One of the recommendations of the now famous Global Commission on Macroeconomics and Health was that similar commissions should be established on a national or regional basis around the world to provide the basis for a new worldwide agenda relating health to development. That commission, headed by Jeffrey Sachs, produced a far-ranging report, which has managed to galvanise the focus of the international community to the central role health plays in promoting the development and security of the world. The Caricom Heads of Government was one of the first regions to respond to the call of the Global Commission to establish similar commissions around the world and established our own Caribbean Commission and Health and Development. That commission recently presented its report to the 26th Meeting of the Caricom Heads of Government in St Lucia on July 3-6, 2005.
The Caricom Commission report, like its global counterpart, is equally far-ranging in its scope and coverage of the session. It offers an immense amount of data on matters related to health and development in the region. It deserves serious attention by anyone concerned with the development of the region and its people. Publicity on the report has been low key. The potential of the report, however, as a tool to galvanise public and private action in support of health and development is immense. Over the next few weeks I shall draw attention to some of the information and analysis contained in the report and hope that readers would be encouraged to secure their own copies of the report and its accompanying papers. While the report will soon be published the material is available on the PAHO (Caribbean Regional Office) website.
Composition of the commission
The heads of government had appointed eleven commissioners headed by Sir George Alleyne the former head of the Pan American Health Organisation (PAHO/WHO) and the present Chancellor of the University of the West Indies. It included three other health specialists namely, the Director of the Tropical Medical Research Institute (Prof Terence Forrester), the Director of the Caribbean Epidemiology Center, CAREC, (Dr Hospedales), and Dr Koplan from Emory University, USA. It included one sociologist (Prof Elsie LeFranc). It also included six economists namely, the President of the Caribbean Development Bank (Dr Compton Bourne), the Deputy Executive Director of the Inter-American Development Bank IADB (Dr Havelock Brewster), the Health Economist at the Ministry of Health, Jamaica (Dr Stanley Lalta), the Coordinator of the Health Economics Unit at UWI, St Augustine Campus (Professor Karl Theodore), the Governor of the Eastern Caribbean Central Bank (Dr Dwight Venner), and myself.
The commissioners not only blended expertise in macroeconomics and health but a few of them headed among the most important regional institutions in their respective fields. The terms of reference of the commissioners required them to 1) establish a policy framework for structuring the health and development agenda of the region 2) assess the economic and social returns to investment in health 3) review the data on returns to investment 4) identify the economic consequences of demographic and epidemiological changes in the region and, 5) estimate the economic and social benefits from high levels of health coverage for the poor and specific targeted programmes. The commission was admirably served by a secretariat, which combined the Caribbean Office of PAHO/WHO, the Caricom Secretariat and PAHO/WHO, Washington.
In addition to its report the commission had twelve separate working papers prepared. These dealt with the Caribbean health situation analysis; cardiovascular diseases and cancer; HIV/AIDS; health services; mental health; health and poverty; and, the export of nursing services from the region. The last study was undertaken by the Institute of Development Studies here at the University of Guyana. The working papers constituted the basis of the report as the chapters of the final report reflect closely the structure and contents of these. I have given this amount of detail to readers to make them aware of the breadth of coverage of the report and to encourage them to go beyond simply reading this and the succeeding articles, which I write.
Health and wealth
The central thrust of the report is that "The Health of the Region is the Wealth of the Region." This sentence framed the Nassau Declaration (2001) in which Caricom Heads of Government had openly, unabashedly and uncompromisingly declared that health was an essential prerequisite for the development and security of the region, while in turn that development and security of the Region themselves also promoted the health and well-being of its citizens. At the time of this declaration the challenges of the HIV/AIDS pandemic were, correctly, at the forefront of their concerns.
The declaration on health has coincided with other major developments in Caricom and worldwide. In Caricom most notably is the Grand Anse Declaration (1989), which led to the formation of the Caribbean Single Market and Economy (CSME). Developments were also impelling the region to respond to new challenges especially those that arose at a global level from the speed of communication and travel and to meet specific norms, standards and obligations, which flowed from multilateral and inter-governmental arrangements, treaties and goals.
Thus, we face at the global level, challenges from the risk of pandemic diseases, health concerns arising from international trade in unsafe foods, global pollution, and industrial accidents occurring anywhere in the world, which can impact seriously on the global environment.
We also have requirements like the Millennium Development Goals (MDG) and other health and health-related global targets.
Fortunately the region has had a successful tradition of cooperation in health, particularly as expressed in the Caribbean Cooperation in Health Programmes phase I and II (CCH) projects, the regional training of health and health-related professionals, and the regional monitoring of health developments through CAREC.
