Trinidad and Tobago 2015 Health Accounts - Main Report

1. Port of Spain, August 2018
TRINIDAD AND TOBAGO 2015 HEALTH
ACCOUNTS – MAIN REPORT

2. The Health Finance and Governance Project
USAID’s Health Finance and Governance (HFG) project will help to improve health in developing countries by
expanding people’s access to health care. Led by Abt Associates, the project team will work with partner
countries to increase their domestic resources for health, manage those precious resources more effectively,
and make wise purchasing decisions. As a result, this five-year, $209 million global project will increase the use
of both primary and priority health services, including HIV/AIDS, tuberculosis, malaria, and reproductive health
services. Designed to fundamentally strengthen health systems, HFG will support countries as they navigate the
economic transitions needed to achieve universal health care.
DATE 2013
Cooperative Agreement No: AID-OAA-A-12-00080
Submitted to: Scott Stewart, AOR
Office of Health Systems
Bureau for Global Health
Recommended Citation: Trinidad and Tobago Ministry of Health. August 2018. Trinidad and Tobago
2015 Health Accounts Main Report. Port of Spain, Trinidad and Tobago.
Abt Associates Inc. | 6130 Executive Boulevard | Rockville, Maryland 20852
T: 301.347.5000 | F: 301.652.3916 | www.abtassociates.com
Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) |
| Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D)
| RTI International | Training Resources Group, Inc. (TRG)

3. TRINIDAD AND TOBAGO 2015
HEALTH ACCOUNTS – MAIN REPORT
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency
for International Development (USAID) or the United States Government.

5. i
CONTENTS
Acronyms..........................................................................................................iii
Acknowledgments............................................................................................ v
Executive Summary .......................................................................................vii
1. Introduction.................................................................................................1
1.1 Background...................................................................................................................1
1.2 Economic Context .....................................................................................................1
1.3 Health System Structure...........................................................................................2
2. Health Accounts in Trinidad and Tobago ...............................................3
2.1 Overview.......................................................................................................................3
2.2 Objectives.....................................................................................................................3
2.3 Methodology ................................................................................................................4
2.4 Data Sources................................................................................................................4
2.5 Limitations ....................................................................................................................6
3. Health Accounts Results: Key Findings....................................................7
3.1 Summary of General Health Accounts Findings.................................................7
3.2 General Health Accounts Findings.........................................................................8
3.3 Analysis of HIV Spending........................................................................................19
4. Policy Implications and Recommendations...........................................23
4.1 Government Commitment to Health Could be Strengthened ...................23
4.2 Increasing Risk Pooling Essential to Reducing OOP Spending.....................24
4.3 Increase Access to Health Services and Allocative Efficiency ......................24
4.4 Strengthen the Health Information Management System (HIMS)...............25
4.5 Institutionalize Health Accounts...........................................................................25
5. Conclusion .................................................................................................27
Annex A: References......................................................................................29

6. ii
List of Tables
Table 2.1: Key Policy Questions Guiding Health Accounts Estimation .........................3
Table 2.2: Institutional Survey Response Rates of Contacted Entities...........................5
Table 3.1: Key Health Accounts Findings ...............................................................................7
List of Figures
Figure 1.1: Real GDP Growth in Trinidad and Tobago for the Period 2008–
2016...........................................................................................................................2
Figure 3.1: Source of THE in the Region ................................................................................8
Figure 3.2: Recurrent Health Spending by Source of Financing........................................9
Figure 3.3: Recurrent Health Spending by Scheme............................................................10
Figure 3.4: Recurrent Health Spending by Managers of Health Funds .........................10
Figure 3.5: Household OOP Health Spending by Provider .............................................11
Figure 3.6: Household OOP Health Spending by Function .............................................12
Figure 3.7: Recurrent Household OOP Health Spending on NCDs ............................13
Figure 3.8: Recurrent Health Spending by Provider ..........................................................13
Figure 3.9: Recurrent Health Spending at Hospitals by Hospital Type ........................14
Figure 3.10: Recurrent Health Spending by Inputs.............................................................14
Figure 3.11: Recurrent Health Spending by Function........................................................15
Figure 3.12: Recurrent Health Spending on Prevention, by Type..................................16
Figure 3.13: Recurrent Health Spending by Disease, with Detail on NCDs ..............17
Figure 3.14: Source of Current Health Spending for NCDs...........................................18
Figure 3.15: Disease Burden for Trinidad and Tobago in 2015 (Based on
DALYs)....................................................................................................................19
Figure 3.16: Recurrent Health Spending on HIV by Financing Source .........................20
Figure 3.17: Recurrent Health Spending on HIV by Manager .........................................20
Figure 3.18: Recurrent Health Spending on HIV by Provider.........................................21
Figure 3.19: Recurrent Health Spending on HIV by Function.........................................21
Figure 3.20: Psychosocial Support Spending on HIV .........................................................22

7. iii
ACRONYMS
AIDS Acquired immune deficiency syndrome
CBTT Central Bank of Trinidad and Tobago
CDAP Chronic Disease Assistance Program
CSO Civil Society Organization
DALY Disability-Adjusted Life Year
ERHA Eastern Regional Health Authority
GDP Gross Domestic Product
HA Health Accounts
HBS Household Budgetary Survey
HEU Health Economics Unit
HIMS Health Information Management System
HIV Human immunodeficiency virus
IEC Information, education, and counseling
MOH Ministry of Health
MRF Medical Research Foundation
NCD Noncommunicable disease
NGO Nongovernmental organization
OECD Organisation for Economic Co-operation and Development
OOP Out-of-pocket
PAHO Pan American Health Organization
PEPFAR President’s Emergency Plan for AIDS Relief
PSS Psychosocial support
RHAs Regional Health Authorities
SHA System of Health Accounts
SDGs Sustainable Development Goals
THE Total Health Expenditure
TT$ Trinidad and Tobago dollars
UHC Universal health coverage
US$ United States dollar
USAID United States Agency for International Development
UWI University of West Indies
WHO World Health Organization

8. iv

9. v
ACKNOWLEDGMENTS
The researchers and authors would like to acknowledge and thank the leadership of Ministry of
Health (MOH) of Trinidad and Tobago for its support and oversight of this project. We give special
thanks to Dr. Ayanna Sebro, former director of the MOH’s HIV/AIDS Coordinating Unit and
current Technical Director, National AIDS Coordinating Committee Secretariat, for her strong
support, hands-on involvement, and guidance from the inception of the project. We are thankful for
the support continued support of Dr. Keven Antoine, current director of the MOH HIV/AIDS
Coordinating Unit. We also wish to highlight the critical support and involvement of staff of the
Regional Health Authorities who worked painstakingly along with our team and provided data and
guidance. Special mention must be made of Chandra John, Veejai Heera, Meena Heera, Keston
Daniel, and Janelle Drysdale-Job.
Thanks also go out to the Central Statistical Office for providing the required data sets for the
conduct of the study.
We also wish to thank the team at Abt Associates and the Health Finance and Governance (HFG)
project, who worked closely with us and provided technical and logistical guidance and support—
namely, Lisa Tarantino, Heather Cogswell, Rachel Rosen, and Patricia Hernandez. We also thank the
President’s Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International
Development (USAID) for its funding of the majority of the work needed to complete this study,
and to the United Nations Development Program (UNDP) for funding the enumerators as well as
the various workshops.
The Health Economics Unit (HEU) team at The University of the West Indies is grateful to the
various donors, nongovernmental organizations, employers, and insurance companies that provided
data during the field work phase of this project, and to the enumerators who carried out the field
work.
This report was prepared by a team from the HEU, Centre for Health Economics of The University
of the West Indies (UWI), which included Roxanne Brizan-St. Martin, Christine Laptiste, Don
Bethelmie, Althea LaFoucade, Stanley Lalta, and Kimberly-Ann Gittens-Baynes. Special thanks are due
to those who provided research and other support—namely, Nkenge Lawrence, Patricia Edwards-
Wescott, Roger McLean, Kimoy Worrell, Haleema Ali-Sisbane, and Cedrina Carr. We also
acknowledge the logistical support provided by our UWI Secretariat.

