The Nassau Declaration, 2001
The Caribbean Community (CARICOM) Heads of
Government asserted in their Nassau Declaration of
2001 that "The Health of the Region is the Wealth of
the Region". The Heads of Government then mandated
the establishment of a task force to formulate a
blueprint of strategies that would give effect to
the Declaration. In 2003, the task force was
established as the Caribbean Commission on Health
and Development (CCHD).
The work of the Commission continues the
decades-old tradition of regional cooperation in
tackling health challenges as directed by Caribbean
Heads of Government and Ministers of Health, most
notably through the Caribbean Cooperation in Health
(CCH) Initiative, adopted in 1984.
This publication is a synthesis of the Report of
the Commission in 2005:
The CSME
The establishment of the Caribbean Single Market
and Economy (CSME), with its free movement of people
and its objective to make the Caribbean more
competitive in the face of globalisation, makes it
imperative for health to be constantly recognised,
in tandem with education, in the production of (or
as a contributor to) human capital.
The CSME requires elaboration of the Policies for
Sectoral Development that constitute Chapter 4 of
the revised Treaty of Chaguaramas, in which health
must logically be included. “In the same manner that
there is need for institutions to harmonize policies
and activities in areas such as trade and justice,
there will be requirements in the area of public
health.”
The free movement of people raises the
question of the need for a Caribbean health
insurance.
Caribbean health
The Region has made commendable progress in
recent decades in terms of all the classic
indicators of population health. This is very
largely the result of government policies that have
emphasised the importance of water and sanitation,
nutrition and primary health care and in spite of
the disadvantages against which health authorities
in the Caribbean have had to work – such as limited
resources, natural disasters, trauma resulting from
violence and accidents, and yet more demanding
publics. There is still a great deal to be done, but
happily it can now truly be said that there is
general understanding among decision-makers and
opinion-leaders in the Caribbean that health is
critical to development as well as an outcome of
development and must have some priority.
There is a growing body of economics literature
that links the population’s health status to
economic growth and several studies deal with the
cost of care. This fact was given particular
emphasis through the release in 2001 of the Report
of the World Health Organization’s Commission on
Macroeconomics and Health (CMH). Similarly, in 2001
the reality of health as an instrument of
development was collectively articulated at the
highest level in CARICOM.
The concern of the Heads of Government in Nassau
went beyond the intrinsic benefits of good health.
They declared that they were “cognizant of the
critical role of health in the economic development
of our people and overawed by the prospect that our
current health problems, especially HIV/AIDS, may
impede such development through the devastation of
our human capital”. The Nassau Declaration also
signalled the need to reorient and restructure the
health services and to emphasise access to them.
The Heads of Government at their meeting in
Montego Bay, Jamaica, in 2003, reaffirmed their
decision “to promote the health and well-being of
the people of the Community in recognition that the
health of the region is the wealth of the region.”
That commitment has been reiterated on a number of
other occasions.
The CMH, chaired by Professor Jeffrey Sachs,
recommended that national CMHs be set up to inform
the discourse on the merits of investing in health.
The Caribbean Commission on Health and
Development (CCHD), mandated by the Caribbean Heads
of Government is the region’s response to the call
of the CMH. Financial support for the work of the
Commission came from the WHO’s Macrohealth
Initiative, CARICOM, The Pan American Health
Organization, the Caribbean Development Bank and
UNDP.
Yet, 21st century challenges - such as
preventable chronic non-communicable diseases, the
scourge of HIV/AIDS, and trauma of violence and
accidents, as well as the new global economic
realities - make it vital for the survival of the
region that it responds without delay and with due
regard to both the challenges and opportunities that
affect development.
Non-communicable diseases
Chronic non-communicable diseases (NCDs) are the
major contributors to overall mortality and
morbidity in the Caribbean. Cardiovascular diseases
(high blood pressure, coronary heart diseases,
stroke), diabetes and cancer accounted for 51 per
cent of the deaths in the region in the latter part
of the 1990s. The risk factors for these disorders
have long been universally established. They include
obesity, physical inactivity, high cholesterol and
tobacco use.
There is a critical need to treat these diseases
appropriately when they occur and to establish
surveillance systems for lifestyle or behavioural
risks as well as injury and violence to inform
policy-making as well as public education. But it is
even more pressing to prevent them.
The costs of some of the major health problems
were calculated, although this was hampered by the
unavailability of representative data from all the
countries. An analysis for Jamaica alone has shown
that the cost of hypertension and diabetes for the
year 2002 was estimated to be about $US 58.5
million, without including the economic value of the
premature death that these diseases cause. The
astronomical costs of these disorders sharpen the
region’s awareness of the need for primary
prevention programmes..
Obesity
In particular, the rising epidemic of obesity in
the region must be tackled seriously on all fronts,
with emphasis on the twin pillars of weight control
– eating right, or balanced eating, and exercise.
Policies must be put in place to increase physical
activity for all age groups.
