faced with declining agricultural output and growing food insecurity5 governments in a number of African countries vowed to reinstate the granting of subsidies to reverse agricultural decline and achieve food security (Denning et al., 2009). The success of such a bold initiative in Malawi in particular has now attracted the support of some international institutions which once opposed such a policy. The programme was praised by the World Bank which also concluded that governments can implement ‘market-smart’ subsidies that “build the basis for a sustainable private sector-led input distribution system that can function on its own (AfricaFocus Bulletin, 2009, n.p.).” In addition the Bank noted that subsidies can also be used to lower cost along the whole of the supply chain6. Above all the Bank stresses that the use of subsidies must be undertaken under rigorous conditions and be better targeted than in the past (AfricaFocus Bulletin, 2009 ). The Malawi experience is proof that government spending can successfully be used to subsidize agriculture, thereby increasing output of the very commodities whose prices have been increasing.

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Bibliography The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

Acosta-Ormaechea , S. & Morozumi, A. (2013). Can a Government Enhance Long-Run Growth by Changing the Composition of Public Expenditure? International Monetary Fund Working Paper WP/13/162 AfricaFocus Bulletin. (2009, January). Africa: Subsidies that Work. http://www.africafocus.org/ country/malawi.php Albala-Betrand, J. M. & Mamatzakis, M. (2001). Is Public Infrastructure Productive? Evidence from Chile. Applied Economic Letters, 8, pp. 195-198. Albatel, A.H. (2000). The Relationship between Government Expenditure and Economic Growth in Saudi Arabia. Journal of King Saud University, Administrative Sciences, 12(2), 173191. Aschuer, D. (1989). Is Government Spending Productive? Journal of Monetary Economics, 23, 177-200. Aschuer, D. (2000). Public Capital and Economic Growth: Issues of Quantity, Finance and Efficiency. Economic Development and Cultural Change, 48(2), 391- 406. Bagdigen, M. & Cetinas, H. (2003). Casuality between Public Expenditure and Economic Growth: The Turkish Case. Journal of Economic and Social Research, 6(1), 53-72. Atkinson, A. B. & Stiglitz, J. E. (1980). Lectures in Public Sector Economics. New York: McGraw-Hill. Barro, R. (1990). Government Spending in a Simple Model of Endogenous Growth. Journal of Political Economy, Vol. 98, S103-S125. Barro, R. (1991) Economic Growth in a Cross Section of Countries. Quarterly Journal of Economics, 106(2), 407-443. Belgrave, A. & Craigwell, R. (1995). The Impact of Government Expenditure on Economic Growth in a Small Caribbean Economy: A Disaggregated Approach. Central Bank of Barbados. Bleaney, M., Gemmell, N. & Kneller, R. (2001). Testing the Endogenous Growth Model: Public Expenditure, Taxation and Growth over the Long Run. Canadian Journal of Economics, Vol. 34,(1), 36-57. Busatto, M. (2011). The Quality of Public Expenditure and its Influence on Economic Growth: Evidence from the State of Rio Grande do Sul (RS). Washington DC: The George Washington University. 68


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Chakraborty, S. (2002). Endogenous Lifetime and Economic Growth. University of Oregon Economics Department Working Papers, 2002-03. Cheng, B. S. & Wei Lai, T. (1997). Government Expenditure and Economic Growth in South Korea: A VAR approach. Journal of Economic Development, 22(1), 11-24.

The Impact of Government Expenditure on Economic Growth in Developing ountries: A Literature Review

Denning, G., Kabambo, P., Sanchez, P., Malik A., Flor, R., et al. (2009). Input Subsidy to Improve Smallholder Maize Productivity in Malawi: Toward an African Green Revolution. PLoS Biol 7(1):e10000233. Devarajan, S., Swaroop V. & Zou H.. (1996). The Composition of Public Expenditure and Economic Growth. Journal of Monetary Economics, 37(2), 313-344. Douglas, S. & Williams, O. (1997). The Impact of Government Expenditure on Economic Growth in the OECS: A Disaggregated Approach. Doward, A., Chirwa, E., Boughton, D., Crawford, E., Jayne, T, et al. (2008). Towards ‘smart’ Subsidies in Agriculture? Lessons from Recent Experience in Malawi. London: Overseas Development Institute. Easterly, W. & Rebelo, S. (1993). Fiscal Policy and Economic Growth: An Empirical Investigation. Journal of Monetary Economics, 32(3), 417-458. Elliot, John E., ed. (1981). Marx and Engels on Economics, Politics, and Society: Essential Readings with Editorial Commentary. Santa Monica, Calif.: Goodyear. Evans, P. & Karras, G. (1994). Is Government Capital Productive? Evidence from a Panel of Seven Countries. Journal of Macroeconomics, 16(2), 271-279. Fan, S. & Rao, N. (2003). Public Spending in Developing Countries: Trends, Determination and Impact. International Food Policy Research Institute. EPTD Discussion Paper No. 99. Fan, S. & Saurkar, A. (2006). Public Spending in Developing Countries: Trends, Determination and Impact. Washington D.C.: International Food Policy Research Institute. Fleshman, M. (2008, October). A Harvest of Hope for African farmers: Malawi Subsidies Stimulate a Bumper Crop. Africa Renewal, Vol.22 (3). Folster, S. & Henrekson, M. (1997). Growth of the Public Sector: A Critique of the Critics. Research Institute of Industrial Economics Working Papers 492. Gallaway, L. E. & Vedder, R. K. (1998). Government Size and Economic Growth. US Congress Joint Economic Committee, 1-15. Gordon, S. (1976). The New Contractarians. Journal of Political Economy, 84(3), 573-590. Great Britain, Ministry of Overseas Development. (1977). A Guide to the Economic Appraisal of Projects in Developing Countries. London: Her Majesty’s Stationery Office. 68


Management Institute for National Development Green, J. & Villanueva, D. (1991). Private Investment in Developing Countries: An Empirical Analysis. Staff Paper – International Monetary Fund, 38(1), 33-58.

