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BARBADOS, 1992-1995
TRENDS IN POLICY DEVELOPMENT
Barbados, one of the oldest democracies in the western hemisphere, has had an almost unparalleled tradition of stable governance, characterized for the most part, by electoral rotation between two political parties. The political culture dictated that successive governments build on the efforts of their predecessors. The principle of universal access to health care was supported by "free" delivery of services to all sectors of the population. There is no variation from the philosophical tenet that health care is the right of all Barbadians. During the review period, 1992-1995, there were no major changes in the politico-philosophical tenets governing the country of Barbados particularly as they relate to policies and principles in support of "Health for All." The actions taken to ensure enhancement of the health sector were largely managerial and infrastructural. The political system faced challenges in relation to health care and achieving the Health for All objectives, but the government of Barbados remains committed to its principles. The Government is confronted with issues of quality maintenance, scarcity of resources, limitation in achieving intersectoral cooperation and the need for expanded training in analysis, operational research, management of change, and institutional development.
The economy of Barbados showed signs of recovery from recession. Gross Domestic Product (GDP) at market prices grew from US $1,588.6m in 1992 to US $1,882.6m in 1995. Per capita GDP increased from US $5,650 to US $6,000 during the period. Real GDP which was US $454.5m in 1989 declined to $395.5 in 1992, but by 1993 had risen to $401.9m and continued through 1994 to ($417.7m), reaching $428.4m in 1995; all sectors of the economy contributed to this growth. In the traded sector, sugar output recorded an overall decline during the period. Favourable weather conditions during 1995 contributed to an 8.0% increase in non-sugar, agriculture and fishing, with milk and chicken production and food crop output all gaining ground over their 1994 performances. Real output in the tourism sector grew from US $56.8m to US $65.4m. Manufacturing output grew from a negative rate of 2.9% in 1993 to 6.7% in 1994 and 7.5% by 1995. Garments and chemicals recorded the greatest increases in the sector. In the non-traded sector, mining and quarrying, construction and wholesale/retail trading all recorded modest growth. The prospects for sustained economic growth are good. As a mixed economy, the role of government is one of regulation, facilitation, provision of public goods and/or the provision of other goods and services where market failure occurs. Government expenditure as a % of GDP declined from 26% in 1993 to 23% in 1995. Control of Government expenditure is one of the objectives of the Government's Structural Adjustment Programme which was negotiated with the International Monetary Fund. Current expenditure increased from US.$543.1m in 1992/93 to $616.2m in 1995/96. Current revenues increased from $502.2m to $574.5m. Capital expenditure tended to remain static during the period 1992/93 to 1994/95 at about $22m but rose to $58.5m in 1995/96. Success in reaching the objective was evidenced by the reduction in the fiscal deficit. In 1992/93, the fiscal deficit net of amortization was $25.9m and this declined to $10.6m in 1995/96. When the fiscal deficit is compared with GDP it declined from 1.6% in 1992/93 to 0.7% of GDP in 1995/96. Financing the fiscal deficit has been achieved from domestic (treasury notes and debentures) and foreign services. Foreign financing approximately accounted for 50% of deficit in 1995/96 The labour force increased from 132.1 (thousand) to 136.8 (thousand) during the period. The unemployment rate which was 23.0% in 1992, increased to 24.3% in 1993 but declined in each of the following years to 19.7% by 1995. Males continued to outnumber females in the labour force. This trend indicates that females entered into the labour market at a faster rate than their male counterparts. Female unemployment was higher than that for males. While the male unemployment rate fell from a high of 21.2% in 1993 to 16.5% in 1995, the female unemployment rates were 27.6% in 1993 and 22.9% in 1995. The number of youths in the labour force continued to show variations, dropping to its lowest during 1994. Barbados has an area of 430 km2 with an estimated mid-year population of 265,173 in 1995. Of this figure 47.9% were males and 52.1% females. It is difficult to define areas as urban or rural because of its size but the most densely populated areas are found along the west, south west and south coasts. Education is provided mainly by government schools. A number of private primary and secondary schools existed which provided education similar to that in government schools. The Barbados Community College (BCC) and the University