11. vii
EXECUTIVE SUMMARY
Overview
The System of Health Accounts (SHA) 2011 captures spending from all sources within an economy:
the government, nongovernmental organizations (NGOs), external donors, private employers,
private insurance companies, and households. This analysis presents a breakdown of spending into
the standard classifications of the SHA 2011 framework, as well as the policy implications of the
results (OECD et al. 2017). The study represents Trinidad and Tobago’s first health accounts (HA)
exercise, and it estimates spending for the fiscal year October 2014 to September 2015.
The completion of the first HA estimation in Trinidad and Tobago is timely, given the rising
incidence of noncommunicable diseases and the continued importance of communicable diseases, in
particular HIV. HA are designed to provide data to support decisions that ensure value for money
and efficiency and effectiveness in allocation of limited resources. HA provide the evidence base
needed for proper planning and implementation of interventions to meet the needs of the
population. Additionally, understanding spending in areas such as HIV and AIDS can inform decisions
on resource mobilization and allocation for the disease to address issues of sustainability in funding.
It is therefore important that the information be of a certain standard of accuracy and completeness.
Findings
In Trinidad and Tobago, total health expenditure (THE) for the 2015 fiscal year was Trinidad and
Tobago dollars (TT$) 9,955,666,420 (United States dollar, US$ 1,574,948,020); this includes current
health spending and gross capital formation. Current expenditure accounted for TT$9,073,090,936
(91 percent), while capital expenditure (spending on goods and services whose benefits are
consumed over more than one year) accounted for TT$882,575,484 (9 percent). Health-related
spending, including spending for psychosocial support (PSS) for HIV and AIDS, environmental health,
and food hygiene, and drinking water control accounted for an additional TT$636,039,781.
The government provides the majority of current health spending (55 percent), with households
being the second largest contributor (44 percent) via out-of-pocket (OOP) spending. The largest
proportion of current health spending is managed by the Regional Health Authorities (RHAs) (41
percent), while the central Ministry of Health (MOH) manages 14 percent. The largest proportion of
household spending happens at pharmacies and at private doctors’ offices, with 49 percent and 34
percent of current OOP expenditures happening at these providers, respectively. Contributions
from private sector employers were small (less than 1 percent of current health spending), with the
majority of their spending provided via insurance policies for their employees. Note that employers’
spending on health may be underestimated due to relatively low response rates during data
collection.
Spending at hospitals (secondary and tertiary) accounted for 35 percent of recurrent health spending
in Trinidad and Tobago. 78 percent of recurrent spending at hospitals goes to general hospitals, 7
percent toward private hospitals, 10 percent toward specialized hospitals (not including mental
health hospitals), and 5 percent to St. Ann’s Psychiatric mental hospital.
At the activity level, approximately 55 percent of health expenditure is for curative care, with
outpatient care accounting for about 30 percent of total current health expenditure and inpatient
care for 25 percent. The purchase of drugs and medical goods via private pharmacies accounts for
21 percent of spending. Prevention spending was estimated at 14 percent of current health
expenditure, although this may be underestimated due to low response rates from NGOs and the

12. viii
lack of disaggregated data. While the majority of recurrent health spending is not disaggregated by
disease or health condition, 21 percent of health expenditure was on noncommunicable diseases
(NCDs). Improvements in data collection and the availability of detailed health spending data will
enable future HA exercises to classify a greater proportion of health spending. It was also noted that
even with the Chronic Disease Assistance Program (CDAP), households accounted for half of total
spending on NCDs. To properly assess the financial effectiveness and efficiency of the program, a
more comprehensive and detailed documentation of CDAP and NCD funding is required.
Spending on HIV represented less than 1 percent of recurrent health spending (TT$37.25 million) in
2015. The government provides the majority of HIV spending (90 percent), with approximately 10
percent coming from donors that is distributed mainly through government. The two biggest
activities for HIV and AIDS were curative care and prevention (85 percent and 12 percent of
recurrent health spending, respectively). Expenditure on advocacy (34 percent) and social services
(31 percent) accounted for the bulk of PSS spending for HIV and AIDS.
Implications and Recommendations
The commitment of the government to directing resources towards health appears to be high in
comparison to the relatively low share of spending on health services from abroad: the government
contributes 55 percent of recurrent health spending, while donor spending represents less than 1
percent. The Pan American Health Organization (PAHO)/WHO proposes that governmental health
spending represent at least 6 percent of Gross Domestic Product (GDP) (Pan American Health
Organization (PAHO) 2014); in the case of Trinidad and Tobago, this spending is at 3.9 percent.
More detailed data on government health spending will support future analyses of and
recommendations about the nature of the government’s financing for health.
In a HA exercise, household expenditure surveys ideally comprise, at the very least, information on
the inpatient/outpatient split and medical goods. In the case of Trinidad and Tobago, the level of
detail on the household OOP spending could be improved in subsequent household surveys—for
example, the Household Budgetary Survey (HBS)—to enrich the HA results.
A major finding of the HA study is that household spending is one of the largest contributors to
health financing in the country. Trinidad and Tobago has committed to work towards meeting the
Sustainable Development Goals (SDGs), which involve financial risk protection as a key objective to
ensure universal health coverage (UHC). In that context, WHO has set the threshold of limit of
OOP spending to be less than 20 percent of health expenditure (PAHO 2014). This finding of high
household spending in Trinidad and Tobago can therefore be used as a baseline measurement to
monitor further advances towards that end.
The exploratory results of health expenditure analysis by disease show that households devote a
large share of their spending to NCDs. Improved monitoring of the SDG and the UHC
commitments could involve a policy decision by the MOH to ensure more complete documentation
of expenditure by disease in the health sector, given that the HA exercise proved it is feasible and
useful to track health spending by disease.
Based on the data limitations encountered, consideration should also be given to ensuring that the
Health Information Management System (HIMS) is properly related to the HA activities. A revision
of the line item budgets and their detail could be highly beneficial, especially to future HA analyses.
The part of the HIMS that can be improved and updated is the MOH’s statistical report (the last
issue available is for 2009–2011). The content of this report is highly relevant for estimating the
expenditure by disease because it can be used to break-down non-earmarked expenditures by
disease or health condition. Similarly, a routine release of data on use of health services, such as total
consultation numbers, days of stay by disease, pharmaceutical provision, and ancillary services, would

13. ix
be key to comprehensive expenditure analyses. An improved HIMS would be an important step in
monitoring quality of health services provision.