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Gregariou, A. & Ghosh, S. (2006). On the Composition of Government Spending, Optimal Fiscal Policy and Endogeneous Growth: Theory and Evidence. Brunei Economics and Finance Working Paper 06-19. Grier, K. B. & Tullock, G. (1989). An Empirical Analysis of Cross National Economic Growth, 1951-80. Journal of Monetary Economics, 24, 259-276. Grossman, P. J. (1990). Government and Growth: Cross-Sectional Evidence. Public Choice, 1990, 63, 217-227. Gupta, S.,Clement, B., Baldacci, E. & Mulas-Granados, C. (2005). Fiscal Policy, Expenditure Composition and Growth in Low-Income Countries. Journal of International Money and Finance, 68, 53-78. Gwartney, J., Lawson, R. & Holcombe, R. (1998). The Size and Function of Government and Economic Growth. Joint Economic Committee Study: United States Congress. Herrera, S. (2007, October). Public Expenditure and Growth. Policy Research Working Paper 4372, World Bank. Hulton, C. (1996). Infrastructure Capital and Economic Growth: How Well you Use it may be more Important than How Much you Have. NBER Working Paper 5847. International Monetary Fund (IMF). (2005). Public Investment and Fiscal Policy: Lessons from the Pilot Country Studies. Islam, A. (1992). Foreign Aid and Economic Growth: An Econometric Study of Bangladesh. Applied Economics, 24(5), 541-544. Khan, M. S. & Reinhart, C. M. (1990). Private Investment and Economic Growth in Developing Countries. World Development, 18(1), 19-27. King, R. & Levine, R. (1993). The Quarterly Journal of Economics, 108(3), 717-737. Knoop, T., (1999). Growth, Welfare and the Size of Government. Economic Inquiry, 37(1), 103-119. Landau, D. (1983). Government Expenditure and Economic Growth: A Cross Country Study. Southern Economic Journal, 49 (3), 783-792. Landau, D., (1986). Government Expenditure and Economic Growth in Less Developed Countries: An Emprical Study for 1960-80. Economic Development and Cultural Change, 35, 35-75.

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Lindauer, D. L. & Velenchik, A. D. (1992). Government Spending in Developing Countries: Trends, Causes and Consequences. The World Bank Research Observer, 7(1), 59-78. Mallik, G & Chowdhury, A. (2002). Inflation, Government Expenditure and Real Income in the Long-Run. Journal of Economic Studies, 29 (3), 240-250.

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Marx, K. (1867) Capital: A Critique of Political Economy Vol1. Moscow: Progress Publishers McConnell, C. R. & Brue, S. L. (1996). Economics: Principles, Problems and Policies. (13th ed). USA: Mcgraw-Hill. Inc. Nuta, A. C. (2008). The Incidence of Public Spending in Economic Growth. EuroEconomica, 20(1), 65-68. Odedokun, M. O. (1997). Relative Effects of Public versus Private Investment Spending on Economic Efficiency and Growth in Developing Countries. Applied Economics, 29, 1325-1336. Prosperitas (2007) Vol. VII, Issue III. Center for Freedom and Prosperity Foundation. Accessed online from http://archive.freedomandprosperity.org/Papers/rahncurve/rahncurve. shtml. May 16, 2013. Pritchett, L. (1996). Mind your P’s and Q’s: The Cost of Public Investment is not the value of Public Capital. World Bank Policy Research Working Paper 1660. Rajkumar, A. S. & Swaroop, V. (2007). Public Spending and Outcomes: Does Governance Matter? Journal of Development Economics, 86 (2008), 96–11. Ram, R. (1986). Government Size and Economic Growth: A New Framework and Some Evidence from Cross-Section and Time-Series Data. American Economic Review, 76, 191-203. Ram, R. (1996). Productivity of Public and Private Investment in Developing Countries: A Broad International Perspective. World Development, 24(8), 1373-1378. Republic of Trinidad and Tobago. (1978). Report of the Committee to Review Government Expenditure. Trinidad and Tobago: Government Printery, Trinidad. Sasmal, J. (2011). Distributive Politics, Nature of Government Spending and Economic Growth in a Low Income Democracy. Journal of Economics and Finance, 16(30), 31-49. Saunders, P. (1985). Public Expenditure and Economic Performance in OECD Countries. Journal of Public Policy, 5, 1-21. Shonchoy, A. S. (2010). What is Happening with the Government Expenditure of Developing Countries: A Panel Data Study. Chiba Japan: Institute of Developing Economies, IDEJETRO.

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Singh, B. & Sahni, B. S. (1984). The Growth between Public Expenditure and National Income. The Review of Economics and Statistics, 66, 630-644. Sjoberg, P. (2003). Government Expenditures Effect on Economic Growth: The Case of Sweden 1960-2001. (Bachelor’s Thesis) SHU: Lulea University of Technology. Solomon, M. & de Wet, W. A. (2004). The Effect of a Budget Deficit on Inflation: The Case of Tanzania. SAJEMS NS, 7(1). Solow, R. (1956). A Contribution to the Theory of Economic Growth. Quarterly Journal of Economics, 70, 65-94. Swan, T. (1956). Economic Growth and Capital Accumulation. Economic Record, 32, 334-361. Tanzi, V. (1997). The Changing Role of the State in the Economy: A Historical Perspective. International Monetary Fund Working Paper, WP/97/114.Wagner, A. (1890). Finanzwissenschaft. (3rd edition). Leipzig. (Partly reprinted in Classics in the Theory of Public Finance. R. A. Musgrave and A.T. Peacock (Eds.), London: MacMillan. (1958). Wahba, J. & Smith, P. (1995). The Role of Public Finance in Economic Development: An Empirical Investigation. Economic Research Forum, Working Paper 9508. World Bank. (2003). Making Services Work for Poor People. World Development Report 2004. Washington, D.C.: World Bank. World Bank. (2007). Strengthening World Bank Group Engagement on Governance and Anticorruption. Washington, D.C.: World Bank. Yasin, M. (2003). Public Spending and Economic Growth: Empirical Investigation of Sub-Saharan Africa. Southwestern Economic Review, 30(1), 59-68.