of the West Indies (UWI) provided tertiary education and training. The B.C.C provided technical and para-professional education, training , and tuition for advanced level studies. UWI offered education at the graduate and post-graduate level. An education gap existed between males and females with more females than males graduating. The adult literacy rate for both male and female was 99%. The National Policy Statement on Women contains the principles for developing strategies and implementing programmes to ensure that women participate fully in the economic, social, cultural and political issues of the country. The Government of Barbados committed itself to addressing the family including the special position of women. It is recognised that nearly half of the households in Barbados are headed by women who bear the brunt of family responsibilities. In July 1995, the Cabinet commissioned a report from the Ministry responsible for Women's Affairs to address these issues. Barbados has made significant progress in reforming laws and enacting new legislation to guarantee women's rights and eliminate discrimination. There were two daily newspapers, eight radio stations and one local television station. Barbadians have access to cable television and the internet. Government is conscious of public demand for more information on health and recognises the role of the media as a partner in responding to this need. In this regard, Government has offered to provide additional training for journalists on health and environmental issues, to assist with the development of skills in assessing and covering these issues. Government's policy in agriculture is to ensure that adequate quantities of wholesome food, whether obtained locally or from foreign sources, are available to and accessible by Barbadian households, particularly the more vulnerable groups in the society. The Ministry of Agriculture intensified its efforts to increase local food production. Farmers received incentives to assist in their cultivation of crops. In the period 1995, the 89% of newborns weighed at least 2500g at birth. Limited data is available on cases of iodine deficiency disorders, number of cases of anaemia in women and children, and number of cases of vitamin A deficiency. There were still cases of protein-energy malnutrition in Barbados, but there have been no significant changes in the proportion of children less than five demonstrating evidence of protein-energy malnutrition at either moderate or severe levels. The absence of a food and nutrition policy and insufficient research are constraints in the effort to improved nutrition for the population. A significant feature of the health profile of Barbadians during the last ten years was the shift from communicable to non-communicable diseases. In 1992, statistics showed that the principal causes of death and hospitalization were cardiovascular and cerebrovascular diseases, cancer, diabetes, other circulatory diseases and AIDS. The age groups most seriously affected by these diseases has widened. However, recent statistics show that the persons most seriously affected by chronic non-communicable diseases (CNCDs) are in the 40-65 age group. There has been a steady decline in teenage pregnancy. Statistics from the Government Statistical Department show that in 1995, 13.9% of total births occurred to teenage girls, as compared to 16.5% in 1992. Approximately 7% of the male population and 1.18% of the female population age 15 years and over are regular smokers. The Barbados Risk Factor Survey, a study which sampled 1% of the population, reported that 9% of the respondents were current smokers while 8% smoked regularly. Almost half of those who ever smoked said they started when they were between the ages of 16 and 20. Similar trends were noted regarding alcohol consumption. Thirty-eight percent of the respondents reported that they drank alcoholic beverages. Concern was expressed about drug use by school age children and adolescents. Investigations revealed that most people who participate in drug rehabilitation programmes started using illegal drugs between the ages of 13 and 16. The Ministry of Education conducts health education and family life education classes in primary and secondary schools. Initiatives to address substance abuse include the establishment by Government of the National Council on Substance Abuse which conducts education programmes, particularly in the schools and demand reduction programmes in the community through the National Drug Resource Centre. Many governmental actions focused on promoting healthy lifestyles and similar actions occurred in the NGO sector. The three major constraints associated with improvement of lifestyles include a lack of communication and linkages between the various actors promoting healthy lifestyles, the need for a comprehensive and sustained health promotion approach, and a need for self-motivation to adapt healthy lifestyles.
