Financing of Essential Public Health Services in the Caribbean Region Case Study Huihui Wang and Patricio V. Marquez Coordinators Karl Theodore, Christine Laptiste, Althea La Foucade, Ewan Scott, Charmaine Metivier, Malini Maharaj, Roxanne Brizan–St. Martin, Kimberly-Ann Gittens-Baynes, Patricia Edwards-Wescott, Heather Harewood, and Vyjanti Beharry Korea–World Bank Partnership Facility (KWPF) China–World Bank Partnership Facility (CWPF) a © 2023 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the govern- ments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be construed or considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifi- cally reserved. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org.  Financing of Essential Public Health Services in the Caribbean Region Case Study Huihui Wang and Patricio V. Marquez Coordinators Karl Theodore, Christine Laptiste, Althea La Foucade, Ewan Scott, Charmaine Metivier, Malini Maharaj, Roxanne Brizan–St. Martin, Kimberly-Ann Gittens-Baynes, Patricia Edwards-Wescott, Heather Harewood, and Vyjanti Beharry Korea-World Bank Partnership Facility (KWPF) China-World Bank Partnership Facility (CWPF) Financing of Essential Public Health Services in the Caribbean Region Table of Contents Reports in the Pharmacovigilance and Essential Public Health Services Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Methodological Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Structure and Functionality of Funding Arrangements . . . . . . . . . . . . . . . . . . . . . . . . 4 Public Health Spending in the Context of National Health Spending . . . . . . . . . . . 4 Overview of Trends in Funding Flows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Main Findings and Future Action Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.2. Areas of Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2. A Caribbean Overview: Essential Public Health Functions . . . . . . . . . . . . . . . . . . . 17 2.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2.2. EPHFs/EPHS in the Americas (Including the Caribbean) . . . . . . . . . . . . . . . . . . 20 3. Government Health Expenditure in the Caribbean . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.1. Health Expenditure as a Percentage of Government Expenditure . . . . . . . . . 26 3.2. Government Health Expenditure as a Percentage of GDP . . . . . . . . . . . . . . . . 27 3.3. Quota Contributions to CARPHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4. CARPHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 4.1. CARPHA’s Regional Public Health Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 4.2. CARPHA’s Sources of Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 4.3. CARPHA’s Health Expenditure (Resource Allocation) Framework . . . . . . . . . 35 5. Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 5.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.2. Six Steps for Mapping Public Expenditure to Essential Public Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 5.3. Main Findings from Data Capture Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 5.4. The Way Forward: Development of a Mapping Instrument for EPHS . . . . . . 46 6. Essential Public Health Expenditure Reporting in Case Studies . . . . . . . . . . . . . . . 49 6.1. Total Expenditure on EPHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 6.2. Total Recurrent Expenditure on EPHS by Services . . . . . . . . . . . . . . . . . . . . . . . . 52 6.3. Total Capital Expenditure on EPHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 6.4. Trends in the Distribution of Expenditures to EPHS in Case Studies . . . . . . . . 60 ii Table of Contents 6.5. EPHS Expenditure, Core Functions and Country Health Policy . . . . . . . . . . . . 71 6.6. An Analysis of Per Capita EPHS Expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6.7. Global Health Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 6.8. Prevention—Recurrent EPHS Expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 6.9. Detection—Recurrent EPHS Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 6.10. Response—Recurrent EPHS Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 6.11. EPHS by Source of Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 7. Innovative Policies and Mechanisms for Funding Public Health Services and Community-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 7.1. Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 8. Conclusions: Agenda for Future Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 8.1. Main Messages of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 8.2. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 APPENDIX 1: CARPHA Member States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FIGURES Figure ES 1. Per Capita EPHS Expenditures by CARPHA and Case Study ­Country (US$) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Figure 2.1. The Steering Role of National Health Authorities . . . . . . . . . . . . . . . . . . . 19 Figure 2.2. Summary of the “Public Health in the Americas Initiative” . . . . . . . . . . . 20 Figure 2.3. Conversion of EPHFs Framework into EPHS Framework . . . . . . . . . . . . . 23 Figure 3.1. Domestic General Government Health Expenditure as a Percentage of General Government Expenditure – Selected English-speaking Countries (2015 to 2019) . . . . . . . . . . . . . . . . . . . . . . . . . 26 Figure 3.2. Domestic General Government Health Expenditure as a Percentage of General Government Expenditure . . . . . . . . . . . . . . . . . . . 27 Figure 3.3. Domestic General Government Health Expenditure (GGHE-D) as a % of GDP Barbados, Grenada, Jamaica and Trinidad and Tobago 2015-2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Figure 3.4. Domestic General Government Health Expenditure (GGHE-D) as a % of GDP 2015-2019-Selected Countries English-speaking Caribbean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Figure 4.1. Breakdown of Income Sources - CARPHA . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Figure 4.2. Total Quota Contributions (US$) of CARICOM Member States 2015–2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Figure 4.3. Total Level of Contributions by Member States 2015–2021 . . . . . . . . . . 34 Figure 4.4. Donor Contributions (US$) 2016–2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Figure 4.5. Total Expenditure 2016–2021 (US$) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Figure 4.6. Distribution of Main Expenditure Areas 2016–2021 . . . . . . . . . . . . . . . . . 36 Figure 5.1. Example of Mapping of Expenditure to EPHS in A Simple Case . . . . . . 42 iii Financing of Essential Public Health Services in the Caribbean Region Figure 5.2. Example of Mapping of Expenditure to EPHS in a Case with Limited/Inadequate Programme Description . . . . . . . . . . . . . . . . . . . . . . 43 Figure 5.3. Example of Mapping of Expenditure to EPHS in a Case where a Programme is Identified with More than One EPHS . . . . . . . . . . . . . . . . . 44 Figure 5.4. EPHS Mapping Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Figure 5.5. Segment of Proposed Mapping Instrument for EPHS . . . . . . . . . . . . . . . 47 Figure 6.1. Total Expenditure on Essential Public Health Services in US$, (i) Barbados, (ii) Grenada, (iii) Jamaica, and (iv) Trinidad and Tobago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Figure 6.2. Expenditure on Essential Public Health Services (in US$), (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago. . . . 52 Figure 6.3. Expenditure on Essential Public Health Services by Core Functions (in US$), (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Figure 6.4. CARPHA: Allocation of Expenditure 2015–2021 to EPHS . . . . . . . . . . . . 55 Figure 6.5. Thematic Grouping of 10 EPHS, CARPHA . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Figure 6.6. Total Capital Expenditure on EPHS (in US$), (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago . . . . . . . . . . . . . . . . 57 Figure 6.7. Capital Expenditure on Essential Public Health Services by Core Functions (US$), (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Figure 6.8. Total EPHS Expenditure as a % of Total Government Health Expenditure - Various Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Figure 6.9. Distribution of Recurrent Expenditure to EPHS 1 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 66 Figure 6.10. Distribution of Recurrent Expenditures to EPHS 2 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 66 Figure 6.11. Distribution of Recurrent Expenditures to EPHS 3 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 67 Figure 6.12. Distribution of Recurrent Expenditures to EPHS 4 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 68 Figure 6.13. Distribution of Recurrent Expenditures to EPHS 5 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 68 Figure 6.14. Distribution of Recurrent Expenditures to EPHS 6 as % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 69 Figure 6.15. Distribution of Recurrent Expenditures to EPHS 7 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 69 Figure 6.16. Distribution of Recurrent Expenditures to EPHS 8 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 70 Figure 6.17. Distribution of Recurrent Expenditures to EPHS 9 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 70 Figure 6.18. Distribution of Recurrent Expenditures to EPHS 10 as a % of Total Health Expenditures (2009/2010 to 2020/2021) . . . . . . . . . . . . . . . 71 Figure 6.19. CARPHA Per Capita EPHS Expenditure US$ . . . . . . . . . . . . . . . . . . . . . . . 74 iv Table of Contents Figure 6.20. Per Capita EPHS Expenditures by CARPHA and Case Study Countries (US$) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Figure 6.21. Distribution of Per Capita Expenditures (US$) by EPHS (CARPHA) . . 75 Figure 6.22. Distribution of Per Capita Expenditures (US$) by EPHS (Barbados) . . 75 Figure 6.23. Distribution of Per Capita Expenditures by EPHS (Grenada) . . . . . . . . 76 Figure 6.24. Distribution of Per Capita Expenditures (US$) by EPHS (Jamaica) . . . 76 Figure 6.25. Distribution of Per Capita Expenditures (US$) by EPHS (Trinidad and Tobago) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Figure 6.26. Estimated Total Prevention Expenditure (in US Dollars), (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago . . . . 83 Figure 6.27. Typology of Health Financing in the Caribbean . . . . . . . . . . . . . . . . . . . . 86 TABLES Table ES 1. Total EPHS Expenditure as a % of Total Government Health Expenditure—Various Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Table ES 2. Percentage Distribution of Recurrent Expenditures to EPHS (as a % of Total EPHS—Various Years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Table ES 3. Percentage Distribution of Capital Expenditures to EPHS (as a % of Total EPHS—Various Years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Table 2.1. Comparative Self-assessment Performance of the EPHFs in the Region of the Americas (including the English-speaking Caribbean and the Netherlands Antilles) . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table 3.1. Actual Country Quota Contributions to CARPHA 2016–2020 . . . . . . . . 29 Table 5.1. Timeframe and Sources of Data Capture . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Table 6.1. Ten Essential Public Health Services by Core Functions . . . . . . . . . . . . . 50 Table 6.2. Three Largest Allocations of EPHS Expenditure Categories by Country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Table 6.3. Total EPHS Expenditure as a % of Total Government Health Expenditure—Various Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Table 6.4. Percentage Distribution of Recurrent Expenditures to EPHS (as a % of Total EPHS—Various Years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Table 6.5. Percentage Distribution of Capital Expenditures to EPHS (as a % of Total EPHS—Various Years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Table 6.6. Country Health Plans by Goals/Objectives Linked to Core Public Health Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Table 6.7. GHS Index Categories and Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Table 6.8. GHS Index 2021-Overall Score Four Case Study Countries 2021 . . . . . 79 Table 6.9. GHS Index Case Study Countries Categories 2021 . . . . . . . . . . . . . . . . . . 80 v Reports in the Pharmacovigilance and Essential Public Health Services Series Reports in the Pharmacovigilance and Essential Public Health Services Series Global Synthesis Report on Pharmacovigilance: Why is the Safety of Medicines Important for Resilient Health Systems? Positioning Report on Pharmacovigilance: The Value of Pharmacovigilance in Building Resilient Health Systems Post-COVID Pharmacovigilance Situation Analysis Report: Safety Monitoring of Medicines and Vaccines Regional Realizing a Regional Approach to Pharmacovigilance: A Review of the European Union Approach The Caribbean Regulatory System: A Subregional Approach for Efficient Medicine Registration and Vigilance Financing of Essential Public Health Services in the Caribbean Region Country Scope Learning from the Republic of Korea: Building Health System Resilience Learning from Best Practices: An Overview of the Republic of Korea Pharmacovigilance System Pharmacovigilance in Brazil: Creating an Effective System in a Diverse Country Starting and Strengthening a National Pharmacovigilance System: The Case of Catalan Regional Activities that Propelled the Spanish Pharmacovigilance System Ghana’s Pharmacovigilance Experience: From Vertical Program Activity to Nationwide System vii Financing of Essential Public Health Services in the Caribbean Region Acknowledgments This report was prepared by a team coordinated by Huihui Wang, Senior Economist, World Bank, and Patricio Marquez, Consultant, World Bank, including Karl Theodore, a Christine Laptiste,a Althea La Foucade,a b Ewan Scott,b Charmaine Metivier,a Malini Maharaj,b Roxanne Brizan-St. Martin,a Kimberly-Ann Gittens- Baynes,a Patricia Edwards-Wescott,a Heather Harewood,c and Vyjanti Beharry.a The team acknowledges the contributions of: Anton Cumberbatch, former Chief Medical Officer, Trinidad and Tobago; Lawrence Jaisingh, Director, Health Policy and Planning, Ministry of Health, Trinidad and Tobago; Reeshemah Cheltenham- Niles, Director, Planning Unit, Ministry of Health and Wellness, Barbados; Stacie Goring, Chief Health Planner (acting), Ministry of Health and Wellness, Barbados; Shakira Mascoll, Health Planner, Ministry of Health and Wellness, Barbados; Gillian Applewhaite, Deputy Permanent Secretary (acting), Ministry of Health and Wellness, Barbados; Halim Brizan, Director, Central Statistics Office, Grenada; and Jasper Barnett, Health Economist, Ministry of Health Jamaica. The team also wishes to recognize the data collectors and research assistants. Special thanks to Christian-Lee Benjamin, Zari-Ann Jaggernauth, Ruqayyah Scott, Celine Wilson, and Eshe Skinner for research support and to Stephanie Theodore who contributed to managing various aspects of the report preparation. Many thanks to Kimoy Worrell for editorial support, and Robert Zimmermann contributed with the review and editing of the final version of the report. The team also thanks Joy St. John, Executive Director, and Mark Sami, Director, Corporate Services, Caribbean Public Health Agency (CARPHA), and Thulani Matsebula, Senior Health Economist, Health, Nutrition, and Population, Latin America and Caribbean Region, World Bank, for their insightful review of the report. Juan Pablo Uribe, Global Director of the WBG’s Health, Nutrition and Population | Director, Global Financing Facility (GFF), and Monique Vledder, Practice Manager, HHNGE, WBG, provided strategic guidance during the preparation of the reports on pharmacovigilance and essential public health services that form this collection. Design and layout for the report was created by Spaeth Hill. The preparation of this report was carried out with the support of the Korea– World Bank Partnership Facility (KWPF) and the China–World Bank Partnership Facility (CWPF) Washington, D.C, August 17, 2023 a. HEU, Centre for Health Economics, The University of the West Indies, St. Augustine, Trinidad and Tobago. b. Department of Economics, The University of the West Indies, St. Augustine, Trinidad and Tobago. c. Department of Preclinical and Health Sciences, Faculty of Medicine, The University of the West Indies, Cave Hill Campus, Barbados. viii Abbreviations and Acronyms Abbreviations and Acronyms AED Accident and Emergency Department BDSPHL Best-Dos Santos Public Health Laboratory CAF Development Bank of Latin America CARPHA Caribbean Public Health Agency CDC Centers for Disease Control and Prevention CERO Central Emergency Relief Organization CMO Chief Medical Officer COVAX COVID-19 Vaccines Global Access COVID-19 Coronavirus disease CSO Central Statistical Office EDF European Development Fund EFF Extended Fund Facility EPHF Essential Public Health Functions EPHS Essential Public Health Services GDP Gross Domestic Product GHE Government Health Expenditure GoB Government of Barbados GOJ Government of Jamaica H1N1 H1N1 strain of the influenza virus HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Disease Syndrome HRIS Health Resources Information System IDB Inter-American Bank IMF International Monetary Fund JADEP Jamaica Drug for the Elderly Programme JEE Joint External Evaluation MoHW Ministry of Health and Wellness MoH Ministry of Health NAC National AIDS Commission NHA National Health Authority NHF National Health Fund NHF National Health Fund NSPH National Strategic Plans for Health ix Financing of Essential Public Health Services in the Caribbean Region OECD Organisation for Economic Co-operation and Development ... OECS Organisation of Eastern Caribbean States OOP Out-of-pocket PAHO Pan American Health Organization PVS Performance of Veterinary Services QEH Queen Elizabeth Hospital RHAs Regional Health Authorities SHA System of Health Accounts USAID United States Agency for International Development UWI University of the West Indies WBG World Bank Group WHO World Health Organization x Financing of Essential Public Health Services in the Caribbean Region Executive Summary 1 Executive Summary It is important to monitor EPHS and the resourcing of the EPHS with a view to quantifying and tracking the adequacy of flows to specific areas of need. There is no debate that Caribbean countries have agreed to the critical importance of essential public health and essential public health functions and services. In fact, almost two decades ago, the Caribbean Commission on Health and Development (CCHD) stressed that: “Any attempt to improve Caribbean health must begin with considering the resolving capacity of the health systems as a whole. All countries have health plans, but they are all bedeviled by the weaknesses in the information systems, the problems in managing the decentralization processes and the shortages of resources, physical, financial. and human. There is a critical need to examine the public health systems to correct the deficiencies in discharging the essential public health functions.” (CCHD, 2006; 99). Further, the Caribbean Cooperation in Health Phase III (CCH III) Regional Health Framework 2010 – 2015 speaks to the need for ‘Strengthened capacity of Member States to perform essential public health functions’ (p.21) (EPHFs), that focus on three core areas: Assessment, Policy Development, and Assurance. This aligns with the findings of this study, where the Ministries of Health dominate spending on Essential Public Health Services (EPHS). This is indicative of countries’ recognition of the importance of EPHS to the resilience of their health systems. Equally important is the monitoring of EPHS. It is also critical to monitor the resourcing of the EPHS with a view to quantifying and tracking the adequacy of flows to specific areas of need. It is of note that this study found that budgetary frameworks and reporting requirements are not set up to systematically track spending on the EPHS. This is a major gap. This study examines the expenditure by Caribbean Community (CARICOM) countries on the delivery of EPHS, in the context of the global response to COVID-19. In particular, the study focuses on financing arrangements enacted to ensure the predictability of funding and the sustainability in the level and flow of funds over the medium and long terms to carry out essential public health functions in Barbados, Grenada, Jamaica and Trinidad and Tobago. The study also highlights the close, synergistic relationship between the Caribbean Public Health Agency (CARPHA) and its Member States. This study analyses spending within the public health systems of the selected countries and CARPHA on the following 10 EPHS: 1 Assess and monitor population health; 2 Investigate, diagnose and address health hazards and root causes; 3 Communicate effectively to inform and educate; 4 Strengthen, support and mobilize communities and partnerships; 5 Create, champion and implement policies, plans and laws; 6 Utilize legal and regulatory actions; 7 Enable equitable access; 8 Build a diverse and skilled workforce; 9 Improve and innovate through evaluation, research and quality improvement; and 2 10 Build and maintain a strong organizational infrastructure for public health. Financing of Essential Public Health Services in the Caribbean Region Pre-pandemic, relatively high out-of-pocket (OOP) payments for health care would have resulted in financial difficulties for many. This situation undoubtedly worsened during the pandemic. This underscores the need for pandemic preparedness and disease surveillance anchored in strong health systems and corresponding health coverage The pandemic has exacerbated the that reach everyone. In Caribbean Small Island financial hardships of those who were Developing States (SIDS), the challenges of already struggling with high out-of- relatively high debt-to-GDP ratios, external dependency and vulnerabilities to natural pocket payments for health care. disasters require that the interactions of health systems, institutions and resources be guided, deliberate and effective in order to prevent further compromise of these economies. The EPHS, with its ten elements as detailed in the study, provided a framework for mapping the allocation of resources to determine if expenditures are directed to areas which support existing policy directives. By flagging what may be potential shortfalls in financing in some components of the EPHS, the study provides a basis for exploring targeted interventions for the health systems of these countries. Additionally, the study reviews the financial flows to EPHS by CARPHA via a review of available information and utilizing the Agency’s audited financial reports. Methodological Approach The following six-step approach was applied to map spending to the 10 EPHS: 1 Definition of terms: public health, essential public health functions, essential public 4 Mapping of selected essen- tial public health service programmes/activities health services and other to essential public health relevant terms service(s) 2 5 Allocation of expenditure to Secondary data collection the selected essential public health service(s) 3 6 Identification and selection Analysis of expenditure on of essential public health essential public health essen- services from data collected tial public health services 3 Executive Summary Structure and Functionality of Funding Arrangements Households and the government are the primary financiers of health care in the study countries, with low levels of private health insurance coverage being a common characteristic. Hence, most of the spending on EPHS comes from the Ministries of Health, which receive funding from both domestic and foreign sources. Therefore, the financing of EPHS in the countries under …the financing of EPHS in the countries study is primarily covered by the government’s recurrent and capital expenditures, which, in all under study is primarily covered by the cases, include contributions from donors. government’s recurrent and capital Government funding is well-coordinated, with expenditures Ministries of Health receiving allocations from the central government. The budget documents are highly structured, indicating the allocation of funds to programmes at the macro-level, sub-programmes at the meso-level, and line items at the micro-level. Nevertheless, there was evidence of flexibility in the use of resources, particularly during the COVID-19 pandemic response. Public Health Spending in the Context of National Health Spending On average, countries’ government health expenditure ranged between 8 percent and 14 percent of total government expenditure. In the case of CARPHA, the analysis of its expenditures over the past 7 years (2015–2021) shows a clear focus on the Assurance function, which aligns with CARPHA’s mandate as the Regional Public Health Agency responsible for training and capacity building. Notably, there was a significant increase in spending on the Assessment function in 2020 and 2021 due to the demands of the COVID-19 pandemic. 