Public Health Challenges in the Caribbean

1. Public Health Challenges in the Caribbean Mirta Roses Periago Director PAHO/WHO Nassau, Bahamas 28 February 2007 Pan American Health Organization

2. Caribbean Commission on Health and Development (CCHD) Disability Adjusted Life Years (Daily's) 2001 Pan American Health Organization

3. CRUDE MORTALITY RATES FOR SELECT DISEASES BY YEAR: CAREC MEMBER COUNTRIES 120 Heart Disease 100 Cancers 80 RATES Cerebro Disease Diabetes Mellitus 60 Hypertensive Disease 40 HIV/AIDS Accidents 20 ARIs 0 85 90 95 2000 YEAR Pan American Health Organization

4. Caribbean Commission on Health and Development (CCHD) • Arising from WHO Commission on Macroeconomics and Health; • Investigation of relationships between health, economic development, and poverty; • CARICOM/PAHO collaboration; • Chaired by former PAHO Director, report submitted to CARICOM. Pan American Health Organization

5. Main messages (1) Caribbean Commission on Health and Development (CCHD) • Recognize and promote the thesis that health is a productive asset and encourage further research in this field; • The Caribbean must re-examine seriously the business case for development of health services targeted to foreign consumers; • Intentional violence and injuries represent a huge burden to the health services; • The lack of systems for regular collection of data, such as the SLS in Jamaica is a major hindrance to research on Caribbean problems. Pan American Health Organization

6. Main messages (2) Caribbean Commission on Health and Development (CCHD) • The Caribbean as a whole must face squarely the enormous problem of obesity and its co-morbidities of the non-communicable diseases. • This will involve major policy changes to effect prevention through attention to a) food security b) increasing physical activity of the population (These changes are spelled out in the Report) Pan American Health Organization

7. Main messages (3) Caribbean Commission on Health and Development (CCHD) The Caribbean must continue and intensify the actions to control the epidemic of HIV/AIDS with special attention to: • battling stigma and discrimination • legislation especially as regard labor laws • scaling up treatment • devoting a higher percentage of funding to prevention measures • ensuring that funds already available are spent Pan American Health Organization

8. Main messages (4) Caribbean Commission on Health and Development (CCHD) Strengthen health systems infrastructure, paying special attention to; • improving the management and maintenance of the physical facilities • planning in the health sector • strengthening surveillance systems for a) communicable diseases b) risk factors for the non-communicable diseases Strengthen public health infrastructure, specifically: • ensuring the monitoring of the essential public health functions • mandating training to advanced levels in public health by the University of the West Indies Pan American Health Organization

9. Main messages (5) Caribbean Commission on Health and Development (CCHD) Address the issue of the export of nursing services as a regional problem: - modify the program of managed migration as endorsed by the Ministers of Health, by including the potential for trade in nursing services as an aspect of Mode 4 form of supply. The two forms of migration to be seen will be: a) permanent migration b) managed temporary migration (NB Countries are already encouraging FDI for nursing training) Pan American Health Organization

10. Main messages (6) Caribbean Commission on Health and Development (CCHD) Health financing • The practice of charging user fees should be discouraged, especially for public health and preventive services. It is regressive and bears heavily on the poor. However, when employed, it should be carefully targeted. • Countries should aim at a health expenditure of at least 6% GDP • The Caribbean should begin to examine the feasibility of a region –wide health insurance Pan American Health Organization

11. Specific policy recommendations to the Heads of Government • Combat tobacco use • tax tobacco products • ban smoking in public places • Target children • make physical education compulsory • ensure healthy school meals • restrict advertising that promotes unhealthy diets • Make regulations and standards • ensure marketed foods show calorie & fat content • regulate importation of fats (consult RNM) Pan American Health Organization

12. The Report of the CCHD emphasized that the major health /disease problems that the Caribbean would have to face in the immediate future are: Non Communicable Diseases HIV/AIDS Injuries and violence Pan American Health Organization

13. Causes of death ( Rank order)Bahamas 1996 2000 HIV disease ( AIDS) 1 1 Ischemic heart disease 5 2 Hypertensive disease 2 3 Diabetes mellitus 3 4 Cerebrovascular disease 4 5 (*Source CMO Report 2002) Pan American Health Organization