As the report notes fortunately, many of the goals of the CCH and other regional cooperative arrangements have goals that are similar to those of the MDGs and other intergovernmental agreements.
Next week I shall continue with coverage of some of the substantive issues in the report.
This week I continue the presentation of issues raised in the Report of the Caribbean Commission on Health and Development. While, as we shall see from the report, major challenges lie ahead, Caricom has achieved, on the whole, what I would describe as spectacular gains in the promotion of health and well-being for its citizens. It is worth revealing that all the Alma Ata goals of 'Health for All by Year 2000' have been achieved. This is a rarity for a developing area. Further, the Caribbean Commission has forecast that: "there is a real possibility that [the region] will achieve or surpass most of the Millennium Development Goals (MDGs)." The main laggards in regional performance in both health and development have been Haiti and Guyana. Although not a member of Caricom at the time, Haiti did not achieve the Alma Ata goals, and achieving the MDGs is very unlikely at this point in time. Similarly Guyana will have difficulties with achieving some of the MDGs, based on its present trajectory.
Demographic
transition
The best indicator of how much has been achieved by the region for the health and development of its people is that the region has achieved what is termed in the literature a "demographic transition." Simply put this means that its population and demographic trends presently take on the profile one would associate with developed economies. Thus on average life expectancy at birth (both males and females) is 74 years. For several countries it is 77 years plus. The range (excluding Haiti) is from 62.4 years in Guyana to 79.2 years in the Cayman Islands. As the Caribbean Commission notes in its report life expectancy has risen by as much as 5 years over the past two decades - an excellent achievement.
Underscoring this profile of life expectancy is the fact that population growth has declined from 1.2 per cent per annum to only 0.7 per cent over the past two decades. This reflects two major forces at work: one is the familiar migration which has dogged the region and the other is the reduction in fertility rates. The total fertility rate has declined and it is now only 2.3 children per woman. Thus in Guyana, the report on the last Survey of Living Conditions (1999), which was prepared by the Institute of Development Studies, University of Guyana, indicated the average household size as 4.15 persons. Projections cited in the Caribbean Commission's report indicate that by 2025 the elderly in the population (those 60 years and over) would constitute over 17 per cent of the region's population.
Mortality analysis
The report also referred to the mortality analysis for the years 1985, 1990, 1995 and 2000. This has revealed a pattern in which non-communicable diseases constituted the most frequent cause of death. The four leading causes over the years cited were: heart disease, cancer, stroke, and diabetes. Together these accounted for over half the deaths in 2000. However, by year 2000, HIV/AIDS had reached fifth position as a leading cause of death. As we shall be discussing HIV/AIDS in a subsequent article as a separate topic I shall not pursue the significance of this here but it should be noted here that it is now the leading communicable disease of concern to the region.
One significant feature of the non-communicable diseases as a cause of death is that the underlying risk factors in these situations are well-known. They include 1) unhealthy eating habits 2) lack of exercise 3) obesity 4) tobacco and alcohol use and 5) poor use of preventative health services.
Alongside non-communicable diseases and communicable diseases, "other factors" have emerged as significant challenges to the maintenance of the good health of the region's population. One is "injuries and violence." Over the past two decades the commission has reported that this category has been a major cause of death among young people, particularly in the age ranges 15-24 and 25-44. Motor vehicular accidents and homicides are indeed the leading individual items in this category of causes of deaths.
Health services
When looked at from the perspective of the health services we find that utilization of these in the region has been very good. Immunization is a tremendous success story and many childhood infectious diseases have been contained or eradicated. The report carries a table which shows immunization coverage against polio, measles, and the DPT infections, and in most countries the ratio of coverage is near universal (100 per cent).
Despite these many achievements the resources devoted to health services have been under severe strain. The report singles out three of these for special mention, namely, insufficient personnel, quality of the workforce, and problems of retaining skills within the country. The report provides information on health expenditures as a proportion of the national budget and GDP as well as the numbers of health professionals per 100,000 population. Here, variation between Caribbean countries is quite striking. Thus the range in the ratio of physicians per 100,000 of the population is from 2 to 22; for nurses from 9 to 86, and for dentists from less than 1 to 4.
In conclusion it should be noted that environmental health in the region is another area of both strong achievements and emerging challenges. Thus the percentage of the population with access to sewerage and excreta disposal and improved water is high. In the former case the ratio was 98 per cent, while in the latter it ranged from universal coverage (100 per cent) in Barbados to about 50 per cent in Belize. Similarly, solid waste collection services in the urban areas are high, with a similarly notable variation in the ratios between countries.
Next week I shall continue this discussion on the main themes of the Caribbean Commission report.