15. 1
1. INTRODUCTION
1.1 Background
Producing HA is a critical step in understanding health spending in Trinidad and Tobago. It helps to
monitor whether health spending is aligned with the country’s goals and national priorities. By
answering questions on how health is funded and managed, who are the main providers, activities,
and the main inputs into health production, the HA can help to measure the performance of the
health system, supporting reform efforts of the government in an economic climate in which
external funding may be decreasing.
An HA estimation provides important evidence needed for guiding policy and getting value for
money in health. Tracking health spending through HA is founded on the principle that “we cannot
manage what we cannot measure.” The institutionalization of HA in Trinidad and Tobago will help to
ensure a process of regular production and use of health spending data that is government-owned.
Such data will help the government to make more-informed decisions to increase efficiency (avoiding
waste) and effectiveness (value for money). The timing of the HA study is critical as the country
discusses moving towards National Health Insurance.
1.2 Economic Context
Trinidad and Tobago’s economy is highly dependent on its energy sector,1 where the fiscal
performance is based on the weighted oil and natural gas prices. As a result, changes in these prices
greatly impact how healthy the government’s fiscal balance will be. From fiscal year 2009 to 2016,
the country ran a fiscal deficit that can be attributed mainly to a continuous increase in the public
sector debt, from 32.1 percent of GDP in fiscal year 2010 to 58.8 percent of GDP in fiscal year
2016.
According to the Central Bank of Trinidad and Tobago’s (CBTT) Data Centre (Central Bank of
Trinidad and Tobago 2018), following the 2008 global financial crisis, Trinidad and Tobago’s economy
experienced a decline in real growth, from 3.4 percent in 2008 to -4.4 percent in 2009. Despite
some signs of recovery in 2010, economic growth declined to -0.3 percent in 2011 as a result of
negative growth in the petroleum sector, as well as decreased levels of economic activity in the non-
petroleum sector. An expansion in the non-petroleum sector, particularly in finance, distribution,
transport, construction, and agriculture boosted economic growth somewhat in 2012 and 2013
(Figure 1.1). However, the country experienced another economic decline from 2014 to 2016.
1
The energy sector in Trinidad and Tobago comprises the petroleum, natural gas, and petrochemical (methanol, urea,
ammonia) markets.

16. 2
Figure 1.1: Real GDP Growth in Trinidad and Tobago for the Period 2008–2016
Source: Central Bank of Trinidad and Tobago’s Selected Economic Indicators: https://www.central-bank.org.tt/statistics/data-centre/selected-econ-
indics-annual
1.3 Health System Structure
1.3.1 Public Sector
The MOH is responsible for corporate governance and leadership of the health sector. This
governance function includes policy setting, quality assurance and regulations, monitoring and
evaluation, and financing of the public health system. The MOH also has responsibility for several
vertical services and national programs, such as the one managed by its HIV/AIDS Coordinating Unit.
3.4
-4.4
3.3
-0.3
1.3
2.7
-0.6 -0.6
-2.3
-5
-4
-3
-2
-1
0
1
2
3
4
2008 2009 2010 2011 2012 2013 2014 2015 2016
RealGDPGrowth
Year

17. 3
2. HEALTH ACCOUNTS IN TRINIDAD AND TOBAGO
2.1 Overview
In 2017, the Trinidad and Tobago MOH embarked on its first HA estimation, inspired by a need to
track funding through the health system, particularly as it relates to HIV and AIDS. This initiative
aims to provide evidence for assessing whether resources for health are sufficient, improve the
allocations for health, and improve equity by reducing financial barriers to accessing health care.
In April 2017, persons from different government agencies and the MOH were trained in the HA
methodology and production tool. This training was aimed at building in-country capacity for further
HA work. After the launch workshop in July 2017, the HA team, with representation from the
Health Economics Unit, Center for Health Economics, (UWI-HEU) and the Health Finance and
Governance project (HFG), began primary and secondary data collection. Data were compiled,
cleaned, triangulated, and reviewed. The preliminary results of the analysis were verified with
country stakeholders at a validation workshop in December 2017 and at a second validation with
MOH representatives in July 2018.
2.2 Objectives
This Trinidad and Tobago HA exercise was conducted for the fiscal year 2015 (October 2014 to
September 2015). The main objective was to provide specific data on the magnitude and
components of health expenditure during that period for both the public and private sectors of the
health system. The HA exercise was guided by key policy questions identified by health system
stakeholders during the planning stage (Table 2.1).
Table 2.1: Key Policy Questions Guiding Health Accounts Estimation
Scope Policy Area Policy Question Relevant
Report
Section
Overall
health
system
Sustainability of
health financing
Who funds the health system, and how much do they
contribute? What is the role of the private sector?
Section 3.2.1
Risk pooling How are funds managed, and to what extent are funds
for health pooled to minimize risk?
Sections 3.2.2,
3.2.3
Financial risk
protection
What level of financial risk protection is available to
households in Trinidad and Tobago? What is the level of
OOP spending?
Sections 3.2.2,
3.2.3, 3.2.4
Efficiency How are funds distributed across levels of care (e.g.,
primary vs. secondary/tertiary spending?). What
percentage of funds are spent on administration?
Sections 3.2.5,
3.2.7
UHC What is the percentage of GDP spent on health, and
what is per capita spending? Is this adequate/sustainable
in view of the country’s move towards UHC?
Sections 3.1
(summary of
results), 4.1
Disease burden/
NCD spending
Which diseases dominate Trinidad and Tobago’s
spending? Is this in line with the disease burden?
Section 3.2.8
National
HIV
response
Sustainability of
HIV financing
Who is funding HIV and AIDS goods and services? Section 3.3.1
Financial risk
protection
What level of financial risk protection is available for
people living with HIV in Trinidad and Tobago when they
seek care?
Section 3.3.1

18. 4
Scope Policy Area Policy Question Relevant
Report
Section
Efficiency How is health spending allocated among HIV treatment,
prevention, PSS, and other activities?
Sections 3.3.1,
3.3.2
Psychosocial
support (PSS)
What is the level of investment in PSS? Who is funding
PSS? For what services? How much PSS is spent at the
community level?
Section 3.3.2
2.3 Methodology
2.3.1 Health Accounts
The HA use the internationally recognized and standardized SHA 2011 framework to summarize,
describe, and analyze the financing of the health system of Trinidad and Tobago. This framework
captures information using primary and secondary data collection techniques to track spending
throughout the economy by all donors, NGOs, the public sector, and the private sector.
The HA answers questions such as: Who pays for health care? How much? For what services?
Actual expenditures, rather than budget inputs, are used to detail funding flows. HA data are crucial
for informing resource allocation decisions, comparing planned with actual expenditures, increasing
transparency and accountability, and evaluating value for money. HA analysis is also an essential
foundation in the planning of major health financing reforms, such as National Health Insurance. For
Trinidad and Tobago, the HA estimation specifically examines spending on HIV and AIDS programs,
since this information is critical for planning for sustainable programming in the face of anticipated
reductions in external funding for the disease response.
2.4 Data Sources
A wide range of secondary data and information was collected from various government documents.
Primary data were collected via surveys from a wide range of informants. Data were simultaneously
collected on both overall health spending and HIV-specific health spending, inclusive of PSS provided
for HIV and AIDS. The following agencies were surveyed to obtain primary data for the HA exercise
(Table 2.2):
a. Donors (both bilateral and multilateral), to understand the level of external funding for
health programs in Trinidad and Tobago. A list of all donors involved in the health sector was
compiled through secondary research and consultation with the MOH and other key
stakeholders.
b. NGOs and Civil Society Organizations (CSOs) involved in health, to understand flows
of health resources through NGOs (including CSOs) that manage health programs. A complete
list of NGOs involved in the health sector was compiled through consultation with the MOH
and other key stakeholders, as well as through desk research. The heterogeneous nature of
NGOs does not facilitate weighting, and those that did not respond to the survey are not
accounted for in the final estimation of total NGO spending. It is important to note that some of
the larger NGOs involved in the health sector did not respond.
c. Employers, to understand the extent to which employers provide health insurance through the
workplace and, where applicable, which employers manage their own health facilities or provide
workplace prevention programs. The employer list was developed using a sample frame from
the Central Statistical Office that is not publicly available.
d. Insurance companies, to understand total expenditures on health by insurance companies
through insurance policies (and not on benefits for the insurance companies’ employees). A list