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15. Prevalence of Obesity(% of age group) Males Females Bahamas (15-64) 13.9 28.0 Jamaica (25-74) 7.2 31.5 Barbados (25-74) 10.0 31.0 (*Source IOTF. Obesity as BMI 30+ ) Pan American Health Organization

16. Trends in Diabetes mortality Pan American Health Organization

17. Atlas of Heart Disease & Stroke , WHO 2004 Pan American Health Organization

18. 22 20 18 16 14 12 UK UK Men US 10 Women Prevalence of Diabetes US Caribbean 8 6 Caribbean 4 West Africa West Africa 2 0 20 22 24 26 28 30 32 Body mass index Pan American Health Organization

19. Costs (US $ Million) for treatment of all diabetes and hypertension Pan American Health Organization

20. AIDS cases in CAREC Member Countries Pan American Health Organization

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24. With respect to HIV/AIDS • “Several recent developments in the Caribbean region (in Bahamas, Barbados, Bermuda, Dominican Republic and Haiti) give cause for guarded optimism -with some HIV prevalence declines evident among pregnant women, signs of increased condom use among sex workers and expansion of voluntary testing and counseling”. (UNAIDS, 2005) Pan American Health Organization

25. Obesity - The policy options Focus on children Protect children against marketing School-based actions - foods sold in schools - nutrition education - physical activity Food availability Government food and agricultural policy Food labeling Taxes and subsidies Pan American Health Organization

26. Diet and the Environment • Our domestic agriculture policy lacks adequate incentives for the production of fruits and vegetables • Our food imports encourage the consumption of high energy dense, manufactured foods • Many school canteens and vendors promote high energy dense foods with little nutrient value • Our local and cable networks advertise fast foods heavily, especially on children’s programs Pan American Health Organization

27. Physical Activity and the Environment • We build communities with insufficient parks and recreation centers which are safe and attractive; • Our school policies have allowed the drastic reduction of physical education; • Few employers/worksites have a policy to increase PA and wellness; • Our transportation policies have favored the use of personal cars …which discourage physical activity. Pan American Health Organization

28. The “3 keys” to efficient management and prevention of chronic disease: 1) Clinical management in Primary Care 2) Population based interventions-inform, educate, facilitate pro-health choices 3) Macro-economic policies that go beyond one sectoral ministry Pan American Health Organization

29. Issues involving regional action Caribbean Commission on Health and Development (CCHD) • Health tourism; • A Caribbean - wide approach to the problem of obesity; • HIV/AIDS - continuing and expanding the effort as indicated; • Strengthening the public health infrastructure; • A policy on export of human resources-especially and urgently for nursing services; • A Caribbean - wide health insurance; • Strengthen existing mechanisms e.g. CCH; • Dissemination of the Report. Pan American Health Organization

30. Caribbean Cooperation in Health The CCH mechanism was developed for Member States to: Collectively focus action and resources towards the achievement of agreed objectives in priority health areas of common concern; and To identify approaches and activities for joint action and/or technical cooperation among countries in support of capacity-building for the achievement of the objectives. Pan American Health Organization

31. Since 1993 CCH phases I and II have been completed and evaluated. CCH phase III is now being developed by Caribbean Member States, and includes each of the key priorities of the Caribbean Commission Report. CCH III also includes the critical issues of importance to the Caribbean that are reflected in the Global Health Agenda and the Health Agenda of the Americas (global commitments and agreements) Caribbean Cooperation in Health Pan American Health Organization

32. Caribbean Cooperation in Health Guiding Principles for CCH phase III • Equity in access to prevention and treatment for all; • Focus on the poor; • Development of a subregional integrated resource mobilization strategy; • Allocation of the required resources at the national level to facilitate the effectiveness of the subregional support: • Caribbean Commission on Health and Development recommends a minimum of 6% of Gross Domestic Product (GDP) for government expenditure on health; • Implementation of an international and regional agreements/policies: • MDGs/WHO policy on diet and physical activity; Ratification of the FCTC; PAHO Guidelines for Essential Public Health Functions Pan American Health Organization