8%–14% The percentage of total ­government expenditure typically allocated by countries to healthcare 4 Financing of Essential Public Health Services in the Caribbean Region Overview of Trends in Funding Flows Tables ES.1 to ES.3 illustrate the allocation of expenditures to the respective EPHS based on the results. The tables provide insight into the trends of recurrent and capital EPHS expenditures for the financial years 2012/13, 2016/17, and 2020/21. While comparisons can be made among the countries, there are notable differences in some circumstances due to the nature of spending-particularly expenditures. capital ­ At the end of the sample period all countries, except for Trinidad and Tobago, experienced an increase in EPHS expenditure as a percentage of total government health expenditure (ES.1). Table ES.2 indicates that there were no expenditure allocations to EPHS 1 in Grenada and Barbados, both of which are considered “smaller” countries. In most of the study countries, EPHS 2 and 7 received the largest expenditure allocations, apart from Trinidad and Tobago where EPHS 1 and 6 had the highest allocations. Grenada experienced a shift in focus from EPHS 2, which declined over the period, to EPHS 7, which significantly increased, while Jamaica experienced the opposite. The focus on EPHS 7 was similar for Barbados, but to a lesser extent than Grenada, while Trinidad and Tobago did not place as much emphasis on this service. It is somewhat difficult to make consistent cross-country comparisons of EPHS capital expenditures, which varied among the countries. However, it was observed that these expenditures were primarily focused on EPHS 2 and 7, except for Trinidad and Tobago, where EPHS 6 consistently received the highest allocation over the three-year period (Table ES.3). When examining the allocation of funds for prevention, a trend similar to that of OECD countries emerges, with an average estimate of less than 3 percent spending on prevention. In the Caribbean nations under consideration, public health and prevention Prevention Spending is a crucial element activities receive approximately 3 percent of expenditure on EPHS, particularly of expenditure in Grenada, and 2percent in in establishing an efficient healthcare Barbados, Jamaica, and Trinidad and Tobago. system. Regarding detection, early disease detection programmes comprise less than 10 percent of prevention spending on average in OECD countries, aligning with the observations for the three case countries with available data on this category. The majority of the expenditure on disease conditions is not specified, with more than half allocated to unspecified diseases due to the limited availability of disaggregated data. Among the identifiable components, non-communicable diseases (NCDs) account for the majority of spending, with infectious and parasitic diseases receiving 2 percent (Grenada), 3.9 percent (Jamaica), and 2 percent (Trinidad and Tobago) of health expenditure. 5 Table ES 1. Total EPHS Expenditure as a % of Total Government Health Expenditure—Various Years EPHS DESCRIPTION BARBADOS GRENADA JAMAICA TRINIDAD 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Assess and Monitor Population 1 0.00% 0.00% 0.00% 0.00% 0.00% 0.02% 0.64% 0.76% 0.80% 7.03% 4.85% 3.11% Health Investigate, diagnose, and 2 address health hazards and 4.26% 4.49% 5.52% 5.23% 1.69% 8.34% 0.86% 1.12% 9.27% 11.83% 14.65% 13.07% root causes Communicate effectively to 3 4.91% 0.38% 0.29% 0.03% 0.00% 0.00% 0.17% 0.25% 1.87% 0.66% 0.53% 0.29% inform and educate Strengthen, support and 4 mobilize communities and 2.25% 0.31% 0.37% 0.00% 0.00% 0.00% 0.14% 0.08% 0.06% 0.00% 0.00% 0.00% partnerships Create, champion and 5 implement policies, plans and 0.00% 0.20% 0.08% 0.00% 0.00% 0.00% 0.42% 0.25% 0.18% 0.00% 0.00% 0.00% laws Utilize legal and regulatory 6 0.12% 0.16% 0.11% 0.58% 0.10% 0.38% 0.16% 0.18% 0.15% 6.91% 5.41% 2.88% actions 7 Enable equitable access 6.42% 6.73% 11.23% 0.12% 2.19% 11.52% 2.68% 2.75% 2.56% 1.91% 1.43% 0.92% Build a diverse and skilled 8 0.04% 0.10% 0.04% 1.30% 0.37% 0.55% 1.12% 1.00% 0.77% 0.00% 0.00% 0.00% workforce Improve and innovate through 9 evaluation research, and 0.00% 0.07% 0.03% 0.00% 0.00% 0.00% 0.15% 0.17% 0.53% 0.18% 0.13% 0.07% quality improvement Build and maintain a strong 10 organizational infrastructure 0.93% 0.30% 0.30% 2.10% 0.38% 1.38% 0.15% 0.22% 0.11% 2.32% 1.26% 2.56% for public health Total EPHS Expenditure as a % of Total Government Health 18.93% 12.75% 17.97% 9.36% 4.73% 22.20% 6.48% 6.78% 16.30% 30.85% 28.26% 22.89% Expenditure 6 Executive Summary 7 Table ES 2. Percentage Distribution of Recurrent Expenditures to EPHS (as a % of Total EPHS—Various Years) EPHS DESCRIPTION BARBADOS GRENADA JAMAICA TRINIDAD AND TOBAGO 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Assess and Monitor 1 0% 0% 0% 0% 0% 0% 10% 11% 5% 23% 17% 14% Population Health Investigate, diagnose, and 2 address health hazards and 23% 35% 31% 56% 36% 38% 13% 17% 57% 38% 53% 57% root causes Communicate effectively to 3 26% 3% 2% 0% 0% 0% 3% 4% 12% 2% 2% 1% inform and educate Financing of Essential Public Health Services in the Caribbean Region Strengthen, support and 4 mobilize communities and 11% 2% 2% 0% 0% 0% 2% 1% 0% 0% 0% 0% partnerships Create, champion and 5 implement policies, plans and 0% 2% 0% 0% 0% 0% 6% 4% 1% 0% 0% 0% laws Utilize legal and regulatory 6 1% 1% 1% 6% 2% 2% 2% 3% 1% 22% 18% 13% actions 7 Enable equitable access 34% 53% 63% 1% 46% 52% 41% 41% 16% 6% 5% 4% Build a diverse and skilled 8 0% 1% 0% 14% 8% 2% 17% 15% 5% 0% 0% 0% workforce Improve and innovate through 9 evaluation research, and 2% 1% 0% 0% 0% 0% 2% 2% 3% 1% 0% 0% quality improvement Build and maintain a strong 10 organizational infrastructure 5% 2% 2% 22% 8% 6% 2% 3% 1% 0% 5% 11% for public health 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Table ES 3. Percentage Distribution of Capital Expenditures to EPHS (as a % of Total EPHS—Various Years) EPHS DESCRIPTION BARBADOS GRENADA JAMAICA TRINIDAD AND TOBAGO 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Assess and Monitor Population 1 0% 0% 0% 0% 0% 0% 0% 0% 0% 25% 25% 25% Health Investigate, diagnose, and 2 address health hazards and root 0% 0% 18% 11% 11% 11% 82% 75% 57% 22% 22% 22% causes Communicate effectively to 3 0% 0% 0% 3% 3% 3% 0% 0% 0% 2% 2% 2% inform and educate Strengthen, support and 4 mobilize communities and 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% partnerships Create, champion and 5 implement policies, plans and 0% 0% 0% 0% 0% 0% 0% 0% 20% 0% 0% 0% laws Utilize legal and regulatory 6 0% 0% 0% 0% 0% 0% 0% 0% 0% 40% 40% 40% actions 7 Enable equitable access 9% 0% 109% 85% 86% 86% 18% 23% 23% 9% 9% 9% Build a diverse and skilled 8 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% workforce Improve and innovate through 9 evaluation research, and quality 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% improvement Build and maintain a strong 10 organizational infrastructure for 91% 100% -26% 0% 0% 0% 0% 3% 0% 2% 2% 2% public health 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 8 Executive Summary Financing of Essential Public Health Services in the Caribbean Region The data presented in Figure ES.1 reveals that per capita expenditure on EPHS by CARPHA for all Member States varied between US$0.39 and US$0.49 during the period from 2016 to 2020. Among the study countries, Jamaica’s per capita EPHS expenditures were on the lower end of the scale ranging from US$13.53 to US$17.84 over the period. Trinidad and Tobago recorded the highest per capita EPHS expenditures ranging from US$121.53 to US$180.98, followed by Barbados, with expenditures ranging from US$47.91 to US$95.62. Grenada’s per capita EPHS expenditures spanned US$5.23 to US$29.68. Figure ES Figure ES 1. Per Capita 1. Per Capita EPHS Expendituresby byCARPHA EPHSExpenditures CARPHAand andCase CaseStudy StudyCountry (US$) ­Country (US$) 200 180 160 140 120 100 80 60 40 20 0 2016 2017 2018 2019 2020 CARPHA Barbados Grenada Jamaica Trinidad and Tobago Main Findings and Future Action Agenda Budgeting is not organized along the EPHS structure. As such, what is considered as EPHS does not necessarily align with the funding decisions made by countries as reflected in the budgets. As a result, it can be challenging to accurately track these It is clear there is a disconnect between expenditures. The process of mapping these the general theoretical framework of expenditures involved a granular and extensive the EPHS and the actual budgetary approach, which is outlined in the methodolog- ical approach. This information is a valuable ­allocations made at the country level. resource for policymakers as it allows them to determine if their funding priorities align with their policy directives. For example, policymakers can use this information to determine whether priority areas are receiving adequate funding. The study brings to the fore two important questions that need to be answered: + Is the level of public health funding adequate? + Is the funding available being efficiently allocated? 9 Executive Summary Unfortunately, the investigation also revealed limitations that prohibit meaningful responses to these basic but key questions. In order to answer these questions, there are important considerations and action areas that should guide future efforts to enhance the EPHS and their corresponding allocations within the context of global health security. 1 Countries need to be able to identify exactly which programmes are being supported by EPHS funds to determine if they are achieving stated goals. This requires reviewing and potentially the restructuring of health finance management systems or budgeting practices, possibly leveraging tools such as the System of Health Accounts. Examining recurrent and capital expenditure allocations for the 10 EPHS, can enhance health reporting and improve the alignment of health expenditures with desired outcomes. Additionally, estab- lishing baselines for evaluating the effectiveness of expenditures and providing guidance for informed policymaking at national and regional levels can further enhance the EPHS. Countries need to be able to identify exactly which programmes are being supported by EPHS funds to determine if they are achieving stated goals. 2 This would be facilitated by the development of a standardized manual that guides the definition and translation of EPHS theoretical concepts into specific budget line items. This will enable countries to review and analyze their health expenditure data in a more comparable and coherent manner, both at the country and regional levels. The manual should include a detailed description of the analytical process of how health expenditures are organized and allo- cated to different programmes, with a focus on identifying the most significant areas of investment. 3 Development of a tool to efficiently track the flow of funds will be critical. This would require agreement on a detailed methodological framework, followed by the development of a corresponding software solution. 4 Regional institutions such as the Caribbean Public Health Agency It is important that a tool to efficiently (CARPHA) and University of the West track the flow of funds to EPHS be Indies, HEU, Centre for Health Economics (UWI-HEU) are possibly well placed to developed. kick-start the standardization process for tracking EPHS expenditure at the regional level. The findings of this study can be used to develop guidelines and recommendations on how best to support the process of standardization, including the retraining of personnel to accurately map different health expenditures to specific budget categories. Regional entities could play a critical role in delivering this training and capacity-building support to member countries. 10 Financing of Essential Public Health Services in the Caribbean Region To conclude, it needs to be emphasized the importance of encouraging Ministries of Health to view EPHS not only as a means of prioritizing their investments but also as a tool for monitoring their performance. While acknowledging that each member state in the CARICOM may have varying national priorities, a significant finding is the importance of enhancing the harmonization of data collection and reporting for EPHS. This will enable the establishment of a solid framework for decision-making on global health security, considering the region’s susceptibility as SIDS. The study findings presented in this report indicates that adopting the EPHS framework is crucial for implementing an effective strategy to enhance the health systems of the region and for underscoring the connection between health and the development of these countries. 11 Executive Summary 12 Financing of Essential Public Health Services in the Caribbean Region Chapter 1 Introduction Chapter 1.  Introduction Chapter 1. Introduction 1.1. Background The focus of this study is on financing arrangements that have been put in place by countries to ensure the predictability of funding and the sustainability in the level and flow of funds over the medium and long terms to carry out their essential public health functions (EPHF). According to the World Bank (2022), pre-pandemic high out-of-pocket (OOP) payments for health care have resulted in extreme poverty for many. This has, no doubt, worsened with the pandemic and as such, highlights the need for “…pandemic preparedness and disease surveillance anchored in strong health systems that reach everyone” (World Bank 2022). More specifically, this study focuses on the funding of Essential Public Health Services (EPHS) in selected Caribbean countries—Barbados, Grenada, Jamaica, and Trinidad and Tobago. It also examines spending on these services by the Caribbean Public Health Agency (CARPHA), in support of its Member States. Two key questions emerge:  s the level of public health funding adequate? 1. I 2. Is the funding available being efficiently allocated? The four countries being studied are representative of the region in multiple ways and embody both the diversity as well as the similarity of the various countries. Three of them are tourism-dependent, and Grenada and Jamaica are classified as upper-middle-income countries. In contrast, Barbados and Trinidad and Tobago are classified as high-income countries according to the World Bank Group country classifications by income level for the 2024 fiscal year (Hamadeh, Van Rompaey, Metreau 2023), with the latter country primarily reliant on oil and gas revenue. Jamaica, the most northerly, with a population of 2.97 million (2021)1 and with a decentralized health care system, is the largest English-speaking Island in the Caribbean. Barbados, with a population of 0.287 million (2021), provides a number of primary, secondary and tertiary services to its population, and has a strong and resilient public health system that can prevent, detect, and respond to infectious disease threats. Grenada, with a population of 0.113 million (2021), is the smallest of the four countries and is part of a group of islands—the Organization of Eastern Caribbean States (OECS)—that have similar characteristics and share a common currency. Trinidad and Tobago, the most southerly located country with a population of 1.4 million (2021), has a health system that is also decentralized. The Ministry of Health provides oversight and executes the public health functions through an array of parallel Vertical Services and five (5) autonomous Regional Health Authorities (RHAs). 1 Source for population data—https://data.worldbank.org 14 Financing of Essential Public Health Services in the Caribbean Region Barbados and Grenada have centralized health systems, unlike Jamaica and Trinidad and Tobago. Additionally, Grenada has limited access to specialized health services on the island. Analyzing expenditure structures and trends, these countries can offer valuable insights into the operations, challenges, and deficiencies of investing in EPHS in countries with comparable dynamics. In the context of Global Health Security, understood as the existence of strong and resilient public health systems that can prevent, detect, and respond to infectious disease threats, wherever they occur in the world (CDC 2022), it is essential for small-open economies to build such public health capacity. These economies are challenged by a number of structural vulnerabilities due to fiscal constraints, being substantially mono-crop in nature, and susceptibility to natural and other disasters. This is the context in which the examination of expenditure on public health services in the The Pan American Health Organization Caribbean is being carried out, to highlight the (PAHO) has identified the persistent importance of investing in preparedness and threat of emerging and re-emerging response capabilities to safeguard against potentially catastrophic health events. diseases as one of the major health challenges faced by these countries. According to the Pan American Health Organization (PAHO), one of the main challenges in health with these countries is the “continued threat of emerging and re-emerging diseases” (PAHO 2018). It is recognized that without the focus on global health security and public health, there may be widespread diseases and deaths, crippling economic effects, and social instability. Such a scenario would only compound the existing challenges faced by these countries. 1.2. Areas of Analysis This study analyses spending within the public health systems of the selected countries on the following 10 EPHS: 1 Assess and monitor population health; 2 Investigate, diagnose and address health hazards and root causes; 3 Communicate effectively to inform and educate; 4 Strengthen, support and mobilize communities and partnerships; 5 Create, champion and implement policies, plans and laws; 6 Utilize legal and regulatory actions; 7 Enable equitable access; 8 Build a diverse and skilled workforce; 9 Improve and innovate through evaluation, research and quality improvement; and 10 Build and maintain a strong organizational infrastructure for public health. 15 Introduction The analysis will focus on the following public health financing issues: + Review of current funding sources and structures for public health funding streams, purposes, and funding mechanisms. + Are funding arrangements compartmentalized and inflexible in the use of resources? + Is Government funding uncoordinated and/or fragmented? + Public health spending as a percentage of national spending; and trends over the period in spending on EPHS. + Past trends and review of the impact of fluctuations in funding for public health. + Current funding flows during the COVID-19 pandemic. + Use of funding resources, both pre-pandemic and during the pandemic. + Innovative policies and mechanisms for funding public health services and community-based interventions and suggest possible options for sustainable funding post-pandemic. + Key lessons. + Agenda for future action and reforms. This report presents the methodological approach used in the study to analyse EPHS expenditures in the countries, along with the main findings. Variations in EPHS funding are also highlighted by service and core functions, with the intent of informing policy. The study also focuses on global health security by examining funding directed towards the prevention, detection and response to health threats, where available data and estimations permit. 16 Financing of Essential Public Health Services in the Caribbean Region Chapter 2 A Caribbean Overview: Essential Public Health Functions 17 Chapter 2.  A Caribbean Overview: Essential Chapter 2. A Caribbean Overview: Essential Public Health Functions Public Health Functions “Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.” — World Health Organization 2015 2.1. Introduction Public health encompasses collective societal actions, occurring primarily through public institutions within the health system, to assure the conditions in which people can be healthy or have improved health. The health system in turn, comprises all organizations, institutions, and resources (state-led and private) whose primary purpose is to improve, promote, protect and restore population health (World Health Organization 2022; Pallipedia 2022). Thus, a principal role of the health system is to create the conditions to enable collective achievement of the goals of public health, under the governance of the State or National Health Authority (NHA). The Essential Public Health Functions (EPHF) first published by the World Health Organization (WHO) in 1998, focused on three core areas: Assessment, Policy Development and Assurance, with the intent of addressing perceived weaknesses in public health.2 These EPHFs were preceded by a set of EPHS in 1994, developed by the Core Public Health Functions Steering Committee, which was convened by the Assistant Secretary for Health in the USA and included representatives “Any attempt to improve Caribbean health must begin with considering the resolving capacity of the health systems as a whole. All countries have health plans, but they are all bedeviled by the weaknesses in the information systems, the problems in managing the decentralization processes and the shortages of resources, physical, financial. and human. There is a critical need to examine the public health systems to correct the deficiencies in discharging the essential public health functions.” — CCHD, 2006; 99 2 The essential public health functions (EPHFs) approach emerged out of an international Delphi study on EPHFs conducted in 1997. This international study included a respondent group of 145 public health experts from all regions of the world. The core monitor group included the members of the WHO EPHFs working group, and 8 senior public health figures from both devel- oping and developed countries. 18 Financing of Essential Public Health Services in the Caribbean Region from the United States Public Health Service agencies and other major public health ­organizations. 3 EPHFs put emphasis on the State’s steering role in health (PAHO 2002; Holder 2007; Pan American Health Organization 2020). Over time, the EPHFs have been collectively defined as one component of a requisite set of competencies, under the primary responsibility of the NHA, which underpin achievement of public health goals, health system reform, universal health coverage and global health security (Centers for Disease Control and Prevention 2022; World Health Organization 2018). Figure 2.1 illustrates six of the main tasks comprising the steering role of the NHA, including Public Health. 2.1. The Steering Role of Figure 2.1. Figure NationalHealth of National HealthAuthorities Authorities DIMENSIONS Leadership Financing National Assurance Regulatory Health (Social Protection in health) Authority Public Health Harmonization (Essential Functions) of health services Source: Holder (2007) Source: Holder (2007). There is no doubt that one of the major responsibilities of the NHA would be health security. Developing health threats such as new and re-emerging diseases, antimi- crobial resistance and bioterrorism, have brought renewed focus on global health security (Centers for Disease Control and Prevention 2022). Global public health emergencies, such as H1N1, and more recently COVID-19, exemplify the extent to which widespread and severe health and socio-economic disruption can result from an emergent disease with the capacity to transcend and overwhelm traditional border control mechanisms (Centers for Disease Control and Prevention 2022; World Health Organization 2018). Global health security calls for strategies Hence the role of the EPHFs is to to mitigate the effect of such acute public “…integrate key actions that underpin health events with the undoubted capacity to global health security, including threaten human health globally (Centers for surveillance and the implementation of Disease Control and Prevention 2022; World Health Organization 2018). Achievement the International Health Regulations.” of global health security requires “…strong — World Health Organization 2018 3 In 1994, in the midst of discussions of healthcare reform and lack of clarity about the role of public health, the Public Health Functions Steering Committee* developed the 10 Essential Public Health Services (EPHS) as a means of communicating the key public health services needed to protect and promote the health of the public. 19 Chapter 2. A Caribbean Overview: Essential Public Health Functions and resilient public health systems that can prevent, detect, and respond to” emergent, recognized health threats (Centers for Disease Control and ­ Prevention 2022; World Health Organization 2018). This is the context in which the EPHFs must be seen. 2.2. EPHFs/EPHS in the Americas (Including the Caribbean) The methodology/operational framework of EPHFs varies across World Health Organization (WHO) regions (Pan American Health Organization 2002; World Health Organization 2018). However, the Americas region established the “Public Health in the Americas Initiative” in 1999, which led to the harmonization of the EPHFs scope, and the development of performance measures and strategies to improve public health practice and infrastructure within this hemisphere. Figure 2.2 summarizes the outcomes of the ‘Initiative’, which involved defining eleven EHPFs for the Region of the Americas, including the countries under review. The performance framework was self-evaluated by local health sector stakeholders in 41 countries via a regional exercise conducted between 2001 and 2002, using a detailed standardized tool, which covered several horizontal health systems func- tions (Pan American Health Organization 2002; World Health Organization 2018). Figure 2.2. Figure 2.2. Summary ofthe Summaryof the“Public “PublicHealth Health in inthe theAmericas AmericasInitiative” Initiative” SUMMARY OF THE “PUBLIC HEALTH IN THE AMERICAS INITIATIVE” 1. Promotion of a common concept of public health and of its essential functions in the Americas 2. Development of a common framework of EPHF performance measures 3. Support for in-country self-evaluation of public health practice, based on EPHF performance measurement, within the conceptual and instrumental framework developed by the Initiative 4. Supporting countries in identifying the activities necessary for strengthening the public health services infrastructure and formulating institutional development programs to improve public health practice 5. Using conclusions dervived from regional EPHF performance measurement to create a framework for a regional program to strengthen the infrastructure and improve public health practice Source: Adapted from Pan American Health Organization 2002 Source: Adapted from Pan American Health Organization 2002. 