Cost Program: Barbados Experience Jonathan M. Yearwood Research and Information Officer National Council on Substance Abuse (NCSA)

Barbados’ Contribution to the Cost Study Estimating The Human, Social, and Economic Costs of Drugs in the Americas In complying with the requirements of the OAS/CICAD Program These reports provided a variety of cost calculations that are required by the umbrella OAS/CICAD Program.

Barbados’ Contribution to the Cost Study The NCSA (Barbados) conducted three (3) separate studies. These reports were: Estimating Direct Government Expenditure on Drug Demand Reduction in Barbados (November 2003) Survey of Emergency Rooms in Barbados (September 2004) The Estimation of Costs Attributable to Substance Abuse and Loss of Productivity for Inmates at Glendairy Prison: Barbados (November 2004). Three studies to provide estimates of the costs incurred due to drug abuse in the island. These reports provided a variety of cost calculations that are required by the umbrella OAS/CICAD Program.

Estimating Direct Government Expenditure on Drug Demand Reduction in Barbados (EDGE)

Objectives of the EDGE Study The main objectives of the study were: To estimate Government Expenditure on demand reduction activities; To collect and report data required for the indicators known as level one indicators; To provide a basis on which to build future studies as the pilot project progresses.

Methodology The methodology employed was: The use of secondary data on drug related costs and activities for some institutions in the health and criminal justice sectors. The secondary data provided the basis for estimating government expenditure. The results were not at all surprising. As was indicated in the proposal for this project, the biggest constraint was the lack of relevant data for cost estimation in Barbados 2. Information on requests for treatment, number of drug related convictions and previous substance abuse studies was obtained, but drug related deaths or injuries due to homicides, accidents of suicides was not available. 3. Finally suggestions for the future of the pilot project in Barbados include a study of hospital emergency rooms and aspects of the criminal justice system in order to determine attributable fractions.

Table 1 Estimates of Total Government Expenditure on Demand Reduction   Year Institution 1996 1997 1998 1999 2000 NCSA $624,457 $678,323 $706,077 $989,036 $1,256,049 Drug Rehab Unit $4,578,509 $4,954,810 $4,436,461 $2,221,621 $2,093,553 Total $5,202,966 $5,633,133 $5,142,538 $3,210,657 $3,349,602

Figure 1 Estimate of Total Government Expenditure on Demand Reduction

Analysis of EDGE Study Administrators need to keep track of spending. No data is provided for yearly requests and therefore an estimate cannot be provided. Administrators within the various agencies will need to be encouraged to keep track of spending on various activities. However, this is an ambitious governance effort and must be treated as a long-term goal rather than a reformation that will occur easily. Cost estimates for the QEH do not provide for a yearly estimate in any robust fashion, in addition no data is provided for yearly requests and therefore an estimate cannot be provided.

Analysis of EDGE Study A standardised data collection instrument for all health-care providers. Central depository for studies of this type will be needed. It appears that a standardised data collection instrument will be needed to collect data on requests for treatment from ALL of the relevant institutions in the island, including polyclinics and private health-care providers. To enable a full utilisation of such information, central depository for studies of this type will be needed. In this case the NCSA appears the natural location for such a store

Emergency Rooms in Barbados Survey of Emergency Rooms in Barbados (The ER Study)

Objectives of ER Study To determine the prevalence of drug use in the patients To establish the relative importance and the characteristics of drug use To quantify the association between drug use and accidents. To test a methodology that may be easily applied in different countries. Collect data on Level 1 direct cost indicators.. To collect data on level 1 direct cost indicators. To determine the prevalence of drug use in the patients admitted to emergency rooms at the Queen Elizabeth Hospital (QEH) and the FMH Emergency Medical Clinic based on clinical impression or toxicology tests. To establish the relative importance and the characteristics of drug use in emergency room patients. To quantify the possible direct and indirect association between the use of drugs and the accident that brought the individuals to the emergency room. To test a methodology that may be easily applied in different countries.

Methodology The study was conducted at the two institutions (QEH and FMH). A CICAD standardized questionnaire was used. Interviews were conducted on a 24-hour & 18 hour respectively. The study was conducted among persons - 12 years and older. Data was collected a two-week period. This study targeted all persons that were 12 years and older who went to either of the two institutions with emergency room facilities in Barbados. The only other criterion for exclusion besides age was that gynecological patients were not interviewed. The study was conducted at the two institutions with emergency room facilities in Barbados, (QEH and FMH). A CICAD standardized questionnaire was used. Interviews were conducted on a 24-hour basis at the QEH by student nurses and on an 18 hour basis at the FMH facility by doctors. The study was conducted among persons - 12 years and older. Data was collected a two-week period that ended on July 4th 2004.

