WHO Consultation - Review of International Experience in NCD Prevention and Control WHO Headquarters, Geneva, Salle D, April 8-10 2010 Lessons learned from CARICOM on NCD prevention and control By Dr George Alleyne Pan American Health Organization Regional Office of the World Health Organization
Noncommunicable Disease and Mental Health World Health Organization Geneva, 2010 Lessons learned in raising the priority of chronic non-communicable diseases in the Caribbean and in the Commonwealth The purpose of this paper is to reflect on and describe the lessons learned in achieving a high level political commitment for the prevention and control of the chronic noncommunicable diseases (NCDs) The lessons learned with respect to raising the priority of NCDs have to be set out in terms of the diseases themselves and the contexts in which they were considered. Priority attention to disease in general may involve technical as well as political considerations although in most instances the former is a precursor or foundation for the latter. The technical priority assigned to any set of diseases is usually on the basis of morbidity or mortality data or evidence of the health or social consequences of the particular disease. In the present case the analysis is complicated, as we review the priority assigned collectively by a grouping of countries as opposed to purely national consideration. There may be several analyses of the magnitude of the problem in epidemiologic terms at the national level, but this does not necessarily translate to a raising of the level of priority at the political or policy level. The NCDs have to contend with numerous other health problems and the assignment of priority status is not based exclusively on health data. The fact that there are many myths surrounding the NCDs, such as that they are a problem only of the developed world, the fact that the NCDs do not figure among the Millennium Development Goals and the low importance given to them by the international donor community all contribute to the low level of priority assigned to them. There is also no single metric of what is meant by priority. There may be priority in terms of political discourse that does not necessarily translate into the development of operational policies or the assignment of the appropriate budget. Conversely examination of the budget allocation may be the best indicator of the priority assigned to the disease. Review of the various approaches to priority setting at the national level emphasizes the complexity of the exercise. Disease priority may be interpreted loosely in two ways. One can separate the priority given to a disease condition or a set of like disease conditions from the priority assigned to the use of one or other intervention to address a 2
disease, although health planners often take the view that the availability of an effective intervention may be a determinant of the priority assigned to a particular condition. The methods used to assign priority to specific interventions have most often been based on economic analysis 1 of the extent to which the intervention maximizes a health gain, which usually involves some calculation of a cost/benefit ratio. 23 The assignment of priorities between disease entities is most frequently based on some measure of the burden of illness, taken together with the possibility of reducing that burden by appropriate intervention as noted above. 4 Apart from the technical aspects there are always considerations of a political, social or economic nature in term of addressing one or other set of disease problems. These include but are not limited to the strength of one or other interest group nationally which may be determined by financial, geographical or other considerations. The priority assigned to the HIV epidemic in its early stages is an example of the influence of interested, powerful stakeholders in shaping the consideration of priority which was shown in a myriad of ways including the possibility of mobilizing a tremendous quantity of resources. Any consideration of lessons must take cognizance of the above. It is useful to examine the extent to which the NCDs have attracted special attention in the Caribbean before adducing the lessons that have been learned. There have been numerous publications on the epidemiology of the NCDs, pointing out that the incidence has been increasing in relative and absolute terms over the past half century 56789 with the data being clearest for hypertension, diabetes and cardiovascular disease. There has also been noticeable change in the risk factors such as obesity 10, due to a decrease in physical activity and overconsumption of calories. 1 Musgrove, P. and J. Fox-Rushby. 2006. Cost-effectiveness analysis for priority setting in Disease control Priorities in Developing Countries. Eds Jamison, D.T. et al. Oxford University Press and The World Bank 2 Hauck, K, P. C. Smith and M. Goddard. 2004. The economics of priority setting for health care: a literature review. The World Bank, HNP Discussion Paper. 3 Sabik, L. M. and R. K. Lie.2008 Priority setting in health care: lessons learned from the experiences of eight countries.international Journal for Equity in health 7:4 doi:10.1186/1475-9276-7-4. http://www.equityhealthj.com/content/7/14. Accessed March 14, 2010 4 World Bank 1993, World Development Report: Investing in Health. New York; Oxford University Press 5 Stuart, K.L. 1968 Hypertension in the tropics. British Medical Journal5584:103-105 6 Miller,G. G. Maude and G. Beckles. 1996. Incidence of hypertension and non-insulin dependent diabetes mellitus and associated risk factors in a rapidly developing Caribbean community: The St.James survey (Trinidad). J Epidem.Comm. Health; 50:497-526 7 Hagley, K.E. 1990 Chronic Non-communicable diseases and their impact on women. West Indian med.j. 39;4-11 8 Holder, Y.and M.J. Lewis 1997. Epidemiological Overview of Morbidity and Mortality. In Health Conditions in the Caribbean. Pan American Health Organization Scientific publication No.561 9 Theodore-Ghandi, B. 1997 Health of the adult. in Health Conditions in the Caribbean. Pan American Health Organization. Scientific Publication No.561 10 Fraser, H.S. T. Forrester, and R.Wilks. 1996.The obesity epidemic of the Caribbean.West Indian. Med. J. 45: 1-5 3