There should be licensing laws to ensure that
consumers know the contents of the foods they eat
and agricultural policies across the region must
ensure that food security is pursued within the
context of incentives or subsidies for local
production of the vegetables, fruits and whole
grains required for a healthy diet.
The environment should be modulated in support of
policies that facilitate weight reduction or ideal
weight maintenance at individual and group levels.
There must be closer regulation of foods, especially
of the steadily increasing importation of foods with
high fat content.
Attention to weight reduction must begin in
schools, focusing on nutrition and the absolute
necessity to include physical education as a
critical part of the school curriculum as important
as the “academic” subjects.
Tobacco use
On the issue of the reduction of tobacco use, the
Report identified as policy options the levying of
appropriate taxes on tobacco products, the banning
of tobacco product advertisements, and forbidding
the sale of such products to minors and the
sponsorship of events which directly or indirectly
induce smoking.
Mental health
Unfortunately, it has bee difficult to obtain
reliable data on the epidemiology of mental illness
in the Caribbean. . But when isolated studies are
done for individual populations the prevalence rates
of the major mental illnesses are not very different
from those reported regionally. Analysis of direct
and indirect cost of the two major mental illnesses
in Jamaica – depression and schizophrenia – revealed
the astonishing figure of $J 3.8 billion for one
year.
The Heads of Government mandated the
development of a regional plan for mental health.
The Report recommends that that mandate must be
vigorously pursued.
HIV/AIDS
Although non-communicable diseases are very
clearly the major causes of mortality in the region,
there are also alarming statistics relating to
HIV/AIDS as a cause of death, particularly among
young persons. The Caribbean is estimated to have
half a million people living with HIV, and the
prevalence rate is second only to that of
Sub-Saharan Africa.
The epidemic mortality rate
among young, productive males is increasing and
young women are the group with the fastest rising
prevalence rate.
The Report recommends urgent
measures to tackle the problems of stigma and
discrimination and expand treatment.
Violence and injuries
Violence and injuries have become a huge burden
on the state and society throughout the Caribbean.
Homicide and motor vehicle accidents account for 9.3
per cent of the years of productive life lost in the
region and are second in impact only to HIV/AIDS.
The cost of injuries and violence amounted to 0.7
per cent of Jamaica’s gross domestic product in
2002. The pattern is similar in all Caribbean
countries. Emergency rooms are filled with trauma
from interpersonal violence, and accidents and
injuries constitute a major cause of mortality and
morbidity in the young, especially among males. The
public health subsector needs to provide
epidemiological data on violence and where it
happens, as to facilitate the organization of the
services to deal with it. Although the effects are
felt very largely in the health sector, the root
causes are much farther afield.
Health systems infrastructure
While the health services had done well in terms
of prevention of the classical communicable diseases
and attending to the basic problems of the child,
with a few exceptions they were not equipped to deal
with the changing epidemiological profile of the
Caribbean and to focus on the current philosophy of
wellness and health promotion in addition to disease
prevention.
There were deficiencies in the exercise of what
are described as essential public-health functions,
and there was great concern over poor quality
assurance and public-health research. Although there
has been discussion about the sharing of clinical
services, little action has been taken in that
regard. However, the region has supported some
services, such as surveillance, which may be
classified as “regional public goods”.
The Report identifies the low priority accorded
to public-health training and the “compelling and
crying need” for strong public-health leadership and
a capable public-health workforce.
Analysis of the health systems and services has
shown that although most countries had a health plan
its development and execution was often stymied by
lack of a good information system and an organised
process of collating data and presenting evidence
for decision-making.
Effective decentralisation has also proved
problematic.
The Report recommends the deployment of
information systems that can produce regular reports
on the state of health, the introduction of
appropriate information technology, and the creation
of sectoral planning units where needed. It
advocates programme budgeting as a norm in the
Ministries of Health, the examination of areas of
deficiency in the health systems with special
attention to quality assurance, research and
development, and surveillance.
It calls for the Caribbean to address urgently
the need for persons with skills in this field and
proposes an examination of the efficacy of
reintroducing the nurse practitioner category of
health worker.
The Report suggests that all countries should
carry out periodic living standards surveys that are
such a rich source of social data and that
appropriate health-related data should be part of
such surveys. It calls for maintenance and
strengthening of institutions that carry out such
functions.
Financing of health services
The Report deals in some detail with the
financing of health services.
One analysis suggests that a three-tiered system
has been institutionalised in some countries whereby
the very wealthy opt for overseas care for all but
the most minor problems and accidents, the upper and
middle income groups have health insurance and opt
primarily for local private care, and the low and
lower middle income groups resort to the publicly
supported health care services.
Total health expenditure as a percentage of GDP
in 1997-2001 was calculated to range from 4.3 per
cent in Saint Lucia and Trinidad & Tobago to 9.8 per
cent in Suriname. Government expenditure on health
as a percentage of total health expenditure over the
same period ranged from 83 per cent in Guyana to 45
per cent in Trinidad & Tobago. The report recommends
that the countries should aim for health expenditure
of at lest 6% GDP and that information should be
exchanged on the various attempts to establish a
regional health insurance scheme.
