STRATEGIC POLICY ON HEALTH AND RELATED SOCIAL SERVICES IN THE CARICOM

1. STRATEGIC POLICY ON HEALTH AND RELATED SOCIAL SERVICES IN THE CARICOM Health Care Organizers and Advisors (HECORA) Inc. Robert M. Brohim M.D., Ph.D., CMC Grand Royal Antiguan Beach Resort, July 15-17, 2009

2. THE CARIBBEAN COMMUNITY • 15 full Member Countries, population +/- 15million • 5 Associate Member States, population +/- 164,000 The populations are of different sizes and are diverse in people, language, skills and levels economic and social of development

3. SOME CHALLENGES • Caribbean is disadvantaged; • small size and small economies that limit resources and investments • natural hazards, such as flooding and hurricanes • regular strain on the economies and health sector that slows down development and causes setbacks • Globalization; • Increased competition both inter-regional and intra-regional • CARICOM Single Market and Economy (CSME) and free movement of persons Advantages in continued cooperation in health as well as other social and economic developmental areas. The CSME brings new challenges but also enables the region to become more competitive in global developments.

8. HEALTH SITUATION IN CARICOM • Second half of the 20th century great advancements – water, sanitation, nutrition, primary health care, vaccinations The health status in the Caribbean can be considered to be good according to health indicators but the challenge is to sustain the current health status and to continuously improve health in an environment of new threats, globalization, increasing cost, and increasing demands

9. Fig. 1 CRUDE MORTALITY RATES FOR SELECT DISEASES BY YEAR: CAREC MEMBER COUNTRIES 120 Heart Disease 100 Cancers 80 Cerebro Disease RATES Diabetes Mellitus 60 Hypertensive Disease 40 HIV/AIDS Accidents 20 ARIs 0 85 90 95 2000 YEAR BURDEN OF DISEASES- MORBIDITY AND MORTALITY

10. NON COMMUNICABLE DISEASES • Cardiovascular (heart diseases, hypertension, stroke) • Cancers (breast, cervical, prostate) • Diabetes Common Risk factors • Smoking (Framework Convention on Tobacco Control (FCTC) • Overweight and obesity (children) • Lack of physical exercise • Alcohol abuse

11. PERCENTAGE OF POPULATION BEING OVERWEIGHT IN THE CARIBBEAN

12. ECONOMIC IMPACT OF DISEASES • Annual cost of violence and injuries in Jamaica estimated at 0.7% of GDP • HIV/AIDS can be 2-3% of GDP • Diabetes and Hypertension annually USD 560 mln in direct cost for Bahamas, Barbados and Jamaica • Schizophrenia and depression annually USD 600mln in Jamaica

13. CRUDE DEATH RATES AND YEARS LOST

14. ACCESS TO HEALTH • National infrastructure and system providing equitable access to health services • Hinterland in certain countries • Specialized services in small countries • Migration of health personnel • In general good primary health care services

18. HEALTH EXPENDITURES

20. HEALTH SPENDING AND OUTCOMES 2001

21. INTERNATIONAL COMPARISON OF HEALTH EXPENDITURES AND OUTCOMES

22. HEALTH FINANCING • Factors that influence organization, management, and financing in order to improve equitable access in health are the relative high poverty rates in the Caribbean and the existence of a large informal sector • The government usually pays for the poor and a (large) part of the informal sector. A burden that the government cannot continue to uphold and therefore important investments in the health sector are being delayed resulting in Deterioration of services • For equitable access and sustainability each citizen should contribute to their ability to pay

23. HEALTH PERSONNEL • Numbers and quality of personnel are in general reasonably good in het Caribbean; nurses, doctors, epidemiologists (public health leadership), health informatics, health management, etc. – migration – • Tendency for too specialized training and services in primary and some secondary health care services