19. 5
of insurance companies providing medical and general coverage was compiled through desk
research and consultation with key stakeholders. Ultimately, the HA study used data on
insurance companies’ market share from the Supervisor of Insurance in the CBTT and detailed
spending data from the survey submitted by one company was used to disaggregate the market
share data from the CBTT.
Table 2.2: Institutional Survey Response Rates of Contacted Entities
Entities Number Contacted Number Responded2 Response Rate
Donors 7 6 86%
NGOs 34 21 62%
Employers 27 10 37%
Insurance 10 7 70%
The following secondary data sources were used:
 Households: To capture household OOP spending for health, the 2008/09 HBS, a nationally
representative survey of all private households in Trinidad and Tobago, was used to estimate
health spending by households. The frame for the HBS was the 2000 Population and Housing
Census conducted by the Central Statistical Office. In order to obtain 2014–2015 equivalent
household health expenditure, the 2008–2009 HBS data on health was adjusted for inflation,
using the price indices on health from the CBTT. The growth in demand for health care was
accounted for by using population growth statistics from 2008–2009 to 2014–2015.
 Executed budgets from the MOH (2015) were used, via the Estimates of Revenue and
Expenditure for Trinidad and Tobago (Republic of Trinidad and Tobago Ministry of Finance
2017a).
 Costing of Health Services in Trinidad and Tobago 2013 report was used as a proxy to
determine cost allocation ratios in Trinidad and Tobago.
 Data from the CBTT provided supplementary statistics such as the GDP for 2015.
 Health services utilization data on the RHAs was obtained from the MOH Statistical Report for
2009–2011.
 The Supervisor of Insurance in the CBTT provided data on total insurance premiums and claims.
 Data from the Ministry of Finance on the health-related spending by Borough, City, and Regional
Corporations
Some reported expenditures were not easily disaggregated. To address this problem, the HA team
estimated and applied cost allocation ratios to disaggregate spending to the SHA 2011 classifications.
In most cases, the splits were developed by using unit and institutional cost data from the Costing of
Health Services in Trinidad and Tobago 2013 study (Ministry of Health Trinidad and Tobago 2013),
and utilization data on the RHAs from the MOH Statistical Report 2009–2011 (Government of the
Republic of Trinidad and Tobago Ministry of Health 2016).
2 If an entity indicated that no health expenditures were made during FY 2015, this is included in the “Number Responded”
tally.

20. 6
2.5 Limitations
The first HA estimation is a significant accomplishment for the MOH of Trinidad and Tobago.
However, some challenges ensued during the data collection, which are important to highlight for
consideration in future HA exercises and to understand when using the results.
Aggregated government health spending data. The main challenge encountered was the lack of
disaggregated government data, particularly for the RHAs and central MOH. For example, the MOH
was unable to provide disaggregated spending data for the vertical programs. Vertical programs were
allocated to prevention in the absence of disaggregated data. The corresponding Statistical Report
for this HA exercise provides additional details on the methodology used to disaggregate health
spending.
Estimation of household OOP expenditure. Use of a secondary source to estimate household OOP
spending (in this case the HBS) in the HA exercise may underestimate health spending by
households. Although the HBS did allow for some level of analysis, there is need to add more health
questions to national surveys for a more in-depth analysis of household OOP spending. Some of the
line items in the HBS survey were ambiguous, and therefore assumptions were inevitable.
Response rates. The response rate for employers was low. Review of the surveys that were
submitted revealed that employer-subsidized insurance was the main benefit across the majority of
employers. The magnitude of underestimation of the overall employers’ contribution is likely to be
low, as their spending on health benefits through employer-subsidized insurance schemes was
captured in data from insurance companies. (There was, however, some level of underestimation of
employers’ other benefits.) The response rate for NGOs was relatively low, contributing to an
underestimation of both general health (prevention) and HIV spending. The magnitude of this
underestimation is likely to be minimal, because the role of non-governmental funding is limited in
Trinidad and Tobago.

21. 7
3. HEALTH ACCOUNTS RESULTS: KEY FINDINGS
THE in Trinidad and Tobago during the 2015 fiscal year is estimated at TT$9,955,666,420; this is the
internationally comparable figure of health spending used by countries completing HA exercises. Of
this spending, TT$9,073,090,936 represents recurrent expenditure (91 percent) and
TT$882,575,484 represents capital expenditure (9 percent). In addition, the exercise has separately
captured health-related expenditures that are of broader public health policy and programing
importance but do not fall under the core health service definition per the SHA 2011 framework.
Health-related expenditures totaled TT$ 636,039,781 for the 2015 fiscal year and included spending
on PSS for HIV and AIDS, and broader activities related to environmental health and food hygiene,
and drinking water control. With the exception of the PSS, the remaining spending was by the
Ministry of Local Government through the local/municipal authorities (Republic of Trinidad and
Tobago Ministry of Finance 2017b).3 (Table 3.1). Trinidad and Tobago’s National Health Expenditure,
which includes health-related spending that is of importance to the individual country, is not
comparable to that of other countries.
3.1 Summary of General Health Accounts Findings
Table 3.1 provides a summary of the level of health expenditure, spending actors, and main health
items and services on which funds are spent.
Table 3.1: Key Health Accounts Findings
Indicator TT$ US$
Health Expenditure
Recurrent expenditure 9,073,090,936 1,435,327,983
Capital expenditure 882,575,484 139,620,037
THE (recurrent + capital) 9,955,666,420 1,574,948,020
THE per capita 7,376 1,167
THE/GDP (%) 6.6%
Total government health expenditure 5,866,664,580 928,083,704
Total general government expenditure 61,966,922,675 9,802,928,106
Government health spending as a percentage
of total general government expenditure (%)
9.5%
Government health expenditure per capita 4,347 688
Government health expenditure as % of GDP 3.9%
Total health-related spending 636,039,781 100,619,040
Sources of supplementary data: Exchange rate (monthly average for fiscal year 2015) and GDP (2015) from CBTT Data Centre. General government
expenditure for 2015 from the MOF 2017 estimates of Expenditure. 2015 mid-year population data from the Central Statistical Office of Trinidad and
Tobago.
3 Health-related spending data was primarily obtained from two sources: supplemental PSS surveys collected information
on PSS spending by NGOs; additionally, in response to comments at the July 20, 2018 validation meeting, data on the
borough, city, and regional corporations’ health-related spending for fiscal year 2015 were added to this estimation
from the MOF’s Estimates of the Revenue and Expenditure for the Financial Year 2017. The PSS surveys accounted for
TT$ 242,420 of health-related spending and the estimate for the Ministry of Local Government’s health-related
spending accounted for TT$ 635,797,361.

22. 8
Figure 3.1 presents a comparative analysis of countries across the Caribbean with different levels of
income that have conducted HA estimations. While Trinidad and Tobago, with its per capita
spending of US$1,167, spends more than twice the Caribbean average of US$551 on health, it has
the highest rate of OOP spending (40 percent) after St. Kitts and Nevis (55 percent). External
partners contribute less than 1 percent of the total health expenditure. Trinidad and Tobago has the
second-lowest government health spending as a proportion of total general government spending
among these countries: 9.5 percent based on the FY 2015 HA versus the average of Barbados, St.
Vincent and the Grenadines, St. Kitts and Nevis, and Dominica, which was 12 percent, as reported in
the Barbados Health Accounts Report (Barbados Ministry of Health 2014, p. 26).4
Figure 3.1: Source of THE in the Region
Notes: All countries’ data displays the funding as a proportion of THE, with the exception of St. Vincent and the Grenadines, which comprises Current
Health Expenditure only. The FS.RI classification was used to determine the source of funding.
Source: Data for Barbados, St. Vincent & the Grenadines, Dominica, and St. Kitts & Nevis is from Annex A in Barbados’s Health Accounts Report
(2012-2013); data from Guyana was obtained from Guyana’s 2016 Health Accounts results, and data from Suriname was taken from Suriname’s 2016
Health Accounts results.
3.2 General Health Accounts Findings
The results presented in this section refer only to recurrent health expenditure, and therefore
do not include capital and health-related spending.
4 Note that the Barbados HA Report for 2012-2013 cites 7.6 percent as the government health spending as a percent of
total government spending. However, 7.6 percent was an estimate sourced from the WHO Global Health Expenditure
Database (accessed in November 2014 at http://apps.who.int/nha/database) and the World Bank DataBank (accessed in
November 2014 at http://databank.worldbank.org/data/home.aspx). Therefore, this report uses 9.5 percent, which is
the statistic that was calculated using the FY 2015 HA information.
59%
81%
54% 56%
72%
62%
37%
40%
9%
33%
38%
14% 34%
55%
1%
10% 13%
7%
15%
4% 8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Trinidad and
Tobago
(FY 2015)
Guyana
(2016)
Suriname
(2016)
Barbados
(FY 2013)
St. Vincent &
Grendadines
(2012)
Dominica
(FY 2011)
St. Kitts & Nevis
(2011)
Government Households Other

