Component 2: Development of financing mechanisms/models to secure the access of migrants to HIV services and their pilot implementation in at least 3 selected countries.


Indicator: The number of countries that have started to use at least one of the financing instruments which were developed with the support of this project has increased (from 0 to at least 3)

Milestones
•    Cost calculations for the service packages provided and cost-benefit analysis developed and in use.
•    Successful approaches and options for social security mechanisms for migrants identified Feasibility studies for the introduction of (sub-) regional funds, regional insurance mechanisms and/or other instruments are conducted
•    Improved funding mechanisms developed.
•    Implementation plan developed and piloting of financing mechanisms initiated
•    First insights and lessons learnt from the implementation of the pilot and support the planning for the region-wide implementation


Deliverables

•    Cost calculations for basic package of services and cost-benefit analysis
•    Agreement on successful approaches for social security mechanisms
•    Feasibility studies for introduction of sub-regional funds, regional insurance mechanisms
•    Agreement on sample type of pilot countries or sub-regions
•    Implementation plan and roll-out plan

Activities
•    Costing of health services packages and cost-benefit-analyses.
•    Identification of successful approaches and opportunities for social security mechanisms for migrants.
•    Planning and implementation of feasibility studies for the introduction of (sub-) regional funds, regional insurance mechanisms and/or other instruments.
•    Development of approaches for the allocation of budgets, writing of grant applications and capacity building for grant applications.
•    Identification of countries and/or sub-regions for the piloting of coordinated finance mechanisms.
•    Support the development of the implementation plan and the piloting of the financing mechanisms.
•    Reflect on first insights and lessons learnt from the implementation of the pilot and support the planning for the region-wide implementation.


Key Challenges:

Sources of funding: public healthcare services in the Caribbean region largely do not foresee the provision of healthcare services for migrant populations. This situation is further complicated by the absence of clear regulations concerning healthcare access of migrant populations in the CSME Agreement. Whilst the respective bottlenecks are political in nature, it implies that countries need to explore new sources of funding to scale up health budgets in order to make prevention and treatment services available to migrants.

Imbalances in resource allocation: HIV/AIDS patients tend to seek treatment on other
islands, either because of insufficient supplies of ARV drugs, or to avoid disclosing their
HIV status in their domestic environment. The lack of a regional health insurance mechanism as well as functioning patient monitoring and M&E system implies that accurate data on patient mobility is largely absent. Use of the of healthcare systems by non-residents is therefore not properly documented, which adds to the difficulty of estimating cost structures.

Imbalances in services costs: the majority of the Caribbean countries have very small
Populations. Implementing and expanding healthcare services therefore confronts the problem of high unit and per capita costs, specifically with regards to procurement practices. While the primary focus of this project is on access to HIV services of migrants, and not on enhancing the efficiency of regional procurement practices, it is important to realize that insufficient supplies of ARV drugs (amongst others, due to high unit costs) is one of the factors driving HIV patients to seek treatment abroad. The costings to be undertaken need to take this into consideration and promote economies of scale, where possible in collaboration with other donors, such as the GFATM.

Barriers in the access to services: The majority of migrants in the Caribbean access health care services through the non-profit and/or the private sector, as public services are often unavailable due to political and legal restrictions, or not commendable due to socio-cultural factors such as discrimination and stigmatization.

Flexibility in resources Distribution: The NAPs are implemented according to budgeted annual action plans (AAP), with little financial flexibility to finance hard-to-reach population groups, adapt processes to best practices, or to implement new concepts.

Intervention Logic

Selection of pilot countries
First, different population sizes have a significant impact on unit and per capita healthcare costs. This impact should be kept in mind when considering the proportion of healthcare spending for mobile populations in different countries, as well as the willingness / capacity of countries to provide universal access to health services.
 Second, it is critical to bear in mind that across the Caribbean region, large differences exist in the composition and the level of health spending. While the English speaking Caribbean islands follow a central government financing mechanism which grants free access to healthcare services to all registered residents within the respective country, the remainder of the Caribbean region’s health systems are based on a social security system which requires citizens to possess a social security card in order to access public health services (with the exception of emergency services). As both systems are tax funded, the difference lies in the mode of access. All countries, regardless of the overall model, rely on a mix of public and private instruments. Thus, while the majority of hospital and public health services is paid for by tax funds, ambulatory care (visits to private doctors and specialists) and pharmaceutical services often depend on out of the pocket payments and limited private health insurance (Barrett and Lalta, 2004)  However, the proportions of public and private spending differ from island to island and need to be ascertained. National health insurance plans only exist in three of the nineteen Caribbean countries. However, our discussions with HEU demonstrated that even where plans are in place; their implementation confronts significant problems on the ground, as the electorate opposes the introduction of fee-based insurance schemes.

Definition of health care package
It is important that the costing refer to identical packages of services across the countries,
both to ensure the comparability of the pilots, and to prevent distortions in the provision of services. It should be taken into consideration that the piloting of financing mechanisms in a selected number of 3 to 5 countries might additionally enhance the influx of migrants from other islands in search of accessible treatment.

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