62065 Human Development Unit Caribbean Country Management Unit Latin America and the Caribbean Region NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS ABREVIATIONS & ACRONYMS Currency Unit: Jamaica Dollar (JMD) API Active Pharmaceutical Ingredients CARICOM The Caribbean Community and Common Market Market Mid-Rate In 2008: CIA Central Intelligence Agency 1.00 US dollar: 74.75 Jamaica Dollars CSO Civil Society Organization One Jamaica Dollar: 0.01338 US Dollars DALY Disability-Adjusted Life Year Fiscal Year: April 1- March 31 FCTC Framework Convention on Tobacco Control GDP Gross Domestic Product HALE Health Adjusted Life Expectancy HIV/AIDS Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome ICT Information and Communications Technology JADEP Jamaica Drug for the Elderly Program JHLS Jamaica Health and Lifestyle Survey JSLC Jamaica Survey of Living Conditions KMA Kingston Metropolitan Area LAC Latin America and the Caribbean MOHE Ministry of Health and Environment NCDs Non-Communicable Diseases NGO Non-Government Organization NHF National Health Fund NLTA Non-Lending Technical Assistance OECD Organization for Economic Cooperation and Development UN United Nations UWI University of the West Indies WDI World Development Indicators WHO World Health Organization Contents Acknowledgements 8 Executive Summary 9 Introduction 12 1. The global and regional burden of non-communicable diseases (NCDs) 13 The burden of NCDs in the Caribbean Region 13 A supporting and enabling environment to address NCDs in the Caribbean 14 2. The effect of demographic and epidemiological transitions on NCDs in Jamaica 15 Conceptual framework for analyzing NCDs in Jamaica 16 The demographic transition in Jamaica 17 The epidemiological transition in Jamaica 17 3. The burden of NCDs in Jamaica 21 4. Risk factors contributing to the burden of disease 25 Obesity 26 Unhealthy diet 27 Physical inactivity 29 Smoking 31 Alcohol use 33 5. Jamaica’s response to NCDs 35 National health fund 36 Chronic disease prevention programs 41 Healthy Lifestyle Program 41 6. Impact of NCD-related policies and programs on people’s lives 43 Has household healthcare expenditure on NCDs declined? 44 Have health service visits increased? 46 7. Economic Implications of NCDs 48 Economic burden of NCDs at individual and household levels 49 Estimated national aggregated out-of-pocket expenditure on NCDs 51 8. Lessons from other countries that are applicable to tackling NCDs in Jamaica 53 9. Policy options 57 Annex A: time-trend analysis methodology 59 Annex B: Economic burden of disease methodology 63 Annex C: The jamaica survey of living conditions 65 References 66 TABLES Table 1. Ten leading risk factors contributing to death in middle-income countries, 2004 13 Table 2. Years of life lost to NCDs (%), 2002 18 Table 3. Top ten causes of death, all ages, Jamaica, 2002 18 Table 4. Estimated DALYs per 100,000 population, 2004 19 Table 5. Top 10 causes of DALYs, Jamaica, 2004 19 Table 6. Percentage of the population reporting NCDs by disease type and socioeconomic subgroups 23 Table 7. Prevalence of weight status of Jamaicans by age and gender, 2008 26 Table 8. Weight characteristics of urban adult Jamaicans 27 Table 9. Distribution (%) of food consumption by sex and place of residence, 2008 28 Table 10. Physical activity levels (%) of Jamaicans by age and gender, 2008 30 Table 11. Activity energy expenditure of urban adult Jamaicans 30 Table 12. Percentage of enrollment in NHF Card and JADEP Program by age group and gender 40 Table 13. Disease conditions of NHF Card and JADEP beneficiaries 40 Table 14. NHF and JADEP Card usage among enrollees by gender (%) 41 Table 15. Individual health service utilization before and after the NHF Program among NCD population 47 Table 16. Economic burden of four major NCDs (2008 Constant JMD) 51 Table 17. Estimated NCD prevalence by socio-demographic category 51 FIGURES Figure 1. The transition of risks 13 Figure 2. Conceptual framework for analyzing determinants of NCDs 16 Figure 3. Life expectancy at birth in Jamaica compared to sample countries from different regions, 2002 20 Figure 4. Observed and adjusted time trend of NCD prevalence among Jamaican adult population 22 Figure 5. Adjusted time trend of NCD prevalence by gender among Jamaica adult population 23 Figure 6. Adjusted NCD prevalence rates by gender over time 23 Figure 7. Age profile of NCDs in Jamaica 2008 24 Figure 8. Obesity prevalence in the Caribbean region (%) 26 Figure 9. Changes (%) in nutritional status of Jamaicans 15–74 years during 2000–2008 26 Figure 10. Distribution of school feeding program in Jamaica (% school reporting program enrollment) 29 Figure 11. Changes (%) in Physical Activity Levels of Jamaicans 15–74 years 2000–2008 29 Figure 12. Frequency of physical activity of 17–29 age group, 2001 30 Figure 13. Smoking behavior by age group, 2008 31 Figure 14. Tobacco use among 13–15 age group, 2001 and 2006 31 Figure 15. Percentage of first time user in Jamaica 31 Figure 16. Observed and adjusted per-capita annual household tobacco expenditures (2008 JMD) 32 Figure 