Survey Information Patient Data collected: the date and time of the emergency; basic demographics of the patients; type of emergency; substance use in the six hours prior to the interview; and the possible relationship between consumption and the emergency. Doctor’s clinical impression was noted No laboratory tests were conducted It should be noted that the instrument collects data on drug use as reported by the patient or as noted clinically by the attending doctor. In addition, the doctors’ clinical impression is relied upon to examine the possible link between the use of a substance and the occurrence of the event that leads to emergency care. According to the CICAD Manual for SIDUC, ‘the doctor forms this clinical impression based on a series of visible physical and psychological signs and the clinical interview with the patient’

Estimation of ER Cost Data - QEH The 1996 by Boston University Report guided the survey. The cost data for the survey was based on assumed patterns of expenditure for 1995 – 2003. No Cost data for FMH The 1996 report by Boston University of an economic analysis of Barbados’ health sector was the most recent available data for cost estimates; The report guided the estimate of the proportion of hospital (QEH) expenditure on accident and emergency services; The cost data for the ER study were then based on assumed patterns of expenditure for 1995 – 2003.

Pattern of Expenditure for QEH In 1995: Expenditure on the QEH = $83.9m. $5.2m (6.2%) – A & E services. In 2002 – 2003 Expenditure on the QEH = $115.3m. $7.15m (6.2%) A & E services In 1995: The expenditure on the QEH = Bds$ 83.9m. Of total expenditure = $5.2m or approximately 6.2% was spent on Accident and Emergency services. In fiscal year 2002 – 2003, the expenditure on the QEH was $115.3m. Assuming the same pattern of expenditure for 2002 – 2003, Then 6.2% of $115.3m or $7.15m was spent on Accident and Emergency services in 2002 – 2003.

Pattern of Expenditure for QEH Cont’d The ER study shows – 3.6% had an emergency related to drug use; 3.6% of the expenditure was consistent for two years; Estimated cost for 2002 – 2003 =3.6% of 7.15m ($260,000) could have been spent on drug related accidents at the QEH. The ER study shows – 3.6% of the persons from the QEH had an emergency related to drug use; Thus, it was assumed 3.6% of the expenditure was consistent for the last two years; Then estimated cost for 2002 – 2003 =3.6% of 7.15m or Bds. $260,000 could have been spent on drug related accidents at the QEH. This figure represents 0.23% of the total expenditure on the QEH in fiscal year 2002

Analysis of ER Study Survey was conducted over a normal two (2) week period. Estimate of 0.8% of admissions are drug related. A rough estimate of admittances from drug consumption should be given. The ER survey was conducted over a normal two (2) week period. This may lead to an underestimation of costs. The current data available provided in The Emergency Survey, provides an estimate of 0.8% of admissions are drug related. This estimate is not fully reliable. In accompanying this with the total number of admissions, a rough estimate of number of admittances from drug consumption could be supplied. There is however no data available on the length of Hospital Stay. The data is requested according to type of classification under the International Statistical Classification of Diseases. This data is not supplied in the reports. Daily cost of a patient is quoted from a 1996 study as BD$101. An estimate for 2002-2003 was derived from this as BD$7.5million in total. No data is provided on numbers admitted, so this figure cannot be broken down to cost per patient. Which is ‘normal’ because of the absence of any festivals, holidays or national events 2. For the purposes of the current cost estimation the data from this project could not be utilised.

The Estimation of Costs Attributable to Substance Abuse and Loss of The Estimation of Costs Attributable to Substance Abuse and Loss of Productivity for Inmates at Glendairy Prison in Barbados (The Prison Study)

Objectives of the Prison Study Objectives of the prison study were to determine: The relationship between drug use and criminal behaviour; The frequency of drug use; Persons imprisoned for crimes or offences associated with substance use; Type of offences committed; The economic loss due to drug related crime The study on Estimation of Costs Attributable to Substance Abuse and Loss of Productivity for Inmates at Glendairy Prison in Barbados was an investigation into the percentage of total crimes associated with the use, production and/or trafficking of illicit drugs. The specific objectives of the prison study were to determine: The relationship between drug use and criminal behaviour among inmates at Her Majesty’s Prison at Glendiary, Barbados; The frequency of drug use among prison inmates; The number of persons imprisoned for crimes or offences associated with substance use and; The nature and type of offences committed by inmates associated with substance use; The economic loss due to drug related crime in Barbados.