20 Financing of Essential Public Health Services in the Caribbean Region According to PAHO’s findings (2002) presented in Table 2.1, none of the EPHFs in the region were found to perform optimally. The overall performance of the 11 EPHFs ranged from below average to average, except for EPHF 9, “Quality Assured Personal and Population-Based Health Services”, which performed at the lowest level, i.e., minimally. The EPHFs that aligned with classically recognized public health actions generally showed better performance, namely: + Surveillance, Research and Control of Risks and Threats to Public Health (EPHF 2); and + Reducing the Impact of Emergencies and Disasters on Health (EPHF 11). Table 2.1. Comparative Self-assessment Performance of the EPHFs in the Region of the Americas (including the English-speaking Caribbean and the Netherlands Antilles) EPHFS REGION OF THE CARIBBEAN AMERICAS 1. Monitoring, Evaluation, Analysis of 0.57 0.56 Health Status 2. Surveillance, Research, and Control of 0.63 0.63 Risks to Public Health 3. Health Promotion 0.54 0.55 4. Social Participation in Health 0.46 0.46 5. Policies, Institutional Capacity: Planning 0.52 0.53 and Management 6. Strengthened Public Health Regulation 0.44 0.42 and Enforcement Capacity 7. Promotion of Equitable Access to Needed 0.56 0.63 Health Services 8. Human Resources Development and 0.36 0.45 Training 9. Quality Assured Personal and 0.21 0.26 Population-based Services 10. Research in Public Health 0.35 0.38 11. Reduced Impact of Emergencies and 0.71 0.71 Disasters on Health AVERAGE 0.49 0.51 Key: Median performance ranges: i) 0.76 to 1.00 (optimal); ii) 0.51 to 0.75 (average); 0.26 to 0.50 (below average); 0.0 to 0.25 (minimum) Source: Holder (2007) The performance of the participating Caribbean States showed a similar pattern—none of the indicators performed in the optimal range and relative strengths revolved around EPHFs 2 (Surveillance, Research, and Control of Risks to Public Health) and 11 (Reduced Impact on Emergencies and Disasters on Health). 21 Chapter 2. A Caribbean Overview: Essential Public Health Functions However, “Quality Assured Personal and Population-Based Services” (EPHF 9), per- formed slightly better than the hemispheric median, receiving a score in the below average rather than in the minimum range. Nevertheless, this function, along with “Research in Public Health” (EPHF 10) was one of the worst performers as Table 2.1 shows. These results signaled the need for the Region “…to undertake a profound review of its public health activities, particularly with a view toward developing its institutional capacity in order to address new health and management challenges.” 4 Overall, while some countries performed better than others, there was scope for improvement across all countries. In the post ‘Initiative’ years—from 2003 to the present—the emphasis has shifted to country-level initiatives. Specifically, in 2005, the PAHO Office of the Eastern Caribbean worked with Member States on projects such as incorporating EPHF strengthening into National Strategic Plans for Health (NSPH) (World Health Organization 2018; Ramagem and Ruales 2008). Eight Eastern Caribbean countries participated in an EPHF performance reassessment leading to identification of country-specific intervention areas. These included re-structuring and strengthening of the NHA role (Anguilla and the British Virgin Islands), strengthening of public health enforcement capacity (Barbados), and explicit incorporation of EPHFs into NSPH—Grenada, St. Kitts and Nevis, and St. Vincent and the Grenadines (Holder 2007). Most recently, the focus of the EPHFs within the Caribbean has been in the context of fitness for purpose as it relates to the universal health access and coverage agenda (World Health Organization 2018). Further, there has been a move away from the score-based problem identification approach to a solutions-based approach to addressing identified gaps in health systems function and public health practice (World Health Organization 2018). In December 2020, the Pan American Health Organization (PAHO) launched a renewal of the EPHFs initiative as the need for a more holistic approach to address pervasive health system barriers to access to services and quality care has become imperative in the wake of the multi-factorial health and socio-economic impacts of the COVID-19 pandemic. This new framework groups the EPHFs into four pillars representing key domains of health system actions: assessment, policy development, allocation of resources and assuring access (Pan American Health Organization 2020). The EPHFs framework was further transitioned into an Essential Public Health Services (EPHS) framework where eleven (11) EPHFs were assimilated into ten (10) EPHS. Figure 2.3 compares the EPHFs and EPHS frameworks and shows that the elements of EPHF 10 were integrated into EPHS 9, and EPHF 11 elements were integrated into EPHS 2 and 5, respectively. Before undertaking a detailed analysis of expenditures under the EPHS, first a review is presented of the broader government health expenditure framework under which the allocations to the EPHS have taken place. It is also equally import- ant to bear in mind the critical issues pertaining to equitable access to health care in general (Theodore et al. 2001). The findings of a review of the EPHS expenditure framework of CARPHA is also presented. 4 Public Health in the Americas”. page 124. Available from: https://www.paho.org/hq/dmdocu- ments/2010/EPHF_Public_Health_in_the_Americas-Book.pdf [Accessed 2022-06-08] 22 Financing of Essential Public Health Services in the Caribbean Region “These results signaled the need for the Region “…to undertake a profound review of its public health activities, particularly with a view toward developing its institutional capacity in order to address new health and management challenges.” — PAHO 2010 Figure 2.3. Conversion Figure 2.3. ofEPHFs Conversionof EPHFsFramework Frameworkinto intoEPHS EPHSFramework Framework ESSENTIAL PUBLIC HEALTH ESSENTIAL PUBLIC HEALTH FUNCTIONS SERVICES + Monitoring, Evaluation, Analysis of + Access and Monitor Population Health status Health + Surveillance, Research and Control + Investigate, Diagnose and Address of Risks to PH Health Hazards and Root Causes + Health Promotion + Communicate Effectively to Inform and Educate + Social Participation in Health + Strengthen, Support and Mobilize Communities and Partnerships + Policies, Institutional Capacity: + Create, Champion and Implement Planning and Management Policies, Plans and Laws + Strengthened PH Regulation and + Utilize Legal and Regulatory Actions Enforcement Capacity + Promotion of Equitable Access to + Enable Equitable Access Needed Health Services + Human Resources Development + Build a Diverse and Skilled andTraining Workforce + Quality Assured Personal and + Improve and Innovate through Evaluation, Research and Quality Population-based Services Improvement + Build and Maintain a Strong + Research in Public Health Organizational Infrastructure for Public Health + Reduced Impact of Emergencies and Disasters in Health Source: Authors' construct 23 Financing of Essential Public Health Services in the Caribbean Region Chapter 3 Government Health Expenditure in the Caribbean 25 Chapter 3.  Government Health Expendi- Chapter 3.  Government Health Expenditure in the Caribbean ture in the Caribbean 3.1. Health Expenditure as a Percentage of Government Expenditure Domestic government health expenditure as a percentage of total government expenditure may give a sense of the importance the state attaches to the health of the population (Theodore et al. 2016). The amount eventually allocated to public health may be impacted by the overall allocation Domestic government health to the health sector. Consequently, reduced expenditure as a percentage of total allocations to the health sector may result in government expenditure gives a sense less available resources for public health. of the importance the government Over the period 2015 to 2019, there was some attaches to the health of the population. variation in government expenditure on health as a percentage of total government expenditure among countries in the English- speaking Caribbean. As shown in Figure 3.1, this percentage ranged between 6.3 percent and 16.9 percent over the period and was largest in The Bahamas, followed by Jamaica (World Bank 2022). At the country level, the share of ­ government health spending showed little change over the period. ­ Figure 3.1. Figure 3.1. Domestic GeneralGovernment DomesticGeneral GovernmentHealth Health Expenditure Expenditureas asaa Percentage Percentage General Government of General of GovernmentExpenditure Expenditure—–Selected SelectedEnglish-speaking English-speakingCountries Countries to 2019) (2015 to (2015 2019) 20.0 18.0 16.0 14.0 Percentage (%) 12.0 10.0 8.0 6.0 4.0 2.0 0.0 2015 2016 2017 2018 2019 Antigua and Barbuda 11.8 11.6 11.6 12.7 11.3 Bahamas, The 13.7 14.6 16.9 15.7 15.3 Barbados 9.1 9.3 9.1 9.9 10.6 Grenada 7.5 7.4 8.4 8.3 9.4 Guyana 10.8 10.0 10.6 10.6 10.3 Jamaica 12.8 12.7 14.0 13.0 13.3 St. Kitts and Nevis 6.6 8.1 8.1 6.3 6.6 St. Lucia 8.4 8.5 8.7 8.5 8.2 St. Vincent and the Grenadines 9.2 9.6 9.5 10.2 9.5 Trinidad and Tobago 8.3 10.2 11.2 10.7 10.2 Source: The World Bank, 2022 Source: World Bank, 2022 Looking closely at the four countries being reviewed, from 2015 to 2019 domestic percent general government health expenditure made up only about 8 percent to 14 ­ of total government spending (Figure 3.2). This percentage remained fairly consistent across all the countries, with a small increase seen in 2017 in all but one—Barbados experienced a slight decrease (World Bank 2022). 26 Financing of Essential Public Health Services in the Caribbean Region Figure 3.2. Figure 3.2. Domestic GeneralGovernment Domestic General GovernmentHealth Health Expenditure Expenditureas asaa Percentage Percentage General Government of General of GovernmentExpenditure Expenditure 15.0 14.0 14.0 13.0 12.8 12.7 13.3 13.0 Percentage (%) 12.0 11.2 10.7 11.0 10.2 10.6 10.0 10.2 9... 9.9 9.0 9.3 9.1 9.4 8.0 8.3 8.4 8.3 7.0 7.5 7.4 6.0 5.0 2015 2016 2017 2018 2019 Barbados 9.1 9.3 9.1 9.9 10.6 Grenada 7.5 7.4 8.4 8.3 9.4 Jamaica 12.8 12.7 14.0 13.0 13.3 Trinidad and Tobago 8.3 10.2 11.2 10.7 10.2 Source: The World Bank, 2022 Source: The World Bank, 2022 3.2. Government Health Expenditure as a Percentage of GDP Across the four countries, government health expenditure averaged just under four percent of GDP over the period (Pan American Health Organization 2020). This falls short of the recommended target of six percent mentioned in the PAHO’s Regional Strategy for Universal Access to Health and Universal Health Coverage (The World Bank 2022). Refer to Figure 3.3 for a visual representation of these findings. However, as shown in Figure 3.4, this is not unusual for the region; none of the English-speaking countries met this target over the period 2015 to 2019 (Pan American Health Organization 2020). The fact that none of the countries are allocating the ‘target’ 6 percent of GDP may highlight the need for increased invest- ment in healthcare to ensure that all citizens have access to quality health services. Of course, one must not lose sight of the fact that it is not just about how much is spent, but also about how, much is spent. While the evidence may point to the need for increased investment in healthcare to ensure universal access to quality health services, one must not lose sight of the crucial reality that it is not just about HOW MUCH is spent, but also about HOW much is spent. 27 Chapter 3.  Government Health Expenditure in the Caribbean Figure3.3. Figure 3.3. Domestic General Government Domestic General Government Health Expenditure (GGHE-D) Health Expenditure (GGHE-D) as a %as a GDP of % of GDP Barbados, Barbados, Grenada, Grenada, Jamaica Jamaica and Trinidad and Trinidad and Tobago and Tobago 2015–2019 2015-2019 7 6 Percentage (%) 5 4 3 2 1 2014 2015 2016 2017 2018 2019 Barbados Grenada Jamaica Trinidad and Tobago Source: The World Bank, 2022 Source: The World Bank, 2022 Figure 3.4. Figure 3.4. Domestic Domestic General General Government Government Health Expenditure (GGHE-D) Health Expenditure (GGHE-D) as a as a % of GDP 2015–2019 — Selected Countries English-speaking Caribbean % of GDP 2015-2019-Selected Countries English-speaking Caribbean 6 5 Percentage (%) 4 3 2 1 0 2014 2015 2016 2017 2018 2019 Antigua and Barbuda Bahamas, The Barbados Dominica Guyana Grenada Jamaica St. Kitts and Nevis St. Lucia Source: The World Bank, 2022 Source: The World Bank, 2022 3.3. Quota Contributions to CARPHA The Caribbean Public Health Agency (CARPHA), which combines the functions of five previous regional health institutions, serves as the regional public health agency for the Caribbean. It is the umbrella agency that addresses public health issues, which include disaster response, surveillance and management of non- communicable diseases (NCDs), communicable diseases, injuries and to achieve Caribbean Cooperation in Health. 5 The Agency also provides laboratory services, training and capacity building exercises. CARPHA is jointly financed by quota contributions from its 26 Member States and International Development Partners. 5 https://carpha.org/Who-We-Are/About 28 Financing of Essential Public Health Services in the Caribbean Region Between 2016 and 2021, international development partners significantly increased their support. Of the four case countries Trinidad and Tobago was the largest contributing country to CARPHA during the period 2016 to 2020, followed by Jamaica, Barbados and Grenada, respectively (CARPHA 2016 - 2020). Together, these countries were required to contribute 68% of the total quota contributions from all Member States. Although there were fluctuations over the period, the actual quota contributions from the case countries amounted to US$14.95 million (99.6 percent of the required US$15.02 million (see Table 3.1). These contributions are vital for CARPHA to support the countries in capacity building and strengthening. A per capita comparison of the case study countries’ contribution to CARPHA shows that on average, over the period 2016-2020, Jamaica contributed per capita US$0.27 per year, whilst Trinidad and Tobago, with the largest in terms of size of contributions also had the largest per capita contribution of US$1.33 per year. Barbados’ and Grenada’s per capita contributions averaged US$1.02 and US$0.45 per year, respectively. In addition to contributions from its Member States, the Agency also receives funding from donors for specific projects. In the next section, we provide a more detailed review financial operations of CARPHA to provide the context of its expenditure on EPHS. Table 3.1. Actual Country Quota Contributions to CARPHA 2016–2020 COUNTRY ANNUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL TOTAL QUOTA 2016 2017 2018 2019 2020 2016–2020 REQUIRED US$ US$ US$ US$ US$ US$ US$ Barbados 316,927 316,944 316,944 - 783,996 50,080 1,467,964 Grenada 41,722 41,772 41,722 41,722 62,670 62,670 250,556 Jamaica 798,803 817,298 580,889 1,229,811 956,630 423,060 4,007,688 Trinidad and 1,846,381 1,846,381 1,846,383 1,846,381 1,846,381 1,846,381 9,231,907 Tobago Total Quota Contributions 3,003,833 3,022,395 2,785,938 3,117,914 3,649,677 2,382,191 14,958,115 Case Countries All Member 4,424,355 States Source: Caribbean Public Health Agency (CARPHA), 2016-2020 29 Financing of Essential Public Health Services in the Caribbean Region Chapter 4 CARPHA 31 Chapter 4.  Carpha Chapter 4.  Carpha CARPHA’s contributions are integral to enhancing the capacity of the region to address public health challenges and ensure the safety and well-being of its citizens. 4.1. CARPHA’s Regional Public Health Framework CARPHA, which was legally established in 2011 and operationalized in 2013, emerged from the unification of five previous CARICOM Regional Health Institutions: + The Caribbean Environmental Health Institute (CEHI); + The Caribbean Epidemiology Centre (CAREC); + The Caribbean Food and Nutrition Centre (CFNI); + The Caribbean Health Research Centre (CHRC); and + The Caribbean Research and Drug Treatment Laboratory (CRDTL). CARPHA provides essential services to twenty-six Member States, with a total population of over 17 million people (CARPHA 2018). The Agency’s primary focus is regional health security, which involves the readiness and response to public health threats and issues that transcend national borders and have the potential to harm both lives and livelihoods. The services offered by CARPHA are, therefore, crucial in complementing the work done by national Ministries of Health of member states. In fact, CARPHA was specifically established to collaborate with, rather than work for, Ministries of Health. Keeping the small size of the countries in mind, the areas of CARPHA support include: + Laboratory Services; + Training and Capacity Building; + Emergency Preparedness and Response; + Research and Ethics; and + Regulatory Oversight. 4.2. CARPHA’s Sources of Funding CARPHA relies on two main sources of funds to provide essential services to its Member States: Member States (CORE) quota contributions and Grants from donors. Additional revenue is generated from fee-for-service activities executed at CARPHA’s St. Lucia and Trinidad and Tobago Campuses. Funds are utilized for operational In 2021, Quota Contributions provided 42% of costs, human resources, and CARPHA’s total income, while Project Revenue from Donors contributed 51% and Income from Services capital expenditure of the Agency. accounted for 4% as shown in Figure 4.1. (Annual Report 2020). 32 Financing of Essential Public Health Services in the Caribbean Region 4.1.Breakdown Figure4.1. Figure ofIncome Breakdownof Sources— IncomeSources CARPHA - CARPHA Quota contributions from member countries Income from services Amortisation of deferred capital grants 42% Interest income 51% Foreign exchange translation (loss)/gain Project revenue from 4% donor resources 1% 2% 0% Source: CARPHA Audited Financial Statements 2016–2021 Source: CARPHA Audited Financial Statements 2016–2021 4.2.1. Quota Contributions Member States are required to make an annual fixed, pre-determined contribution to CARPHA, which is mainly used to cover the human resources needs of the Agency. However, despite a fixed expected annual quota contribution of approximately US$4.42 million, payments by members are often sporadic and below quota. Figure 4.2 shows the level of quota contributions over the period January 2015 to December 2021, with the most favorable receipt in 2019 (CARPHA Annual Report 2020). Jamaica, Barbados, Guyana, Bahamas, Haiti and Trinidad and Tobago are among the top contributors owing to their economic performance level and population. Despite agreed quotas and timeframes, contributions are often sporadic and below the required quota payments. Figure 4.3 shows the total level of contributions made by each member state over the period 2015 to 2021 and highlights the challenges in ensuring consistent funding from member states. Figure 4.2. Figure 4.2. Total QuotaContributions TotalQuota (US$)of Contributions(US$) CARICOMMember ofCARICOM MemberStates States 2015–2021 2015–2021 $6,320,779 $4,499,989 $4,291,608 4,328,413 $4,018,886 4,192,358 $3,393,900 2015 2016 2017 2018 2019 2020 2021 Source: CARPHA Audited Financial Statements 2016–2021 Source: CARPHA Audited Financial Statements 2015–2021 33 Chapter 4.  Carpha Figure4.3. Figure 4.3.Total Levelof TotalLevel ofContributions byMember MemberStates Contributionsby 2015–2021 States2015–2021 Turks & Caicos Islands Trinidad & Tobago Suriname St Vincent & the Grenadines St Lucia Contributions Received 2015 St Kitts & Nevis Contributions Received 2016 St Maarten Contributions Received 2017 St Eustatius Saba Contributions Received 2018 Netherland Contributions Received 2019 Antilles Montserrat Contributions Received 2020 Jamaica Contributions Received 2021 Haiti Guyana Grenada Curacao Commonwealth of Dominica Cayman Islands Bonaire British Virgin Islands Bermuda Belize Barbados Bahamas Aruba Antigua & Barbuda Anguilla 0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 14,000,000 Source: CARPHA Audited Financial Statements 2015–2021 and Author’s Calculations Source: CARPHA Audited Financial Statements 2015–2021 and Author’s Calculations 34 Financing of Essential Public Health Services in the Caribbean Region 4.2.2. Grant Resources from International Development Partners (IDPs) According to its Annual Report (2020), CARPHA’s funding is supplemented by grants from a range of international development partners (IDPs) to cover the costs of programmes. IDPs include the World Bank, World Health Organization/ Pan-American Health Organization (WHO/PAHO), European Union (EU), Inter-American Development Bank (IDB), National Cancer Institute (NCI), World Diabetes Foundation (WDF), Pan-Caribbean Partnership Against HIV and AIDS (PANCAP), Centers for Disease Control and Prevention (CDC), Public Health Agency of Canada (PHAC), Agence Francaise de Development (AFD) and the United Nations Environment Programme (UNEP). To deliver on its mandate, CARPHA utilizes grants to fund collaborative projects aligned with the needs of Member States and CARPHA’s strategic priorities. A limited amount of grants is also used for funding Technical and Support Officers for specific projects (CARPHA Annual Report 2020). Grants generally account for half of the annual income of the Agency, while other sources of income are relatively minimal (CARPHA Projects Overview http://www.carpha.org). Figure 4.4 illustrates the volatility of donor contributions over the period 2016 to 2021. The highest level of donor funds was received in 2020 (US$10 million), which was mainly in response to the COVID-19 pandemic. 4.4. Donor Figure4.4. Figure Contributions (US$) Donor Contributions 2016–2021 (US$) 2016–2021 12,000,000 10,00,000 10,006,664 8,000,000 6,261,632 6,000,000 4,799,696 4,000,000 3,802,243 4,252,583 2,000,000 2,601,163 _ 2016 2017 2018 2019 2020 2021 Source: CARPHA Audited Financial Statements 2016–2021 Source: CARPHA Audited Financial Statements 2016–2021 4.3. CARPHA’s Health Expenditure (Resource Allocation) Framework CARPHA incurs expenses in three main areas each year: Staff Costs, Operating and Administrative Expenses, and Project Expenses from Donor Resources. Other expen- diture items include Capital Expenditure, Provisions for Depreciation and Doubtful Receivables. From 2016 to 2021, CARPHA’s total expenditure varied (Figure 4.5). 35 Chapter 4.  Carpha The peak in 2017 was mainly due to allowances for doubtful receivables of US$8.5 Million. However, the gradual increase in expenditures from 2019 to 2021 was primarily driven by CARPHA’s response to COVID-19 in the Region. Generally, spending on projects from donor resources accounted for the largest share of expenditure over the period 2016 to 2021. While staff costs spiked in 2019 and accounted for almost half of the expenditure of the Agency (49 percent), it fell to 33 percent in 2020 and 32 percent in 2021, respectively (Figure 4.6). Figure 4.5. Figure Total Expenditure 4.5. Total 2016–2021 (US$) Expenditure 2016–2021 (US$) 20,000,000 18,000,000 17,367,752 16,000,000 14,000,000 12,000,000 9,613,135 10,000,000 10,406,757 9,257,736 8,000,000 7,330,607 6,798,923 6,000,000 4,000,000 2,000,000 0 2016 2017 2018 2019 2020 2021 Source: CARPHA Audited Financial Statements 2016–2021 Source: CARPHA Audited Financial Statements 2016–2021 Figure4.6. Figure 4.6. Distribution of Main Distribution of Main Expenditure Areas 2016–2021 Expenditure Areas 2016-2021 49% 47% 46% 43% 40% 39% 38% 35% 33% 32% 27% 20% 19% 18% 18% 15% 14% 5% 2016 2017 2018 2019 2020 2021 Staff costs Operating and administrative expenses Project expenses from donor resources Source: CARPHA Audited Financial Statements 2016–2021 Source: CARPHA Audited Financial Statements 2016–2021 36 Financing of Essential Public Health Services in the Caribbean Region Chapter 5 Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services 37 Chapter 5.  Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services Chapter 5.  Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services Despite the marked differences in reporting systems among the countries, the six-step process was generally followed with relevant adjustments to account for inherent differences in data recording practices. This approach allowed for a more nuanced understanding of the data and facilitated a more effective analysis of the results. 5.1. Overview A six-step methodological approach for mapping EPHS expenditure was applied in this study. This is summarized as follows: 1 Definition of terms: public health, essential public health functions, essential public 4 Mapping of selected essen- tial public health service programmes/activities health services and other to essential public health relevant terms service(s) 2 5 Allocation of expenditure to Secondary data collection the selected essential public health service(s) 3 6 Identification and selection Analysis of expenditure on of essential public health essential public health essen- services from data collected tial public health services To ensure a comprehensive and accurate analysis, a collaborative approach was adopted, which included in-country experts and key informants. These played a vital role, particularly in Steps 3 and 4, providing rich information that was critical for weighting and allocation of expenditures towards the selected EPHS. 38 Financing of Essential Public Health Services in the Caribbean Region 5.2. Six Steps for Mapping Public Expenditure to Essential Public Health Services The details of the six methodological steps to mapping public expenditure are presented in the following sub-sections. Definition of Terms: Essential Public Health Services and Other Important Terms 1 For the purpose of this study, this EPHS framework defined the boundaries used to determine which elements of health expenditure are considered “essential”. The framework from the Centers for Disease Control (CDC), which assigns the EPHS to three broad categories: Assessment; Policy Development; and Assurance, was also used. 2 A comprehensive approach was employed to identify the EPHS, which involved analyzing expenditures within the System of Health Accounts (SHA) frame- work and examining EPHS reports from other countries (OECD 2017). These were used to clarify the definition of public health within the EPHS framework and to identify the relevant expenditure data. The term ‘public health’ in this study specifically refers to the governmental public health enterprise, with par- security ticular attention paid to areas deemed essential for building health ­ capacity in the post-pandemic period. These include technical areas and global health security agenda priority areas aimed at achieving critical health security impacts. Included here, are epidemiologic surveillance, immunization and vaccination, disease prevention programs, public health laboratories, and similar population-based health services. Table 5.1. Timeframe and Sources of Data Capture COUNTRY BUDGET/FISCAL YEAR DATA CAPTURE DATA SOURCES PERIOD (FISCAL YEAR) The Estimates of Barbados 1st April – 31st March 2009/2010 to 2020/2021 Expenditures and Revenues (Estimates) Estimates of Revenue Grenada 1st January – 31st January 2012-2021 and Expenditure The Government of Jamaica 1st April – 31st March 2010/2011 to 2020/2021 Jamaica Estimates of Expenditure Ministry of Finance Trinidad and 1st October – 30th 2010 to 2021 Estimates of Tobago September Expenditure Audited Financial CARPHA 1st January – 31st December 2016 to 2021 Statements Source: Authors' construct 39 Chapter 5.  Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services Secondary Data Collection: 1 Annual budget documents were the primary source of data on health and health-related expenditures, particularly for the period 2009/2010 to 2020/2021. The main documents utilized were the Estimates of Expenditures for each country (Table 5.1 illustrates). 2 The Estimates of Expenditure present disaggregated expenditures at three levels: Economic, Functional and Programmatic levels. While the main functional level would have been “Health” overseen by the Ministry of Health of each country, programmatic areas such as “General Administration” were disaggregated and further detailed by economic classifications such as alloca- tions of salaries/personnel emoluments and goods and services, other. 3 In most cases, health expenditures are channeled through Ministries of Health, but there are exceptions. For example, expenditures on HIV and AIDS are decentralized across different ministries. This study focuses on expenditures undertaken by the Ministry of Health and Regional Health Authorities, and these were meticulously captured and mapped6 . Total government expendi- tures were also used for comparison and analysis—the main source being the central government’s Estimates of Expenditure. In cases where actual data were unavailable, revised estimates were used. 4 In the case of CARPHA, a review of available information was undertaken. The Agency’s Audited Financial Statements for the period 2016 to 2021 were used to obtain actual expenditures for the 6-year period 2016-2021. The expenditure was broken down across three main areas: staff costs, operating and administrative expenses and project expenses from donor resources. Donor Resources were obtained from the Agency’s Annual Reports for the period 2016 to 2021. Identification and Selection of Essential Public Health Services: 1 Among the countries, Estimates of Expenditure captured health service expenditure at varying levels of detail and accompanying information on the purpose of the expenditure in the context of EPHS. Typically, expenditure data was presented by function, programme, sub-programme, and task or activity. Descriptions of these items were provided in some cases, enabling the identification of EPHS-related expenditures. However, in other cases, such descriptions were lacking, leading to challenges in identifying EPHS- related expenditures. 2 A major challenge in the identification and selection of EPHS utilizing the public expenditures was the manner in which the expenditure data was recorded. In cases where descriptions or explanations were absent, an in-depth understanding of the functions of each sub-programme, task, or activity was necessary to identify and select the EPHS corresponding to specific expendi- tures. A mapping exercise was undertaken to address these data limitations. 6 In the case of Trinidad and Tobago and Jamaica, the majority of the Essential Public Health Functions are performed via the Vertical Services of the Ministry of Health and the Regional Health Authorities (RHAs). 40 Financing of Essential Public Health Services in the Caribbean Region Mapping of Essential Public Health Services: 1 The challenge of determining which EPHS should be assigned to the various Sub-programmatic areas was informed by a two-fold strategy: firstly, investigation of the individual services provided and secondly, interrogation of the weighting of expenditure allocations for each sub-programme. This was achieved through a collaborative process by engaging key institutional stakeholders of the Ministries of Health. Following this process, expenditure was allocated to the ten EPHS. Where possible, recurrent health expenditures on programmes or budget activities were further disaggregated by line items to allow for assign- ment to the best aligned EPHS. Additionally, Consultations with Ministry personnel sub-programme descriptions were used to were also conducted to corroborate further determine, and appropriately initial impressions of the respective assign, the services provided along with ­corresponding spending. programmes and sub-programmes as EPHS targets. Where programmes were aligned to more than one EPHS, a percentage split was utilized based on the programme description provided in the Estimates of Expenditure and the corroboration of the key informants based on their operational knowledge of the administration, management and objectives of the programmes executed by the Ministries of Health. These consultations also helped to determine and justify how expenditures were to be allocated for programmes/sub-programmes that executed multiple EPHS. In some instances, allocations to the EPHS were done by weighting personnel emoluments of different programmes. Allocation of Expenditure to the Selected EPHS: 1 The outcome of consultations in Step 4—the mapping of relevant programmes to their associated EPHS—was followed by the allocation of the associated expenditures or shares of expenditures to the EPHS. Next, lines of expenditure were then grouped by EPHS and collated to find totals for each EPHS. Total expenditure for EPHS were collated by adding all totals for each of the ten EPHS. Analysis of Expenditure on Essential Public Health Services: 1 Following the allocation of expenditure to EPHS, the SHA country reports (Trinidad and Tobago, Ministry of Health 2018; Barbados, Ministry of Health 2014; Grenada; HEU 2017) were then utilized to determine the proportion of this expenditure spent on prevention and preventative activities. The value obtained was further allocated to different disease conditions using the allocations as derived from the SHA reports. For Jamaica, in the absence of a SHA, allocations to prevention actives were arrived at using national data informed by the SHA findings in other case studies. 41 Chapter 5.  Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services Figures 5.1 to 5.3 provide three scenarios of the translation from budget/­ expenditure data (line items/programme description) to EPHS with justification for mapping and the corresponding weights, where applicable. Figure 5.1. Figure 5.1. Example of Mapping Example of ofExpenditure Mappingof Expenditureto toEPHS EPHSin inAA Simple Case Simple Case Level of Disaggregation of Data Available Function Sub function Clear Description Country Expenditure of Programme in Programme Data Expenditure Data Sub-programme Activity EPHS easily identified Expenditure allocated to EPHS EPHS Category 1. Assess and monitor population health 2. Investigate, diagnose and address health hazards and root causes 3. Communicate effectively to inform and educate 4. Strengthen, support and mobilize communities and partnerships 5. Create, champion and implement policies, plans and laws 6. Utilize legal and regulatory actions 7. Enable equitable access 8. Build a diverse and skilled workforce 9. Improve and innovate through evaluation, research and quality improvement 10. Build and maintain a strong organizational infrastructure for public health Source: Authors’ Construct Source: Authors' construct 42 Financing of Essential Public Health Services in the Caribbean Region Figure 5.2. Figure 5.2. Example of Mapping Example of ofExpenditure Mappingof Expenditureto toEPHS EPHSin inaa Case with Case with Limited/Inadequate Programme Description Limited/Inadequate Programme Description Level of Disaggregation of Data Available Function Sub function Limited/Inadequate Country Expenditure Description of Programme Programme Data in Expenditure Data Sub-programme Activity EPHS not easily identified Key Informant Utilization of Other Interviews Country Data Sources Expenditure allocated to EPHS EPHS Category 1. Assess and monitor population health 2. Investigate, diagnose and address health hazards and root causes 3. Communicate effectively to inform and educate 4. Strengthen, support and mobilize communities and partnerships 5. Create, champion and implement policies, plans and laws 6. Utilize legal and regulatory actions 7. Enable equitable access 8. Build a diverse and skilled workforce 9. Improve and innovate through evaluation, research and quality improvement 10. Build and maintain a strong organizational infrastructure for public health Source: Authors’ Construct Source: Authors' construct 43 Chapter 5.  Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services Figure 5.3. Figure 5.3. Example Example of Mappingof of Mapping ofExpenditure Expenditureto toEPHS EPHSin inaa Case where Case where a a Programme Programme isis Identified Identified with with More More thanOne than OneEPHS EPHS Level of Disaggregation of Data Available Function Sub function Limited/Inadequate Country Expenditure Description of Programme Programme Data in Expenditure Data Sub-programme Activity EPHS not easily identified Key Informant Utilization of Other Interviews Country Data Sources More than one EPHS identified Key Informant Utilization of Other Interviews Country Data Sources Weighting Expenditure allocated to EPHS EPHS Category 1. Assess and monitor population health 2. Investigate, diagnose and address health hazards and root causes 3. Communicate effectively to inform and educate 4. Strengthen, support and mobilize communities and partnerships 5. Create, champion and implement policies, plans and laws 6. Utilize legal and regulatory actions 7. Enable equitable access 8. Build a diverse and skilled workforce 9. Improve and innovate through evaluation, research and quality improvement 10. Build and maintain a strong organizational infrastructure for public health Source: Author’s Construct Source: Authors' construct 44 Financing of Essential Public Health Services in the Caribbean Region 5.3. Main Findings from Data Capture Exercise Based on discussions during the data capture exercise, there seemed to be incon- sistencies in data reporting within and among the case study countries. Further, there was a lack of conformity with some international approaches, such as the SHA. Consistency of budget reporting across years within the countries also posed challenges as changes in Government Administrations sometimes resulted, not only in changes in possible Administrative “Head” titles, but also in the reporting format for expenditure. With regard to the collection of data, there were also challenges when the formats and the system of accounting had been modified, especially in light of comparisons among countries. Despite the differences, the discussions held with personnel from the Ministries of Health from the study countries provided clarity with respect to how data should be considered, and expenditures allocated to the various EPHS. Further details of the methodological processes used for each country, is provided in the Detailed Methodological Annex that accompanies this report. Based on the SHA methodology, prevention activities refer only to expenditure on health prior to diagnosis, which are related notably through population-based programmes such as information campaigns, vaccination, early case detection and healthy condition monitoring programmes. In instances where both prevention and treatment are captured together, disaggregation of the associated expenditures is problematic. As such, the assumption was made that prevention estimates from the SHA reports were applicable. During the desk review of CARPHA, efforts were constrained by the understandably limited, publicly available details on Project Expenses from Donor Sources. It was noted that some expenditure items would most likely span more than one EPHS. In these instances, given the lack of details disaggregated by activities, expenditures ­ llocated to the most likely/aligned EPHS without reallocation splits as was were a done for the case study countries. During the desk review on CARPHA, efforts were constrained by the lack of publicly available details on Project Expenses from Donor Sources. 45 Chapter 5.  Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services 5.4. EPHS Figure 5.4. Figure Mapping Process EPHS Mapping Process Identification Determination Collaboration on of the“criterion” of the objectives the determination Calculation Allocation of codes for of weighting and description of the relevant expenditure the EPHS of programme EPHS identified Source: Authors’ Construct Source: Authors' construct 5.4. The Way Forward: Development of a Mapping Instrument for EPHS Having utilised the six-step process as detailed in the preceding discussion, it would be beneficial to develop an instrument to further guide the process for mapping EPHS against allocations of expenditures, particularly during Steps 3 and 4. As such, an output of this research is a preliminary draft of a proposed instrument. The instrument was constructed using the CDC’s dissection of the activities captured under each EPHS (CDC, 2020). The CDC’s criteria are used to guide the mapping of programmes or sub-programmes to the EPHS for the proposed instru- ment (CDC 2020). The mapping will give a detailed description of what activities the programmes fulfil and therefore, which EPHS would be better linked to the programmes. Using the recommended instrument (Figure 5.5) with stakeholder consultation and validation by health practitioners, managers, planners, and government administrators and planners, the identification of the most applicable and relevant EPHS health expenditure allocations can be identified for various programmes. For example, where a programme or sub-programme has to be mapped, the process is described in Figure 5.4. This suggested approach validates determinations initially considered “subjective” because of: + The decision on whether a programme or sub-programme can be considered as an EPHS; + The assignment of weights to EPHS for expenditure allocations; and + The approach adopted for mapping EPHS across different case studies. 46 Financing of Essential Public Health Services in the Caribbean Region Figure 5.5. Figure Segmentof 5.5. Segment ProposedMapping ofProposed MappingInstrument Instrumentfor forEPHS EPHS Programme 1 EPHS Criterion EPHS Description Criterion Description Programme Title Code Code Programme Description Maintaining an ongoing understanding of health in the jurisdiction by collecting, monitoring, and analyzing data on a health and factors that influence health to identify threats, patterns, and emerging issues, with a particular emphasis on disproportionately affected populations Using data and information to determine the root causes of b health disparities and inequities Assess and monitor population health Working with the community to understand health status, c status, factors that needs, assets, key influences, and narrative 1 influence health, Collaborating and facilitating data sharing with partners, d and community including multisector partners needs and assets Using innovative technologies, data collection methods, and e data sets Utilizing various methods and technology to interpret and f communicate data to diverse audiences Analyzing and using disaggregated data (e.g., by race) to g Source: Authors’ Construct track issues and inform equitable action Engaging community members as experts and key partners h 1 Percentage of EPHS 1 Criteria Met =(# met/8) x 100 Anticipating, preventing, and mitigating emerging health a threats through epidemiologic identification Monitoring real-time health status and identifying patterns to b develop strategies to address chronic diseases and injuries Investigate, diagnose, and Using real-time data to identify and respond to acute c address health outbreaks, emergencies, and other health hazards 2 problems and Using public health laboratory capabilities and modern d hazards affecting technology to conduct rapid screening and high-volume testing the population Analyzing and utilizing inputs from multiple sectors and e sources to consider social, economic, and environmental root causes of health status Identifying, analyzing, and distributing information from f new, big, and real-time data sources 2 Percentage of EPHS 2 Criteria Met = (# met/6) x 100 Developing and disseminating accessible health information a and resources, including through collaboration with multi-sector partners b Communicating with accuracy and necessary speed Using appropriate communications channels (e.g., social media, c peer-to-peer networks, mass media, and other channels) to effectively reach the intended populations Communicate Developing and deploying culturally and linguistically effectively to appropriate and relevant communications and educational inform and d resources, which includes working with stakeholders and 3 educate people influencers in the community to create effective and culturally about health, resonant materials factors that Employing the principles of risk communication, health influence it, and e literacy, and health education to inform the public, when how to improve it appropriate Actively engaging in two-way communication to build trust with f populations served and ensure accuracy and effectiveness of prevention and health promotion strategies Ensuring public health communications and education efforts are asset-based when appropriate and do not reinforce g narratives that are damaging to disproportionately affected populations 3 Percentage of EPHS 3 Criteria Met = (#met/7) x 100 Source: Authors’ Construct 47 Chapter 5.  Summary of Methodological Approach for Mapping Expenditures to Essential Public Health Services Figure 5.5. Segment of Proposed Mapping Instrument for EPHS (continued) Programme 1 EPHS Criterion EPHS Description Criterion Description Programme Title Code Code Programme Description Convening and facilitating multisector partnerships and a coalitions that include sectors that influence health (e.g., Strengthen, support, planning, transportation, housing, education, etc.) and mobilize 4 communities and Fostering and building genuine, strengths-based relationships partnerships to b with a diverse group of partners that reflect the community improve health and the population Authentically engaging with community members and c organizations to develop public health solutions Learning from, and supporting, existing community d partnerships and contributing public health expertise 4 Percentage of EPHS 4 Criteria Met = (#met/4) x 100 Source: Authors’ Construct Source: Authors' construct 48 Financing of Essential Public Health Services in the Caribbean Region Chapter 6 Chapter 6 Essential Public Health Expenditure Reporting in Case Studies Case Studies 49 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Chapter 6. Essential Public Health Expen- diture Reporting in Case Studies 6.1. Total Expenditure on EPHS Measuring the performance of EPHS is a major undertaking, both in terms of complexity and cost. It demands a robust information system, as well as relatively strong technical and administrative capacities (Khaleghian and Das Gupta, 2004). Typically, EPHS are delivered by multiple institutions in the health system with the Ministry of Health being the entity charged with the responsibility of coordinating and leading public health initiatives. However, in many low- and middle-income countries, resource constraints often make it difficult for ministries of health to fully execute their core public health functions. Nevertheless, the ten EPHS aim to promote “optimal health for all by addressing systemic and structural barriers”. The EPHS are linked to three core functions of Public Health: Assessment, Policy Development and Assurance (CDC, 2020). Table 6.1 refers. Table 6.1. Ten Essential Public Health Services by Core Functions ASSESSMENT POLICY DEVELOPMENT ASSURANCE 1. Assess and monitor 3. Communicate effectively to 7. Enable equitable access. population health. inform and educate. 8. Build a diverse and skilled 2. Investigate, diagnose and 4. Strengthen, support and workforce. address health hazards mobilize communities and 9. Improve and innovate and root causes. partnerships. through evaluation, research 5. Create, champion and and quality improvement. implement policies, plans 10. Build and maintain a strong and laws. organizational infrastructure 6. Utilize legal and regulatory for public health. actions. Source: Centers for Disease Control and Prevention 2020 1 Core Function 1: Assessment: This involves collecting and analysing infor- mation about the health status and health needs of communities, vulnerable groups and the overall population as well as the factors that influence their health status. The surveillance data that is collected is utilised to anticipate, monitor and address threats to population health. 2 Core Function 2: Policy Development: A multifaceted function that includes effective communication and partnerships with communities. It also requires creating, championing and implementing plans/policies to address threats to population health. 3 Core Function 3: Assurance: Ensures equitable provision of quality health ser- vices by a diverse skilled workforce through a health system, through research and innovation and a strong organizational infrastructure (CDC 2020). Though an imperfect measure, expenditure on EPHS can serve as an indication of the Ministry of Health’s priorities. This information can then be utilised by countries to determine whether their current and historical expenditure is in line with their public health goals and objectives. 50 Financing of Essential Public Health Services in the Caribbean Region Health expenditures escalated across the four countries during the 2020–2021 period with the onset of the COVID-19 pandemic. In part this was driven by increased health promotion, epidemiological s ­ urveillance, testing and general monitoring of community health under response efforts. The trends in total expenditure on EPHS varied among countries (Figure 6.1). For Barbados, the trend is reflective of an overall decline in health expenditure. In con- trast, Grenada, Jamaica and Trinidad and Tobago showed steady, slow increases in expenditure with one or two periods of minimal declines. With the onset of COVID-19, particularly during the 2020–2021 period, there were increases in expenditure in all the case study studies since the response required a revamping of health promotion, community health epidemiological surveillance, testing and general monitoring of ­ (Figure 6.1). In Jamaica and Grenada particularly, there were steeper increases in 2021, largely due to increased capital flows from grant funding. 