Attention will be paid to the problem at the level of the Caribbean region as a whole and the regional initiatives that have been established. Perhaps the first recent effort at a Caribbean response to the epidemic of NCDs was seen in the development of the Caribbean Cooperation in Health Initiative which was approved by Ministers of Health in 1986. This was in line with a long history of cooperation in the region in health matters. 11 The CCH which is now in its third iteration had the following as its major objectives: 1) Identifying priority health areas and using them as vehicles to optimize the use of resources and foster technical cooperation among countries; 2) Developing projects in the priority areas as a way to solve critical health problems and as vehicles for improving the overall health delivery system; 3) Mobilizing all national and external resources to address the most important health problems of the neediest groups; and 4) Encouraging cooperation among countries, agencies and institutions to improve technical cooperation in health. The chronic diseases were the first priority area and emphasis was placed on reducing the morbidity and mortality from these diseases. The vaccine preventable diseases figured among the priority areas and were addressed very successfully as the Caribbean region led the world in polio, measles and rubella elimination. The next major significant regional attempt to prioritize the chronic diseases was the Nassau Declaration by the CARICOM heads of Government in 2001 which declared that The Health of the Region is the Wealth of the Region and gave direction to the regional approach to addressing several diseases including the Chronic Diseases. 12 The Nassau Conference instructed that a Regional Strategic Plan for the prevention and Control of the chronic non-communicable diseases be developed. This was a highly laudable effort that was developed with wide participation of several stakeholders and had the imprimatur of the Ministers of Health through the Council of Health and Social Development (COHSOD) and even the Heads of Government themselves. The Plan addresses issues such as the quality of care, the screening of groups at high risk, information systems, the development of the appropriate policies for prevention and control and the promotion of healthy life-styles. Unfortunately the plan languished because of lack of the necessary resources and lack of clarity as to the primary responsible agency. Another outcome of the Nassau Conference that has had repercussions in terms of the NCDs was the decision of the Heads of Government to establish the Caribbean Commission on Health and Development to propel health to the center of the development agenda The report of the Commission emphasized the major problems with which the Region had to deal. These were; -Cardiovascular disease-coronary heart disease, stroke, hypertension and diabetes -HIV/AIDS 11 Working document for the Regional Summit on chronic non-communicable diseases. Port of-spain, Trinidad and Tobago. 15 September 2007. http://www.caricom.org/jsp/community/chronic_non_communicable diseases/executive_summary.pdf Accessed March 18, 2010 12 Nassau Declaration of the Twenty-Second meeting of the Conference of CARICOM heads of Government, Nassau, Bahamas, July, 2001. http://www.caricomlaw.org/docs/nassaudeclaration%20on%health.htm Accessed 18 March 2010 4
-health consequences of injuries and violence. Among the recommendations for regional attention to the NCDs were the need to develop primary prevention strategies that focused on the common risk factors, the development of surveillance systems and programs of secondary prevention. The data from these various initiatives were presented to Caribbean governments by the Chair or members of the Commission and led to the recognition of the gravity of the situation in the Region. It was Trinidad and Tobago which particularly appreciated the importance locally and by extension regionally, so with the support of CARICO, PAHO/WHO and the Public Health Agency of Canada the Summit of CARICOM Heads of Government was convened in Port-of-Spain, Trinidad and Tobago in September, 2007 which under the heading of The Port-of-Spain Declaration Uniting to Stop the Epidemic of Chronic NCDs issued a 15 point declaration. The essential points of this Declaration were: Tobacco - Implement the WHO Framework Convention on Tobacco Control: taxation, legislation, earmark some revenue for health promotion & disease prevention, ban smoking in public places Healthy Diet - Trade policies on food imports, agriculture policies, Healthy school meals, Food labeling, reduce or eliminate trans fats Physical activity-physical education in schools; physical activity in work places; improve public facilities for physical activity Health services - screening and management of NCDs to achieve 80% coverage by 2012;; primary and secondary prevention, comprehensive health education Monitoring - Surveillance of risk factors; monitoring of the actions agreed upon in Declaration (CARICOM Secretariat, CAREC, UWI & PAHO/WHO) Mobilizing Society - National Commissions on NCDs; including public, private sector and civil society, media and communications industry Caribbean Wellness Day Second Saturdays in September. The penultimate regional declaration that emphasized the importance of the NCDs was the Thirtieth meeting of the CARICOM Heads of Government in Georgetown, Guyana July 2009, which declared as follows ; Realising the Nassau Declaration (2001): The Health of the Region is the Wealth of the Region THE CONFERENCE: Supported the plans for the follow up to the Port-of-Spain Declaration (2007) Uniting to Stop the Epidemic of Chronic NCDs, including elevating the Caribbean experience to the global level; Agreed to advocate for a special UNGASS on NCDs and include NCDs within the M & E system for the MDGs [N.B. MDG # 6] and to request that this issue be placed on the Agenda of the Meeting of Commonwealth Heads of Government (CHOGM) to be held in Trinidad and Tobago in November, 2009. 5