24. Human Resources per 10,000 population

25. HUMAN RESOURCES PER 10,000

26. INTRA REGIONAL MIGRATION • There is no universally accepted definition of a “migrant” nor of minorities • 20th century migration was towards Europe and North America +/- 6mln. • early 20th century thousands of Caribbeans, especially, Jamaicans and Barbadians, worked on the Panama Canal, which opened in 1914 • large migration to the banana operations in Central America (1920’s – 1930’s) • Cane cutters from the Eastern Caribbean, Guyana and Haiti moved to the Dominican Republic and other countries. • The evolving oil industry in Trinidad, Venezuela and Curacao attracted another stream of migrants in the 1970’s. The independence in the 1960’ and 1970’ temporarily slowed down extra-regional migration but the need for skilled personnel abroad, especially in health, education , services industry has opened new windows

27. INTRA REGIONAL MIGRATION 2 • Pull factors for migration in the Caribbean; are economical growth in other areas, frequently from USA investments that create labour shortages and in recent years the growth of the tourism and service industry in the Caribbean, diversifying from more traditional industries as sugar. • Push factors are mainly poverty, lack of opportunity, overcrowding and land shortages. The diversification of the economies has also resulted in more migration of females in recent years.

28. INTRA REGIONAL MIGRATION 3 • Last 40 years intra-Caribbean migration has been at 500,000 people. • Main sending countries being Haiti, the Dominican Republic, Guyana and Jamaica. The main receiving countries are the Bahamas, the Virgin Islands (British and USA) and the Turks and Caicos Islands (TCI). • The largest migration takes place from Haiti. Estimated numbers of Haitians are in the Dominican Republic (500,000-700,000), the Bahamas (40,000-75,000 20% of the population), TCI (6,000 30% of the population). • In Guyana and Suriname there are tens of thousands of Brazilians working as illegal gold miners (garimpeiros).

29. MIGRATION AND HEALTH • Transmission of diseases • Malaria • HIV/AIDS • Chronic diseases • More frequently bad risk people that increase the burden of disease • Migration driven for health benefits • Illegals do not contribute to the overall sustainability of the health system (no insurance)

30. CARICOM REGIONAL HEALTH POLICY • Nassau Declaration in 2001 declared “The Health of the Region is the Wealth of the Region” • CARICOM Heads of Government have identified HIV/AIDS, Non Communicable Diseases and Mental Health as being the health priorities in the region • CARICOM Secretariat • Council for Human and Social Development (COHSOD) • Directorate of Human and Social Development (CCS) • Department of Health Sector Development • Caribbean Cooperation in Health (CCH) I, II and III? • PanCaribbean Partnership against HIV/AIDS (PANCAP) • The Heads of government issued the declaration of Port of Spain; “Uniting to stop the epidemic of chronic NCD’s • Mental Health policy in cooperation with PAHO. Jamaica best practice

31. HUMAN RESOURCE POLICY • Quality Health Services is a balance; • Infrastructure, - Human Resources, - Equipment, -logistics, - Financing - Information Communication Technology and policy • WHO has no universal norm but it is estimated that below 2.3 / 10,000 physicians, nurses and midwifes 80% skilled birth attendance and immunization cannot be achieved (depending factors are population density etc.) • Migration 200 nurses in 3 years at value of USD 20 mln.

32. LEGISLATIVE POLICY FRAMEWORK-HARMONIZATION • Free movement of people – draft bill domestic regulations • Regional registration of pharmaceuticals • Regional position on the Trade Related Intellectual Property Rights TRIPS) • Buggaring (MSM, vulnerable group)

33. HEALTH FINANCING • Health expenses according to National Health Accounts studies (NHA) – sources – intermediaries – providers – line items • Financers – Patients – Health Services Providers • Government; • Public health goods (vaccinations, disease surveillance, vector control) • Standards and regulations • Poor and near poor (targeting) • Equitable access

34. HEALTH FINANCING 2 • National Health Fund (NHF), Chronic Disease Assistance Programme (CDAP) aimed at partial treatment • Government paying for the poor and near poor • National Health Insurance programmes (informal sector and targeting of the poor) incentives INDIRECT TAXATION; alcohol, tobacco, gas, value added tax, uniform administrative registration per family. Advantages concerning administration, remote areas, informal sector.