6.1. Total Expenditure on Essential Public Health Services in US$, Figure 6.1. Figure (i) Barbados,(ii) (i) Barbados, (ii)Grenada, (iii)Jamaica, Grenada,(iii) Jamaica,and (iv)Trinidad Trinidadand and(iv) Tobago andTobago 45,000,000 35,000,000 40,000,000 30,000,000 35,000,000 25,000,000 30,000,000 25,000,000 20,000,000 20,000,000 15,000,000 15,000,000 10,000,000 10,000,000 5,000,000 5,000,000 0 0 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 2020/2021 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 (i) Barbados (ii) Grenada 100,000,000 300,000,000 90,000,000 80,000,000 250,000,000 70,000,000 60,000,000 200,000,000 50,000,000 40,000,000 150,000,000 30,000,000 20,000,000 100,000,000 10,000,000 0 50,000,000 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 2020/2021 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 (iii) Jamaica (iv) Trinidad and Tobago Source: Authors’ Construct Source: Authors' construct 51 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies 6.2. Total Recurrent Expenditure on EPHS by Services 6.2.1. Case Study Countries The allocation of recurrent expenditure across the ten EPHS was concentrated in four EPHS. With the onset of the COVID-19 pandemic, there was a noticeable increase in expenditure on EPHS 2, which relates to surveillance, across all ­ countries. (Figure 6.2). Figure 6.2. Expenditure on Essential Public Health Services (in US$), Figure 6.2. Expenditure on Essential Public Health Services (in US$), (i) Barbados, (i) Barbados, Grenada, (ii) Jamaica, (ii) Grenada, (iii) (iii) (iv) Jamaica, Trinidad and(iv) Trinidad and Tobago. Tobago 10. Build and maintain… 10. Build and maintain… 9. Improve and innovate… 9. Improve and innovate… 8. Build a diverse and… 8. Build a diverse and… 7. Enable equitable access 7. Enable equitable access 6. Utilize legal and… 6. Utilize legal and… 5. Create, champion and… 4. Strengthen, support... 5. Create, champion and… 3. Communicate effectiv… 4. Strengthen, support... 2. Investigate, diagnose… 3. Communicate effectiv… 1. Assess and monitor… 2. Investigate, diagnose… 0 100,000,000 200,000,000 1. Assess and monitor… 2009/2010 2010/2011 2011/2012 2012/2013 0 5,000,000 10,000,000 2013/2014 2014/2015 2015/2016 2016/2017 2012 2013 2014 2015 2016 2017/2018 2018/2019 2019/2020 2020/2021 2017 2018 2019 2020 2021 (i) Barbados (ii) Grenada 10. Build and maintain a… 10. Build and maintain a… 9. Improve and innovate… 9. Improve and innovate… 8. Build a diverse and… 8. Build a diverse and… 7. Enable equitable access 7. Enable equitable access 6. Utilize legal and… 6. Utilize legal and… 5. Create, champion and… 5. Create, champion and… 4. Strengthen, support… 4. Strengthen, support… 3. Communicate effectively… 3. Communicate effectively… 2. Investigate, diagnose and… 2. Investigate, diagnose and… 1. Assess and monitor… 1. Assess and monitor… 0 100,000,000 0 100,000,000 2010/2011 2011/2012 2012/2013 2013/2014 2010 2011 2012 2013 2014 2015 2014/2015 2015/2016 2016/2017 2017/2018 2016 2017 2018 2019 2020 2021 2018/2019 2019/2020 2020/2021 (iii) Jamaica (iv) Trinidad and Tobago Source: Authors’ Construct Source: Authors' construct 52 Financing of Essential Public Health Services in the Caribbean Region Expenditure on EPHS 2 was the most significant among the three EPHS with the largest expenditure allocations (Table 6.2). EPHS 7, which treats with enabling equitable access to health services, was also significant for three out of the four countries. Trinidad and Tobago was an outlier, with the second largest allocation of EPHS expenditure going to EPHS 6 (legal and regulatory actions, licensing, enforcement and compliance) and EPHS 1 (data gathering), being the third largest allocation. In Grenada, EPHS10 (organizational infrastructure) and in Jamaica, EPHS 8 (skill and diversity of the workforce), were among the top three expenditure allocations. When linking these findings to the broad core functions, it was evident that Trinidad and Tobago had a more significant expenditure on services geared towards Policy Development than Barbados, Grenada and Jamaica. Conversely, expenditure on Assurance was greater for the latter countries (Figure 6.3). Grenada and Jamaica had similar expenditure distributions in the core areas. In all countries, the core area of “Assessment” was dominated by expenditure allocations to EPHS 2, particularly for Grenada and Barbados. Table 6.2. Three Largest Allocations of EPHS Expenditure Categories by Country EPHS RANKING BARBADOS GRENADA JAMAICA TRINIDAD AND TOBAGO 1. Assess and monitor - - 3 population health 2. Investigate, diagnose and address health hazards and 2 1 2 1 root causes. 3. Communicate effectively to 3 - - inform and educate. 6. Utilize legal and regulatory - - - 2 actions 7. Enable equitable access. 1 2 1 - 8. Build a diverse and skilled - - 3 - workforce. 10. Build and maintain a strong organizational - 3 - - infrastructure for public health. Source: Authors' construct 53 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Figure6.3. Figure 6.3. Expenditure Expenditure on Essential Public on Essential HealthServices PublicHealth Servicesby byCore CoreFunctions Functions (in US$), (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago (in US$), (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago 45,000,000 9,000,000 40,000,000 8,000,000 35,000,000 7,000,000 30,000,000 6,000,000 25,000,000 5,000,000 20,000,000 4,000,000 15,000,000 3,000,000 10,000,000 2,000,000 5,000,000 0 1,000,000 0 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 2020/2021 12 13 14 15 16 17 18 19 20 21 20 20 20 20 20 20 20 20 20 20 Year Assessment Policy Development Assurance Assessment Policy Development Assurance (i) Barbados (ii) Grenada 100,000,000 300,000,000 90,000,000 80,000,000 250,000,000 70,000,000 60,000,000 200,000,000 50,000,000 40,000,000 150,000,000 30,000,000 20,000,000 100,000,000 10,000,000 0 50,000,000 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 2020/2021 0 10 20 1 20 2 20 3 20 4 20 5 20 6 20 7 20 8 20 9 20 0 21 1 1 1 1 1 1 1 1 1 2 20 20 Assessment Policy Development Assurance Assessment Policy Development Assurance (iii) Jamaica (iv) Trinidad and Tobago Source: Authors’ Construct Source: Authors' construct The diagram depicts a relatively even distribution of EPHS expenditure across thematic areas in three of the four countries. Grenada was the outlier, where Assessment and Assurance account for 53% and 44% of expenditure, respectively. During 2020/2021, Grenada, witnessed a steady increase in expenditure on Assurance, particularly enabling equitable access. In summary, the COVID-19 pandemic led In Jamaica, there was a surge in expenditure to an increase in expenditure across all across all three thematic areas due to the demands of effectively responding to functions, particularly in the Assurance COVID-19. Barbados saw a sharp decline in function, reflecting an emphasis on expenditure across all thematic areas during enabling equitable access. the 2017/2018-2018/2019 period, coinciding with a change of government and the onset of an IMF arrangement. However, recovery took place in the ensuing period. Trinidad and Tobago similarly experi- enced a decline in all thematic areas in 2019 to 2020, followed by recovery. 54 Financing of Essential Public Health Services in the Caribbean Region These trends are encouraging as they align with the expectations for a public health agency like CARPHA. 6.2.2. CARPHA Over the 7-year period, CARPHA primarily allocated its public health expenditure across eight of the EPHS. As shown in Figure 6.4, EPHS 2, which deals with surveillance and addressing health hazards, accounted for the largest share of CARPHA’s expenditure throughout the period — a trend that continued in 2020 and 2021. The Agency maintained a relatively stable level of expenditure on EPHS 10 in 2020 and 2021. Figure6.4. Figure 6.4.CARPHA: CARPHA: Allocation Allocation of Expenditure Expenditure 2015–2021 toEPHS 2015–2021to EPHS TOTAL EPHS 10 TOTAL EPHS 9 TOTAL EPHS 8 TOTAL EPHS 7 TOTAL EPHS 6 TOTAL EPHS 5 TOTAL EPHS 4 TOTAL EPHS 3 TOTAL EPHS 2 TOTAL EPHS 1 - 5,000,000 10,000,000 15,000,000 20,000,000 25,000,000 30,000,000 2015 2016 2017 2018 2019 2020 2021 Source: Authors’ Construct Source: CARPHA Audited Financial Statements 2016-2021 and Authors' Allocation From Figure 6.5, it can be seen that over the 7-year period, most of CARPHA’s expenditure was allocated to the Assessment component, which includes Using public health laboratory capabilities, Anticipating, preventing, and mitigating emerging health threats through epidemiologic identification and Monitoring real-time health status and identifying patterns. This is not surprising given CARPHA’s role as the Regional Public Health Agency responsible for assessing and monitoring population health status and investigating, diagnosing and addressing health problems and hazards affecting the Region’s population. Expenditure on Assessment was significant in 2020 and 2021 reflecting the demand for specific services as the COVID-19 pandemic evolved. 55 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies 6.5.Thematic Figure6.5. Figure Grouping of Thematic Grouping 10 EPHS, of 10 EPHS, CARPHA CARPHA 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 - 2015 2016 2017 2018 2019 2020 2021 Assessment Policy Development Assurance Source: CARPHA Audited Financial Statements 2016–2021 and Author’s Calculations Source: CARPHA Audited Financial Statements 2016-2021and Authors' Calculations It is worth noting that the review suggests that from 2016 to 2019, CARPHA’s spending on Assurance peaked and exceeded spending on Assessment. EPHS under the Assurance theme involved agencies providing services aimed at improving the workforce and strengthening evaluation and research. While Assessment expen- diture dominated in 2020 and 2021, expenditure for all three thematic areas rose due to the need to adequately respond to COVID-19, which required intensive and consistent responses in all three areas. CARPHA was established as the sole regional public health agency, to fill the existing gaps in public health, respond to common regional public health challenges and strengthen public health capacity in member states. Its chief goal is to improve the health status of the peoples of the Region. CARPHA’s functions are regional in scope, and it collaborates closely with the Ministries of Health of Member States to deliver on the EPHS. 6.3. Total Capital Expenditure on EPHS 6.3.1. Case Study Countries Barbados focused on EPHS 7 and 10, while Grenada To strengthen public health and Jamaica concentrated on EPHS 2 and 7. Trinidad infrastructure and enabling and Tobago dedicated its capital expenditure to equitable access, capital EPHS 1, 2 and 6, respectively (Figure 6.6). For all expenditures on EPHs were countries, EPHS 2 was very important. In Grenada, the focus was on enabling equitable access (EPHS 7) concentrated on specific areas. and addressing health hazards (EPHS 2), with capital expenditure heavily ­ ommunity services. This trend was consistent both before concentrated on c and during the pandemic. 56 Financing of Essential Public Health Services in the Caribbean Region Figure TotalCapital Figure 6.6. Total CapitalExpenditure Expenditure on on EPHS EPHS (in (in US$), US$), (i)(i) Barbados, Barbados, (ii) Grenada, (ii) Grenada, Jamaica,and (iii)Trinidad (iii) Jamaica, (iv) Trinidad and Tobago (iv) Tobago 10. Build and maintain… 10. Build and maintain… 9. Improve and innovate… 9. Improve and innovate… 8. Build a diverse and… 8. Build a diverse and… 7. Enable equitable access 7. Enable equitable access 6. Utilize legal and… 6. Utilize legal and… 5. Create, champion and… 5. Create, champion and… 4. Strengthen, support... 4. Strengthen, support... 3. Communicate effectiv… 3. Communicate effectiv… 2. Investigate, diagnose… 1. Assess and monitor… 2. Investigate, diagnose… 1. Assess and monitor… -2,000,000 0 2,000,0000 4,000,000 6,000,000 2009/2010 2010/2011 2011/2012 2012/2013 0 1,000,000 2,000,000 2013/2014 2014/2015 2015/2016 2016/2017 2012 2013 2014 2015 2016 2017/2018 2018/2019 2019/2020 2020/2021 2017 2018 2019 2020 2021 (i) Barbados (ii) Grenada 10. Build and maintain a… 10. Build and maintain a… 9. Improve and… 9. Improve and… 8. Build a diverse and… 8. Build a diverse and… 7. Enable equitable… 7. Enable equitable… 6. Utilize legal and… 6. Utilize legal and… 5. Create, champion… 5. Create, champion… 4. Strengthen, support… 4. Strengthen, support… 3. Communicate… 3. Communicate… 2. Investigate, diagnose… 2. Investigate, diagnose… 1. Assess and monitor… 1. Assess and monitor… 0 100,000,000.00 0 40,000,000.00 2010/2011 2011/2012 2012/2013 2013/2014 2010 2011 2012 2013 2014 2015 2014/2015 2015/2016 2016/2017 2017/2018 2016 2017 2018 2019 2020 2021 2018/2019 2020/2021 2021/2022 (iii) Jamaica (iv) Trinidad and Tobago Source: Authors’ Construct Source: Authors' construct 57 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies It is not surprising that most countries targeted capital spending towards strengthening the public health infrastructure and enabling equitable access. For all countries with health hazards in focus, EPHS 2 was very important. In Jamaica, only capital expenditures on programmes providing EPHS were considered, excluding all other activities. This included capital expenditure related ­ to projects funded by the Government of Jamaica and projects financed by multilateral/bilateral agencies, with counterpart funding from the Government of Jamaica. In Barbados, the COVID-19 pandemic led to a decrease in capital expenditures for EPHS 10 and a redirection of funds towards EPHS 7, primarily through investments in Polyclinics. Capital Health Expenditures in Barbados encompass expenses related to Capital Assets, Land Acquisitions, Capital Transfers, and Debt Servicing Amortization. Regarding Trinidad and Tobago, the distribution of capital expenditures revealed that EPHS 6, the legal and regulatory measures to safeguard public health specifically, the Insect Vector Control Division), received the highest proportion of (­ funding, representing nearly 40% of total expenditure. Moreover, EPHS 2, which focuses on assessing and monitoring the health status of the population, was allocated the second-highest proportion of funding, accounting for 25% of the expenditure. total ­ In Trinidad and Tobago, the Assessment and Policy Development functions were the most significant. Barbados and Grenada allocated most of their capital expenditure towards the Assurance function, while for Jamaica, it was the Assessment function that received the most funding. It is worth noting that the Assurance function was underfunded in Grenada before 2018, but there was an overall increase in its allocation during the study period (Figure 6.7). Analyzing the Capital EPHS e ­ xpenditures based on core functions, it was found that the Assessment and Assurance functions were predominant in most countries, except for Trinidad and Tobago. 58 Financing of Essential Public Health Services in the Caribbean Region Figure 6.7. Capital Expenditure on Essential Public Health Services by Core Figure 6.7. Capital Functions (US$),Expenditure on Essential (i) Barbados, Public (ii) Grenada, Health (iii) Services Jamaica, by (iv) Core Functions Trinidad and (US$), Tobago (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago 1,600,000 1,600,000 1,400,000 1,400,000 1,200,000 1,200,000 1,000,000 800,000 1,000,000 600,000 800,000 400,000 600,000 200,000 400,000 0 200,000 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 2020/2021 0 12 13 14 15 16 17 18 19 20 21 20 20 20 20 20 20 20 20 20 20 Assessment Policy Development Assurance Assessment Policy Development Assurance (i) Barbados (ii) Grenada 20,000,000 25,000,000 18,000,000 16,000,000 20,000,000 14,000,000 12,000,000 15,000,000 10,000,000 8,000,000 6,000,000 10,000,000 4,000,000 2,000,000 5,000,000 0 0 20 /2 1 20 /2 2 20 3/2 3 20 /2 4 20 /2 5 20 /2 6 20 /2 7 20 /2 8 20 /2 9 /2 0 1 11 01 12 01 1 01 14 01 15 01 16 01 17 01 18 01 19 01 20 02 02 20 /2 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 10 20 Assessment Policy Development Assurance Assessment Policy Development Assurance (iii) Jamaica (iv) Trinidad and Tobago Source: Authors’ Construct Source: Authors' construct 59 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies 6.4. Trends in the Distribution of Expenditures to EPHS in Case Studies A closer look at the total expenditure by core function for the financial years 2012/13, 2016/17, and 2020/21 shows that all countries, except Trinidad and Tobago, witnessed an increase in EPHS expenditure as a percentage of total gov- ernment health expenditure in the final year of the study (Figure 6.8 and Table 6.3). Over the period of review, the Assessment function consistently received the highest percentage of health expenditure across all countries, with EPHS 2 accounting for most allocations. In addition, Trinidad and Tobago had the highest percentage allocations to EPHS 2, 6, and 10, while Barbados consistently allocated the highest percentage to EPHS 7. Tables 6.4 and 6.5 present the percentage allocation of recurrent and capital expenditures to the respective EPHS for the same three years. This is calculated as the expenditure allocated to the respective EPHS as a percentage of the total EPHS expenditure for the particular year. The largest expenditure allocations were observed for EPHS 2 (investigating, diagnosing, and addressing health hazards and root causes), accounting for 13% to 57% of recurrent expenditures and EPHS 7 (enable equitable access), which represented 1% to 63% of recurrent expenditures. Trinidad and Tobago, however, had the largest allocations to EPHS 1 (assessing and monitoring population health), and EPHS 6 (utilizing legal and regulatory actions) when compared to the other case study countries. In contrast, EPHS 5 (creating, championing, and implementing policies, plans and laws), and EPHS 9 (improving and innovating through evaluation research and quality improvement), received the least amount from the total health expendi- tures among the countries. Capital expenditures were focused on EPHS 2 and 7, with Trinidad and Tobago also directing funds to EPHS 6. These expenditures were particularly consistent over the period with some notable exceptions with external funding. For example, Grenada, recorded its capital expenditure by programmatic areas and type of funding, that is, grants or loans from local revenue. In 2012, grants accounted for approximately 61 percent of total capital expenditure, whereas local revenue represented percent. By 2021, grants accounted for 99 percent and local revenue, approxi- 39 ­ mately 1 percent. This trend suggests a decline in local revenue funding as grants funding increased. Between 2012 to 2019, most funding via grants were allocated to hospital services in Grenada. However, in 2020 and 2021, 40 percent and 90 percent of grant funds were allocated to administration, respectively. Capital expenditure funded from local revenue was mainly allocated to community services from 2012 to 2016. But, from 2017 to 2021, most local revenue funds were allocated to hospital services. 60 Financing of Essential Public Health Services in the Caribbean Region Figure 6.8. Figure 6.8.Total TotalEPHS Expenditure EPHS as a as Expenditure % of a%Total Government of Total Health Health Government Expenditure — Various Years Expenditure - Various Years 35.00% 30.85% 28.26% 30.00% 25.00% 22.20% 22.89% 18.93% 17.97% 20.00% 16.30% 12.75% 15.00% 9.36% 10.00% 6.48% 6.78% 4.73% 5.00% 0.00% 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Barbados Grenada Jamaica Trinidad Assessment 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Barbados Grenada Jamaica Trinidad 1 2 Policy Development 8.00% 6.00% 4.00% 2.00% 0.00% 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Barbados Grenada Jamaica Trinidad 3 4 5 6 Assurance 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Barbados Grenada Jamaica Trinidad 7 8 9 10 Source: Authors’ Construct Source: Authors' construct 61 Table 6.3. Total EPHS Expenditure as a % of Total Government Health Expenditure—Various Years EPHS DESCRIPTION BARBADOS GRENADA JAMAICA TRINIDAD 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Assess and Monitor 1 0.00% 0.00% 0.00% 0.00% 0.00% 0.02% 0.64% 0.76% 0.80% 7.03% 4.85% 3.11% Population Health Investigate, diagnose, and 2 address health hazards and 4.26% 4.49% 5.52% 5.23% 1.69% 8.34% 0.86% 1.12% 9.27% 11.83% 14.65% 13.07% root causes Communicate effectively to 3 4.91% 0.38% 0.29% 0.03% 0.00% 0.00% 0.17% 0.25% 1.87% 0.66% 0.53% 0.29% inform and educate Strengthen, support and 4 mobilize communities and 2.25% 0.31% 0.37% 0.00% 0.00% 0.00% 0.14% 0.08% 0.06% 0.00% 0.00% 0.00% partnerships Create, champion and 5 implement policies, plans and 0.00% 0.20% 0.08% 0.00% 0.00% 0.00% 0.42% 0.25% 0.18% 0.00% 0.00% 0.00% laws Utilize legal and regulatory 6 0.12% 0.16% 0.11% 0.58% 0.10% 0.38% 0.16% 0.18% 0.15% 6.91% 5.41% 2.88% actions 7 Enable equitable access 6.42% 6.73% 11.23% 0.12% 2.19% 11.52% 2.68% 2.75% 2.56% 1.91% 1.43% 0.92% Build a diverse and skilled 8 0.04% 0.10% 0.04% 1.30% 0.37% 0.55% 1.12% 1.00% 0.77% 0.00% 0.00% 0.00% workforce Improve and innovate 9 through evaluation research, 0.00% 0.07% 0.03% 0.00% 0.00% 0.00% 0.15% 0.17% 0.53% 0.18% 0.13% 0.07% and quality improvement Build and maintain a strong 10 organizational infrastructure 0.93% 0.30% 0.30% 2.10% 0.38% 1.38% 0.15% 0.22% 0.11% 2.32% 1.26% 2.56% for public health Total EPHS Expenditure as a % of Total Government 18.93% 12.75% 17.97% 9.36% 4.73% 22.20% 6.48% 6.78% 16.30% 30.85% 28.26% 22.89% Health Expenditure Source: Authors' construct 62 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies 63 Table 6.4. Percentage Distribution of Recurrent Expenditures to EPHS (as a % of Total EPHS—Various Years) EPHS DESCRIPTION BARBADOS GRENADA JAMAICA TRINIDAD AND TOBAGO 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Assess and Monitor Population 1 0% 0% 0% 0% 0% 0% 10% 11% 5% 23% 17% 14% Health Investigate, diagnose, and 2 address health hazards and root 23% 35% 31% 56% 36% 38% 13% 17% 57% 38% 53% 57% causes Communicate effectively to 3 26% 3% 2% 0% 0% 0% 3% 4% 12% 2% 2% 1% inform and educate Financing of Essential Public Health Services in the Caribbean Region Strengthen, support and 4 mobilize communities and 11% 2% 2% 0% 0% 0% 2% 1% 0% 0% 0% 0% partnerships Create, champion and 5 implement policies, plans and 0% 2% 0% 0% 0% 0% 6% 4% 1% 0% 0% 0% laws Utilize legal and regulatory 6 1% 1% 1% 6% 2% 2% 2% 3% 1% 22% 18% 13% actions 7 Enable equitable access 34% 53% 63% 1% 46% 52% 41% 41% 16% 6% 5% 4% Build a diverse and skilled 8 0% 1% 0% 14% 8% 2% 17% 15% 5% 0% 0% 0% workforce Improve and innovate through 9 evaluation research, and quality 2% 1% 0% 0% 0% 0% 2% 2% 3% 1% 0% 0% improvement Build and maintain a strong 10 organizational infrastructure 5% 2% 2% 22% 8% 6% 2% 3% 1% 0% 5% 11% for public health 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Source: Authors' construct Table 6.5. Percentage Distribution of Capital Expenditures to EPHS (as a % of Total EPHS—Various Years) EPHS DESCRIPTION BARBADOS GRENADA JAMAICA TRINIDAD AND TOBAGO 2012/13 2016/17 2020/21 2012 2016 2021 2012/13 2016/17 2020/21 2012/13 2016/17 2020/21 Assess and Monitor Population 1 0% 0% 0% 0% 0% 0% 0% 0% 0% 25% 25% 25% Health Investigate, diagnose, and 2 address health hazards and root 0% 0% 18% 11% 11% 11% 82% 75% 57% 22% 22% 22% causes Communicate effectively to 3 0% 0% 0% 3% 3% 3% 0% 0% 0% 2% 2% 2% inform and educate Strengthen, support and 4 mobilize communities and 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% partnerships Create, champion and 5 implement policies, plans and 0% 0% 0% 0% 0% 0% 0% 0% 20% 0% 0% 0% laws Utilize legal and regulatory 6 0% 0% 0% 0% 0% 0% 0% 0% 0% 40% 40% 40% actions 7 Enable equitable access 9% 0% 109% 85% 86% 86% 18% 23% 23% 9% 9% 9% Build a diverse and skilled 8 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% workforce Improve and innovate through 9 evaluation research, and quality 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% improvement Build and maintain a strong 10 organizational infrastructure 91% 100% −26% 0% 0% 0% 0% 3% 0% 2% 2% 2% for public health 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Source: Authors' construct 64 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Financing of Essential Public Health Services in the Caribbean Region Capital expenditure in Jamaica comprised projects funded by the Government of Jamaica and projects and those financed by multilateral/bilateral agencies with counterpart funding from the Government of Jamaica. These project-related expenditures were aimed at addressing NCDs, HIV and Maternal Health and Child Mortality via large grants and loans. Similarly, Barbados showed a clear relationship between capital expenditure and loans. Capital expenditures were between 1 percent to 2.3 percent of total MoHW expenditures over the study period, with the exception of 2019/2021 based on a jump to 12.14 percent from the inflow of COVID-19 grants from the European Investment Bank. Donor flows to Barbados are normally directed to HIV spending under the framework of curative care (Bhuwanee 2018). 