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Health Financing in the Caribbean: A Possible Role for National Health Accounts?

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HEALTH FINANCING IN THE CARIBBEAN: A POSSIBLE ROLE FOR NATIONAL HEALTH ACCOUNTS? Ewan Scott, Althea La Foucade and Karl Theodore

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Health Financing in The Caribbean: A Possible Role for National Health Accounts?

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

ABSTRACT The assumption is made that a fundamental objective of the health system is the achievement of the best possible fit between health needs and access to health-enhancing goods and services1. The paper then positions the development of health accounting systems within the context of the primary objectives of the health sector as a whole and the health financing system(s) in particular. The implication here is that the adoption of a health accounting system should be part and parcel of the health reform process. The authors argue that if nothing else, the people of the Caribbean have learnt from experience [sometimes bitter] that any proposed changes in the health system have to be informed by an understanding and appreciation of the developmental role of the system. One implication of this is that, to the extent that the National Health Accounts (NHA) can be seen as a resource monitoring instrument and/or framework, it will certainly have a role in the implementation of any changes emanating from the reform process. Taking off from this, it is strongly suggested that appropriate criteria for assessing the functioning of the post-reform health system will necessarily be linked to information provided by the NHA as it seeks to meaningfully complement the financing objectives, in particular, the efficiency and equity objectives. Keywords: National Health Accounts, Caribbean, Health Financing, Health Reform, Efficiency, Equity

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INTRODUCTION It is difficult to identify a single country in the Caribbean region that has not signaled some level of concern with the functioning of its health sector. What is interesting is that, even before health sector reform became the recognized practice internationally, some countries in the region had already carried out studies aimed at getting the health system to function better. Moreover, although many countries have gone along the health sector reform path, it has not always been obvious that the major stakeholders—policy makers, providers and consumers—have a clear understanding of the extent to which the new policies and programmes being adopted will produce their intended results. This situation is further compounded by the deficiencies in the health information systems in the region. One such deficiency relates to the lack of definitional consistency —both within and across countries—and the underlying weakness of the economic logic that informs the compilation of information on the flow of resources into and within the health system2. One of the main propositions of this paper is that the System of National Health Accounts (NHA) can be seen as one solution for addressing the two limitations identified above. More than a decade ago, attempts had been made by the Pan American Health Organization (PAHO) to introduce NHA to the Eastern Caribbean. More recently, these attempts were restarted by the United States Agency for International Development (USAID) with support from the, Centre for Health Economics (HEU) at the University of the

Defined as the full range of inputs into the production of health. Such inputs may take the form of goods or services and may range from benefits derived as a recipient of health promotion, to the services of the medical specialists performing complex major surgery. 2 As the examples of Malawi and India have shown, countries outside of the region are already building experience with NHA as an instrument of health system strengthening. See Zere et al (2010) and Maeda et al. (2012).


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LITERATURE REVIEW Objectives of the Health System and of Health Financing in the Region It is not uncommon to have a number of criteria being identified for evaluating health financing systems. Hsiao (1995, p. 23) identifies six such criteria “…universal coverage, equal access, control of expenditures, efficient use of resources, equity in financing, and consumer choice…” while Schieber and Maeda (1997) and Barnum and Kutzin (1993) point to four: efficiency, equity, administrative simplicity and revenue

generation. However, it is often possible to regroup these into two broad perspectives on the role of health financing in the national economy. One perspective emphasizes criteria and practices that pertain to the welfare of the population, while the other emphasizes the monitoring of the resource flows into and within the health system. In the first case, the emphasis is on equity—ensuring that access to, and benefits from, the health production processes are fairly distributed to individuals of all socio-economic groupings (SEGs). Such an approach stresses the need for financing mechanisms that embody incentives for smoothing out unfair utilization of services, such that there is an inherent bias toward equitable outcomes. On the other hand, concerns over the operations of the health system would emphasize the creation of incentives and systems that strive to ensure the achievement of technical/operational efficiency in the health sector. Ideally, these two perspectives—efficiency and equity— should be convergent (Birdsall & James, 1993). However, what seems to have emerged in practice is a pair of parallel perspectives driven mainly by the conventional dichotomy between equity and efficiency considerations (Bourguignon, 1991; Barr, 1993; Birdsall & James, 1993). There is little doubt that there is validity in both perspectives. However, researchers and policy makers have generally taken the position that, within the context of the Caribbean, where living conditions are characterized by the persistence of poverty and mal-distribution of economic opportunities, the equity dimension, being grounded as it is in principles of solidarity, has to be given preeminence if the health system is to so influence the socioeconomic system that it results in a pattern of outcomes that are significantly different from what one would otherwise expect (Theodore, 1986). This

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

West Indies. It is therefore gratifying to note that within recent times, two countries of the region—Dominica and St. Kitts and Nevis—have taken steps to develop and establish NHA to monitor the use and flow of expenditure in their health systems. Although it is certainly useful to place the design and implementation of NHA within the context of the region’s health system in general and its health financing systems in particular, it would seem to make sense to see the NHA as the missing link in the health sector reform (HSR) process. To emphasize this point, the paper will begin by identifying the objectives of the health system in the Caribbean and with an examination of the theoretical construct of health financing—one of the main targets in the HSR process. This is followed by a Discussion and Analysis which encompasses a review of the experience of the region as it relates to health financing and highlights the role that NHA can play in determining whether the health systems have delivered on the primary objective of equity. The final section—Conclusions and Recommendations—explores the potential for NHA to strengthen the implementation of the reform strategy.

