by Dr Ishma Harford

There are quite a few misperceptions around health financing. For example, ask who pays for health, and the most popular response may be the government. But that would paint only half the picture.

As of the most recent figures, for 2023, government spending accounts for approximately 45% of all health spending in Grenada. But there is an even bigger purchaser: every Grenadian household paying for care directly, at 48% (WHO Global Health Expenditure Database, 2023).

That consumer spending is the easiest to identify. It’s a direct transaction: one can draw a straight line from a patient’s pocket into the coffers of a health facility, whether private pharmacy, lab or doctor’s office. This is known as out-of-pocket spending. Government spending, by comparison, is somewhat of an illusion.

The question that dispels the mirage is simple. Where does the government get the money it spends on health? That answer comes back to you, not as a direct consumer, but indirectly, as the taxpayer. The VAT on most groceries, the tax on your income, the duty on what you import. A portion of it goes back to health.

Sum your direct consumption and your indirect funding through tax, and the picture becomes clear. By far, the largest payer for health is you.

Which raises the question of what government’s role really is in all of this? The best answer is that it acts as a proxy, a middleman, entrusted with your money and expected to spend it on your behalf, wisely and in your interest. And a proxy answers to the person in whose service it has been commissioned. When you pay for a service, you expect it to be up to standard, to get value for money, and to see the receipt.

The measure by which we hold our proxy accountable has already been set out by the World Health Organisation (WHO). Every health system has three objectives: To improve our health, respond to what we expect of it, and protect us from the financial cost of being sick. Measured against those, the promise is broken twice.

First, at the counter. At 48%, Grenada’s out-of-pocket spending is the highest among our Organisation of Eastern Caribbean States (OECS) neighbours, and well above the regional average of about 30%. To be fair, some would argue that few Grenadian households face catastrophic health bills or are forced into poverty by them. But that measure only counts the money people spend. It cannot count the services forgone because the money was never there to begin with. A household that goes without care looks financially protected on paper.

Second, in the care itself. When medication is out of stock, or the appointment wait time stretches into months, we tend to accept it as the government’s generosity running short, rather than as a service already paid for failing to arrive. We would all prefer immediate service, and that may not always be feasible. But the question is not whether we wait, but why. A wait decided by need, explained honestly and kept within a known standard, is a system working within its means. A wait caused by an empty shelf that no one accounts for is a system failing to deliver what it was paid for.

We pay twice, once through our taxes and once at the counter. So, when do we start asking to see the receipt?

Dr Ishma Harford is a medical doctor and a Commonwealth Scholar who holds a master’s degree in Health Analysis, Policy and Management. The Health Imperative is an educational, non-partisan column about health, the system that delivers it, and all the implications in between.

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