6.4.1. Trends in Distribution of Annual Recurrent Expenditure to EPHS 1 EPHS 1: Assess and Monitor Population Health: Figure 6.9 shows the annual distribution of recurrent health expenditure to EPHS 1 across the countries and CARPHA. Trinidad and Tobago emerged as the highest spender on this EPHS, whereas Barbados had no allocations over the study period. Expenditures made by Trinidad and Tobago and CARPHA declined in the latter years of the study. Grenada’s peak allocations were in 2017/2018 following a redirection of expenditures toward this EPHS. 2 EPHS 2: Investigate, Diagnose, and Address Health Hazards and Root Causes: Figure 6.10 shows the significant allocations to EPHS 2, except for Jamaica, which were further supported by CARPHA. Expenditures incremen- tally increased during the review period, particularly between 2019 and 2020. 3 EPHS 3: Communicate Effectively to Inform and Educate: Of all categories, EPHS 3 was on the lower end of expenditures except for Barbados, where expenditures dramatically decreased in the latter years. CARPHA and the other countries had low but consistent contributions to EPHS 3 (Figure 6.11). 65 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Figure 6.9. Distribution of Recurrent Expenditure to EPHS 1 as a % of Total Figure 6.9. Distribution of Recurrent Expenditure to EPHS 1 as a % of Total Health Expenditures (2009/2010 to 2020/2021) Health Expenditures (2009/2010 to 2020/2021) 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 01 01 01 01 01 01 02 02 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 09 10 11 12 13 14 15 16 17 18 19 20 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct Source: Authors' construct Figure 6.10. Distribution of Recurrent Expenditures to EPHS 2 as a % of Total Figure 6.10. Health Distribution of Expenditures Recurrent Expenditures (2009/2010 to 2020/2021)to EPHS 2 as a % of Total Health Expenditures (2009/2010 to 2020/2021) 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 01 01 01 01 01 01 02 02 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 09 10 11 12 13 14 15 16 17 18 19 20 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct Source: Authors' construct 66 Financing of Essential Public Health Services in the Caribbean Region Figure 6.11. Distribution of Recurrent Expenditures to EPHS 3 as a % of Total Figure 6.11. Distribution of Recurrent Expenditures to EPHS 3 as a % of Total Health Health Expenditures (2009/2010 to 2020/2021) Expenditures (2009/2010 to 2020/2021) 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 01 01 01 01 01 01 02 02 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 09 10 11 12 13 14 15 16 17 18 19 20 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct Source: Authors' construct 4 EPHS 4: Strengthen, Support and Mobilize Communities and Partnerships: EPHS 4 was among the least emphasized EPHS. Figure 6.12 shows that Barbados and Jamaica had the largest allocations to this EPHS, while Grenada and Trinidad and Tobago made no contributions over the study period. The allocation to EPHS 4 in Barbados decreased significantly from 2015/2016. 5 EPHS 5: Create, Champion and Implement Policies, Plans and Laws: EPHS 5 received consistent but relatively low allocations from Jamaica, and Barbados in the latter years. While the allocations were greater than those for EPHS 4, EPHS 5 received less than 8 percent of expenditures in Jamaica and less than 3 percent in Barbados. It is worth noting that Jamaica’s expenditure on EPHS 5 decreased in the latter years of the study. CARPHA’s allocations to this EPHS between 2016 and 2017 were between 2 percent and 3 percent of total health expenditure (Figure 6.13). 6 EPHS 6: Utilize Legal and Regulatory Actions: Trinidad and Tobago had the highest percentage allocation towards EPHS 6. While there was a marked difference between Trinidad and Tobago and the other case studies for expenditure on this EPHS, there was a decline in allocations over the period particularly between 2019 and 2021 (Figure 6.14). 67 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Figure 6.12. Distribution of Recurrent Expenditures to EPHS 4 as a % of Total Figure 6.12. Distribution of Recurrent Expenditures to EPHS 4 as a % of Total Health Health Expenditures Expenditures (2009/2010 (2009/2010 to 2020/2021) to 2020/2021) 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 01 01 01 01 01 01 02 02 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 09 10 11 12 13 14 15 16 17 18 19 20 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct Source: Authors' construct Figure 6.13. Distribution of Recurrent Expenditures to EPHS 5 as a % of Total Figure 6.13. Health of Recurrentto Distribution (2009/2010 Expenditures 2020/2021)to EPHS 5 as a % of Total Health Expenditures Expenditures (2009/2010 to 2020/2021) 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% 0 1 2 3 4 5 6 17 18 9 0 1 01 01 01 01 01 01 01 02 02 01 20 20 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 / / 10 11 12 13 14 15 16 17 18 19 20 09 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct Source: Authors' construct 68 Financing of Essential Public Health Services in the Caribbean Region Figure6.14. Figure 6.14.Distribution Distributionof Recurrent Expenditures of Recurrent to EPHS Expenditures to 6 as % of EPHS 6 Total Health as % of Total Expenditures (2009/2010 to 2020/2021) Health Expenditures (2009/2010 to 2020/2021) 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 01 01 01 01 01 01 02 02 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 09 10 11 12 13 14 15 16 17 18 19 20 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct Source: Authors' construct 7 EPHS 7: Enable Equitable Access: EPHS 7, like EPHS 2 received one of the largest allocations, which was maintained consistently throughout the study period. Jamaica, Barbados and Grenada were the leaders in allocations to EPHS 7, while Trinidad and Tobago lagged significantly. Though CARPHA pro- percent). vided greater support for this EPHS, it was still relatively low (under 5 ­ Figure 6.15 refers. 8 EPHS 8: Build a Diverse and Skilled Workforce: Jamaica’s allocation to EPHS 8 was just over 10 percent of total health expenditure, followed by CARPHA and Grenada and Barbados (Figure 6.16). There was a declining trend for alloca- tions in the latter years of the study. Figure 6.15. Figure 6.15. Distribution Distribution of Recurrent of Recurrent Expenditures Expenditures to 7 to EPHS EPHS as a %7of asTotal a % of Total Health Expenditures Health (2009/2010 Expenditures to 2020/2021) (2009/2010 to 2020/2021) 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 1 1 1 01 01 01 02 02 20 20 20 2 2 2 2 2 2 2 2 2 9/ 0/ 1/ 2/ / / / 6/ 7/ 8/ 9/ 0/ 13 14 15 0 1 1 1 1 1 1 1 2 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct 69 Source: Authors' construct Chapter 6. Essential Public Health Expenditure Reporting in Case Studies 9 EPHS 9: Improve and Innovate through Evaluation Research, and Quality improvement: Figure 6.17 shows that CARPHA had the largest allocation to EPHS 9 with an expenditure peak of 14 percent of its total health expenditure in 2014/2015, declining to 6 percent in 2015/2016 and raising again to 10 percent in 2020/2021. Conversely, less than 4 percent of total health expenditures were allocated by the case study countries to this EPHS. 10 EPHS 10: Build and Maintain a Strong Organizational Infrastructure   for Public Health improvement: Apart from Grenada in 2011/2012 and Trinidad and Tobago, the countries allocated less than 15% of expenditures to EPHS 10 over the period. Over 15 percent of CARPHA’s total health expenditure was allocated to this EPHS, peaking at 39 percent in 2016/2017 before declining gradually to 15 percent in 2019/2020 and then sharply percent in 2020/2021 (Figure 6.18). recovering to 19 ­ Figure 6.16. Figure 6.16.Distribution Distributionof Recurrent Expenditures of Recurrent to EPHSto Expenditures 8 as a % of EPHS 8 Total as a %Health of Total Expenditures (2009/2010 to 2020/2021) Health Expenditures (2009/2010 to 2020/2021) 20.00% 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 0 1 2 3 14 15 6 7 8 9 0 1 01 02 02 01 01 01 01 01 01 01 20 20 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 3/ 4/ 18 19 20 09 10 11 12 15 16 17 1 1 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Source: Authors'Construct construct Figure 6.17. Figure 6.17. Distribution Distribution of Recurrent of Recurrent Expenditures Expenditures to EPHSto EPHS 9 as 9Total a % of as a % of Total Health Health Expenditures (2009/2010 Expenditures (2009/2010 to 2020/2021) to 2020/2021) 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 01 01 01 01 01 01 02 02 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 09 10 11 12 13 14 15 16 17 18 19 20 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Source: Authors'Construct construct 70 Financing of Essential Public Health Services in the Caribbean Region Figure 6.18. Figure 6.18. Distribution Distribution of Recurrent of Recurrent Expenditures Expenditures to 10 to EPHS as a 10 EPHS asTotal % of a % of Total Health Health Expenditures Expenditures (2009/2010 (2009/2010 to 2020/2021) to 2020/2021) 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 0 1 2 3 4 5 6 7 8 9 0 1 01 01 01 01 01 01 01 01 01 01 02 02 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 09 10 11 12 13 14 15 16 17 18 19 20 20 20 20 20 20 20 20 20 20 20 20 20 Barbados Grenada Jamaica Trinidad and Tobago CARPHA Source: Authors’ Construct Source: Authors' construct 6.5. EPHS Expenditure, Core Functions and Country Health Policy With the exception of Trinidad and Tobago, little to no recurrent expenditure was allocated to EPHS 1 (assessing and monitoring population health). This is one of the two EPHS linked to the Assessment function (Tables 6.4 and 6.5). Recurrent expen- diture allocated to EPHS 3 to 6, which is linked to the Policy Development function, was also low, particularly in areas for EPHS 3 (effectively communicating to inform and educate) and EPHS 4 (strengthening, supporting and mobilizing communities and partnerships). The largest expenditure allocations were associated with services across the Assurance function. However, the lowest expenditure allocations were associated with EPHS 8 to 10, which are related to the areas of building a diverse and skilled workforce (EPHS 8), improving and innovating through evalua- tion, research and quality improvement (EPHS 9) and building and maintaining a strong organizational infrastructure for public health (EPHS 10). Except for Trinidad and Tobago, capital expenditure attracted limited allocations towards services geared to the Policy Development function. Caution should be exercised in interpreting these allocations since EPHS with low expenditure allocations may not be captured if embedded in other expenditure items. For this reason, it is important to capture expenditure items in Health Accounts so that further analysis can be done to assess the effectiveness of both recurrent and capital health expenditures. The lower spending on the Policy Development function may indicate an expenditure gap, which may be worthy of attention by countries. However, a different narrative emerges when the country 71 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies It is possible that the observed allocation patterns are reflective of the countries’ various health plans. Further, some EPHS may require larger allotments than others. health plans are matched with the health functions, as shown in Table 6.6. general trend of the Assurance function receiving the largest recurrent The ­ ­ expenditure allocation seems to be mirrored in the broad goals of the strategic plans/development. This may imply a stronger focus on health services/activities that are more aligned to the Assurance function. Thus, what we may be observing is countries’ expenditure being aligned with their various plans. Further, we may also be observing a situation where the expenditure required for some EPHS is considerably more than others. EPHS 2 for example, will usually require a larger expenditure outlay than EPHS 3. What is important though is the resilience and sustainability of the health system, particularly within the context of global health security. Table 6.6. Country Health Plans by Goals/Objectives Linked to Core Public Health Function COUNTRY HEALTH PLAN GOALS/OBJECTIVES CORE FUNCTION Promotion and Protection of the Health of the Assessment population National Strategic Provision of safe and quality-centered services Assurance Barbados Plan for Health (NSPH) 2018–2022 Improvement of the performance of the health Assurance system Engagement and mobilization of partners in health Policy Development Leadership and Governance: To create an enabling environment for the development and delivery of Assurance quality health care services in Grenada Health Services Delivery: An equitable, sustainable and quality health service which responds to the Assurance needs of the population Human Resources for Health: A cadre of competent, motivated health care workers Assurance providing quality health care Strategic Plan for Grenada Pharmaceuticals and Medical Technology: Health 2016–2025 Provision of an adequate quantity of good quality, Assurance safe and affordable medicines, vaccines and health care technology Health Financing: To secure adequate and sustainable funds to support national health ** development goals. Health Information System: An Effective National Information System for health to support Assurance evidenced-based decision-making (Continued) 72 Financing of Essential Public Health Services in the Caribbean Region Table 6.6. Country Health Plans by Goals/Objectives Linked to Core Public Health Function (Continued) COUNTRY HEALTH PLAN GOALS/OBJECTIVES CORE FUNCTION Safeguarding access to equitable, comprehensive Assurance and quality health care The stewardship capacity of the Ministry of Health is strengthened to improve leadership and Policy Development governance to achieve universal access to health and universal health coverage Increased and improved health financing with Vision for Health ** equity and efficiency Jamaica 2030 — Ten-year Strategic Plan Ensuring human resources for health in sufficient number and competencies, committed to the Assurance mission Social participation and inter-sectoral collaborations to address the social determinants Policy Development of health Making reliable and modern infrastructure Assurance available for Health Service Delivery The Healthcare System of Trinidad and Tobago will be sustainable and modern and deliver higher standards of healthcare: • Improve the performance of health sector agencies Assurance Government of the Trinidad and • Ensure the sustainable funding of the Republic of Trinidad Tobago health sector and Tobago, 2016 • Improve access to healthcare services The people of Trinidad and Tobago will be empowered to lead healthy lifestyles: Promote Policy Development preventative health care Source: Authors' construct 6.6. An Analysis of Per Capita EPHS Expenditure CARPHA’s per capita EPHS expenditure on its 26 Member States ranged between US$0.39 and US$0.49 over the 2016 to 2020 period (Figure 6.19). In 2020, the per capita EPHS expenditures by CARPHA trended upward. Among the study countries, Jamaica’s per capita EPHS expenditures were on the lower end of the scale ranging from US$13.53 to US$17.84 over the period. Trinidad and Tobago recorded the highest per capita EPHS expenditures ranging from US$121.53 to US$180.98, followed by Barbados, with expenditures ranging from US$47.91 to US$95.62. Grenada’s per capita EPHS expenditures spanned US$5.23 to US$29.68 (Figure 6.20). 73 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Figure 6.19. CARPHA Per Capita EPHS Expenditure US$ Figure 6.19. CARPHA Per Capita EPHS Expenditure US$ 0.6 0.5 0.4 0.3 0.2 0.1 0 2016 2017 2018 2019 2020 Source: Authors’ Construct Source: Authors' construct Figure 6.20. Per Capita EPHS Expenditures by CARPHA and Case Study Countries Figure (US$) 6.20. Per Capita EPHS Expenditures by CARPHA and Case Study Countries (US$) 200 180 160 140 120 100 80 60 40 20 0 2016 2017 2018 2019 2020 CARPHA Barbados Grenada Jamaica Trinidad and Tobago Source: Authors’ Construct Source: Authors' construct 74 Financing of Essential Public Health Services in the Caribbean Region 6.6.1. Per Capita Expenditure by EPHS Figure 6.21 reveals that CARPHA’s largest per capita expenditures were directed to EPHS 2 (Investigate, diagnose and address health hazards and root causes). EPHS 10 (Build and maintain a strong organizational infrastructure for public health) ranked second. Figures 6.22 to 6.25 illustrate the distribution of per capita expenditures across the countries. Figure 6.21. Distribution of Per Capita Expenditures (US$) by EPHS (CARPHA) Figure 6.21. Distribution of Per Capita Expenditures (US$) by EPHS (CARPHA) 10. Build and maintain a strong organizational… 9. Improve and innovate through evaluation, research… 8. Build a diverse and skilled workforce 7. Enable equitable access 6. Utilize legal and regulatory actions 5. Create, champion and implement policies, plans and… 4. Strengthen, support and mobilize communities and… 3. Communicate effectively to inform and educate 2. Investigate, diagnose and address health hazards… 1. Assess and monitor population health 0 0.2 0.4 0.6 0.8 1 1.2 2016 2017 2018 2019 2020 Source: Authors’ Construct Source: Authors' construct Figure 6.22. Distribution of Per Capita Expenditures (US$) by EPHS (Barbados) Figure 6.22. Distribution of Per Capita Expenditures (US$) by EPHS (Barbados) 10. Build and maintain a strong organizational… 9. Improve and innovate through evaluation, research… 8. Build a diverse and skilled workforce 7. Enable equitable access 6. Utilize legal and regulatory actions 5. Create, champion and implement policies, plans and… 4. Strengthen, support and mobilize communities and… 3. Communicate effectively to inform and educate 2. Investigate, diagnose and address health hazards… 1. Assess and monitor population health 0 50 100 150 200 250 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 Source: Authors’ Construct Source: Authors' construct 75 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Figure 6.23. Distribution of Per Capita Expenditures by EPHS (Grenada) Figure 6.23. Distribution of Per Capita Expenditures by EPHS (Grenada) 10. Build and maintain a strong organizational… 9. Improve and innovate through evaluation, research… 8. Build a diverse and skilled workforce 7. Enable equitable access 6. Utilize legal and regulatory actions 5. Create, champion and implement policies, plans and… 4. Strengthen, support and mobilize communities and… 3. Communicate effectively to inform and educate 2. Investigate, diagnose and address health hazards… 1. Assess and monitor population health 0 5 10 15 20 25 30 35 40 45 2016 2017 2018 2019 2020 Source: Authors’ Construct Source: Authors' construct Figure 6.24. Distribution of Per Capita Expenditures (US$) by EPHS (Jamaica) Figure 6.24. Distribution of Per Capita Expenditures (US$) by EPHS (Jamaica) 10. Build and maintain a strong organizational… 9. Improve and innovate through evaluation, research… 8. Build a diverse and skilled workforce 7. Enable equitable access 6. Utilize legal and regulatory actions 5. Create, champion and implement policies, plans and… 4. Strengthen, support and mobilize communities and… 3. Communicate effectively to inform and educate 2. Investigate, diagnose and address health hazards… 1. Assess and monitor population health 0 5 10 15 20 25 30 35 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 Source: Authors’ Construct Source: Authors' construct 76 Financing of Essential Public Health Services in the Caribbean Region Figure 6.25. Distribution of Per Capita Expenditures (US$) by EPHS (Trinidad and Tobago) Figure 6.25. Distribution of Per Capita Expenditures (US$) by EPHS (Trinidad and Tobago) 10. Build and maintain a strong organizational… 9. Improve and innovate through evaluation, research… 8. Build a diverse and skilled workforce 7. Enable equitable access 6. Utilize legal and regulatory actions 5. Create, champion and implement policies, plans and… 4. Strengthen, support and mobilize communities and… 3. Communicate effectively to inform and educate 2. Investigate, diagnose and address health hazards… 1. Assess and monitor population health 0 50 100 150 200 250 300 350 400 450 2016 2017 2018 2019 2020 Source: Authors’ Construct Source: Authors' construct Much like CARPHA, Grenada and Trinidad and Tobago directed the highest per capita expenditures to EPHS 2, whilst both Barbados and Jamaica allocated most resources to EPHS 7. Trinidad and Tobago, and Barbados made significant contri- butions to per capita EPHS spending on their populations surpassing Grenada and Jamaica in overall EPHS expenditures. “The WHO defines “global health security” as a combination of proactive and reactive measures aimed at reducing the risk and severity of major public health events. — World Health Organization 2021 6.7. Global Health Security The Global Health Security Agenda (GHSA) focuses on preventing outbreaks of infectious diseases, early detection and rapid and effective response to biological threats (CDC 2022). The COVID-19 pandemic highlighted the issue of global health security and the need for a coordinated multisectoral approach to building strong and resilient health systems to address emerging threats. In light of this, national and international institutions have sought to build institutional capacity to address threats as they emerge. However, the effectiveness of the GHSA network is only as strong as its weakest link, making it critical to strengthen the response capacity at the national level. 77 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies The Global Health Security (GHS) Index is a useful tool for evaluating a country’s preparedness in this area. The GHS Index assesses countries across six categories, based on 37 indicators using 177 questions. Each country receives a score out of 100 for each category with the final overall score being a weighted sum of all six categories (Economist Impact 2021). Table 6.7, reproduced from the GHS Index Global Health Security Index 2021: GHS Index Methodology, provides a brief summary of the six categories. Table 6.7. GHS Index Categories and Indicators CATEGORY INDICATORS PREVENTION: Prevention of the emergence Antimicrobial resistance (AMR), zoonotic or release of pathogens, including those disease, biosecurity, biosafety, dual-use constituting an extraordinary public health risk research and culture of responsible science, and in keeping with the internationally recognized immunization definition of a Public Health Emergency of International Concern. DETECTION AND REPORTING: Early Laboratory systems strength and quality, detection and reporting for epidemics of laboratory supply chains, real-time surveillance potential international concern, which can and reporting, surveillance data, accessibility spread beyond national or regional borders. and transparency, case-based investigation, and epidemiology workforce RAPID RESPONSE: Rapid response to and Emergency preparedness and response mitigation of the spread of an epidemic. planning, exercising response plans, emergency response operation, linking public health and security authorities, risk communication, access to communications infrastructure, and trade and travel restrictions HEALTH SYSTEM: Sufficient and robust health Health capacity in clinics, hospitals, and system to treat the sick and protect health community care centres; supply chain for the workers. health system and healthcare workers; medical countermeasures and personnel deployment; healthcare access; communications with healthcare workers during a public health emergency; infection control, practices, and capacity to test and approve new countermeasures COMPLIANCE WITH INTERNATIONAL IHR reporting compliance and disaster risk, NORMS: Commitments to improving national reduction; cross-border agreements on public capacity, financing plans to address gaps, and animal health and emergency response; adhering to global norms. international commitments; completion and publication of WHO Joint External Evaluation (JEE) and the World Organisation for Animal Health (OIE) Performance of Veterinary Services (PVS) Pathway assessments; financing; and commitment to sharing of genetic and biological data and specimens RISK ENVIRONMENT: Overall risk environment Political and security risks; socio-economic and country vulnerability to biological threats. resilience; infrastructure adequacy; environmental risks; and public health vulnerabilities that may affect the ability of a country to prevent, detect, or respond to an epidemic or pandemic and increase the likelihood that disease outbreaks will spill across national borders Source: Economist Impact, 2021. 