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Health Financing in the Caribbean: A Possible Role for National Health Accounts?

does not mean that efficiency considerations should be relegated to a low order of priority, but simply that these enter the picture in a different way. Consistent with Arrow (1963), our assumption is that health care is unlike many other goods, in that the utility derived from its consumption is directly linked to the experience of pain or discomfort or to the balance between life and death. It follows that criteria for evaluating the performance of the health sector will have to incorporate the importance placed on the way in which utility is derived from health care. Compounding this special place of health care in the welfare quest of individuals are two additional features. The first is the fact that health care is an option good— individuals/households place value on the ability to retain the good for the event that it should be needed (La Foucade, 2001; Zweifel & Breyer, 1997). The second is the fact that the health care afforded to one individual may impinge on the utility of others. This is partly captured by reference to the externalities inherent in some forms of health care. The position taken in this paper is that the primary objective of the health system—and by extension, the health financing system—needs to be rooted in value principles which reflect the special characteristics of the commodity referred to as ‘health care’. The specific suggestion is that these should be the value principles of solidarity and equity. Solidarity is suggested because of the uncertainty of individual health needs and the external utility impact of health care, and equity, because the nature of the utility attached to health care is closely linked to the relief of pain and the avoidance of death. What this means is that solidarity and equity will serve to define the objectives, and influence the content of health policy. On the other hand, efficiency criteria will serve to define the constrained environment in which 76

national health policy goals are designed. What is clear is if solidarity and equity are to be the pillars of the reformed health financing system, our assessment of the health sector reform process will be expedited if we are able to track all expenditures in the health system, both in the public and private sectors, and to relate these expenditures to actual outcomes. Since this is precisely what a National Health Accounts System will make possible, it is somewhat puzzling that the NHA was never proposed as an integral HSR ingredient in the Caribbean and elsewhere. Scope of the Study: The Theoretical Context of Health Financing The Relationship Between the Economic System and the Health Financing System While we acknowledge that health status is determined by a range of factors that are not always directly dependent on the operations of the health care industry or even the health system for that matter (Kindig, 1997; Donaldson & Gerard, 1993; and Brotherson, 1976), in this paper, we will not undertake a thorough exploration of the boundaries between the health sector and other sectors in the overall system. We begin by assuming that the link between the health system and health status is one aspect of an important relationship between the health sector and the broader economic system, or more precisely, between the health system and the socio-economic welfare of the population. Further, we note that while the health system straddles the social, political and economic dimensions of the society, health financing issues point to considerations which are mainly economic. The relationship is captured by Figure 1. At the heart of the model portrayed is the economic system which sets the wheels in motion for activity in all sectors of the


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 services are negotiated. This mediation is facilitated by two key institutions: (i) the factor market where incomes are determined; and (ii) the final goods market where prices and costs are determined. As shown in Figure 1, income is the means through which individuals negotiate a fit between their health needs and available health services. Income influences the quantity and quality of services consumed as well as the choice of health care provider or institution, while prices and cost act as direct barriers/constraints to accessing health services. Left to themselves, these two economic institutions—the factor market and the final goods market—can therefore lead to unacceptable outcomes, in which individuals and groups with the greatest needs have the most limited access to services. However, since the health system is a sub-component of the economic system, it follows that health care financing can be used to achieve the preferred distribution given the existing configuration of incomes, prices and costs, which would, by themselves, make such

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

economy. On the sources side, the health financing system is assumed to be comprised of three elements: general tax revenues, health insurance, and out of pocket payments. Health systems are characterized by the specific configuration of these elements and in this sense, each country’s health system is a sub-system of its economic system. This follows from the fact that, regardless of the type of financing, the fundamental source of all resources is the national income. The health system therefore provides the platform for bridging the gap between health needs, the production and/or supply of health services3, and the satisfaction of health needs. Within this context, a fundamental objective of the health system is the creation of an environment that brings about the best possible fit between effective provisioning of health services and satisfaction of health needs— as depicted by the two boxes at the extreme right and left of the diagram. The economic system is the mediator or main intermediary, through which these needs and

Figure 1: The Economic System and the Financing of Health Care PRICES AND COSTS

HEALTH NEEDS

ECONOMIC SYSTEM

HEALTH SERVICES

INCOMES

3

In what follows, we use ‘health services’ as an all-encompassing term covering the full range of health-enhancing and health-maintaining goods and services as previously defined.

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Management Institute for National Development outcomes improbable. It further follows, that monitoring the distributional outcomes, given the flows within the health system, would then become a major public policy responsibility.

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

The Role of Health Financing in Achieving Equity At the very least, the concern with the fit between health needs and health services is a concern with horizontal equity. Horizontal equity, as discussed in the literature on social justice and welfare, is the principle that requires equals to be treated equally. When applied to the delivery of and access to health care goods and services, horizontal equity is discussed in reference to equal access for equal need (La Foucade, 2001). Given the possibility of health needs being determined by factors that are independent of the individual’s economic status, an adherence to the principle of horizontal equity would invalidate income as an appropriate means for matching individual needs with services. Horizontal equity is related to another very important concept – the concept of medical poverty. If medical poverty is defined as that state in which individuals with given health needs do not have adequate access to health services, it may be possible for an equity-neutral or equity-violating financing instrument to contribute to increased levels of medical poverty by propagating a continued mismatch between needs and services. The literature has identified outof-pocket expenditure as a major factor in this mismatch. With a NHA system in place, it will be possible to muster the evidence to determine if any given health system is financed largely on an out-of-pocket basis, and whether the consumption of healthgenerating goods and services are likely to be based on the individual’s ability to pay, being simply a reflection of the prevailing distribution of incomes in the society, not a 78