The Environmental Engineering Division of the Ministry of Health regulated and monitored the impact of development projects on the environment. This involves monitoring of the environmental quality with respect to water, disposal of solid and liquid waste, air quality, noise pollution and the control and disposal of hazardous chemicals. Water Quality Monitoring (Surveillance) programmes existed for the ground water supply (done in conjunction with the Barbados Water Authority and the Public Health Inspectorate) and the near-shore beach water quality. In addition, it manages and controls disposal sites for solid waste (bulky waste), liquid waste (blood, grease, grey-water) and asbestos. The Sanitation Service Authority (SSA) currently has responsibility for collection and disposal of domestic household garbage. It also operates a limited commercial service and manages the landfill--the garbage disposal facility. A Solid Waste Management Plan was on stream to address waste minimization, waste recycling and waste reuse. The Public Health Inspectorate (Environmental Health Officers) is the main mechanism for monitoring the quality of the (domestic) environment. Food safety and the control of communicable diseases fall under this division. Adequate financing for this sector is a major constraint for implementation of programs to enhance the quality of the environment. Plans are underway to construct a new scientifically managed solid waste disposal landfill in an effort to ensure that the health for all goals are accomplished by the year 2000. The Ministry of Health and the Environment is primarily responsible for food safety. Emphasis was placed on training at all levels, which included the setting up of food handling clinics for food handlers. Nationally, a committee was established to review existing legislation, plan strategies in keeping with guidelines from Codex Alimentarius and address issues relating to veterinary public health. These measures impacted positively on the quality of health care to the population. Consequently, there were only sporadic cases of food borne illnesses from time to time. All residents had access to adequate and safe water supply. Over ninety percent of the population have piped water from the government’s main supply installed in their homes. Water is obtained from deep wells from which it is pumped, treated and temporarily stored in reservoirs for distribution throughout the island. Sewage disposal generally is the responsibility of the Ministry of Health and the Environment. The main methods of sewage disposal were water borne system of septic tanks and wells, and the sanitary pit latrine. The Bridgetown Sewerage Project is a secondary treatment facility for the city which discharges its effluent into the sea. The Barbados Water Authority estimated that 90% of the ground water resources was committed and utilised for public and private abstractions. During periods of drought, the abstractions levels were greatly affected by salt-water intrusion into the wells located in the freshwater lens which floats on top of the salt-water. This was especially true of wells along the west coast.
In 1994, the Ministry of Health training plan for the period 1995-2000 took into account the explicit aims and objectives of its overall development plan for the corresponding period. Limited financial resources was the main constraint to improve health personnel training, deployment and performance. The Ministry of Health's recurrent expenditure increased from US$73.3m to US$91.7m. As a share of the Government of Barbados' recurrent expenditure, the recurrent spending by the Ministry of Health rose from 13.5% to 15.9%. The rising prevalence of chronic non-communicable diseases and their complications, in addition to the aging of the population contributed to the shift in demand for medical/health care interventions which are costly and technologically intensive. Some Barbadians made out-of-pocket payments for their health care and, in 1996, this was estimated at U.S $36.5m. Approximately 20% of the population has private health insurance; reimbursements by insurance companies were estimated at U.S $7.5m. However, government is the largest provider of health care and contributed the largest share of total expenditure on health. Health policies assured equitable access for the entire population by providing medical services free of charge at the point of delivery of services. The largest share of Government's health expenditure was directed towards hospital services with secondary and tertiary care consuming the major proportion. Next, was expenditure on primary health care which included sanitation and environmental health services, the latter having the largest share of growth. Notwithstanding the effects of international adjustments and stabilisation policies, Barbados maintained an effective drug delivery system. Eighty to ninety percent of essential drugs was available on location at most facilities, and the remainder was available through the Barbados Drug Service (BDS). Through this service, residents receive free medication at the point of service. High quality vaccines were bought through the PAHO revolving fund. Limited government financing was the main constraint to improving accessibility of essential drugs. The BDS, collaborated with the Drug Tenders Committee, and maintained a continuous supply of formulary drugs and related items. Local pharmaceutical distributors were fully involved in the supply process and no direct purchases were made overseas. Drugs and related items represented an average of 11.13% of the current health expenditure. Efforts were made to ensure that imported drugs were manufactured in accordance with the United States Pharmacopoeia and the British Pharmacopoeia standards. The Blood Collecting Centre at the Queen Elizabeth Hospital collected approximately 3,000 units of blood per year; donations were voluntary and non-remunerated. Donated blood was tested for syphilis, hepatitis B, HIV, Hepatitis C, and, HTLV-1.