Methodology A random stratified sample among non-remand inmates; 150 inmates were chosen; The actual sample size was 140 inmates (93%) A survey among a random stratified sample of the inmate population at Glendiary; The population list numbered 817 non-remand inmates; A stratified random sample was taken based on the type of crimes of the inmates; A total of 150 inmates were chosen from a representative fraction from each category of criminal activity; The actual population size was 140 inmates which represented a 93% response rate.

Stratified Sample Type of crimes Other RTO Damage Robbery Theft Burglary Fire- arms Sexual Drug crime Violent Total Non- remand 52 12 59 133 68 57 200 166 817 Percent 6% 1% 7% 16% 8% 24% 20% 100 Sample 9 2 11 24 10 37 30 150

Major Categories of the Survey Under the influence of illicit drugs and alcohol. Acquisition of drugs. Involvement in the drug economy. Drug trafficking and production: Crimes committed under the influence of illicit drugs and alcohol. Crimes committed for the acquisition of drugs. Crimes committed due to involvement in the drug economy. Conflicts during drugs sales; Turf or gang conflicts; Revenge attacks; Conflicts with anti-drug forces Crimes associated with drug trafficking and production: Small / corner sales of drugs; Clandestine laboratories; Illicit crops; Money laundering; Precursor chemicals; Drug trafficking

Economic Loss Due to Drug-related Crimes The formula Cost of incarceration Loss of productivity cost Economic cost of a prisoner (Perez et al 2004) + The formula uses persons who are convicted of distribution, sale, processing, or production of illicit drugs, and attempts to calculate the current cost and what it would cost if all the persons who should be incarcerated for these crimes were actually in jail. The estimated economic cost of drug-related crimes was based on the cost of 19 inmates in the sample population convicted of drug trafficking: The formula used: Economic cost of a prisoner = Cost of incarceration + Loss of productivity cost (Perez et al 2004) Cost of incarceration = [(Number of convictions) x (Length of sentence) x (Daily cost of a prisoner)] Loss of productivity cost = [Number of months served in prison x Legal minimum wage] *** The cost of housing inmates in prison over the period of their sentences. Cost of incarceration = [(Number of conviction) x (Length of sentence) x (Daily cost of a prisoner)] Number of convictions The number of convictions is reflected in the times sentenced for offences. Length of sentence The length of sentence obtained from the prison records and is the duration of the sentence for current crime(s) and represents the maximum sentenced time. Daily cost of a prisoner The Report of the Steering Committee on Penal Reform issued in March 1997. stated the cost per inmate was $28.30 per day in 1996. A crude estimated daily cost between January 1996 and September 17th, 2004 was determined based on recorded annual inflation rates. The number of days served by each inmate between January 1st, 1996 and September 17th, 2004, was used to calculate the average cost for each inmate and the average daily cost. Number of months served The number of months served in prison between January 1st, 1996 to September 17th, 2004 Legal minimum wage The legal minimum wage of Barbados is stated in the Wages Council Order of June 1997, (commonly referred to as the Shop Assistants Act). The order states that shop assistants under 18 years of age should receive $158 per week, while those over 18 years of age should receive $170 per week.

Cost of Incarceration Results The average cost Daily = BDS $33.65. Over eight years (1996 -2004) = $72,962.83. To maintain the 19 inmates for the duration of their sentences BDS $1,386,293.69.

Loss of Productivity Results The average loss of productivity BDS $14,378.42 The total loss of productivity BDS $273,190.00 Almost four times less than the cost of housing the prisoners.

Total Economic Loss 19 (10%) inmates over the eight year period BDS$87,341.25 The total economic loss to Barbados $1,659,483.69, Estimated cost to the Barbadian government $16,600,000.00 An average economic loss for 19 sample inmates over the eight year period BDS$87,341.25 The total economic loss to Barbados $1,659,483.69, The 19 inmates, represent  10% of the total number of inmates sentenced for drug related offences; i.e. 200 inmates on September 17th, 2004, Thus the estimated cost to the Barbadian government for drug related sentences over the given eight years, $16,600,000.00