36. CARICOM SECRETARIAT HEALTH PROGRAMMES AND PROJECTS • Fully depending on grants, no seed funding (lack of ownership and priority setting not always aimed at the neediest countries, favouring certain institutions and inequitable opportunities for regional expertise to participate • Conditionalities associated with extra regional funding • Little or no ownership • Submitting to trends not in balance and in line with our priorities • Little use of regional capacity and intellect (in cooperation with international) in programme/project identification, design, implementation, M&E, review and assessment

37. RECOMMENDATIONS -TRADE AGREEMENTS • Trade agreements that support health, healthy life styles and health foods. CARICOM must become Transfat Free • Trade Related Intellectual Property Rights (TRIPS) – (patient right against patent rights). Use of flexibility in TRIPS • Government orders • Compulsory licensing • Identification of healthy products

38. RECOMMENDATIONS -INSTITUTIONAL REQUIREMENTS • Caribbean Public Health Authority (CARPHA) • CAREC, CFNI, CHRC, CRDTL, CEHI CARPHA must have the competence and capacity to provide clearly defined services to Member States (common) needs and priorities • Strengthening of the CARICOM Secretariat Health Desk • CCH management and monitoring • Input in governance of Regional and cooperating institutions and (CARPHA, PANCAP, UWI) • Establish CARICOM Medical Centers of excellence

39. RECOMMENDATIONS-SUSTAINABLE EDUCATION • Increase the volume of health workers • Multifunctionality of health workers • Develop arrangements in line with managed migration of health workers with investments of destination countries to invest in education in the CARICOM (commercialization) • Introduce special scholarships and study loans for education of health workers • Regional programmes for continuing education

40. RECOMMENDATIONS-COMPETITIVENESS IN HEALTH • Establishing CARICOM Medical Centers of Excellence (cardiac surgery, neurosurgery, radiotherapy and cancer treatment, and a kidney transplantation center) National certified dialyses centers-> tourism • Regional emergency medical service and trauma center (tourism) • Exclusive health tourism e.g. cosmetic surgery (high investment but can cooperate with hotels)

41. RECOMMENDATIONS • Develop strategies to sustain the health gains in the Caribbean. Especially our vaccination coverage and explore the introduction of underutilized vaccinations. • Finalize the programme for the Caribbean Cooperation in Health III (CCH III), with links to responsibilities of the Regional Health Institutions (RHI’s) – CARPHA - and budgets. The CCH III should at least include the core of priorities set by the Heads of Government (NCD’s, HIV/AIDS and Mental health) with cross sectional supporting policies in Human Resource Development, Health Information Systems, and Health promotion.

42. RECOMMENDATIONS 2 • The CARICOM Secretariat should reserve a budget for regional health programmes and projects, at least as a manner of seed funding • CARICOM countries should commit, as a priority, to the Essential Public Health Functions (EPHF). • Planning the establishment of CARICOM Medical Centers of Excellence • Total health expenditures be at least be 7.0% of GDP and the government health expenditures about 55-60% of the total health expenditures, with regular National Health Accounts Studies

43. RECOMMENDATIONS 3 • Develop basic guidelines for Caribbean countries for the development of National (social) health financing policies. • Develop and implement regional and national policies for managed migration aiming at a more commercial approach • Develop a more commercial approach to migration of health personnel, negotiate with destination countries to invest in Caribbean trained professionals for export • Speed up the process for implementation of the domestic regulations and the minimal requirements for professionals related to the free movement of professionals

44. RECOMMENDATIONS 4 • Intensify the role of the Caribbean Accreditation Bodies, especially CAAM-HP with a clear status of graduates from accredited institutions. • Establish a CARICOM registration for pharmaceuticals and a regional policy to utilize the flexibilities in the Trade Related Intellectual Property Rights (TRIPS). • Establish professional emergency response systems with a trauma center in the CARICOM.