Regionally, Barbados had formal partnerships with the Caribbean Community Secretariat (CARICOM). Regional Nursing Council, University of the West Indies (UWI), Commonwealth Caribbean Medical Research Council (CCMRC), Caribbean Epidemiology Centre (CAREC), Caribbean Food and Nutrition Institution (CFNI) and Caribbean Environmental Health Institute (CEHI). Internationally, partnerships existed with the United Nations and UNAIDS. There Is need for increased cooperation between Barbados and regional, sub-regional and international organisations. Since Barbados had a high Gross Domestic National Product (GDP) per capita, it was categorized as a "developed country" and therefore it attracted little external funding.
The government’s policy goal Is to provide comprehensive health care and to achieve this, emphasis was placed on a community approach to primary health care and on strengthening institutional capacity at the secondary and tertiary levels of care. The priority programmes Are committed to improving the condition of vulnerable high-risk population groups such as the elderly, the disabled, children, adolescents and the mentally ill. The items listed in the Barbados Drug Formulary are provided free at the point of service to persons 65 years of age and over, children under 16 years of age and persons being treated for hypertension, diabetes, cancer, asthma and/or epilepsy. Zidovudine (AZT) is given to all HIV + pregnant women. Non-governmental organisations that provide services to Barbadians are the Barbados Family Planning Association, the Barbados Cancer Society, the Heart Foundation of Barbados, the Kidney Association, the Association for Disabled Persons and the Diabetic Association. The main constraints for the improvement of health policies and strategies Are financial resources, insufficient community involvement in their own health, and increased technology. The Government operated the Queen Elizabeth Hospital (QEH), a large secondary and tertiary care facility, four district hospitals for geriatric care, a main geriatric institution, a mental health hospital and a half-way house, two small rehabilitation institutions for the physically and mentally handicapped, an AIDS Hostel, a Children Development Centre for disabled children and adolescents, a Nutrition Centre, eight polyclinics that provide a wide range of preventive and curative services, and limited rehabilitative services. The non-hospital private sector had about 100 general practitioners. Senior doctors who worked in government hospitals or polyclinics had private practices. There was one small private hospital - Bayview Hospital - with under 30 beds. The Minister of Health has overall responsibility for policy making and political direction of the Ministry and decision making is centralized. As administrative head, the Permanent Secretary functions as the chief executive and accounting officer. The accounting system is a centralized budgetary control one, that followed prescribed policies and procedures of the Government. The final decision on the health services budget is made by the Cabinet. The Chief Medical Officer has responsibility for the technical/professional aspects of the health service. The increased level of computerization provided better information systems which led to improved management in the delivery of health care as, for example, improvements in the timeliness in retrieving information, patient flow, data generation, and enhancement in the quality of work . Community involvement in Barbados did not keep pace with the strategy set out in the Declaration of Alma Ata. However, a noteworthy initiative was the Integrated Vector Control Pilot Programme which was started in a community with a school based component. This project mobilised the community to look after its own vector control activities. Several initiatives were taken to ensure that the natural or man-made disasters had the least influence on health and health status. There are plans for ongoing training of health personnel and the general public. Chronic non-communicable diseases, particularly obesity, hypertension, diabetes and their complications, as well as AIDS and cancer emerged as the major causes of morbidity and mortality. The research projects undertaken by the Ministry included the Risk Factor survey and the Cervical Cancer Control project. The Faculty of Medical Sciences, UWI, undertook extensive research in the areas of hypertension and diabetes and collaborative activities exists between the Ministry and the UWI for the setting up of a Diabetes Model Clinic and the preparation of "Guidelines for the Clinical Management of Diabetes". The establishment of the Renal Dialysis Unit and Invasive Cardiology Unit at the QEH positively effected the management and treatment of kidney and cardiovascular diseases. 