Eastern Caribbean Countries Health Systems and Private Sector Assessments 2011

1. Eastern Caribbean CountriesHealth Systems and Private Sector Assessments2011 Lisa Tarantino Antigua and Barbuda Assessment Team Abt Associates, Inc. April 24, 2012

2. 7 Countries Assessed • Antigua and Barbuda • Barbados • Dominica • Grenada • St. Kitts and Nevis • St. Lucia • St. Vincent and the Grenadines

3. Objectives • Improve sustainability of systems and HIV/AIDS programming in view of diminishing donor funding (PEPFAR funded) • An overview of the entire health sector organized around the six HSS building blocks • A description of pressing health issues and priority system challenges • A summary of private sector contributions to health • Actionable recommendations to strengthen health system and leverage private health sector • Develop action plans for addressing priority recommendations

4. Guiding Principles • Holistic view of the health system – comprised of public, private (for-profit) and NGO/FBO elements • Collaborative, high level of engagement with partners and stakeholders: MOHs, private sector, USAID, PAHO, NGOs, etc. • Given declining vertical funding for HIV/AIDS, need for integration into existing health systems and services • Recommendation criteria: • Contributes to the sustainability of the health system • System focused and addresses key performance criteria • Equity, Access, Quality, Efficiency, Sustainability • Feasible in short term, essential in long term

5. Key findings: Antigua and Barbuda

6. Governance and Leadership Weaknesses and Threats • Government budget constraints • Inadequate reporting impacts accountability (CBH, MSJMC, MOH) • MOH needs human resources for planning and developing regulations • Inadequate strategic planning • Significant gaps in legislation and regulation of the health sector • Some infrastructure investment needed (MOH) Strengths and Opportunities • PHC level is well managed • MOH works with professional councils, which are active • Media has a public information service and a watchdog function • Neighboring country laws and regulations can be easily adapted • International guidelines used for environmental health & sanitation • Public sector reform may impact health sector positively

7. Human Resources for Health • Weaknesses and Threats • Lack of a comprehensive HRH policy • Absence planning mechanism in MOH • Ad-hoc transfers of personnel results in loss of capacity, mismatch of personnel and needs of institutions, demotivation • Established/Non-Established disparities impacting morale • Limited personnel and services in dental psychiatric/mental health, rehabilitation • Pharmacy school viability • Limited supervisory and appraisal capacity in primary health care • Strengths and Opportunities • High levels of competence and dedication exist • Adequate number of health workers across most cadres & specializations • Scholarships to support training • Health training services exist, eg nursing school, relevant faculties of UWI to support pre and in-service training (MSJMC internship program) • Public Sector Modernization presents opportunity to address anomalies in staff designations & conditions of employment 7

8. Service Delivery Strengths and Opportunities • Strong primary care, particularly for infectious diseases, maternal and child health • Adequate number of facilities, distributed evenly across the country (both public and private), new hospital • Most specialized tertiary care available in-country • Infrastructure and education/literacy of the population Weaknesses and Threats • No system for quality assurance of health services • Efficiency of service delivery not optimal • Over reliance on MSJMC for minor health issues • Centralized HIV/AIDS treatment • Gaps in patient referral process • Insufficient health promotion and education

9. Health Information Systems Strengths and Opportunities • Adequate physical resources for HIS in the public sector • Established routine data collection and reporting process at primary health care facilities • Established surveillance system Weaknesses and Threats • Fragmentation of the HIS: • Routine data from MSJMC is not collected by MOH (except for surveillance) • Private facilities not part of the system • Separate data collection and processing systems for different types of HIV/AIDS data • Efficiency of data management at central level • Inadequate use of data for planning

10. Pharmaceuticals & Medical Products Strengths and Opportunities • Sufficient pharmaceutical human resources, facilities • Good access to quality pharmaceuticals • Collaborative relationship with PPS in procuring and monitoring pharmaceuticals • Existence of national and regional training programs • Adequate financial resources for procurement Weaknesses and Threats • Weak regulatory framework • Insufficient monitoring/regulation of facilities and pharmaceuticals, especially in the private sector • Inadequate Pharmaceutical MIS/data for decision making • Inadequate pharmaceutical management coordination • Absence of Standard Operating Procedures • Lack of standard treatment protocols • Inconsistent pharmacovigilencepractices

11. Health Financing Strengths and Opportunities • 7% payroll tax (with no ceiling salary) committed to health care • Public services available without significant financial barriers • 15-20% of population has private insurance (about 15,000 people) • Not a huge need for major capital investment (MSJMC) Weaknesses and Threats • Lack of available data on what existing service commitments really cost or projections on funding growth in future. • Fragmented financing: No good data on total public health expenditure.  • Growing burden of chronic disease, where primary health system is weakest.  • There is a danger that tertiary care commitments will erode the primary care system.

12. Key Recommendations

13. St. Lucia, Antigua and Barbuda, Dominica Prepare population and leadership for the fact that system is not currently sustainable, and build political will for change (Antigua and Barbuda) Invest in financial analysis (costing, NHA) and strategic planning Prioritize updates and passage of key legislation and gazette regulations to enforce enacted laws Improve efficiency and quality at all levels of care (strengthen referral system, collect and use data from hospital, private sector) Pursue opportunities to engage the private sector as a partner 13

14. Next steps – Action! • Dissemination and validation workshops resulted in: • Prioritization of recommendations by public and private sector stakeholders • Action steps discussed, negotiated and agreed • Commitments by development partners to consider prioritized recommendations and plans • Technical support sought and accessed from USAID (and others) • Technical support initiated in areas of health financing strengthening (costing) and private sector mapping 14

15. Thank you! Lisa Tarantino Antigua and Barbuda Assessment Team Abt Associates, Inc. April 24, 2012