reflection of the distribution of the society’s health needs. Apart from mitigating the impact of the existing distribution of incomes, the health financing system can itself become a tool of income redistribution. Such is the case for example where health financing may be organized using solidarity principles, such as under regimes of public health expenditure or social health insurance. In such situations, there is cross subsidization from individuals with more resources to those less fortunate, and from those with a lower incidence of illness to those who require care more frequently, all else being equal. In a context such as that in many Caribbean territories, where the distribution of income is known to be highly inequitable, the health financing system has the potential to be an important mechanism of redistribution and can create an appropriate fit between health needs and access. It will be important to be able to monitor whether the financing system is making its potential contribution to human development through its equity dimension. The Role of Health Financing in Achieving Efficiency As indicated above, although the health system aims to achieve an appropriate balance between health needs and health services, the pursuit of efficiency will be necessary to ensure that this is done without undue waste of the society’s scarce resources. This means that it will be necessary to incorporate efficiency criteria in health policy design and implementation. Given its capacity to influence behaviours on both the demand and supply side, the financing mechanism can itself be viewed as one of the main cost drivers in the health system. This is most clearly seen when the provider payment mechanism is included as part of the health financing system and we observe the principal-agent relationship at work.


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

The Potential of NHA for Health System Strengthening We now turn our attention to the extent to which the use of the NHA framework may be of use in the region. National Health

Accounts provides, inter alia, an accounting framework for estimating resource flows in a health care system, showing where resources come from and how they are used. Ideally, it accounts for all expenditures by looking not only at public sector financing but also at the private sector, including households, firms and non-governmental organizations. NHAs also capture domestic as well as foreign components in total health spending. According to Berman (1997), the NHA methodology is very useful in developing countries which tend to have pluralistic health care systems and where financing comes from multiple sources, and where providers receive payment from more than one source. The fertile data that are generated from a national health accounting system are of far more use than simply keeping track of where funding for health is coming from. Rather, NHAs provide the essential information needed to monitor specific aspects of the health system. They can be used, for example, to examine the relative importance of national spending on prevention or health promotion versus treatment. NHAs can also be used to assess the contribution of various financing agents to overall health spending or to expenditure on specific diseases. Further, these information systems can be used to monitor the ratio of capital to recurrent expenditure or of the relative use of any input employed in the production of health services. Since NHAs provide a global view of a country’s health financing—they entail a comprehensive framework for bringing together data on inputs and outputs—they can successfully be used as a tool of stewardship in the health system (World Health Organization, 2000). The information base resulting from a consistent use of NHA provides an understanding of any imbalances that may be inherent in the health system. In designing the NHA system,

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

For example, financing systems that hinge upon fee-for-service payments to providers carry inherent incentives for the agent [the provider] to employ treatment protocols aimed at driving costs upward. If, on the other hand, the financing system embodies a capitation system with controls on the number and the duration of patient contacts, there will be a tendency for the production process to generate health services at lower unit costs (Hsiao, 1995). As the countries in the Caribbean go about the business of reforming their financing systems with a view to achieving higher levels of health, an important aspect of the reforms has to be the strengthening of the capacity to monitor the allocation and use of resources. Here again we highlight the role that can be played by NHA in consistently providing the information required to determine whether a particular policy is yielding expected results. It is acknowledged that medical technology is one of the main drivers of the cost of health care today (Birdsall & James, 1993). A reformed health financing system will therefore incorporate the gatekeeping necessary to ensure that only those cases medically requiring a high-cost intervention are in fact given access to this option. By its inclusion of a referral system, the health system is designed by nature to be cost minimizing. One important efficiency requirement of the financing system will be to do nothing that will compromise the operations of the referral system. Keeping track of what services are paid for, and under what circumstances, is the role of the NHA, again pointing to the link between the NHA and a reformed health financing system.

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Health Financing in the Caribbean: A Possible Role for National Health Accounts?

therefore, care should be taken to ensure that the contribution that the health financing system is making to the socioe-conomic system should be monitored. This requirement would certainly guide the kinds of modifications that must be made to the NHA design which other countries or regions may have already adopted. For example, if we use the OECD System of Health Accounts (SHA) as our starting point, the development of a NHA in the Caribbean would require a modification of the statement of purposes of the SHA as contained in the OECD’s manual. What is needed for the Caribbean is a statement of purpose which encourages policy formulation to emphasise the human welfare dimensions of the health system, while keeping proper focus on efficiency considerations. The OECD statement of purpose (2001: 6) states that the aims of the SHA are to: • provide a set of internationally comparable health accounts • provide a framework of main aggregates relevant to provide guidance for comparative research • propose a framework for consistent reporting of health care services over time • present an economic model of supply and use of health care services • monitor economic consequences of health care reform and health care policy. The majority of these objectives seem relevant to almost any country. However, in the context of the Caribbean region, NHA should not simply be seen as a tool for monitoring the consequences of health reform but instead should really be viewed as an integral part of the overall health reform process. NHA can add value to health reform 80

in the region because it will equip policy makers with the much needed information to inform and guide national planning. These points are excellently addressed in a recent OECD report (OECD 2011). For the Caribbean region, if NHA is to capture the imagination of the region, and if it is to live up to its full potential, the objectives of NHA must be extended to explicitly include at least two additional requirements, namely, providing a means of: • monitoring and assessing the equity outcomes of the health financing, and • monitoring and assessing the evolution of health reforms Discussion and Analysis: Has Health Financing in the Caribbean Delivered? In this section we review the financing experience in the region and explore the extent to which the health financing systems have delivered on objectives as previously set out—equity and efficiency. Regional Trends in Health Financing The countries of the Caribbean have generally been able to boast of good health status (as measured by key indicators) and have managed to curb many of the health threats normally associated with developing countries (Jamison, Mosley, Measham & Bobadilla, 1993). Mortality rates have been falling and life expectancy rates are very close to levels found in the most developed countries (Table 1). In the process of achieving this, they have, in many cases, endeavoured to guarantee universal access to basic health services by all citizens. This has put pressure on the health system as it seeks to respond to population needs with changing reallocations of resources. In one sense, this has been the thrust of regional health sector reform.