6 HEALTH SERVICES No formal health promotion program with a philosophy, defined policy, objectives and consequent activities exists. Different groups emphasize different components of health promotion in accordance with their own interest. A number of initiatives were undertaken such as the national consultation on health promotion to develop a common framework for understanding and advancing health promotion. Family planning services are integrated into the MCH programme. All pregnant women, deliveries, and infants were attended to by trained personnel. Barbados participated in the Baby Friendly Initiative being promoted jointly by UNICEF and WHO. Ninety-three percent of the eligible population (i.e., infants reaching their first birthday) was fully immunized. One hundred percent of women was immunized with tetanus toxoid (TT) during pregnancy. Several actions were taken to ensure that adequate immunization coverage for EPI target diseases were reached. At the end of 1995, of the 1250 people who tested positive for HIV, 632 developed AIDS and of those, 530 (83.9%) have died. The Vector Control Division of the Ministry of Health routinely conducts mosquito surveillance throughout the country targeting especially high risk areas. The mosquito indices (AEDES-House and Breteau) are reported weekly. The AEDES indices targeted areas for intervention. There was local treatment with larvicides and insecticides and thermal fogging of areas with greatest mosquito activity or occurrence of dengue fever. Dengue Fever is a notifiable disease and an active surveillance programme existed to facilitate the early detection of an outbreak. Leptospirosis is a notifiable disease with approximately 30 notifications annually. The mortality varies from 5-10 cases per year. Through the Rodent Control Program, rat-bait was distributed to all residents at no cost; the business sector, plantations and estates were supplied with rodenticide. Government buildings including the seaport and airport were also included in the control programmes. Common conditions that occur in children under 5 years were: respiratory illness, diarrhoeal disease, and skin rashes. Most visits to polyclinics are for diabetes mellitus (Maturity Onset) and hypertension. Osteoarthritis was also a significant cause in the elderly adult population. A major problem in dealing with the chronic non-communicable diseases was the high prevalence of obesity (50% over 50 years). 7.TRENDS IN HEALTH STATUS Life expectancy at birth for male is 72.9 and for female 77.4. To curb the mortality from priority diseases such as cancer, cardiovascular diseases and diabetes, the Ministry of Health embarked on programmes to promote healthy lifestyles through proper nutrition, adequate physical exercise and the establishment of a nutritional counselling clinic for persons with non-communicable diseases. Chronic non communicable diseases posed a challenge to the health services as treatment of these is expensive. In 1995, there was an epidemic of dengue fever in which more than 2000 cases were reported; two persons had dengue hemorrhagic fever. One death resulted from this epidemic. There were a number of institutions in Barbados which provide services for the disabled, namely: the Challenor School, the Learning Centre and the Thelma Vaughn Children's Home which are privately operated but receive grants from Government; the St. Andrews Children Centre, the Children's Development Centre, the St. Philip District Hospital and the School for the Deaf which are public institutions. The Children's Development Centre is a multidisciplinary, multipurpose unit catering to the needs of the disabled. The Ministry of Health screens newborns to detect disabilities at an early stage. It strengthened its rehabilitative programmes relating to disabilities due to accidents. The Government instituted testing of all school age children to detect disabilities and impairment. These testings are done at ages five, seven and nine. Children with severe hearing impairment are accommodated at the government-run School for the Deaf. The Ministry of Health catered for some of the severely handicapped adults in its Geriatric and Psychiatric Hospitals. Some community support services that existed for disabled persons who remained at home. A welfare disability grant/pension is available through the Welfare Department. The Ministry of Labour and Community Services set up a Task Force to develop a National Policy for disabled persons. Government's main constraints in its efforts to improve disability patterns were lack of trained staff and finance.
The basic objectives in regard to health, health services, health system, health resources and the environment are:
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