User fees
One of the fundamental issues addressed in the
Report is the growing application of “user fees”
collected from health service clients to compensate
for shortfalls in the budgets for public health
services. Concern was expressed that the practice of
applying user fees, although its general impact is
uncertain, may indeed be regressive, as it affects
negatively the most vulnerable segments of the
population, such as the poor, the elderly and
children.
Given the growing number of the elderly and the
increased prevalence of diseases that require
prolonged care, the “user fees” practice should be
discouraged. The Report proposes that public health
services should be funded from the public purse. It
draws attention to what may be regarded as best
practice for addressing the health problems of the
poor while simultaneously increasing educational
attainment – that is, providing cash incentives for
attendance at the appropriate health and educational
facilities.
Health tourism
The Region’s linguistic character and geographic
proximity to the centre of world economic power,
together with its physical attractiveness and
reputation as a holiday resort area, presents a
great opportunity to sell health to the world,
especially to our rich northern neighbours. This, of
course, will require maintenance of high standards
of water supply and sanitation, environmental
health, food safety and avoidance of risky (or at
risk) behaviour.
The Caribbean Epidemiology Centre (CAREC)
estimated that more than $US 200 million had been
lost in one year by the region’s tourism industry
through failure to attend to the above.
The positive opportunities for health tourism
would be mainly in the areas of surgery,
convalescent care and rehabilitation, use of spas,
drug and alcohol-dependency programmes, long-term
care and the lure of lower-cost local health
services. Healthy climate and environment,
well-trained health practitioners, good
telecommunications and transport infrastructure,
excellent hotel and tourism services, and
competitive labour costs make the region attractive
for the development of health tourism. There should
be careful and urgent analysis of the prospects for
health tourism, especially of the barriers, and
mechanisms put in place to remove the barriers.
Migration of nurses
The migration of nurses has been a problem for
Caribbean Ministries of Health for many years. The
demand for Caribbean nurses in the English-speaking
northern metropolitan centres is testimony to the
quality of training that obtains in the region.
Ironically, the problem of migration of nurses
coincides with the need for adequately staffed,
strong public health services with nurses playing a
major role. The Ministers of Health have endorsed a
programme of “managed migration” to ameliorate some
of the factors contributory to migration that their
countries can control or influence. The shortage of
nurses and migration from the Caribbean is occurring
while there is unused training capacity in the
region.
A clear distinction must be made between the
permanent migration of nurses and any programme of
temporary migration under the Mode 4 form of supply
of the WTO General Agreement on Trade in Services
(GATS). The Report proposes as a complement to the
programme of managed migration as endorsed by the
Ministers a regional approach in which temporary
migration is actively promoted. The Report suggests
a regional approach to this problem.
Dissemination of Report
The Report of the Caribbean Commission on Health
and Development was submitted to the Heads of
Government, as required, through the Council of
Human and Social Development (COHSOD). It was
considered important, however, to disseminate the
findings and conclusions to the Caribbean publics in
general, since all are stakeholders in the health
and development of their respective countries and of
the Region.
APPENDIX A
Terms of Reference of Caribbean Commission on
Health
1. Establish policy framework that will assist
the CARICOM Member Countries in structuring their
health and development agendas
2. Produce evidence of aggregate returns to
investment in health in such areas as foreign direct
investment, tourism and trade.
3. Identify the economic and social returns to be
derived from investment in interventions that
address principally the health priorities that arise
from the Nassau Declaration
4. Identify the economic consequences of the
demographic/epidemiological changes in the Caribbean
on the health systems, their costs and operations
5. Estimate the economic and social benefits to
be derived from ensuring high level of health
coverage for the poor or specific programmes
targeted to that specific group.
APPENDIX B
Members of the Commission
Sir George A. O. Alleyne (Chair), Director,
Emeritus Pan American Health Organisation (PAHO/WHO)
Dr Compton Bourne, President Caribbean Development
Bank (CDB)
Dr Havelock Brewster, Deputy Executive Director,
Inter-American Development Bank (IDB)
Professor Terrence Forrester, Director, Tropical
Medicine Research Institute, University of the West
Indies (UWI)
Dr C. James Hospedales, Director Caribbean
Epidemiology Centre (CAREC)
Dr Jeffrey Koplan, Vice President for Academic
Affairs, The Robert Woodruff Health Sciences Centre,
Emory University, USA
Dr Stanley Lalta, Health Economist, Ministry of
Health, Jamaica
Professor Elsie LeFranc, Professional Fellow, Sir
Arthur Lewis Institute of Social and Economic
Studies, UWI
Professor Karl Theodore, Head, Department of
Economics, and Coordinator, Health Economics Unit
,Faculty of Social Sciences, UWI
Professor Clive Thomas, Director Institute of
Development Studies, University of Guyana
Sir Dwight Venner, Governor, Eastern Caribbean
Central Bank
Secretariat:
Mrs. Veta F. Brown, Caribbean Program
Coordinator, PAHO/WHO
Dr Edward Greene, Assistant Secretary General,
CARICOM