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Table 1: Infant Mortality and Life Expectancy in the Caribbean: Selected Countries (1984-2012)

Countries

Infant Mortality 1984 1995

Bahamas

22.8

19.0

2012

Life Expectancy 1985 1994

2012

14

70

75

73

Barbados

18.0

15.2

17

74

76

75

Dominica

24.0

-

12

68

72

-

Grenada

14.0

14.6

11

-

70

72

Guyana

28.0

-

29

-

64

66

28.0

25.1

7

62

65

-

27.0

18

21

-

70

72

St. Lucia

17.0

16.5

15

-

72

75

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

St. Kitts/Nevis St Vincent and the Grenadines

Sources: Caribbean Regional Health Study; IDB/PAHO 1996; World Bank (2013)

While health services have traditionally been provided mainly by the public sector and have been based on a decentralized supply model, there is now a move toward greater private sector coverage and involvement. Data on the shares of spending on health care show that in the past, the state was responsible for providing the lion’s share of expen-

diture on health care. However, a comparison of work by Suarez (1995) with more recent data confirms that there is a trend towards modest change in the structure of private / public health expenditure. As Table 2 shows, for the countries identified, many have experienced significant reductions in the share of public expenditure on health. For the region

Table 2: Share of Public Spending in National Health Expenditure (%)

Country 1990

2002

2011

Antigua/Barbuda Bahamas Barbados Dominica Grenada Guyana Jamaica St Kitts/Nevis St. Lucia St. Vincent and the Grenadines Suriname Trinidad and Tobago

66 56 66 70 66 71 63 70 70 70 47 71

67.5 47.8 68.4 67.3 52.8 84.7 57.4 57.3 53.3 82.2 49.7 50.9

68.2 46.8 64.0 72.1 48.4 79.1 54.1 55.9 48.3 81.7 53.2 52.9

Average

66

61.6

60.4

Sources: Suarez (1995); PAHO (1998). WHO (2013)

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Health Financing in the Caribbean: A Possible Role for National Health Accounts?

as a whole, while there was a four percentage drop in the 12 years after 1990, the decade after that saw a drop of around one percent. The region seems to be stabilizing around a public sector share close to 60 percent. It is noteworthy that for the four countries showing an increase in the public sector share over the past decade or so, the average was 3.1% while for the eight countries showing a reduced public share the average was 3.2%. There is no question that data on health expenditure in the Caribbean public sector are readily available. However, in the absence of NHA, similar data with respect to private financing have not been as easily obtainable. Moreover, even though the data show that within recent times, the health systems of the region are experiencing a situation in which private spending on health is slowly coming more in line with public spending, we need to be careful about drawing firm conclusions in this regard. For one thing, in those countries where there has been an increased share in private expenditure, this may simply be reflecting the higher prices for services in that sector and not an increas-

ing share in the volume of services provided. Health services related private expenditure data remain a major challenge for health policy analysts and researchers. This is surely one area where a commitment to implementing NHA can certainly yield great dividends. In Table 3, we present one of the more interesting features of public sector health financing in the Caribbean— the remarkable stability, over a fairly long period, of health’s share in public spending. We observe from the above data, that even though the share of health in public spending declined for eight of the ten countries listed, the very small changes suggest that, in spite of periods of economic stringency, the governments of the region have continued to make the effort to hold on to their role in health financing. The period average for the share of health in total public spending was 11.9, with the range between 10.6 and 12.9. When we consider that for all the countries listed, the level of public spending in 2011 was much higher than in 1985, the miniscule decline in the share (0.2%) speaks volumes.

Table 3: Percentage Share of Health in Public Spending (1985-2011)

Country

1985

1989

1993

1996

2002

2011

Antigua/Barbuda

13.5

11.8

13.5

14.7

9.8

15.9

Bahamas

-

17.7

-

11.2

15

14.9

Barbados

16.5

14.4

13.7

14.7

12.4

10.9

Dominica

15.6

13.8

13.3

13.1

9.1

12.3

Grenada

12.8

14.1

13.5

-

9.7

11.0

Guyana

5.1

7.7

-

10.2

11.2

16.2

St Kitts/Nevis

11.5

12.3

10.6

7.5

8.0

6.9

St Lucia

12.32

-

-

8.3

11.4

11.1

St Vincent/Grenadines

12.7

14.2

-

13.6

10.7

11.7

Trinidad/ Tobago

9.1

8.3

-

7.3s

8.8

8.0

AVERAGE

12.1

12.7

12.9

11.2

10.6

11.9

Sources: IDB/PAHO (1996);; Central Bank of Barbados (2001); Government Estimates of Expenditure for various countries. : WHO (2013).