23. 9
3.2.1 Sources of Health Funding: Who Pays for Health Care?
In Trinidad and Tobago, the government and households are the two largest contributors to health
spending, accounting for 55 percent and 44 percent, respectively (Figure 3.2). This distribution of
health spending is a reflection of the government’s commitment to financing health. Contributions by
donors, NGOs, and employers (via insurance companies) account for less than 1 percent of health
spending. None of the surveyed employers reported funding workplace programs, nor were they
involved in any prevention activities; thus, the data reflects their contributions to private insurance
schemes on behalf of their employees.
Figure 3.2: Recurrent Health Spending by Source of Financing
3.2.2 To What Extent Is Health Spending Pooled To Minimize
Financial Risk?
Risk pooling in health spending is one indication of the level of equity in health financing, given that it
highlights the extent to which individuals are financially burdened when they require health care.
Pooling resources across a large group of individuals based on ability to pay, in order to provide
health services on the basis of need, is important for spreading risk evenly across a population. In
Trinidad and Tobago the government scheme5 accounts for 55 percent of recurrent expenditure
(see Figure 3.3). These funds are pooled resources with risks distributed across the population. Less
than 1 percent of health funds is pooled via insurance schemes and NGO schemes, and 44 percent
of health expenditure is borne by households, whose costs of health goods and services are incurred
OOP. OOP payments do not provide risk pooling across individuals, given that households bear the
full cost of health services at the time of need. According to the WHO (2010), OOP spending of
more than 20 percent increases the likelihood of poverty in a country. This indicates that the
government of Trinidad and Tobago should address OOP spending in order to achieve the SDGs.
5 Financing schemes are the financing arrangements through which people obtain health services. Therefore, a
government scheme is a program with its own budget, and a government entity has overall responsibility for it;
oftentimes, government schemes are managed by government units, although this is not necessarily the case. The 55
percent of funds that are pooled via government schemes in Trinidad and Tobago includes funds from government
agencies that are managed by government entities, such as the central MOH and the RHAs.

24. 10
Figure 3.3: Recurrent Health Spending by Scheme
3.2.3 Who Manages Health Funds?
Due to the decentralization of services, the RHAs and the central MOH manage 41 percent and 14
percent of health spending respectively; households are responsible for 44 percent of expenditures,
through OOP payments. Of the RHAs that manage health funds, the South West RHA and the
North Central RHA manage the largest share of all health spending, at 11 percent each, followed by
the Tobago RHA and Division of Health and Social Services (DHSS) collectively, at 6 percent (Figure
3.4).
Figure 3.4: Recurrent Health Spending by Managers of Health Funds
3.2.4 At Which Providers Do Households Spend Funds on Health
Services?
The HA information makes it possible to disaggregate household OOP health spending to identify at
which types of providers households spend their funds. Most households in Trinidad and Tobago

25. 11
spend almost half of OOP funds on medical goods at pharmacies. This is followed by spending at
ambulatory care providers (private physicians’ offices) and private hospitals, at 34 percent and 12
percent respectively (Figure 3.5). Spending at private providers could be a reflection of a perceived
higher quality of care in the private sector. A negligible proportion of household OOP spending is on
overseas care, which may be attributed to the relative availability of specialist services in Trinidad
and Tobago or to the relatively high cost of overseas care.
Figure 3.5: Household OOP Health Spending by Provider

26. 12
Figure 3.6: Household OOP Health Spending by Function
Figure 3.6 shows that the majority of household OOP spending is for pharmaceuticals (prescribed
medicines/over-the-counter medicines) (47 percent), outpatient care (39 percent), and inpatient care
(9 percent). Collectively, curative care accounts for 48 percent of total household OOP spending.
The HA results did not identify any health-related spending by households because the data on
household spending did not provide sufficient detail to determine whether there was any health-
related spending by households. However, data on health-related spending by households may be
available through existing datasets in Trinidad and Tobago and future HA studies should make an
effort to incorporate them into the estimation.
In the analysis, 76 percent of household OOP spending could not be allocated to specific diseases or
conditions. However, of the 24 percent that could be disaggregated, about 97 percent was spent on
noncommunicable diseases. The main types of NCDs that households spent on were sense organ
disorders (diseases of the eyes, nose, ears; 55 percent) and oral diseases (40 percent), as shown in
Figure 3.7. It was noted that spending on diabetes and hypertension accounted for approximately 2
percent and 1 percent of total OOP spending, respectively.
Although this hypothesis is not fully supported by available data, the low share of expenditure on
diabetes and hypertension by households may be due to the availability of government programs
such as the CDAP. Additionally, the low share of spending on diabetes and hypertension may be due
to the lack of disaggregated data. In general, household spending on sense organ disorders and oral
diseases was on eye care and dental expenses, respectively; this detail is typically available in
household spending datasets. Meanwhile, diabetes and hypertension-related OOP spending may be
included in the 76 percent that could not be attributed to a specific disease or condition. In
subsequent HA exercises, a better disaggregation of the data would be needed to understand on
which diseases and conditions households are spending funds.

27. 13
Figure 3.7: Recurrent Household OOP Health Spending on NCDs
Note: Figure 3.7 only represents household OOP spending on NCDs that is included in the 24 percent of household
OOP spending that could be allocated to specific diseases and conditions.
3.2.5 Which Providers Receive Funds To Deliver Care?
The main providers receiving funds to deliver care in Trinidad and Tobago are hospitals, which
account for 35 percent of total expenditure on health. Pharmacies and clinics and health centers
(which includes private doctors’ offices, health centers, and district health facilities) each account for
22 percent of health spending (Figure 3.8).
Figure 3.8: Recurrent Health Spending by Provider
An examination of the spending by type of hospital revealed that 78 percent of total hospital
spending goes to general hospitals (Figure 3.9), with the main ones being San Fernando General
Hospital, Eric Williams Medical Science Complex, and Port of Spain General Hospital. Private
hospitals accounted for 7 percent of expenditure, all specialized hospitals (non-mental health)
accounted for 10 percent, and 5 percent of recurrent heath spending at hospitals went to St. Ann’s
Psychiatric mental health hospital.

28. 14
Figure 3.9: Recurrent Health Spending at Hospitals by Hospital Type
3.2.6 Which Inputs Are Used To Deliver Health Services?
Materials and services used in the production of health care account for 50 percent of recurrent
health spending; this includes pharmaceuticals, health care services such as laboratory services,
health care goods such as medical equipment, and non-health care services such as on the job
training for medical professionals. Wages account for 50 percent of inputs (general wages and self-
employed remunerations) (Figure 3.10). Self-employed professional remuneration includes payment
to independent health professionals such as payments made by patients to a physician practicing
independently in a small office.
Figure 3.10: Recurrent Health Spending by Inputs
Note: “Other Materials and Services” are health and non-health materials and services other than pharmaceuticals.