33. Subregional Program Areas • Subregional Program Areas • Chronic Diseases, Mental Health, Communicable Diseases, Strengthening Health Information Systems, Human Resource Management,Food and Nutrition, Environmental Health, Family and Community Health Services, • Matrix • HIV/AIDS – Integrating HIV/AIDS with Sexual and Reproductive Health Programs (critical to the achievement of a number of the MDGs • Indicators to capture mobile population within the context of the CSME Pan American Health Organization

34. Priority Areas and Crosscutting Areas of CCH III Priority Areas: • HIV/AIDS • Chronic Diseases • Mental Health Crosscutting Areas: • Information Systems • Human Resource Management • Health Promotion Pan American Health Organization

35. What is the DCPP? DCPP is an alliance of organizations/partners designed to review, generate and disseminate information on how to improve population health in developing countries. Fogarty International Center World Bank World Health Organization Bill & Melinda Gates Foundation Population Reference Bureau Partners Pan American Health Organization

36. Objectives of DCPP (1) Inform health sector decision-making in developing countries to decrease illness, disability, death, and economic burden by: • Developing an evidence base to inform decision-making by: • Providing estimates of the cost-effectiveness and impact of single interventions and packages • Collaborating in defining disease burdens globally and regionally • Summarizing implementation experience in different regions and globally Pan American Health Organization

37. Objectives of DCPP (2) • Communicating major findings • Suggesting the “best buys” and the “worst buys” in any given setting • Disseminating the results widely to multiple audiences • Stimulating national priority setting and program implementation Pan American Health Organization

38. Combat Tobacco Use DCPP Tobacco-related diseases are the fastest-growing cause of disease and disability in developing countries. Tax tobacco products to increase consumers’ costs by at least 33% to curb smoking. Restrict smoking in public places and workplaces. Provide nicotine replacement therapy and other cessation tools. Ban tobacco advertising. Pan American Health Organization

39. Reduce fatal and disabling injuries DCPP Injuries and violence caused more than 5 million deaths in 2001, with an especially heavy toll on young men. • Promote use of seatbelts. • Install speed bumps at dangerous intersections. Pan American Health Organization

40. Ensure equal access to high-quality health care DCPP When women lack access to health care, the health of the whole family suffers. • Encourage providers to treat the most common causes of bad health. • Help providers choose the most cost-effective interventions. Pan American Health Organization

41. Health Agenda for the Americas 2008-2017 • What is it? • An expression of the shared vision of the countries of the Americas for 10 years to make concrete improvements in health • Proposed new long-term planning instrument that sets strategic goals to address health-sector needs in the Americas • What is its purpose? • To provide a collective framework for subregional and national planning & resource mobilization • To maintain coherence among international players in the health sector • To provide goals on a time-horizon that will allow for achievement of measurable impact, as well as frame PASB’s own Strategic Plan Pan American Health Organization

42. Health Agenda for the Americas 2008-2017 (HHA) Principles and values • Human rights, universality, access, and inclusion. • Pan American solidarity. • Equity in health. • Social participation Pan American Health Organization

43. Health Agenda for the Americas 2008-2017 (HHA) Areas of action • Strengthening the National Health Authority • Tackling Health Determinants • Harnessing Knowledge, Science, and Technology • Strengthening Solidarity and Health Security • Diminishing Health Inequities among and within Countries • Reducing the Risk and Burden of Disease • Increasing Social Protection and Access to Quality Health Services • Strengthening the Management and Development of People Working for Health Pan American Health Organization

44. Caribbean Cooperation in Health CCH 1994 Health Systems Human Resources Noncommunicable Disease Communicable Disease Family and Reproductive Health Food and Nutrition Mental Health Environmental Health Nassau Declaration 2001 HIV/AIDS Noncommunicable Disease Mental Health Caribbean Commission for Health and Development (CCHD) 2005 HIV/AIDS Obesity and Co-morbidities Violence and injuries Financing the health system Social statistics and HIS How can we achieve Success Pan American Health Organization

45. How can we achieve Success • Establish monitoring and evaluation mechanism • Agreement on the Caribbean Health priority Agenda • Consensus on regional goals, targets and indicators with particular reference to national implementation and circumstances • Assign and/or secure resources for both administration and implementation • Establish timeframe and reporting mechanisms • Assign/delegate responsibility for monitoring and evaluation (possibly to PAHO and CARICOM ) Pan American Health Organization