17. Adjusted per-capita expenditure on tobacco by household economic quintiles (2008 JMD) 32 Figure 18. Profile of tobacco users in Jamaica 33 Figure 19. Percent of Jamaicans aged 15-74 with drinking behavior 33 Figure 20. Prevalence of alcohol use by age groups, 2001 33 Figure 21. Observed and adjusted households annual per-capita expenditures on alcohol (2008, JMD) 34 Figure 22. Adjusted annual per-capita expenditure on alcohol by household quintile (2008 JMD) 34 Figure 23. (a) Rates of approval and disbursement of institutional benefit projects, 2004–2008 and (b) Number of institutional benefits projects approved, 2004–2008 36 Figure 24. NHF approval by project type for the period 2004–2008 37 Figure 25. NHF Card subsidy rates 38 Figure 26. NHF Card Enrollment by Cases 38 Figure 27. NHF individual benefits between 2003 and 2009 – number of claims paid by NHF Card and JADEP 38 Figure 28. NHF sources of revenue 39 Figure 29. NHF income allocation in 2008 (%) 39 Figure 30. NHF Card and JADEP enrollment between 2003 and 2010 40 Figure 31. Adjusted annual per-capita drug expenditure for household with chronic disease patient and household with non-chronic disease patient (2008 JMD) 45 Figure 32. Adjusted annual per-capita medical expenditure for household with and without chronic disease patient (in 2008 JMD) 45 Figure 33. Individual annual medical expenditures before and after NHF Program among NCD population (in 1000 2008 constant JMD) 45 Figure 34. Probability of NHF and JADEP enrollment among eligible population by expenditure quintiles 46 Figure 35. Adjusted health service visits (%) for individuals with and without NCDs 46 Figure 36. Average individual annual economic burden of NCDs in Jamaica 2006 and 2007 (2008 constant Jamaica Dollars) 49 Figure 37.Individual annual direct healthcare cost spent in public and private health facilities attributable to NCD (2008 JMD) 50 Figure 38. Individual annual direct healthcare cost attributable to NCD by insurance coverage (2008 JMD) 50 Figure 39. Estimated national aggregate economic burden of NCDs by socioeconomic group (2008 JMD in millions) 52 Figure 40. Estimated national economic burden by five major NCD conditions, (2008 Jamaica constant dollars, in millions) 52 8 ACKNOWLEDGEMENTS This report was prepared by a team led by Shiyan Chao (Task Team Leader) including Yuyan Shi, Carmen Carpio, Willy De Geyndt, and Zukhra Shaabdullaeva. The team benefited from the input, comments, and valuable guidance of officials from the Ministry of Health, the National Health Fund, and the Planning Institute of Jamaica, and researchers from the University of the West Indies (UWI). Special thanks are due to Professor Wilks and his team from the UWI for sharing findings from previous analyses undertaken by the team and for providing useful comments on the draft report. The team is grateful to Mr. Hugh W. Lawson and his team from the National Health Fund for their support. The team would also like to thank Dr. Eva Lewis-Fuller, Dr. Kevin Harvey, Dr. Sonia Copeland, and Dr. Tamu Davidson from the Ministry of Health, Professor Figueroa from UWI, and Dr. Pauline Knight and Ms. Barbara Scott from Planning Institute of Jamaica for their guidance and support. The team is grateful for the guidance from Sir George A.O. Alleyne, Director Emeritus, and Dr. James Hospedales, Director for Non- communicable diseases from the Pan American Health Organization. Peer reviewers for the report were Montserrat Meiro-Lorenzo (Senior Health Specialist, HDNHE), Patricio V. Marquez (Lead Health Specialist, ECSH1), and Ethan Yeh (Economist, ECSH1). Sylvia Robles, Ethan Yeh, Owen Smith, Olusoji Adeyi, and Michael Engelgau provided input and comments at the concept note stage. Additional comments were received from Margaret Grosh, Afef Haddad, and María Eugenia Bonilla Chacín. Critical review and comments were received at various stages of the preparation of this report. The team is particularly thankful to Françoise Clottes (Country Director, LCC3C), Yvonne Tsikata (Former Country Director, LCC3C), Keith Hansen (Sector Director, LCSHD), Joana Godinho (Sector Manager, LCSHH), and David Warren (Sector Leader, LCSHD). 9 EXECUTIVE morbidity, accounting for the largest number of hospital discharges. This rapidly increasing trend exhibits vast disparities among SUMMARY socioeconomic subgroups, especially between males and females, as the prevalence of NCDs among females has increased faster than among males. Most prevalent NCDs are hypertension, diabetes The countries of the Caribbean region have experienced a rapid and asthma. Patterns of a specific disease vary considerably and complex epidemiological transition in the past decades. Chronic by socioeconomic subgroups, with females, seniors, and rural diseases are the leading causes of death throughout the Americas, residents at higher risk. but the epidemic has hit the Caribbean region particularly hard. Recognizing the threat of Non-Communicable Diseases (NCDs), Unhealthy diet, physical inactivity, smoking, and harmful heads of government of the Caribbean Community and Common alcohol