cent (Barbados and The Bahamas) to 50 per cent in. Belize. Cases of water-related diseases have been reported (typhoid in Jamaica and cholera in Belize).
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iv© 2006, Pan American Health Organization 525 23rd Street N.W. Washington, DC 20037 USA www.paho.org © 2006, Caribbean Community SecretariatPO Box 10827 Turkeyen, Greater Georgetown Guyana www.caricom.org Produced in Jamaica, 2006 byIan Randle Publishers 11 Cunningham Avenue Box 686 Kingston 6 www.ianrandlepublishers.com Copyright © by the Pan American Health Organization (PAHO) and the Caribbean Community Secretariat (CARICOM) National Library of Jamaica Cataloguing in Publication Data Caribbean Commission on Health and Development Report of the Caribbean Commission on Health and Development p.; cm Includes index ISBN 978-976-8082-20-6 (pbk) 976-8082-20-8 ISBN 978-976-600-176-6 (pbk) 976-600-176-6 1. Public health Œ Caribbean Area 2. Health planning Œ Caribbean Area 3. Economic development Œ Health Aspects 4. Medical economics Œ Caribbean Area I. Title 362.1 21 All rights reserved. No part of this publication may be reproduced, storedin a retrieval system or transmitted in any form or by any means electronic, photocopying, recording or otherwise, without the prior permission of the publisher and author. Book design by Allison BrownCover design by Marilyn EntwistlePrinted in the United States of America front matter.pmd11/4/2005, 1:11 PM4

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vTable of Contents LIST OF TABLES .xiLIST OF FIGURES xiiEXECUTIVE SUMMARY .xiiiACKNOWLEDGEMENTSxxiINTRODUCTIONxxiiiABBREVIATIONS AND ACRONYMS xxixCHAPTER 1 Œ OVERVIEW OF THE HEALTH SITUATION 1.1Population and demographic trends .11.2Trends in Mortality ..11.3Noncommunicable Diseases..21.4Communicable Diseases ..21.5Injury and Violence ..51.6Health Services Utilization ..61.7Health Expenditure..61.8Human Resources 71.9Environmental Health ..7CHAPTER 2 Œ OVERVIEW OF THE ECONOMIC SITUATION 2.1Introduction 82.2Economic performance 1970Œ2002..82.3Debt 112.4Employment 122.5Poverty and Income distribution ..132.6Structural Changes ..132.7Challenges 14CHAPTER 3 Œ HEALTH INVESTMENT AND ECONOMIC GROWTH 3.1Returns to Health as a Productive Asset .153.2Channel for the Health to Wealth Link .16front matter.pmd11/4/2005, 1:11 PM5

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vi3.3.Impact of Health Investment.173.3.1H ealth and Foreign Direct Investment (FDI) 183.3.2H ealth and Tourism .183.3.3Modeling the Relationship .193.3.4H ealth Tourism 213.4Conclusions 223.5Recommendations 22CHAPTER 4 ΠNONCOMMUNICABLE DISEASES AND MENTAL HEALTH 4.1Economic Development and the Epidemiological Transition 244.2Noncommunicable Diseases.254.2.1Cardiovascular Diseases.254.2.2Cardiovascular Disease Risks.264.2.2.1T obacco.274.2.2.2Hypertension.284.2.2.3Diabetes and Obesity284.2.2.4Nutrition and Living Conditions 294.2.3Cardiovascular Diseases in the Caribbean: Summary.294.3Potential interventions .,.304.4Cancer 304.5Mental Health314.5.1Depression314.5.2Schizophrenia324.5.3Other Mental Health Problems . 324.6The Economic Burden of Cardiovascular Disease and Mental Health 334.6.1Cardiovascular Disease..334.6.2Depression and Schizophrenia..344.7Conclusions 354.8Recommendations 35CHAPTER 5 ΠOBESITY5.1Epidemiology 375.2Trends in Food Availability/Intake ..395.3Physical Activity 405.4The Cost of Obesity 405.5Public Policy Options 405.6Conclusions 415.7Recommendations .. 42CHAPTER 6 ΠHIV/AIDS6.1The Sociocultural aspects ..436.2Epidemiological profile ..446.2.1HIV Prevalence among Vulnerable Populations 46front matter.pmd11/4/2005, 1:11 PM6

