If history is any guide, it takes a long time for healthcare systems to move from fragmented, poorly coordinated interventions to an effective integrated delivery system that benefits everyone. Even then, difficulties in prioritising the use of public funds persist as new treatments develop and costs rise and there are risks that benefits may not be distributed equitably. In attempts to deal with eye-catching health problems, international aid donors and philanthropists have not given sufficient attention to investments in long-term, strategic health system development.

Caribbean health sevrice managers and social scientists will brainstorm strategic scenarios to 2040 focussed on ways to resolve four universal issues in the context of the region: whether insurance or taxes are more efficient and equitable financing arrangements; whether, within a public budget constraint, it is better to subsidise a limited range of services for everyone or a comprehensive range of services for the more needy; whether public or private providers are more cost-effective; and whether an integrated or commissioned provider model improves efficiency and equity best. The scenarios will be subjected to financial and economic analysis.

This project is special for at least three reasons. The first is that the idea originated with a health insurance fund manager and OPI Associate in Jamaica and is now being driven by health policy practitioners in seven Caribbean countries: Antigua, Aruba, Barbados, Bahamas, Curacao, Jamaica and Trinidad & Tobago. Second, these seven Caribbean nations represent a microcosm of the problems facing larger countries in Latin America, Sub-Saharan Africa, Asia and Eastern Europe. They are economically and politically diverse and have followed different policy directions but all share common features: rising incomes and middle-class expectations, increasing income disparities, aging populations and an increasing incidence of chronic diseases. Private expenditure on healthcare and health insurance are growing but may fail to benefit the poorest, while a coherent role for tax-funded healthcare may be being eroded by a growing multiplicity of funding arrangements and service delivery options. Third, the methodology involves applying Shell-type scenario building techniques, not unique but unusual in a public policy setting.

The project will be based in the University of the West Indies in Kingston. OPI staff and associates from South Africa, Sri Lanka, Mexico and the UK will support it.