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Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 difference in the case of physicians and a 70% difference in the case of nursing and midwifery personnel – the difference in life expectancy was less than 8%. On the face of it, this speaks well for the region. Finally, we turn to the issue of equity. Here the results are not encouraging. One study4 tells us that, “Estimated probabilities and odds ratios point to a number of issues including:

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

In order to consider other aspects of health system performance in the Caribbean we look on data on inputs and outputs. We consider the use of nursing and medical human resources across the health sectors of the region and compare the use of these resources within the various health systems with the output (life expectancy) in the region. (See Table 4). Interestingly enough, we see that although the difference in inputs as between the two developed countries indicated and the Caribbean countries was very significant – a hundred percent

Table 4: Life Expectancy at Birth and Consumption of Human Resources [Nursing and Medical] within the Public Health Sector

Selected Countries

Physicians per 10,000 people. (2005-2012)

Nursing and Midwifery Life Expectancy| personnel per 10,000 at Birth people (Years), 2012 (2005-2012)

Canada

20.7

104.3

81.1

United States

24.2

98.2

78.7

Average

22.4

101.3

79.9 72.8

Antigua and Barbuda Bahamas, The

28.2

41.4

75.9

Barbados

18.1

48.6

77.0

Belize

8.3

19.6

76.3

Dominica

77.6

Grenada

6.6

38.3

76.1

Guyana

2.1

5.3

70.2

Jamaica

4.1

10.9

73.3

Saint Lucia

74.8

Saint Kitts and Nevis

73.3

Saint Vincent and the Grenadines

72.5

Suriname

70.8

11.8

35.6

70.3

28.5

73.8

Trinidad and Tobago

AVERAGE

11.3

Sources: UNDP Human Development Report 2000;, (2013); WHO (2013) 4

Althea La Foucade, Ph.D Thesis, Department of Economics, UWI, (2001)

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Management Institute for National Development (i) the urban-rural bias/discrepancies: ‌the odds of access for an individual residing in the most urban area‌is 1.66 times higher than for individuals in the most rural area ‌. (ii) the system biases against the elderly; and

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

(iii) the perception of the nature of the commodity being produced by the public health sector as an inferior product; (La Foucade, 2001: 161 ) Conclusions and Recommendations This paper had two objectives, one main and one subsidiary. The main objective was to clarify, in the context of the Caribbean, the role of health financing in getting the health system to work better. A theoretical framework was presented and we attempted to examine some aspects of the performance of the health systems, with a particular focus on efficiency and equity outcomes. We saw that all health financing was sourced from the national income and, that if properly applied, could end up benefiting the national income. With these two outcomes in mind, the health financing challenge was to bring about a proper match between heath needs and health services.

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Mainly because of data limitations, our review of the health systems yielded no definitive results, although, particularly in respect of equity, the available literature seemed to point to a negative performance assessment. The issues raised highlighted the second objective of the paper, which was to explore the case for the adoption of NHA by all countries of the region interested in succeeding with health sector reform. The capacity of NHA to track both the sources and uses of health expenditure seemed to make NHA the missing link in the reform processes undertaken in the region. What is more, we argued that beyond its value as a monitoring instrument, NHA has the potential to make the implementation of health sector reform more purposeful and better targeted. Finally, and most importantly, the point was made that since the scope of health sector reform was national, it was necessary to find a way to bring the operations of the private health sector operations under more careful policy scrutiny, keeping in mind the interconnected relationship between the public and private health sector. Since this is a normal output of the NHA, this was seen as strengthening the case for its adoption by countries seeking to modernize their health systems in general, and their financing systems, in particular.


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014

Bibliography Arrow, K. J. (1963). Uncertainty and the Welfare Economics of Medical Care. American Economic Review, 53(5), 941-967. Baker, J. L. (1997). Poverty Reduction and Human Development in the Caribbean: A Cross Country Study. Washington D.C.: The World Bank.

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

Barnum, H. & Kutzin, J. (1993). Public Hospitals in Developing Countries: Resource Use, Cost, Financing. London: The Johns Hopkins University Press. Barr, N. (1993). The Economics of the Welfare State. London: Weidenfeld and Nicolson. Berman, P. A. (1997). National Health Accounts in Developing Countries: Appropriate Methods and Recent Applications. Health Economics 6(1), 11-30. Birdsall, N. & James, E. (1993). Efficiency and Equity in Social Spending: How and Why Governments Misbehave. In M. Lipton & J. van der Gaag (Eds.), Including the poor: Proceedings of a Symposium Organized by the World Bank and the International Food Policy Research Institute.(335-358) Washington D.C.: The World Bank. Bourguignon, F. (1991). Optimal Poverty Reduction, Adjustment and Growth: An Applied Framework. World Bank Economic Review 5(2), 315-338. Brotherston, J. (1976). The Galton Lecture: 1975. Inequality: Is it Inevitable? In C. O. Carter & J. Peel (Eds.), Equalities and Inequalities in Health. London: Academic Press. Central Bank of Barbados. (2001). Economic and Financial Statistics (July 2001). Barbados. Coopers & Lybrand Consulting Group. (1993). Government of Trinidad and Tobago NHIS Project: Statistical Research Report. Donaldson, C. & Gerard, K. (1993). The Economics of Health Care Financing: The Visible Hand. London: Macmillan. Dunlop, D. W. & Martins, J. M. (1997). An International Assessment of Health Care Financing: Lessons for Developing Countries. Economic Development Institute of the World Bank. Washington D.C.: The World Bank. Government of Dominica. (2000). Estimates of Revenue and Expenditure, 1999/2000. Dominica. Government of Grenada. (2000). Estimates of Revenue and Expenditure, 1999/2000. Grenada.

85


Management Institute for National Development Government of St Christopher and Nevis. (2000). Estimates of Revenue and Expenditure, 1999/2000. St Christopher and Nevis. Government of St Lucia. (2000). Estimates of Revenue and Expenditure, 1999/2000. St Lucia. Government of St Vincent and the Grenadines. (2000). Estimates of Revenue and Expenditure, 1999/2000. St Vincent and the Grenadines.