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viiiCHAPTER 10 Œ HEALTH FINANCING 10.1H ealth Financing: Concerns, Goals and Guiding Principles 7910.2Health Expenditure and the Public-Private Mix . 8010.2.1T otal Health Expenditure and Public-Private Mix 8010.2.2Allocation of Health Expenditure8310.2.3Health Spending and Health Outcomes 8310.3F inancing National Health Care Systems 8310.3.1Tax F unds and Budgetary Allocations 8410.3.2National Health Insurance .. 8510.3.3U ser Fees in Caribbean Countries . 8610.4The Demand Challenges ..8810.4.1M orbidity and Mortality Patterns 8910.4.2T echnological Imperatives 8910.4.3Organization of Delivery of Health Services .8910.4.4Income Driven Demand ..8910.4.5Choice and Growth of the Private Sector ..9010.5Efficiency Issues and Innovations ..9010.5.1Public Health Expenditure .9010.5.2Improving Management and Purchasing Options 9010.6Equity Issues ..9310.6.1Coverage and Equity .9310.6.2Access to Care and Utilization ..9310.6.3Coverage of Ser vices and Unmet Needs .. 9410.6.4T argeted Funds for Treatment of the Poor . 9410.7Conclusions 9510.8Recommendations ..96CHAPTER 11- GENERAL CONCLUSIONSThe Commission™s Mandate ..98Caribbean Health ..98Major Challenges 99Conclusions and Recommendations 100Next Steps .100References . 101AppendixWorking Papers of the Commission .107Terms of Reference of the Commissioners and Members of the Commission.108Conclusions and Recommendations 111Index ..120front matter.pmd11/4/2005, 1:11 PM8

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xiList of Tables Table 1:CARECŒCDC Estimates of People Living with HIV/AIDS Estimates of People Living with HIV/AIDS in CAREC Member Countries .. 3Table 2:Immunization Coverage for Caribbean Countries, 1997 and 2003 5Table 3: Human Resources by 10,000 population6Table 4:Growth of Real Income Per Capita in 2000 PPP$, 1970Œ2000 9Table 5:Government Expenditure, Revenues, Deficits and Debt 11Table 6:Inflows of Foreign Direct Investment in the Caribbean (US$ Millions 1994Œ2001) ..18Table 7:Visitor Expenditure as a Percentage of GDP 19Table 8:Age-Adjusted Death Rates of Coronary Heart Disease, Stroke and Total Cardiovascular Disease, Caribbean Countries, Selected Years in the 1990s . 25Table 9:Age-Adjusted Death Rates for Selected Cardiovascular Conditions, late 1990s, per 100,000 .26Table 10:Cardiovascular Risk Factors in Community Surveys, Means + Standard Deviations 27Table 11:Age-Adjusted Death Rates for Selected Neoplasms, late 1990s, per 100,000 30Table 12:Economic Burden of Disease for Jamaica (2002) .. 33Table 13: Projected Impact of HIV/AIDS on Overall Labour Supply and Employmentin Selected Sectors by 2005 ..49Table 14:Top Ten Causes of Contribution to PYLL, CAREC Member Countries . 54Table 15:Jamaica Injury Surveillance System (JanuaryŒDecember, 2003) . 55Table 16:Principal Causes of Mortality among 15Œ44 Year Olds, 2000 Percentage of Total Cases of Mortality in Age Groups . 56Table 17: Regional Health Authorities .61Table 18: Comparative Performance Assessment Š the Caribbean and Region of the Americas .66Table 19:Number of Immigrants to the United States by Educational Attainment for Selected Developing Economies, 1990..71Table 20:Trends in Some Ratios Reflecting the Significance of Worker Remittances in CARICOM, 1990Œ2000 74Table 21:Number of Registered Nurses, Vacancies and Vacancy Rates by Country .. 75Table 22 :Health Expenditure in Caribbean Countries, 1997Œ2001. 81Table 23:Health Expenditure in Relation to Population and GDP, 2001 .. 82Table 24:Tax Revenue in Selected Countries Š Percentage of GDP (2000) . 84front matter.pmd11/4/2005, 1:11 PM11

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