consumption are major risk factors. Obesity, mainly the Market (CARICOM) convened a Regional Summit, “Stemming the result of unhealthy diet and lack of physical activity, is the most Tide of Non-Communicable Diseases�, on September 15, 2007, prevalent NCD, particularly among adult women. Women are far which called for comprehensive and integrated prevention and less physically active than men in all age groups. Globalization and control strategies aimed at containing the emerging epidemic of urbanization have contributed to unhealthy eating behavior such NCDs. as eating out, eating more staple foods and fewer vegetables and fruits, and consuming sugar-saturated soft drinks and fast food. Jamaica is a Caribbean country that has initiated comprehensive The proportion of physically inactive adults has doubled over the programs to address NCDs. The government created the National last decade. The prevalence of smoking is relatively high in all Health Fund (NHF) to reduce the cost of treatment of NCDs and age groups but more so among men and the poorer population. finance some prevention programs. Household tobacco expenditure has shown a steady increase from 2000 to 2008. Economically better-off households spend more on The main objective of this study is to learn from Jamaica’s tobacco but both poor and rich households alike show a growing experience in tackling major NCDs and related risk factors, to trend in tobacco use between 2000 and 2008. This trend is partly provide policy options for Jamaica to improve its NCD programs due to smokers forming their smoking habit at a very young age and to share with other countries the lessons learned from its with easy access to local tobacco products. Finally, excessive alcohol experience. consumption is alarming, with males consuming more alcohol than females. Poor regulations and generally relaxed societal The study attempts to answer three questions: (i) whether the attitudes reinforce this trend. NHF and its drug subsidy program have reduced out-of-pocket spending on NCDs; (ii) whether access to treatment of NCDs has Reducing the burden of NCDs in Jamaica is a national policy. improved; and (iii) what the economic burden on NCD patients and The government of Jamaica has recognized the importance of their families is. preventing and controlling NCDs and created the NHF to reduce the cost of treatment of NCDs by providing free or subsidized The report presents an overall picture of the epidemiological medicines to patients with NCD conditions. The NHF also financed and demographic transitions in Jamaica, its current burden of various prevention programs to promote healthy lifestyles and to NCDs, and the change in the trend of NCDs in the past decade, reduce exposure to the risk factors that lead to NCDs. using publicly available data, particularly data from the Jamaica Living Condition Household Surveys. It assesses the risk factors The government’s policy and program on NCDs has shown and analyzes Jamaica’s response to NCDs with emphasis on the positive results and access to treatment has improved. Coverage of impact of the National Health Fund on people’s lives. Estimates of these programs is, however, still limited and uneven and the NHF the economic burden of NCDs are provided and policy options to has not effectively reached the poor. More people are seeking care improve Jamaica’s NCD programs are suggested. by visiting the provider of their choice, more are spending less on pharmaceuticals but more on doctor’s fees and laboratory tests, and more are using private sector facilities. Coverage of NHF and Main Findings JADEP (Jamaica Drug for the Elderly Program) cards remain limited NCDs impose an increasing burden on the population’s health and uneven, however, despite broad awareness among Jamaicans. in Jamaica. Jamaica is undergoing a demographic transition and The NHF has made some NCD drugs more affordable but the an epidemiological transition similar to that of nearly all other distribution of NHF benefits is unequal among socioeconomic countries in the Caribbean region. Its population is aging and groups. The economically better-off population group appears to will continue to do so because of declines in the rates of fertility benefit more from the government subsidy of pharmaceuticals and mortality. Jamaica is carrying a double burden of both and is more likely to enroll in the NHF program. The richest 20 communicable diseases and NCDs. percent of the population with NCDs were estimated to spend sevenfold more than the poorest 20 percent, suggesting the need NCDs have spread progressively among the entire population for the program to more effectively target the poor and extend their in the last decade and are the leading cause of mortality and enrollment in it. 10 The NHF drug subsidy program has achieved its primary goal NCD strategy will require more funds. The NHF is a well- of making NCD drugs more affordable. This study assesses the organized entity. It may be possible to finance the NHF out of initial impact of the NHF drug subsidy program in reducing out- general taxation