The Commonwealth Heads of Government met in Port-of-Spain, Trinidad and Tobago in November 2009. The Prime Minister of St.Kitts /Nevis presented the problem of the NCDs and there was agreement on a declaration which in the strongest language possible emphasized their importance and supported the call for a UNGASS in September 2011 to deal with the NCDs as a major developmental problem. This sequence of events reveals the increasing political priority that has been assigned to the NCDs if one uses the attention of the Heads of Government as a metric. It should be pointed out that the recommendations of the Port-of-Spain Declaration have been translated into specific actions at the regional and local levels, although there is still a great deal to be accomplished and there is need to ensure that all the recommendations are acted upon and that there is continuity and coordination of such action. As a consequence of the call for a UNGASS on NCDs in 2011, the Caribbean has undertaken a systematic lobbying effort through its diplomatic contacts to make this possible. What are the lessons that have been learned in raising the priority of NCDs in the Caribbean and possibly the Commonwealth? The lessons cited below benefited from the work of a research student who conducted interviews with 28 key informants in 2008 in order to understand better the process leading to and the perceptions of the Summit. First it is important to recognize that this was a progression and did not occur as a result of one single effort. Thus it was necessary to build up a constituency and consciousness of the importance of the problem through ever more focused approaches. There was the technical, individual country effort as occurred in Barbados and the Bahamas for example. Given the political structure of the countries with their cabinet systems and sectoral responsibilities, it was critical to have the imprimatur of the Ministers of Health and their active support in raising the issue to the level of the Heads of Government without the Ministers being concerned about a loss of control or responsibility for what was traditionally conceived as a sectoral issue. It became apparent that the support of the sectoral Minister was essential for there to be a shift to the wholeof-government consideration that was implicit in having the matter raised and dealt with at the level of the Heads of Government. The second lesson learned was the absolute necessity for there to be data to make the case for the NCDs to be raised to a higher priority level. The Caribbean Epidemiology Center and the Caribbean Food and Nutrition Institute had collected serial data on the NCDs and their risk factors which allowed the case to be made of the consistent and persistent nature of the problem and its severity in relation to other countries and health conditions e.g. HIV/AIDS. The fact that the age adjusted mortality from coronary heart disease in Trinidad and Tobago was several times higher than in Canada made an impact. In addition, the risk factors and their modifiability were other important data to be presented. The availability of the economic data as collected in the Caribbean Commission on Health and Development also helped to make the case. But there was one other important lesson that was learned with respect to the presentation of data. The demonstration of the human cost of the diseases was as important as the morbidity and 6
mortality statistics or data on the burden of disease. Prime Ministers reacted perhaps more strongly to the images of amputees because of diabetes than to the data showing that the Caribbean countries occupied the first seven places in the Americas in terms of prevalence of the disease. Thus it was important to have not only the regional data, but to speak to the head, heart and the pocket. Finally as a part of the preparation for the Summit, each Ministry of health prepared an individual analysis of the burden and trends of NCDs and risk factors, based on a common template, which was used o brief their Head and delegation attending. These data were also displayed at the Summit The third lesson learned was the critical nature of having a political structure that facilitated regional appreciation of the problem and could mandate regional action that was complementary to national action. The Caribbean Community is a formal political structure supported by the Treaty of Chaguaramas with a Secretariat that services the organs of the Community. One such organ is the Council of Health and Social Development in which the Ministers of Health sit. The supreme organ of the Community is the Conference of Heads of Government and there must be support from the CARICOM Secretariat to facilitate the presentation of the necessary documentation to the various organs of the Community and to ensure the necessary follow-up. The relevance of NCDs to the highest level of government was facilitated by presentations of the Report of the CCHD to every one of the individual cabinets of the Caribbean as well as to other ministerial groupings beside health. Thus there was sensitization of all sectors of government before the issue was raised to the level of a conclave of the Heads of Government. The fourth lesson learned was the importance of collaboration at the various stages. The Pan American Health Organization/ Regional Office of the World Health Organization