78 Financing of Essential Public Health Services in the Caribbean Region “A high score on the GHS index does not necessarily correspond with an effective response to a health threat. The COVID-19 pandemic ­demonstrated this as some countries with high GHS scores on the 2019 GHS Index were among the worst performers when the pandemic hit — Abbey et al. 2020 However, the index is useful for identifying available resources and capacities to respond to a global health threat while highlighting potential gaps. The global GHS average was 38.9 out of a possible 100 while the regional average for Latin America and the Caribbean (LAC) was 26.8. All four countries in the present study scored below the global average but were above the regional, with the exception of Grenada, which was marginally under this average. Trinidad and Tobago scored the highest among the four countries, ranking 88th out of 195 countries and coming closest to the global average. Grenada registered the lowest overall score among the case study countries and was ranked 157th out of 195 countries (Table 6.8). Table 6.8. GHS Index 2021-Overall Score Four Case Study Countries 2021 RANK COUNTRY INDEX SCORE CHANGE FROM 2019 OVERALL 88 Trinidad and Tobago 36.8 -0.9 98 Barbados 34.9 +2.7 120 Jamaica 31.8 +0.9 157 Grenada 26.7 +1.1 Source: Bell and Nuzzo, 2021 When analyzing the six categories as a group, it was found that the case study countries performed exceptionally well in terms of the risk environment and ­ compliance with international norms. They all scored above the global average for the former category, while three countries scored below the global average in the latter. Countries performed poorly in the areas of detection, followed by prevention and health systems. Table 6.9 refers. 79 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Table 6.9. GHS Index Case Study Countries Categories 2021 RANK COUNTRY INDEX CHANGE RANK COUNTRY INDEX CHANGE SCORE FROM 2019 SCORE FROM 2019 PREVENTION (Global Average 28.4) HEALTH SYSTEM (Global Average 31.5) Trinidad and 100 Barbados 23.8 0.0 81 33.7 −0.1 Tobago Trinidad and 103 22.3 0.0 124 Jamaica 19.3 +4.8 Tobago 148 Jamaica 13.7 −4.1 154 Grenada 14.2 +2.4 186 Grenada 5.3 +4.2 168 Barbados 12.0 +2.4 DETECTION AND REPORTING COMPLIANCE WITH INTERNATIONAL NORMS (Global Average 32.3) (Global Average 47.8) 136 Jamaica 19.3 +0.5 59 Barbados 54.7 +7.5 Trinidad and 160 Barbados 13.8 +5.9 98 46.4 −8.3 Tobago Trinidad and 163 12.6 +0.5 106 Grenada 45.0 0.0 Tobago 173 Grenada 10 +4.2 112 Jamaica 43.6 0.0 RAPID RESPONSE (Global Average 37.6) RISK ENVIRONMENT (Global Average 55.8) Trinidad and 52 43.2 −0.1 41 Barbados 69.5 +0.2 Tobago 98 Barbados 36.0 −1.1 58 Grenada 63.4 +1.4 Trinidad and 102 Jamaica 35.5 +4.3 63 62.7 −0.8 Tobago 179 Grenada 22.6 −5.1 76 Jamaica 59.4 −0.2 Source: Bell and Nuzzo, 2021 The GHS Index categories allow for closer examination of health security gaps. For the risk environment category, Barbados and Grenada scored below the global average for the environmental risk indicator, highlighting potential concerns with urbanization, land use and natural disaster risk. Grenada and Jamaica scored below the global average for the public health vulnerabilities indicator, indicating gaps in access to quality healthcare, the level of public health spending per capita, water and sanitation, and the level of public trust in medical and health advice. Turning to the health system category, only Trinidad and Tobago scored above the global average. The four countries’ scores were above average for indicators related to health capacity in health facilities and health care but below average for indicators related to supply chain management for the health system and health care workers, communication with health care workers and medical countermea- sures and personnel deployment during a public health emergency. All countries scored 100 on cross-border agreements on public and health emer- gency response in the norms category. However, they scored 0 for the Joint External Evaluation (JEE) and Performance of Veterinary Services (PVS) indicator, suggesting 80 Financing of Essential Public Health Services in the Caribbean Region that JEE and PVS assessments and gap analyses were not completed nor published. Countries also scored below average for the financing indicator which implies that gaps may exist in financing for epidemic preparedness and financing the emer- gency response. Across all four countries, the prevention category had several weak areas related to zoonotic disease, biosecurity, biosafety, dual-use research and culture of responsible science. In addition, the indicators related to laboratory supply chains were a The GHS Index scores and indicators weak area for all countries. Indicators relating reveal concerning weaknesses in the to laboratory systems strength and quality, and health security at the country level, surveillance were below the global average for all countries apart from Jamaica. especially given the resource constraints that countries face. These metrics signal that prevention and early detection of biological threats must be prioritized as countries have limited capacity to treat with surges in hospital occupancy during public health emergencies. While the concept of global health security resides in the notion of a global collaboration, the COVID-19 pandemic has shown that a more practical approach could involve a regional collaborative effort at first, followed by international collaboration if necessary for early rapid detection and science-based response. Another key lesson emerging from the pandemic is the importance of decision making and the role of the national community in executing global health security strategy when moving from potential capacity to actual response. In addition to a country’s ability to treat individuals affected by biological threats, global health security and risk cannot be delinked from the population’s health status. This presents an added challenge given the epidemiological patterns in the study countries, particularly regarding non-communicable diseases. The EPHS serve as the means through which the goals of the public health system are executed under the GHS agenda. As Lal (2022) noted: “When it comes to public health crises, global health security efforts—while essential—will fall short unless concretely tied to broader health systems strengthening initiatives.” (Lal 2022). It is important that EPHS are fully functional even prior to a crisis. Early detection and response are key to mitigating the impact of global threats. Within the broader context of a country’s path towards Universal Health Coverage (UHC), the WHO (2021) noted that utilising a primary health care approach alongside the EPHFs can help countries achieve both UHC and health security. The argument here is that resilience must be built into health care systems through an integrated approach which marries the push towards UHC with the systemic incorporation of health security. Three recommendations were presented as key investments: 1 Strengthening EPHF focusing on a primary health care approach incorporating health security; 2 All-hazards emergency risk management; and 3 Measures to promote inclusive governance cross-societal engagement and involvement. (World Health Organization 2021). 81 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies This raises three concerns: the role financing plays in health security, the capacity of countries to respond to global threats and the effective delivery of EPHS. Each of these concerns will be reflective of how much countries allocate to the EPHS, particularly in Prevention, Detection and Response. Thus, at the country level, the ability to address the key areas of the GHS Agenda is underpinned by government expenditure on the EPHS. 6.8. Prevention—Recurrent EPHS Expenditure Due to the lack of disaggregated data on EPHS, estimating prevention spending can be challenging. Instead, the results from the SHA studies for the case study countries were used to estimate prevention spending related to the EPHS. For instance, in Grenada, recurrent expenditure on prevention was estimated as 3% of total health expenditure and 7% of government spending. Using this baseline, a sharp increase in prevention spending was noted during the 2020/2021 period (Figure 6.26). For Barbados, prevention expenditure was estimated at 2% of total health expenditure, whilst for Jamaica, and Trinidad and Tobago, it was 14%, based on completed Health Accounts. Similar to Grenada, these figures were used as a baseline to estimate prevention expenditure for EPHS. Preventing expenditure slowly declined in Barbados during the period with only a couple instances of increases in 2012/2013 and 2019/2020. Interestingly, during the COVID-19 pandemic in 2020-2021, there was a slight decrease in prevention spending possibly due to the prioritization of COVID-19 activities before the first regional cases. During this period Barbados opened a second state-of-the-art infectious disease isolation facility. The overall decline in prevention spending for the period may reflect an increased emphasis on curative care. Grenada, Jamacia, and Trinidad and Tobago all increased prevention expenditure on EPHS, particularly during the 2020/2021 period. Prevention Spending is a major component of EPHS expenditure and provides insight into the effectiveness of a health system. 82 Financing of Essential Public Health Services in the Caribbean Region Figure 6.26. Estimated Total Prevention Expenditure (in US Dollars), Figure 6.26. Estimated Total Prevention Expenditure (in US Dollars), (i) Barbados, (i) Barbados, (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago (ii) Grenada, (iii) Jamaica, (iv) Trinidad and Tobago 4,500,000 1,800,000 4,000,000 1,600,000 3,500,000 1,400,000 3,000,000 2,500,000 1,200,000 2,000,000 1,000,000 1,500,000 800,000 1,000,000 600,000 500,000 0 400,000 200,000 20 0/2 0 20 1/2 1 20 2/2 2 20 3/2 3 20 4/2 4 20 5/2 5 20 6/2 6 20 7/2 7 20 8/2 8 20 9/2 9 /2 0 1 1 01 1 01 1 01 1 01 1 01 1 01 1 01 1 01 1 01 1 01 20 02 02 0 20 9/2 0 12 13 14 15 16 17 18 19 20 21 20 20 20 20 20 20 20 20 20 20 20 (i) Barbados (ii) Grenada 14,000,000 100,000,000 12,000,000 90,000,000 80,000,000 10,000,000 70,000,000 8,000,000 60,000,000 6,000,000 50,000,000 4,000,000 40,000,000 2,000,000 30,000,000 0 20,000,000 10,000,000 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 2020/2021 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 (iii) Jamaica (iv) Trinidad and Tobago Source: Authors’ Construct Source: Authors' construct The OECD (2017) reported that “only a small fraction of health spending goes towards prevention activities” with OECD countries estimating prevention spending at less than 3%. Similarly, the countries under investigation spend less on prevention compared to treatment (Gmeinder et al. 2017). Although not surprising, given the relatively high cost of treatment, it raises an important consideration for the Caribbean. As the resource endowment of the region is not on par with that of OECD countries, where the capacity for treatment is much higher, it makes sense for the Caribbean to prioritize prevention spending over treatment. The average per capita health expenditure in the OECD countries was US$4,948 in 2019, further emphasizing the need for a similar approach in the Caribbean.7 Curative care accounts for the majority of health spending in the Caribbean, which is consistent with global trends. The SHA reports indicate that spending on curative care, inpatient and outpatient was estimated at 75 percent (Barbados), 78 percent (Grenada), and 55 percent (Jamaica). These results are comparable to the OECD country report in which curative care accounted for approximately 60 percent (Gmeinder et al. 2017). 7 World Bank (2022) https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=OE 83 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies To increase investments in prevention, the public must have a better understanding of prevention activities. From routine activities, including immunization, food safety inspection, and assuring safe drinking water, to more visible ones like safe workplace regulations, pollution controls, traffic speed limits and weapon restric- tions—the population must consistently be made aware of the importance of public health. Raising public awareness will aid in both making the case for higher levels of investment and enabling international comparability. The region should be investing twice as much as the OECD countries in prevention at a minimum given that average per capita health expenditure in the region is just over US$700, around 14% of the OECD average. 6.9. Detection—Recurrent EPHS Activities Despite some issues with unspecified preventative activities, the SHA studies showed that the second highest preventative activity was related to Healthy Condition Monitoring Programmes. In Grenada, early disease detection pro- grammes, accounted for 10 percent of total health expenditure. In Jamaica and Trinidad and Tobago, spending on epidemiological surveillance, risk and disease control programmes accounted for 7 percent, with spending on early disease detection programmes accounting for less than 1 percent in both countries. Disaggregated expenditure on preventative activities in Barbados were unavail- able at the time of the study. Gmeinder et al. (2017) identified that early disease detection programmes accounted for less than 10 percent of prevention spending in a number of OECD countries. Regionally, spending on immunization programmes accounted for approx- imately 1 percent of health spending. In 28 European countries, spending ranged between 0.09 percent and 2.51 percent, with a median of 0.30 percent (Pascaline Faivre et al, 2021). 6.10. Response—Recurrent EPHS Activities Unfortunately, a lack of disaggregated data prevented the examination of expen- diture geared towards the Response aspect of the global health security agenda in the pre-COVID-19 period. One noteworthy project in Grenada, which seems to align with issues of global health security during this period, was the OECS Regional Health Project with the World Bank. This project accounted for a significant increase in EPHS 2 for Grenada and included: + Laboratory testing capacity for detection of priority diseases based on JEE Scores; 84 Financing of Essential Public Health Services in the Caribbean Region + Emergency operations center capacities, procedures and plans; + Indicator/event-based surveillance 2020; and + Designated laboratories with COVID-19 diagnostic equipment, test kits and reagents. As it pertains to the COVID-19 period, the Grenada Estimates of Revenue and Expenditure for 2019-2021 show the addition of an expenditure line for MoH Administration COVID-19, but no expenditure was recorded. The same is also true for other line items, including the India-UN Development Partnership Fund-COVID-19 Response project, the EDF COVID-19 Response Project and the Public Awareness COVAX projects. In Barbados where a line item was located under the Office of the Prime Minister for COVID-19 in 2019/2020, no actual expenditure was recorded for that period. Expenses records were also missing for the Programme 366 National Crisis Management; Sub-programme- Programme Management- COVID-19 — both ­ established to coordinate and manage activities relating to the COVID-19 pandemic. The issue also persisted in 2022/2023 when these items were transferred ­ to the MoHW with no expenditure details. In the 2020/2021 financial year, Jamaica’s Ministry of Health allocated ­ approximately US$52.9 million (J$8.01 billion) to a new line item in the budget -Activity 10668 COVID-19 Response. The National Health Fund (NHF) was also given the responsibility to procure and distribute pharmaceuticals, medical equipment, personal protection equipment and other items as part of the ministry’s COVID-19 programme. The value of these items was approximately US$23.7 million (Jamaica National Health Fund, 2021). The government also announced a goal of vaccinating 2 million persons by March 2022 and allocated US$34.6 million for vaccine procurement and US$6.7 million to support vaccine roll out, which included temporary staff across the four RHAs at a cost of approximately US$1.6 million) (Planning Institute of Jamaica 2022). In June 2020, the Government of Trinidad and Tobago signed a loan agree- ment with the Development Bank of Latin America (CAF) to strengthen the country’s capacity to respond to the COVID-19 pandemic. 8 CAF signed two loans with Trinidad and Tobago—one for US$100 million and the second for US$50 million, to help mitigate the economic impact of COVID-19, and fund the operational health emergency response. The multilateral organization also donated US$400,000 donation prior to these two loans to support the country’s response efforts. CAF also organized capacity-building webinars for the country’s health personnel to enhance their knowledge and skills in responding to the pandemic. 8 https://www.finance.gov.tt/2020/06/26/caf-covid-19-signing-ceremony/ 85 Chapter 6. Essential Public Health Expenditure Reporting in Case Studies Due to inadequate disaggregated data, a significant amount of expenditure (53% in Barbados, 60% in Grenada, and 73% in Jamaica and Trinidad and Tobago) could not be allocated to specific disease conditions. However, of data that was disaggregated, the majority of expenditure was allocated to non-communicable diseases with spending on infectious and parasitic diseases accounting for a relatively small percentage (2 percent in Grenada, 3.9 percent in Jamaica and ­ 2 percent in Trinidad and Tobago) of health expenditure. It should be noted that the issue of inadequate disaggregated data in these countries stems from challenges in collecting and recording of information, which was also evident in the previous SHA studies. Additionally, prevention spending according to the SHA covers a narrower set of activities than those considered by public health methods. 6.11. EPHS by Source of Funding Across the Caribbean region, health financing comes from several sources including taxes (income, value-added, sales or excise); social health insurance; private insurance payments; and out-of-pocket payments (OOP) by households (Nakhimovsky et al. 2013; Bhuwanee et al. 2013). Figure 6.27 portrays the typology of health financing for several Caribbean countries. In all case countries, the majority of expenditure on EPHS was covered by local revenue. In Grenada, this amounted to 98 percent while around 2 percent of expenditure was financed by external sources through grants and/or loans. A similar trend was observed in Barbados. In Jamaica and Trinidad and Tobago, health is financed by a hybrid of taxes, social health expenditures and private health insurance. Typology of Figure 6.27. Typology ofHealth HealthFinancing Financingin inthe the Caribbean Caribbean Tax/Budget Finanacing Social Health Insurance Hybrid (Taxes, SHI and (60+%) (SHI) (60+%) Private Health Insurance) Anguilla Aruba Antigua Barbados Bermuda Bahamas Belize Cayman Island British Virgin Islands Dominica Curacao Jamaica Grenada St. Maarten Trinidad and Tobago Montserrat Suriname St. Kitts Turks and Caicos Islands St. Lucia St. Vincent Note: In Note: In all countries,fairly all countries, fairlyhigh highlevels levelsof ofout-of-pocket out-of-pocketpayments payments(means -33%) (means -33%) Source: Lalta, 2013 Source: Lalta, 2013 86 Financing of Essential Public Health Services in the Caribbean Region Recurrent expenditures are financed through government expenditures and account for over 90 percent of health expenditures in the countries under review, while capital expenditures are significantly lower and supported mainly by grants/loans. This is a potential concern regarding the sustainability and longevity of capital expenditures that are necessary for improving the quality and ­ efficiency of healthcare services. Additionally, mapping the EPHS sources of fund- ­ utside of government expenditures is a challenge given that the budget reports ing o of the governments do not directly or explicitly report on the funding sources allocated to specific lines of expenditures. This is a major gap. 87 Financing of Essential Public Health Services in the Caribbean Region Chapter 7 Innovative Policies and Mechanisms for Funding Public Health Services and Community-Based Interventions 89 Chapter 7. Innovative Policies and Mechanisms for Funding Public Health Services and Community-Based Interventions Due to the COVID-19 pandemic, funding from external sources significantly increased. For instance, Grenada received new capital funding from a World Bank grant for the COVID-19 response and access to an OECS Regional Health Project. Trinidad and Tobago also received COVID-19 support from the CAF. There may be opportunities for implementing and/or strengthening fiscal inter- ventions, which may impact positively on the health of the population while raising revenues (La Foucade et al. 2018). Jamaica provides an example of a sustainable approach to boosting tax-based financing by funding health services and commu- nity-based interventions via ear-marked funds, derived from a special consumption tax (20 percent), tobacco excise taxes (5 percent) and a specific national insurance contribution. 7.1. Key Findings Several areas for reflection emerged from the study that can inform future actions to strengthen the EPHS in the context of global health security: + This study primarily focuses on mapping funding sources, as opposed to assessing performance, given the lack of disaggregated data. Therefore, caution should be exercised when interpreting the implications of reduced spending. For example, an increase in capital expenditure on assets like prop- erty and plant, machinery and equipment, and grants to public institutions in one financial year, may lead to a subsequent decrease in the following years. Disaggregation of data and explanatory notes in the documentation phase would be needed to get a better understanding of spending patterns. + The countries utilize two critical pillars—Assessment (EPHS 2) and Assurance (EPHS 7)—in their strategy to provide equitable opportunities for their populations. The Caribbean’s performance in containing COVID-19 was relatively good, particularly in the early stages of the pandemic (Murphy et al., 2021). This could be attributable to the emphasis on diagnostic capacity (EPHS 2) and ensuring equitable access to available public health interventions (EPHS 7). However, some countries also prioritized communication (EPHS 3) and/or organizational infrastructure (EPHS 10). + Countries should receive support in strengthening their capacity to capture data and allocate actual expenditures accurately and efficiently. The SHA methodology could guide approaches to achieve this goal and better track the impact of the EPHS. + Lack of disaggregated data constrains the explication of funding allocated to specific arms of global health security, including prevention and responses. By extension, it has been difficult to determine if trends in spending are mainly a reflection of the prevailing epidemiological profile/pattern of infectious and parasitic diseases of local or regional significance. 90 Financing of Essential Public Health Services in the Caribbean Region + Grenada’s documentation of funding received from the OECS Regional Health Project with the World Bank highlights the importance of having mechanisms to record all donations and grants. In contrast there was generally a lack of documentation in Barbados where actual capital expenditures during the COVID-19 period including assets under construction like property and plant; machinery and equipment and grants to public institutions, were not captured. + In some cases, spending on aspects of the COVID-19 response was low, but the value of what countries received by virtue of being CARICOM member states may be relatively high. For example, PAHO and the Serum Institute of India donated equipment, supplies, materials, and vaccines. Arguably, this would necessitate reduced spending in aspects of global health security by the member countries. However, in practice, the country would still be able to meet the requirements for a strong EPHS response, even in the absence of “spending.” 91 Financing of Essential Public Health Services in the Caribbean Region Chapter 8 Conclusions: Agenda for Future Action 93 Chapter 8.  Conclusions: Agenda for Future Action “ The EPHS “…provide a framework for public health to protect and promote the health of all people in all communities” —Public Health National Center for Innovations 2020 8.1. Main Messages of the Report Caribbean countries have agreed to the critical importance of essential public health and essential public health functions and services for building efficient, resilient health systems. In this regard, it is worth noting that almost two decades ago, the Caribbean Commission on Health and Development (CCHD) stressed that: “Any attempt to improve Caribbean health must begin with considering the… capacity of the health systems as a whole… There is a critical need to examine the public health systems to correct the deficiencies in discharging the essential public health functions.” (CCHD, 2006; 99). There is evidence that the countries have worked both at the various national levels and at the regional level to coordinate efforts pertaining to essential public health. There is also evidence of capacity building and training related to these areas. However, what is also clear, is that there is no evidence of corresponding attention on tracking of resource allocations to the EPHS. What is also clear, is that there is no The study has shown that countries’ budgets evidence of corresponding attention are not structured to match the ten EPHS on tracking of resource allocations to functions and significant effort is required the EPHS. to track the expenditure. If we accept that a health system that allocates expenditure along the guidelines provided by the EPHS is likely to benefit from increased efficiencies in resource allocation, then some effort should be placed on tightening the match between what is considered to be EPHS and what is happening at the country level in terms of budgetary allocations. While acknowledging that individual CARICOM member states will have differing national priorities, a key conclusion of the study is that there is need to better harmonize collection of and reporting on EPHS spending data to enable a robust framework for global health security decision-making, given the region’s inherent vulnerabilities as SIDS countries. As such, there are important areas for action for CARICOM countries. 