29. 15
3.2.7 How Is Spending Allocated Among Treatment, Prevention and
Other Activities?
Overall, spending on health care is predominantly for curative care, at approximately 55 percent
(Figure 3.11). The SHA 2011 defines curative care as a health care contact where “the principal
intent is to relieve symptoms of illness or injury, to reduce the severity of an illness or injury, or to
protect against exacerbation and/or complication of an illness and/or injury that could threaten life
or normal function” (OECD, EUROSTAT, WHO 2017, p. 84), Curative care includes inpatient care,
outpatient care, day care, and home-based care.
The purchase of pharmaceuticals represents 21 percent of spending. Spending on prevention
accounted for approximately 14 percent, but this may be an underestimated value, due to low NGO
response rates because NGOs typically provide preventive services.
Figure 3.11: Recurrent Health Spending by Function
In the HA, prevention is defined as spending to prevent and detect diseases in their early stages, and
can be classified into primary and secondary prevention. Information on the type of prevention
activity was not available for 73 percent of health spending on prevention; for the 27 percent that
could be classified according to the type of activity, 63 percent went towards healthy condition
monitoring programs, 26 percent towards epidemiological surveillance and risk and disease control
programs, 4 percent each for immunization programs and information, education and counseling
programs, and 2 percent towards early-disease detection programs (Figure 3.12). The difference
between healthy condition monitoring programs and early-disease detection programs relates to the
type of monitoring or screening. Early disease detection activities can include screening, diagnostic
tests, and medical examinations for a disease before symptoms are apparent; examples include
breast cancer screening or HIV and AIDS testing. Healthy condition monitoring programs target
specific conditions or age groups, such as antenatal or postnatal care.

30. 16
Figure 3.12: Recurrent Health Spending on Prevention, by Type
Note: Figure 3.12 only represents prevention spending that is included in the 27 percent of prevention spending that could
be allocated to a specific type of prevention activity.
3.2.8 What Diseases and Health Conditions Does Trinidad and
Tobago Spend on?
21 percent of recurrent health expenditure is spent on NCDs. The top three funded NCDs are
sense organ diseases (6 percent), oral diseases (5 percent), and mental and behavioral diseases and
neurological conditions (3 percent). Spending for HIV and AIDS accounts for <1 percent of all
recurrent expenditure (Figure 3.13).

31. 17
Figure 3.13: Recurrent Health Spending by Disease, with Detail on NCDs
As improvements in data collection enable a greater proportion of spending to be allocated to a
disease or health condition, this analysis will permit a comparison of spending with national
priorities. Over time, as data collection becomes more detailed, more of the “not classified”
expenditures will be allocated to specific disease categories.
The country’s CDAP provides citizens with free prescription drugs and other pharmaceutical items
to combat 12 conditions.6 However, HA estimates found that NCDs are still funded approximately
evenly between households and government (50 percent and 49 percent of recurrent health
spending on NCDs, respectively; see Figure 3.15).
6 Diabetes, asthma, cardiac diseases, arthritis, glaucoma, mental depression, high blood pressure, benign prostatic
hyperplasia (enlarged prostate), epilepsy, hypercholesterolemia, Parkinson’s disease, and gastrointestinal disorder.

32. 18
Figure 3.14: Source of Current Health Spending for NCDs
Efforts to improve the availability of service utilization and costing data to disaggregate spending by
disease and condition will enable more-accurate analysis in the future, and will help to assess
whether spending is in line with the disease burden. For example, at a high level, the Institute of
Health Metrics and Evaluation’s disease burden calculations show the dominance of NCDs in
mortality and Disability-Adjusted Life Years (DALYs; Figure 3.15).

33. 19
Figure 3.15: Disease Burden for Trinidad and Tobago in 2015 (Based on DALYs)
Source: Institute of Health Metrics and Evaluation 2018: https://vizhub.healthdata.org/gbd-compare/
Note: Diseases and conditions in blue represent noncommunicable diseases, the red represents infectious diseases, and the green represents injuries.
Darker shades indicate larger increases in DALYs. Therefore, this figure illustrates NCDs’ dominant burden of disease.
Note: ASD: Autistic spectrum disorders; CKD: Chronic kidney disease; CMP: Cardiomyopathy and myocarditis; COPD: Chronic obstructive
pulmonary disease; HTN HD: Hypertensive heart disease; IHD: Ischemic heart disease; Iron: Iron-deficiency anemia; LF: Lymphatic filariasis; LRI:
Lower respiratory infections; Mech: Exposure to mechanical forces; MSK: Musculoskeletal disorders; NN: neo-natal; PEM: Protein-energy
malnutrition; PUD: Peptic ulcer disease; SIDS: Sudden infant death syndrome; RHD: Rheumatic heart disease.
3.3 Analysis of HIV Spending
Recurrent health spending for HIV in fiscal year 2015 totaled TT$37.25 million, which represents
less than 1 percent of total recurrent health expenditure.
3.3.1 Recurrent Health Spending on HIV
HIV spending is predominantly financed by the government, which is responsible for 90 percent of all
HIV spending (Figure 3.16). This is higher than in other Caribbean countries that have conducted HA
recently; for example, Guyana’s 2016 HA study found that the government is responsible for 62
percent of recurrent HIV spending, while donors contribute 35 percent, and corporations,
households, and NGOs contribute a combined total of 3 percent (Guyana Ministry of Public Health
2018). In Suriname, the 2016 HA found government recurrent spending on HIV to be 68.8 percent,
followed by donors at 16.6 percent, respectively); corporations and households comprising the
remaining 14.6 percent (Suriname Ministry of Health 2018). This finding is an encouraging sign of
sustainability in the national HIV response, especially in the context of reduced external financing.

34. 20
Figure 3.16: Recurrent Health Spending on HIV by Financing Source
The government manages more of the HIV funding than it provides (95 percent compared to 90
percent, respectively; see Figure 3.17). This is because some donor-funded HIV programs are
managed through the MOH. Of note is that OOP payments do not represent any of the recurrent
health spending on HIV and AIDS.
Figure 3.17: Recurrent Health Spending on HIV by Manager
The largest proportion of health spending for HIV goes to hospitals (50 percent), followed by health
centers and district health facilities (21 percent), the Medical Research Foundation (MRF; 16
percent), and other ambulatory care providers such as diagnostic laboratories (19 percent; see
Figure 3.18). The finding that spending at hospitals is more than three times larger than spending at
the MRF is surprising, given that the MRF is responsible for offering treatment of HIV that includes
antiretroviral drugs.