INMATE ID MOUTHS IN PRISON NO. OF CONVICTIONS LENGTH OF SENTENCE (MTHS) TOTAL COST PER DAY DAILY COST WAGES PER MTH COST IN PRISON ECONOMIC LOSS 1 9 18 $8,662.23 $33.97 $6,192.86 $17,120.64 $23,313.50 2 39 60 $36,150.75 $33.26 $26,398.57 $55,872.36 $82,270.93 3 $8,356.50 $5,974.29 $23,094.92 4 49 180 $45,241.36 $32.97 $33,320.00 $166,192.75 $199,512.75 5 13 36 $12,578.01 $33.81 $9,034.29 $34,082.36 $43,116.64 6 16 $15,253.31 $33.75 $10,977.14 $34,016.22 $44,993.36 7 28 $25,807.10 $33.52 $18,700.00 $56,306.39 $75,006.39 8 30 $6,488.18 $4,638.57 $28,534.40 $33,172.97 24 $7,031.69 $5,027.14 $22,827.52 $27,854.66 10 11 $4,517.95 $3,230.00 $57,068.80 $60,298.80 12 132 $7,439.33 $5,318.57 $125,551.35 $130,869.92 $7,677.11 $5,488.57 $62,557.37 14 48 $44,547.55 $33.02 $32,761.43 $55,478.05 $88,239.48 15 300 $276,987.92 $310,307.92 $14,651.36 $33.76 $10,540.00 $45,371.97 $55,911.97 17 $6,997.72 $5,002.86 $62,071.65 26 $24,524.69 $33.55 $17,752.86 $56,363.18 $74,116.03 19 $63,261.65 TOTAL   $375,069.78 $639.31 $273,190.00 $1,386,293.69 $1,659,483.69 MEAN $19,740.51 $33.65 $14,378.42 $72,962.83 $87,341.25

Analysis Prison Study The formula is unclear as outlined below: Number of Convictions vs. Total sentences: Length of Sentence: , i.e. does the Research Manual seek to attain that on average each inmate serves 2 years? 3. These approaches are unnecessary The formula proposed in the Research Manual (2004) is unclear as it relates to a couple of the variables, as outlined below: Number of Convictions: It is unclear as to whether this is the number of new convictions in a particular year or the TOTAL number of prisoners incarcerated in prison in any single year. Length of Sentence: It is unclear whether this is a sum total of days of each sentence in a particular year per prisoner or an overall average of TOTAL sentences If it is assumed that in general there will be ‘X’ number of inmates in Prison at any one time which allows for an average over the year, then the formula is much more simplified.

Analysis Prison Study Cont’d A systematic database of prison records which includes reason for incarceration, length of sentence, profession and average income. There will be a need to establish whether the data requested relates to the number of new convictions per annum or the current stock of convictions for which a full sentence has not been served. Utilising new convictions would allow an understanding of new costs/trends in crime and their relationship to cost changes. However, the average stock of persons in custody in any one year would allow a yearly presentation of costs without the difficulty in dealing with the length of sentence.

Analysis Prison Study Cont’d Estimating loss of productivity: Due to the non-normal distribution of income in Barbados, the loss of productivity would be underestimated. If median income in the island is utilised, a more accurate figure may result. Income is skewed towards the lo Due to the non-normal distribution of income in Barbados, the loss of productivity would be underestimated. If median income in the island is utilised, a more accurate figure may result. wer income earners

Conclusion The Cost Studies provided baseline data from which government expenditures on demand reduction activities and prison costs could be estimated. These costs estimations may vary from existing government procedures for estimating costs. The Cost Studies provided baseline data from which government expenditures on demand reduction activities and prison costs could be estimated. These costs estimations may vary from existing government procedures for estimating costs. The gap between government estimates and those of the cost studies may vary due to the presence of other tangible and intangible costs absent from the cost study estimates.

Conclusion The gap between government estimates and those of the cost studies may vary due to the presence of other tangible and intangible costs absent from the cost study estimates. The Cost Studies provided baseline data from which government expenditures on demand reduction activities and prison costs could be estimated. These costs estimations may vary from existing government procedures for estimating costs. The gap between government estimates and those of the cost studies may vary due to the presence of other tangible and intangible costs absent from the cost study estimates. What is therefore needed is a bridging of government and cost study estimates which will allow for more robust costs estimations. Such an approach will result in credible and acceptable cost estimates by individual countries associated with the cost study project and CICAD.

What is therefore needed is a bridging of government and cost study estimates which will allow for more robust costs estimations. Such an approach will result in credible and acceptable cost estimates by individual countries associated with the cost study project and CICAD.

Discussion