94 Financing of Essential Public Health Services in the Caribbean Region 1 Countries need to be able to identify exactly which programmes are being supported by EPHS funds to determine if they are achieving stated goals. This requires reviewing and potentially restructuring of health finance management systems or budgeting practices, possibly leveraging tools such as the System of Health Accounts. Examining recurrent and capital expenditure allocations for the 10 EPHS, can enhance health reporting and improve alignment of health expenditures with desired outcomes. Additionally, establishing baselines for evaluating the effectiveness of expenditures and providing guidance for informed policymaking at national and regional levels can further enhance the EPHS. 2 This would be facilitated by the development of a standardized manual that guides the definition and translation of EPHS theoretical concepts into specific budget line items. This will enable countries to review and analyze their health expenditure data in a more comparable and coherent manner, both at the country and regional levels. The manual should include a detailed description of the analytical process of how health expenditures are organized and allo- cated to different programmes, with a focus on identifying the most significant areas of investment. Countries need to be able to identify exactly which programmes are being supported by EPHS funds to determine if they are achieving stated goals. 3 Development of a tool to efficiently track the flow of funds will be critical. This would require agreement on a detailed methodological framework, followed by the development of a corresponding software solution. 4 The Caribbean Public Health Agency (CARPHA) and the University of the West Indies, HEU, Centre for Health Economics (UWI-HEU) are possibly well placed to kick-start the standardization process for tracking EPHS expenditure at the regional level. The findings of this study can be used to develop guidelines and recommendations on how best to support the process of standardization, including the retraining of personnel to accurately map different health expen- ditures to specific budget categories. A regional entity, such as UWI-HEU, could play a critical role in delivering this training and capacity-building support to member countries. It is important that a tool to efficiently track the flow of funds to EPHS be developed. 5 Policymakers in the region should be exposed to the experiences of countries and regions that have similar types of standardization, for example, the OECD. 95 Chapter 8.  Conclusions: Agenda for Future Action 8.2. Conclusion It is fair to say there is ample room for improvement in specific areas, particularly with expenditure data capture despite the countries reviewed. It will be important to increase focus on those EPHS sub-domain areas that need strengthening, such as aspects of Policy Development, so that areas can be prioritized in the context of health security. There is need for a strategic audit and development of human resources since these are key areas of focus for improving the responsiveness of healthcare workforce (EPHS 8). Another Policy Development area to be considered as a priority is Health Communication (EPHS 3); as we saw in the case of COVID-19, this was crucial in enhancing the community’s response to a prevailing emergency. Notwithstanding these priority areas, there should a determined effort to maintain funding for key domains such as Assessment. While acknowledging that curative services will continue to dominate health spending for the foreseeable future, the countries of the Caribbean will need to be motivated to give greater priority to investment in preventive services, with more emphasis on near-term interventions such as behaviour change programmes. There is also a need for countries to take the social determinants of health even more seriously, with a determined effort to improve living conditions and place more stringent regulations on commercial determinants of health. In this regard, it will be important to ensure that the prevention focus embedded in the EPHS becomes more dominant in a region of the world which will simply not be able to afford treating ever-increasing numbers of sick people. 96 Financing of Essential Public Health Services in the Caribbean Region APPENDIX 1 CARPHA Member States + Anguilla + Antigua and Barbuda + Aruba + Bahamas + Barbados + Belize + Bermuda + BES Islands + Bonaire + St. Eustatius + Saba + British Virgin Islands + Cayman Islands + Curacao + Dominica + Grenada + Guyana + Haiti + Jamaica + Montserrat + Saint Kitts and Nevis + Saint Lucia + Sint Maarten + Saint Vincent and the Grenadines + Suriname + Trinidad and Tobago + Turks and Caicos Islands 97 References References Abbey, E. J., Khalifa, B. A. A., Oduwole, M. O., Ayeh S.K., Nudotor, R. D., Salia, E. L., Lasisi, O., Bennett, S., Yusuf, H .E., Agwu, A. L., Karakousis, P. C. 2020. The Global Health Security Index is not predictive of coronavirus pandemic responses among Organization for Economic Cooperation and Development countries. PLoS One. Oct 7;15(10):e0239398. doi: 10.1371/journal.pone.0239398. PMID: 33027257; PMCID: PMC7540886. Barbados Statistical Service. 2022. “Population and Demography Statistics.” Accessed October 21st, 2022. https://stats.gov.bb/subjects/social-demographic- statistics/population-demography-statistics/vital-statistics-population-rates- of-birth-death-and-infant-mortality-annual-2010-2021/. Bell, J. A., Nuzzo, J. B. 2021. “GHS Index Global Health Security Index: Advancing Collective Action and Accountability Amid Global Crisis, 2021.” Accessed September 21, 2022. https://www.ghsindex.org/report-model/. Barbados Ministry of Health (MoH). 2014. “Barbados 2012-2013 Health Accounts.” Bridgetown, Barbados. Bhuwanee, K. 2018. Barbados 2016/2017 Health Spending Estimation Final Results. September 2018. USAID. Health Finance and Governance. Bhuwanee, K., Bethelmie, D., Cogswell, H., Young, D., Theodore, K., La Foucade, A., Laptiste, C., McLean, R., Brizan-St. Martin, R., Lalta, S., Hatt, L. 2013. Dominica 2011 National Health Accounts and HIV Subaccounts. Bethesda, MD: Health Systems 20/20 Caribbean Project, Abt Associates Inc. Produced for review by the United States Agency for International Development. https://www.hfgproject. org/dominica-2010-2011-national-health-accounts-hiv-subaccounts/. Butera, Jean, Barry, Hawa; Wilbur, Melanie. September 2018. Capital investment in health systems: what is the latest thinking? Rockville, MD: Health Finance & Governance Project, Abt Associates Inc. Caribbean Commission on Health and Development (CCHD). 2006. Report of the Caribbean Commission on Health and Development. Washington, D.C.: PAHO and the CARICOM. Caribbean Community (CARICOM). 2009. Caribbean Cooperation in Health Phase III (CCH III) Regional Health Framework 2010 – 2015. Accessed April 4th, 2023. http://www.caribbeanelections.com/eDocs/strategy/caricom_strategy/ CARICOM_Health_Framework_2010.pdf. Caribbean Public Health Agency (CARPHA). 2021. “Audited Financial Statements For the year ended December 31, 2021.” Accessed June 22, 2022. https:// www.carpha.org/Portals/0/Documents/Financials/2021%20Audited%20 Financial%20Statements.pdf. ______. 2020. “Audited Financial Statements For the year ended December 31, 2020.” Accessed June 22, 2022. https://new.carpha.org/Portals/0/Documents/ Financials/2020%20Audited%20Financial%20Statements.pdf. 98 Financing of Essential Public Health Services in the Caribbean Region ______. 2020. Annual Report January – December 2020. ______. 2019. Annual Report January – December 2019. ______. 2019. “Audited Financial Statements For the year ended December 31, 2019.” Accessed June 22, 2022. https://new.carpha.org/Portals/0/Documents/ Financials/2019%20Audited%20Financial%20Statements.pdf. ______. 2018. Annual Report January – December 2018. ______. 2018. “Audited Financial Statements For the year ended December 31, 2018.” Accessed June 22, 2022. https://new.carpha.org/Portals/0/Documents/ Financials/2018%20Audited%20Financial%20Statements.pdf. ______. 2017. Annual Report January – December 2017. ______. 2017. “Audited Financial Statements For the year ended December 31, 2017.” Accessed June 22, 2022. https://new.carpha.org/Portals/0/Documents/ Financials/2017%20Audited%20Financial%20Statements.pdf. ______. 2016. Annual Report January – December 2016. ______. 2016. “Audited Financial Statements For the year ended December 31, 2016.” Accessed June 22, 2022. https://new.carpha.org/Portals/0/Documents/ Financials/2016%20Audited%20Financial%20Statements.pdf. Centers for Disease Control and Prevention (CDC). 2022. “What Is the Global Health Security Agenda?” Accessed September 21, 2022. https://www.cdc.gov/global- health/security/what-is-ghsa.htm. Centers for Disease Control and Prevention (CDC). 2020. 10 Essential Public Health Services. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://phnci. org/uploads/resource-files/EPHS-English.pdf. ECLAC. 2021. Economic Survey of Latin America and the Caribbean: Trinidad and Tobago. Economist Impact. 2021. “GHS Index Global Health Security Index 2021: GHS INDEX METHODOLOGY.” Accessed September 21, 2022www.ghsindex.org. European Network on Debt and Development. 2021. “Grenada, Covid-19 and debt.” Accessed June 13, 2022. https://www.eurodad.org/grenada_covid19_debt. Faivre, P. et al., Immunization funding across 28 European countries, EXPERT REVIEW OF VACCINES, 2021, VOL. 20, NO. 6, 639–647. Gmeinder, M., Morgan, D., Mueller, M. 2017. “How much do OECD countries spend on prevention?.” Accessed August 15th, 2022. https://www.oecd-ilibrary. org/docserver/f19e803c-en.pdf?expires=1661167693&id=id&accname=g uest&checksum=695EAB35DF1939EE75EA37A2C4400C18. Government of Barbados (GoB). 2022. “Barbados Estimates 2022-2023. Revenue and Expenditure.” ______. 2021. “Barbados Estimates 2021-2022. Revenue and Expenditure.” ______. 2020. “Barbados Estimates 2020-2021. Revenue and Expenditure.” ______. 2019. “Barbados Estimates 2019-2020. Revenue and Expenditure.” 99 References ______. 2018. “Barbados Estimates 2018-2019. Revenue and Expenditure.” ______. 2017. “Barbados Estimates 2017-2018. Revenue and Expenditure.” ______. 2016. “Barbados Estimates 2016-2017. Revenue and Expenditure.” ______. 2015. “Barbados Estimates 2015-2016. Revenue and Expenditure.” ______. 2014. “Barbados Estimates 2014-2015. Revenue and Expenditure.” ______. 2013. “Barbados Estimates 2013-2014. Revenue and Expenditure.” ______. 2012. “Barbados Estimates 2012-2013. Revenue and Expenditure.” ______. 2011. “Barbados Estimates 2011-2012. Revenue and Expenditure.” ______. 2010. “Barbados Estimates 2010-2011. Revenue and Expenditure.” Government of Grenada. 2022. “Estimates of Revenue and Expenditure of the Year 2022: Protecting Lives, Safeguarding Livelihoods and Investing for Growth and Resilience.” ______. 2021. “Estimates of Revenue and Expenditure of the Year 2021: Towards Vision 2035: Recovery, Transformation and Resilience.” ______. 2020. “Estimates of Revenue and Expenditure of the Year 2020: Towards Vision 2035: Empowering our Communities, Growing our Economy, Protecting our Environment, Strengthening our Institutions.” ______. 2019. “Estimates of Revenue and Expenditure of the Year 2019: Building Resilience, Advancing Social Development, Transforming our Economy.” ______. 2018. “Estimates of Revenue and Expenditure of the Year 2018: Safeguarding out Gains and Continuing our Progress.” ______. 2017. “Estimates of Revenue and Expenditure of the Year 2017: Working Together to Build on our Success for a better Country.” ______. 2016. “Estimates of Revenue and Expenditure of the Year 2016.” ______. 2015. “Estimates of Revenue and Expenditure of the Year 2015.” ______. 2014. “Estimates of Revenue and Expenditure of the Year 2014.” ______. 2013. “Estimates of Revenue and Expenditure of the Year 2013.” Government of Jamaica Ministry of Finance and the Public Service. 2022. “Estimates of Expenditure 2022-2023 For the Financial Year Ending 31st March 2023.” Government of Jamaica Ministry of Health and Wellness, 2022. Communication from Key Informant Ministry of Health. Government of Jamaica Ministry of Finance and the Public Service. 2021. “Estimates of Expenditure for 2021-2022 For the Financial Year Ending 31st March 2021.” ______. 2020. “Estimates of Expenditure 2020-2021 For the Financial Year Ending 31st March 2021.” ______. 2019. “Estimates of Expenditure 2019-2020 For the Financial Year Ending 31st March 2020.” Government of Jamaica Ministry of Health and Wellness, 2019. Vision for Health 2030 Ten year Strategic Plan 2019-2030. 100 Financing of Essential Public Health Services in the Caribbean Region Government of Jamaica Ministry of Finance and the Public Service. 2018. “Estimate of Expenditure 2018-2019 For the Financial Year Ending 31st March 2019.” ______. 2017. “Estimates of Expenditure 2017-2018 For the Financial Year Ending 31st March 2018.” ______. 2016. “Estimates of Expenditure 2016-2017 for the Financial Year ending 31st March 2017.” Government of Jamaica Ministry of Finance and Planning. 2015. “Estimates of Expenditure 2015-2016 for the Financial Year Ending 31st March 2016.” ______. 2014. “Estimates of Expenditure 2014-2015 For the Financial Year Ending 31st March 2015.” ______. 2013. “Estimates of Expenditure 2013-2014 For the Financial Year ending March 31st 2014.” Government of Trinidad and Tobago - Ministry of Energy and Energy Industries. 2022. Oil and Gas industry Overview [Internet]. 2022 [cited 2022 Sep 23]. Available from: https://www.energy.gov.tt/our-business/oil-and-gas-industry/. Government of Trinidad and Tobago. 2021. Review of the Economy 2021. Government of the Republic of Trinidad and Tobago, Ministry of Finance, 2021. Estimates of Expenditure for 2021 for Financial Year Ending 2021. ______. 2020. Estimates of Expenditure for 2020 for Financial Year Ending 2020. ______. 2019. Estimates of Expenditure for 2019 for Financial Year Ending 2019. ______. 2018. Estimates of Expenditure for 2018 for Financial Year Ending 2018. ______. 2017. Estimates of Expenditure for 2017 for Financial Year Ending 2017. ______. 2016. Estimates of Expenditure for 2016 for Financial Year Ending 2016. ______. 2015. Estimates of Expenditure for 2015 for Financial Year Ending 2015. ______. 2014. Estimates of Expenditure for 2014 for Financial Year Ending 2014. ______. 2013. Estimates of Expenditure for 2013 for Financial Year Ending 2013. ______. 2012. Estimates of Expenditure for 2012 for Financial Year Ending 2012. ______. 2011. Estimates of Expenditure for 2011 for Financial Year Ending 2011. ______. 2010. Estimates of Expenditure for 2010 for Financial Year Ending 2010. Hamadeh, N, Van Rompaey, C, Metreau, E. 2023. “World Bank Group country classifications by income level for FY24 (July 1, 2023- June 30, 2024)”. Data Blog, World Bank Blogs. June 30, 2023. https://blogs.worldbank.org/opendata/ new-world-bank-group-country-classifications-income-level-fy24. Hatt, Laurel., Danielle Altman, Slavea Chankova, Carol Narcisse, Donna-Lisa Pena, Pamela Riley, Jordan Tuchman, Taylor Williamson, and Andrew Won. 2012. Grenada Health Systems and Private Sector Assessment 2011. Bethesda, MD: Health Systems 20/20 project and SHOPS project, Abt Associates Inc. HEU, Centre for Health Economics. 2019. “Grenada 2017 Health Accounts.” The University of the West Indies, St Augustine. January 2019. (Unpublished). 101 References Holder, Reynaldo. 2007. “Essential Public Health Functions in the Eastern Caribbean.” Accessed June 8th, 2022. https://www3.paho.org/paho-usaid/ documents/events/weblaunch07/EPHF_event_Dr_Reynaldo_Holder.pdf. International Monetary Fund (IMF). 2022. “World Economic Outlook Database” Accessed August 7th 2022. https://www.imf.org/en/Publications/WEO/ weo-database/2022/April/weo-report?c=343,&s=NGDP_RPCH,GGXWDG_ NGDP,&sy=2010&ey=2020&ssm=0&scsm=1&scc=0&ssd=1&ssc=0&sic=​ 0&sort=country&ds=.&br=1. Jamaica Information Service, 2022. Ministry of Health and Wellness [WWW Document]. URL https://jis.gov.jm/government/ministries/health-wellness/ (accessed 10.31.22). Khaleghian, P., and Das Gupta, M. 2005. “Public Management and the Essential Public Health Functions.” World Development 33 (7): 1083-1099. La Foucade, A., Metivier, C., Gabriel, S., Scott, E., Theodore, K., Laptiste, C. 2018. The Potential for Using Alcohol and Tobacco Taxes to Fund Prevention and Control of Non-communicable Diseases in Caribbean Community Countries. Rev Panam Salud Publica. Dec 17;42:e192. doi: 10.26633/RPSP.2018.192. PMID: 31093219; PMCID: PMC6386120. Lal, A. 2022. “Opinion: Global Health Security Must Be Tied to Health Systems | Devex.” Accessed September 21, 2022. https://www.devex.com/news/ opinion-global-health-security-must-be-tied-to-health-systems-99937. Lalta, S. 2013. International experiences with health financing and lessons for the Caribbean. [PowerPoint slides]. Presented at the Queen Elizabeth Hospital Conference on Health Financing in Barbados. Ministry of Health and Wellness (MoHW), Government of Barbados (GOB). 2017. “Barbados National Strategic Plan for Health 2018-2022. Working Together for a Healthier Nation (Draft).” Bridgetown: MHW. Ministry of Health and Wellness (MoHW), Government of Barbados (GOB). 2022. “Health and Wellness Barbados National Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2020-2025.” Accessed August 8th, 2022. https://www.iccp-ortal.org/system/files/plans/brb_b3_s21_ncd%20 strategic%20plan%202020-2025.pdf. Ministry of Health and Social Security. Government of Grenada. Strategic Plan for Health 2016-2025. Murphy, M. M., Jeyaseelan, S. M., Howitt, C., Greaves N., Harewood H., Quimby, K. R., Sobers, N., Landis, R. C., Rocke, K. D., Hambleton, I. R. 2020. COVID-19 containment in the Caribbean: The experience of small island developing states. Research in Globalization, Volume 2, 2020. https://doi. org/10.1016/j.resglo.2020.100019. Nakhimovsky, S., Brizan-St. Martin, R., Cogswell, H., Young, D., Theodore, K., La Foucade, A., Laptiste, C., Bethelmie, D., McLean, R., Lalta, S., and Hatt, L. 2013. St. Kitts and Nevis 2011 National Health Accounts and HIV Subaccounts.Bethesda, MD: Health Systems 20/20 Caribbean 102 Financing of Essential Public Health Services in the Caribbean Region project, Abt Associates Inc. Produced for review by the United States Agency for International Development. https://www.hfgproject.org/ saint-kitts-nevis-2011-national-health-accounts-hiv-subaccounts/. National Health Fund. 2022. “Who we are - The National Health Fund” Accessed August 8th, 2022. https://www.nhf.org.jm/about-us/who-we-are. ______. 2021. “National Health Fund Annual Report 2020-2021.” Jamaica. ______. 2019. National Health Fund Annual Report 2019-2020. Jamaica. ______. 2011. “National Health Fund Annual Report 2010-2011.” Jamaica NCD Alliance. 2022. https://ncdalliance.org/news-events/news/barbados- to-improve-population-health-and-generate-funds-with-higher-sugary- drinks-tax. (Accessed August 29th, 2022) OECD/Eurostat/WHO. 2017. A System of Health Accounts 2011: Revised edition, OECD Publishing, Paris, https://doi.org/10.1787/9789264270985-en. Pallipedia The Free Online Palliative Care Dictionary. 2022. “Health Care System.” Accessed June 8th, 2022. https://pallipedia.org/health-care-system. Pan American Health Organization (PAHO). 2020. Fiscal Space for Health in Latin America and the Caribbean, Fiscal Space for Health in Latin America and the Caribbean. Accessed June 12th, 2022. https://iris.paho.org/bitstream/handle/10 665.2/52410/9789275220009_eng.pdf?sequence=1&isAllowed=y. ______. 2020. “The Essential Public Health Functions in the Americas: A Renewal for the 21st Century Conceptual Framework and Description.” Accessed June 8th, 2022. https://iris.paho.org/bitstream/handle/10665.2/53124/9789275122 655_eng.pdf?sequence=1&isAllowed=y. ______. 2018. “PAHO-WHO Country Cooperation (CCS) Jamaica 2017-2022.” ______. 2008. “Barbados Monitoring and Analyzing Health systems Change/Reform. Accessed October 21st, 2022. https://www.paho.org/hq/dmdocuments/2010/ Health_System_Profile-Barbados_2008.pdf. Pan American Health Organization (PAHO), Caribbean Community Secretariat (CARICOM). 2006. Report of the Caribbean Commission on Health and Development. Accessed April 4th, 2023. https://iris.paho.org/bitstream/handle/ 10665.2/9995/9789768082206_eng.pdf?sequence=1&isAllowed=y. Pan American Health Organization (PAHO). 2002. “Public Health in the Americas, conceptual renewal, performance assessment and bases for action”. Accessed June 8th, 2022. https://www.paho.org/hq/dmdocuments/2010/EPHF_Public_ Health_in_the_Americas-Book.pdf. Planning Institute of Jamaica (PIOJ). 2022. Economic and Social Survey Jamaica 2021. Public Health National Center for Innovations. 2020. 10 Essential Public Health Services. Available from: https://phnci.org/uploads/resource-files/EPHS- English.pdf. (Accessed Aug 20, 2022) 103 References Ramagem, C., Ruales, J. 2008. “The essential public health functions as a strategy for improving overall health systems performance: trends and challenges since the public health in the Americas Initiative, 2000-2007.” World Health Organization. Roche, M., Alvarado, M., Sandoval, R. C., Gomes, F. D. S., Paraje, G. 2022. Comparing taxes as a percentage of sugar-sweetened beverage prices in Latin America and the Caribbean. Lancet Reg Health Am. 2022 Jul;11: None. doi: 10.1016/j.lana.2022.100257. Statistical Institute of Jamaica. 2022. “Population Statistics.” Accessed October 21st, 2022. https://statinja.gov.jm/Demo_SocialStats/PopulationStats.aspx. The World Bank. 2022. “Grenada.” Accessed September 14, 2022. https://data. worldbank.org/country/grenada. ______. 2022. “Health,” Accessed August 20, 2022. https://www.worldbank.org/en/ topic/health/overview#1. ______. 2022. “World Development Indicators.” Accessed June 10 th, 2022. https:// databank.worldbank.org/reports.aspx?source=world-development-indicators#. Theodore, K., Lalta, S., La Foucade, A., Cumberbatch, A., Laptiste, C. 2016. Editors. Branka Legetic, Andre Medici, Mauricio Hernandez-Avila, George Alleyne, Anselm Hennis. Responding to NCDs Under Severe Economic Constraints: The Links with Universal Health Care in the Caribbean. In, Economic Dimensions of Non-Communicable Disease in Latin America and the Caribbean. Disease Control Priorities. Third Edition. Companion Volume. Washington, DC: PAHO. pages 133-139 (2016). ISBN 978-92-75-11905-1. Theodore, K., La Foucade, A., Stoddard, D., Thomas, W. and Yearwood, A. 2001. Health System Inequalities and Poverty in Jamaica. In Investment in Health: Social and Economic Returns. Pan American Health Organization, The Inter- American Development Bank and The World Bank. Washington D.C. Pan American Health Organization Scientific and Technical Publication No. 582. 2001. p 189-206. ISBN 9275115826. Trinidad and Tobago Ministry of Health. 2018. Trinidad and Tobago 2015 Health Accounts Main Report. Port of Spain, Trinidad and Tobago. August 2018. Trinidad and Tobago NGL Limited. 2022. “T&T’s Energy Sector” [Internet].2022. Available from: https://ngl.co.tt/about/tts-energy-sector. World Health Organization (WHO). 2022. “Health Security.” Accessed August 18th, 2022. https://www.who.int/health-topics/health-security#tab=tab_1. ______. 2022. “The Global Health Observatory Explore a world of health data. Accessed August 18th, 2022. https://www.who.int/data/gho/data/countries/ country-details/GHO/barbados. ______. 2022. “World Health Organization Health Systems Strengthening Glossary.” Accessed June 8th, 2022. https://www.who.int/healthsystems/hss_glossary/en/ index5.htmlbook. 104 Financing of Essential Public Health Services in the Caribbean Region ______. 2021. “Building Health Systems Resilience for Universal Health Coverage and Health Security during the COVID-19 Pandemic and beyond: WHO Position Paper.” https://www.who.int/publications/i/item/WHO-UHL-PHC-SP-2021.01. ______. 2018. “Country Cooperation Strategy at a glance- Jamaica.” Accessed October 21st, 2022. https://apps.who.int/iris/bitstream/handle/10665/136900/ ccsbrief_jam_en.pdf;sequence=1. ______. 2018. “Essential public health functions, health systems and health security: developing conceptual clarity and a WHO roadmap for action.” Accessed June 12th, 2022. https://www.who.int/publications/i/item/9789241514088. ______. 2000. “The World Health Report: Health Systems, Improving performance.” Accessed August 28th, 2022. https://cdn.who.int/media/docs/default-source/ health-financing/whr-2000.pdf?sfvrsn=95d8b803_1&download=true. 105