35. 21
Figure 3.18: Recurrent Health Spending on HIV by Provider
Total curative care for HIV accounts for 85 percent of all HIV expenditure, with prevention
accounting for 12 percent (Figure 3.19). Outpatient curative care includes patient visits to collect
their antiretroviral drugs.
Figure 3.19: Recurrent Health Spending on HIV by Function

36. 22
3.3.2 Psychosocial Support (PSS) for HIV
PSS spending for HIV is considered health-related spending and not direct health spending according to
the SHA 2011 framework; in Trinidad and Tobago PSS spending for HIV totaled TT$132,800. All of
the PSS funds for HIV and AIDS were managed by NGOs. PSS spending for HIV and AIDS was
mainly focused on advocacy (34 percent) and the provision of social services (31 percent). Other
areas of spending included nutritional/food support, counselling and spiritual support, and support to
orphans and vulnerable children (Figure 3.20).
Figure 3.20: Psychosocial Support Spending on HIV

37. 23
4. POLICY IMPLICATIONS AND RECOMMENDATIONS
The HA exercise revealed areas that can prove useful to policymakers in the Trinidad and Tobago
context, to improve both the system’s financing and future HA exercises. The major implications and
recommendations are highlighted in the following points.
4.1 Government Financing for Health Could be Increased
4.1.1 Explore fiscal space for increasing health spending
Of countries in the region that have conducted HA studies since 2011, Trinidad and Tobago has the
second highest THE as a percentage of GDP in the region, after Barbados (Barbados Ministry of
Health 2014, p. 26; Guyana Ministry of Public Health 2018; Suriname Ministry of Health 2018).7 At
the same time, a closer analysis highlights the significant role that households play in health spending,
relative to government contributions. Government health spending as a percentage of GDP (3.9
percent) still lags behind the PAHO/WHO recommendation of 6 percent. The government
contributes 9.5 percent of its budget to health, which is the second-lowest such contribution in the
region among countries that have conducted a HA study since 2011 (Barbados Ministry of Health
2014, p. 26; Guyana Ministry of Public Health 2018; Suriname Ministry of Health 2018).8
In order to manage increasing demand and costs of health care in uncertain economic times, and to
achieve the Sustainable Development Goal of universal health coverage (including financial risk
protection and access to health care), Trinidad and Tobago will need to explore ways to increase
fiscal space to increase resources for health in a way that does not burden households. This could
include, for example, conducting analyses that demonstrate the potential risks if households continue
to fund nearly half of all health spending OOP. Also, in-depth assessment of efficiency of health
spending can often indicate opportunities for increased efficiency, thus freeing up resources for
health goods and services; the HA estimation results highlight some potential entry points for this
analysis, such as spending at hospitals, and on drugs.
4.1.2 Increase domestic resource mobilization on HIV and AIDS
Less than 1 percent of overall recurrent health expenditure in Trinidad and Tobago comes from
donors (Figure 3.2), while donors provide 10 percent of recurrent health expenditure on HIV and
AIDS (Figure 3.16). This indicates that a significant proportion of donor spending on health funds
HIV and AIDS programming. In order to increase sustainability of HIV and AIDS services, the
7 Annex A in Barbados’s 2012–2013 Health Accounts Report shows that THE as a percentage of GDP was 8.7% (for
Barbados), 5.3% (for St. Vincent and the Grenadines), 6.0% (for St. Kitts and Nevis), and 6.1% (for Dominica). Note
that the percentage for St. Vincent and the Grenadines is for current health expenditure instead of THE. The 2016
Guyana Health Accounts study found that THE as a percentage of GDP was 4.0%; the 2016 Suriname Health Accounts
study found that this figure was 6%.
8 Annex A in Barbados’s 2012–2013 Health Accounts Report shows that government spending on health as a percentage
of total government expenditure was 11.1% (Barbados), 15.0% (St. Vincent and the Grenadines), 8.9% (St. Kitts and
Nevis), and 15.5% (Dominica). Note that the percentage for St. Vincent and the Grenadines uses current health
expenditure instead of THE. The 2016 Guyana Health Accounts study found that the government spending on health as
a percentage of total government expenditure was 10.4%, and the 2016 Suriname Health Accounts found that this
figure was 13%.

38. 24
government should consider which HIV and AIDS programs rely on donor funding to ensure
sustainability of those programs as donor support declines.
4.2 Increase Risk Pooling Essential to Reduce OOP Spending
A major finding of the HA exercise was that household spending is one of the largest contributors to
health financing in the country. High OOP spending may lead to coping strategies by households that
force them to trade off health spending for other types of welfare spending. This may result in
worsening health status from delayed care and from avoiding expenditure on drugs or diagnostic
tests. It can also push households further into poverty (Xu et al. 2010). Further, the level of OOP
spending is expected to be diminished through specific interventions such as CDAP.
Private providers play a major role in the health sector, especially in ambulatory care services. Since
these services generally have a lower cost in the public sector, it is worth exploring what is driving
the population to pay more and use the private sector; for example, this may be due to a personal
choice about affordability or households may be driven to the private sector in hopes of receiving
higher quality care. This may point to the need to conduct an assessment of how these services are
delivered in the public sector, especially to those who may be uninsured and have to pay OOP in the
private sector.
The HA study also highlighted the low level of private health insurance expenditure, which is
concentrated among government and large businesses. This can be considered from two angles. Low
levels of insurance spending can be indicative of inadequate pooling and financial protection,
especially for uninsured households. The results suggest that there is a need for national pooling
arrangements like a National Health Insurance scheme to offer access to an essential package of
health services for all at an affordable cost and with financial protection to the poor. Another factor
that may contribute to low levels of private insurance spending in this area is the lack of
infrastructure in the public sector health facilities to manage insurance, e.g., billing systems. This
means that when insured persons access care in the public sector, insurance companies cannot be
billed and therefore are unable to pay on behalf of their insureds.
Trinidad and Tobago has committed in the international arena to work towards meeting the SDGs,
which involve financial risk protection as a key objective to ensure UHC. In that context, the WHO
has set the threshold of limit of OOP spending to be less than 20 percent of THE. The study’s
findings can therefore be used as a baseline measurement to monitor further advances towards that
end.
4.3 Increase Access to Health Services and Improve
Allocative Efficiency
The largest proportion of funds in Trinidad and Tobago were spent providing health services at
hospitals: 35 percent of spending was at hospitals, while 22 percent occurred at clinics and health
centers (Figure 3.9). Health services that are offered at primary level facilities are more accessible to
the population of Trinidad and Tobago than services offered at hospitals. Therefore, these findings
call for an investigation into the distribution of health facilities that provide care throughout Trinidad
and Tobago to determine whether there is equitable access to health care services across the
country, and whether there are potential efficiency gains if more resources were spent at primary
level facilities. The findings of such an investigation may conclude that a greater proportion of health
spending ought to happen at the primary level to improve accessibility and allocative efficiency.
Furthermore, the majority of health spending funded curative care (55 percent of recurrent health
spending was on curative care while 13 percent was on preventive care; Figure 3.12). While Trinidad
and Tobago has pursued a primary health care approach since 2000 through the provision of

39. 25
services at the community level, by increasing spending on preventive care and health services at
primary level facilities, Trinidad and Tobago may be able to reduce overall costs of care.
4.3.1 Consider the allocative efficiency of HIV and AIDS services
UNAIDS recommends that 25 percent of HIV and AIDS spending goes towards prevention
(UNAIDS 2016). The 2015 Health Accounts found that Trinidad and Tobago does not meet this
target, with 12 percent of HIV and AIDS health spending funding prevention while 85 percent funds
curative care (Figure 3.20). It is important to note that the HA considers the provision of
antiretroviral therapy to be curative care. Therefore, these findings indicate that further investigation
of the type of HIV services provided would identify ways to increase the cost efficiency of HIV and
AIDS services by increasing expenditure on prevention activities.
Furthermore, 50 percent of HIV and AIDS health spending funds services at hospitals, while 21
percent of HIV and AIDS health spending occurs at health centers and district health facilities, and 16
percent occurs at the MRF, which includes the provision of antiretroviral drugs (Figure 3.19). By
reducing the proportion of funding for HIV and AIDS services that is spent at hospitals, Trinidad and
Tobago may be able to increase the equity, accessibility, and allocative efficiency of HIV and AIDS
services.
4.4 Strengthen the Health Information Management System
(HIMS)
Trinidad and Tobago’s commitment to achieving the SDGs and UHC means being able to monitor
progress towards these goals. This HA exercise has demonstrated that tracking detailed spending is
feasible. However, if spending is to be tracked in a more accurate way, it is important for the
government to commit to ensure better documentation and availability of utilization and expenditure
data.
For example, the standard structure of household surveys comprises questions about
inpatient/outpatient split and medical goods. The level of detail of the household OOP spending data
could be improved by minor refinements to subsequent household surveys (for example the
Household Budgetary Survey) to enrich the HA results.
Based on the data limitations encountered, consideration should also be given to ensuring that the
HIMS properly records health service utilization and provides financial data that not only facilitates
improved planning and programming but can also help produce HA more quickly to inform policy
discussions. Part of the HIMS that can be improved and updated is the MOH’s statistical report (the
last issue available covers 2009–2011); updating this data would be a useful first step to strengthening
the HIMS.
A routine release of data on major health activities in the country, such as total consultation
numbers, days of stay by disease, pharmaceutical provision, and ancillary services, would be critical
to having a comprehensive expenditure analysis. An appropriate HIMS would also be a basic step in
monitoring quality.
Although public sector records are relatively compatible, there is need to include reporting from the
private sector, to ensure that interventions are coordinated. Already some of the main NGOs in the
country share records with MOH. The ultimate goal is that data for policy analysis purposes can
generate the evidence required, linking expenditure with utilization and health outcomes throughout
the health system.
4.5 Institutionalize Health Accounts
Based on the national information needs and the international experience, it is advisable to ensure
that the process of this HA data collection and analysis be continued as recommended by