is the major collaborator in health with the Caribbean countries and with the CARICOM secretariat. PAHO /WHO with CARICOM provide the joint Secretariat for the CCH and has been a critical facilitator of any and all of the success in health in the region through its program of technical cooperation. It assists the CARICOM Secretariat in the organization of the health meetings of the Community. The University of the West Indies as the only regional tertiary institution has participated in several of the regional ventures. The role of NGOs is particularly important. A Healthy Caribbean Coalition has been formed recently by all or most of the health NGOs in the region which will facilitate regional action especially in response to the mandates coming from the political instances. The international relevant NGOs-the International Diabetes Federation, the World Heart Federation and the International Union against Cancer joined forces and lobbied the Commonwealth governments strongly to support the declaration on NCDs and continue to be active in trying to ensure that the mandates from CHOGM are followed. Mention must also be made of the collaboration from friendly governments. The Government of Canada through its various agencies has been a major supporter of the efforts in the Caribbean to raise the profile of the NCDS in the political arena. The collaboration of the media was of fundamental importance in creating a groundswell of opinion, e.g. One Caribbean media printing supplements on NCDs that were distributed to households all across the Region with the Sunday newspapers. 7
The fifth lesson was that it is important for health professionals to understand the nature of the political process which is perhaps different at the national and regional collective levels. It is not uncommon to hear that the failure to assign priority to one or other area or to act is because of lack of political will, 13 but it was clear in this instance that there was really no lack of will to address the issue and assign priority to it. The first step was to appreciate the political interests of the main stakeholders, understanding that they may be different in a setting such as the Caribbean in which collective action was being sought. Health in this setting is valued as an aspect of the functional cooperation that is important to the sense of community in the region; a fact that facilitates collective political agreement in this area. There was also the need to create the political incentives for the leaders. These incentives were mainly in demonstrating the benefit that would accrue to their addressing a critical area that could only be beneficial collectively and individually. However one other aspect of this is that it was necessary to show the leaders that there was some possibility of there being results from their Declaration. It has been left to the technical functionaries to put in place these mechanisms and present to leaders with some regularity the results derived from their declarations. In this instance it was probably true that the recipe for policy formulation given by Kingdon did apply here. 14 He postulates the need for the confluence of three process streams flowing through the system-problems, policies and politics. The problems could be amply demonstrated, it was reasonably easy to show the policies that were appropriate and there was an appropriate political moment that was favored by the work of the relevant champions. The final lesson is that it is critical to have vocal and effective champions at technical and political levels. The Caribbean Community has a quasi cabinet with distribution of sectoral responsibilities. The Prime Minister of St.Kitts/Nevis-the Hon Dr.Denzil Douglas has been a most effective champion, articulating cogently for the importance of health generally and more specifically in this case for there to be greater emphasis placed on the NCDs. The Prime Minister of Trinidad and Tobago, perhaps stimulated by the fact that his country has the highest burden of NCDs in the Region has also been an effective champion. It was he who invited his colleague Heads to the Summit in Port-of Spain in 2007, and the fact that the CHOGM was held in Port-of Spain under his chairmanship was not unrelated to the fact that a strong declaration on NCDs emanated from that meeting. The Caribbean diplomats in London played their part in advocating with the Commonwealth Secretariat for the inclusion of NCDs as a major item in CHOGM and those in New York are deeply immersed in advocating for the UN Summit as mandated by the heads of Government and by CHOGM. Summary The Summit of CARICOM Heads of Government on NCDs was a first in the world, as their Declaration focused on the problem and the risks and gave clear policy directions for an inter-sectoral approach, which addresses many key risk factors. Certain conditions 13 M.R. Reich. (2002) The politics of reforming health policies IUHPE Promotion & Education Vol.IX/4 138-142 14 J. W. Kingdon. (2003) Agendas, Alternatives and Public Policies. Second Edition. Addison-Wesley Educational Publishers Inc. 8
need to be present and/or cultivated in order to succeed at achieving high level commitment, but it is possible to make the case and persuade policy makers to take action. It is necessary to build the appropriate constituency and buttress the arguments with appropriate data. A political structure that facilitates collective action is important and it is possible to build on this through a collaborative effort that involves international agencies, the private sector, the non-governmental organizations and the help of a supporting government, in this case Canada. It is not sufficient to be conversant with the technical aspects, but knowledge of the political process and the route towards public policy are essential. A key ingredient is the strong support of capable technical and political champions. 9