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

Government of Trinidad and Tobago. (2000). Estimates of Revenue and Expenditure, 1999/2000. Trinidad and Tobago. Griffin, C. (1988). User Charges for Health Care in Principle and Practice. Economic Development Institute of the World Bank, Seminar Paper No. 37. Washington D.C.: The World Bank. Health Economics Unit. (2000). Towards the Regional Financing of Health Services in the OECS. Final Report submitted to the Pan American Health Organization/World Health Organisation. Trinidad and Tobago: The University of the West Indies, Health Economics Unit. Health Economics Unit. (1999). Identifying a Financing System and a Costing Framework for the Health System of Trinidad and Tobago. Final Report Submitted to the Cost and Financing Sub Committee of the Implementation Steering Committee. Health Economics Unit. (1999). Provider Payment Mechanisms in the Caribbean. Draft Final Report Prepared for the Pan American Health Organization. Washington D.C.: PAHO. Hsiao, W. C. (1995). A Framework for Assessing Health Financing Strategies and the Role of Health Insurance. In D. W. Dunlop & J. M. Martins (Eds.), An International Assessment of Health Care Financing: Lessons for Developing Countries. Washington D.C.: The World Bank. Inter-American Development Bank & Pan American Health Organization (IDB/PAHO). (1996). Caribbean Regional Health Study. Caribbean Group for Cooperation in Economic Development. Inter-American Development Bank & Pan American Health Organization (IDB/PAHO). (1993). Building National Consensus on Social Policy Trinidad and Tobago. Report of the Pilot Mission on Socio-Economic Reform of the Inter-American Development Bank. Social Agenda Policy Group. Jamison, D. T., Mosley, H., Measham, A. & Bobadilla, J. (1993). Disease Control Priorities in Developing Countries. Washington D.C.: Oxford University Press.

86


Caribbean Journal of Public Sector Management, Vol. XI No. 1, March 2014 Kindig, D. A. (1997). Purchasing Population Health: Paying for Results. USA: University of Michigan. La Foucade, A. (2001). An Inquiry into the Equity Orientation of Health Systems and the Implications for the Individual. (Unpublished doctoral dissertation). St Augustine, Trinidad: The University of the West Indies.

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

Maeda, A., Harrit, M., Mabuchi, S., Siadat, B. & Nagpa S. (2012) Creating Evidence for Better Health Financing Decisions (Directions in Development). Washington: World Bank Publications. OECD. (2001). The State of Implementation of the OECD Manual:A System of Health Accounts (SHA) in OECD Member Countries. (Unpublished report). Paris: OECD Health Policy Unit. OECD. (2011). Where is the Money and What are we doing with it? Creating an Evidence Base for Better Health Financing and Greater Accountability: A Strategic Guide for the Institutionalization of National Health Accounts. OECD Report. Schieber, G. J. & Maeda, A. (1997). A Curmudgeon’s Guide to Financing Health Care in Developing Countries. In G. J. Schieber (Eds.), Innovations in Health Care Financing: Proceedings of a World Bank Conference, March 10-11, 1997. (1-40). Washington D.C.: The World Bank. Suarez, R. (1995). National Health Expenditure and Financing in Latin America and the Caribbean: Challenge for the 1990s. Health Development Series (3). Washington D.C.: Pan American Health Organization and World Health Organization (PAHO/WHO). Theodore, K. (2000). Health Financing and Health Reform in the Caribbean: Where do we go from here? St Augustine, Trinidad: Health Economics Unit, the University of the West Indies. Theodore, K. (1996). Background Paper, Health Conditions in the Caribbean Chapter 1: Background - General, Social, Political and Economic Context (1960-1995). St. Augustine, Trinidad: Health Economics Unit, the University of the West Indies. Theodore, K. (1996). Macroeconomic Implications of National Health Insurance in Jamaica. A report Prepared for the Ministry of Health of Jamaica. Theodore, K., Stoddard, D., Yearwood, A. & Thomas, W. (1998). Health and equity in Jamaica. Investment in Health, Equity and Poverty in LAC (EQUILAC and IHEP), PAHO/ UNDP Case Study. Trinidad and Tobago: The University of the West Indies, Health Economics Unit.

87


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Trinidad and Tobago. Ministry of Health. (1995). Trinidad and Tobago Health Sector Reform Programme: Health Sector Financing. Health and Life Sciences Partnership, the Ministry of Health of Trinidad and Tobago with assistance from the Inter-American Development Bank (IDB). United Nations Development Programme (UNDP). (2013). Human Development Report 2013 - The Rise of the South: Human Progress in a Diverse World. New York.

Health Financing in the Caribbean: A Possible Role for National Health Accounts?

World Bank. World Development Indicators Online Database. Accessed online December 16, 2013. World Health Organization (WHO). (2000). World Health Report 2000: Health Systems, Improving Performance. Geneva. World Health Organization (WHO). (2013). WHO Database: Region of the Americas 2002-2011. Accessed from http://apps.who.int/gho/data/node.country.country. November 16, 2013. World Health Statistics 2013. Geneva: World Health Organization Zere, E., Walker, O., Kirigia, J., Zawaira, F., Magombo, F. & Kataika, E. (2010). Health Financing in Malawi: Evidence from National Health Accounts, BMC International Health and Human Rights. 10:27. Zweifel, P. & Breyer, F. (1997). Health Economics. New York: Oxford University Press.

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Health Financing in the Caribbean: A Possible Role for National Health Accounts?


Caribbean Journal of

Public Sector Management The Caribbean Journal of Public Sector Management serves to highlight, explore and debate public sector issues both locally and regionally. It seeks to encourage research in public sector leadership and management, and develop a body of literature which provides practical solutions for the Caribbean public sector. This special issue focuses primarily on issues related to public health in the Caribbean. Specifically, it provides a valued resource for research and training institutions, other related institutions, and scholarly practitioners interested in keeping abreast of developments in the health sector both locally and regionally.

Management Institute for National Development

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Caribbean Journal of Public Sector Management  

The Caribbean Journal of Public Sector Management (CJPSM) is a publication of the Management Institute for National Development (MIND). The...

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