40. 26
international agencies, and be performed on a regular basis. This recurrent process leads to
strengthened knowledge of the health accounts methodology and a progressive refinement of the
production and use of HA data.
Steps to advance the institutionalization of HA include making the appropriate resources available by
including a budget line for HA, and designating a team to lead the process. Furthermore,
institutionalization implies the ownership and strengthened collaboration to share and analyze data,
interpret findings and integrate the results into policy and decision-making. An important component
of institutionalization in Trinidad and Tobago is to ensure that the routine data systems mentioned
above are refined to enable faster production of HA results. To date, one of the bottlenecks of the
accounting process is data collection; an automated approach can improve timeliness and accuracy,
resulting in more useful spending data.

41. 27
5. CONCLUSION
HA estimations should be viewed as integral to the overall health financing reform and management
process. Reforms need information, and HA allow policymakers to diagnose health financing
problems, inform potential solutions, and evaluate progress on policies. This first HA study for
Trinidad and Tobago provides insights into health spending and resource use in the health sector.
The information gathered can be used to identify and analyze important stakeholders in the health
sector; that is, it facilitates an assessment of the financial importance of key players in the health care
system. It allows an analysis of the existing situation, identifying financing issues and gaps, and can
provide a linkage between health expenditure and health outcomes.
As the country moves forward with HA, the HA estimation process should become a part of the
health system and health reform implementation, monitoring and evaluation. Institutionalization of
HA would greatly enable analysis that facilitates more efficient and effective spending in the health
system. As part of this institutionalization, it is important to better sensitize actors in the private and
public sector about the importance of providing data for HA exercises, and to show them how the
results of the study could be of use to them. It is of equal importance that HA information become a
routine part of data collection within the country and a part of health sector planning. For cost
efficiency, this means integrating data collection for HA into existing data collection exercises. HA
can add value to health reform because the results can equip policymakers with important
information to guide national planning and monitor health system performance. Trinidad and Tobago
is off to a great start with this initial exercise, which will undoubtedly be improved and strengthened
in subsequent HA efforts.

43. 29
ANNEX A: REFERENCES
Barbados Ministry of Health. December 2014. Barbados 2012-13 Health Accounts Main Report.
Bridgetown, Barbados.
Central Bank of Trinidad and Tobago. 2018. “Data Centre: Monthly Exchange Rates”. Accessed
August 9, 2018 from: https://www.central-bank.org.tt/statistics/data-centre/exchange-rates-
monthly
Central Bank of Trinidad and Tobago. 2018. “Data Centre: Output Annual”. Accessed August 9,
2018 from: https://www.central-bank.org.tt/statistics/data-centre/output-annual
Central Bank of Trinidad and Tobago. 2018. “Data Centre: Selected Economic Indicators”. Accessed
August 3, 2018 from: https://www.central-bank.org.tt/statistics/data-centre/selected-econ-indics-
annual
Government of the Republic of Trinidad and Tobago Central Statistical Office. 2017. “Population
Mid Year Estimates”. Accessed August 9, 2018 from: http://cso.gov.tt/data/?productID=31-
Population-Mid-Year-Estimates
Government of the Republic of Trinidad and Tobago Ministry of Health. 2016. Ministry of Health
Statistical Report 2009-2011. Accessed November 2017 from:
http://www.health.gov.tt/downloads/DownloadDetails.aspx?id=376
Guyana Ministry of Public Health. 2018. Brief: 2016 Guyana Health Accounts. Georgetown, Guyana.
Institute of Health Metrics and Evaluation. 2018. GBD Compare. Accessed June 5, 2018 from:
https://vizhub.healthdata.org/gbd-compare/
The Joint United Nations Programme on HIV/AIDS (UNAIDS). November 28, 2016. “Feature Story:
Closing the HIV prevention investment gap.” Accessed August 6, 2018 from:
http://www.unaids.org/en/resources/presscentre/featurestories/2016/november/20161128_closi
ngHIVpreventioninvestmentgap
Ministry of Health Trinidad and Tobago. 2013. Costing of Health Services in Trinidad and Tobago.
OECD, EUROSTAT, WHO. 2017. A System of Health Accounts 2011. Revised edition. Paris: OECD
Publishing. http://dx.doi.org/10.1787/9789264270985-en. Accessed April 26, 2018 from:
http://www.oecd.org/publications/a-system-of-health-accounts-2011-9789264270985-en.htm
Oxford Business Group. 2016. “Trinidad and Tobago's insurance sector adapts to a changing
operating environment.” Accessed February 5, 2018 from:
https://oxfordbusinessgroup.com/overview/show-strength-resilient-face-difficult-economic-
conditions-sector-looks-ways-adapt-changing
Pan American Health Organization/World Health Organization. 2014. Strategy for Universal Access to
Health and Universal Health Coverage. Accessed August 3, 2018 from:
https://www.paho.org/uhexchange/index.php/en/uhexchange-documents/technical-
information/26-strategy-for-universal-access-to-health-and-universal-health-coverage/file
Republic of Trinidad and Tobago Ministry of Finance. 2017a. Estimates of Expenditure for the
Financial Year 2017. Accessed March 2017 from: https://www.finance.gov.tt/wp-
content/uploads/2016/09/Estimates-Expenditure-2017-Final-Book-Numbered.pdf
Republic of Trinidad and Tobago Ministry of Finance. 2017b. Estimates of the Revenue and
Expenditure of the Statutory Boards and Similar Bodies and of the Tobago House of Assembly

44. 30
for the Financial Year 2017. Accessed July 25, 2018 from: http://www.finance.gov.tt/wp-
content/uploads/2016/09/Estimates-Statutory-Boards-2017-Final-Book-Numbered.pdf
SIDALAC et al. 2004. National HIV/AIDS Accounts TRINIDAD and TOBAGO, 2002-2003. Level and
Flow of Resources and Expenditures to Confront HIV/AIDS.
Suriname Ministry of Health. 2018. Suriname 2016 Health Accounts: Summary Report. Paramaribo,
Suriname.
World Health Organization (WHO). 2010. Health systems financing: the path to universal coverage.
Accessed April 26, 2018 from: http://www.who.int/whr/2010/en/
Xu, Ke et al. 2010. Exploring the thresholds of health expenditure for protection against financial risk:
World Health Report Background Paper, No. 19. Geneva.