or by linking its financing to payroll taxes. of-pocket spending on healthcare by NCD patients and in utilizing These measures would make the fund more sustainable healthcare, comparing NCD patients with non-NCD patients. The to be able to meet the increasing needs for prevention and results from the analysis of the Household Surveys before and after treatment. Other methods for mobilizing resources could be the establishment of the NHF indicate that NCD patients under the through expanding public-private partnerships. NHF paid less out of pocket for their pharmaceuticals than NCD patients without NHF cover. • Improve efficiency of the NHF by: (1) assessing the prevention programs financed by the NHF and their NCDs have resulted in a large direct and indirect economic effectiveness; (2) striking the appropriate balance between burden for individuals in Jamaica. An average individual suffering prevention and drug subsidy programs; and (3) improving from an NCD spends approximately one-third of household targeting of the poor under the drug subsidy programs. income (JM$ 55,503) on healthcare services and pharmaceutical Activities could focus on geographic areas where poverty, purchases. Direct healthcare costs associated with NCDs are disease, and violence are concentrated and areas where regressive and impose a greater burden on poor households than the poor population would benefit from NHF coverage. better-off households. • Reduce the risk factors through policy interventions. Legislation and regulations are needed to control tobacco Priorities to Strengthen the National and alcohol production and use, and to reduce trans-fat Response to NCDs and salt intake by working with manufacturers and the food production industry to provide a healthy food supply. The preliminary analysis of Jamaica’s NCD policy and programs indicates that the drug subsidy program supported by the NHF has • Improve the surveillance system to monitor the risk helped NCD patients reduce their spending on treatment. There is factors and NCDs. The dearth of reliable registration little evidence indicating that the trend of NCDs is declining, and and reporting of cause-specific mortality and morbidity much more needs to be done to stop and reverse the increasing makes targeting difficult. Improved information on risk trend. The impact of prevention programs supported by the NHF factors is a necessary first step in order to feed data into has been limited. Treating patients by prescribing drugs at a lower the NCD policy dialogue. Health information systems need cost to the patient is a worthwhile objective but preventing the to be developed to collect and report data on risk factors, disease from occurring is more cost effective. mortality, morbidity, and the determinants of NCDs. Jamaica may consider the following policy options and interventions for • Evaluate the effectiveness of policies, strategies, and enhancing its NCD prevention and control programs: interventions. There is a need to refine target groups and accelerate, adjust, or change interventions as a necessary • Build a comprehensive National Strategy on NCDs. The process of learning from results on the ground. determinants of NCDs are based on behaviors and social conditions that require a comprehensive, multilevel, • Policies should target prevention actions at primary, and multisector strategy. Reversing the NCD epidemic secondary, and tertiary levels. Primary prevention aims in Jamaica requires a National Strategy that combines to prevent exposure to the risk factors that cause NCDs. the three levels of prevention. The focus so far has These may include policies on anti-smoking, encouraging been more on clinical interventions by prescribing and physical activity, promoting a healthy diet, and reducing subsidizing medications and less on population-based harmful use of alcohol. Secondary prevention strategies primary prevention. The National Strategy will need to attempt to diagnose and treat an existing disease in its put population-based prevention at center stage and define early stages before it results in significant morbidity. achievable and measureable goals with specified time Policy options to be considered at the secondary level of frames. care include adopting new care models such as Disease Management Programs and integrated care models, • Expand the financing sources for implementing the NCD strengthening the surveillance on NCDs, and using strategy and improve the financial sustainability of the information and communications technology such as NHF. The costs to the healthcare system from NCDs are electronic patient records and clinical decision support high and are likely to increase. Government budgets and the systems. Tertiary prevention aims to reduce the negative NHF are the primary sources of financing NCD prevention impact of an established disease by restoring function and treatment. Increasing financing for NCD prevention and reducing disease-related complications. Activities and treatment is a fiscal challenge due to the impact of the at this level should focus on avoiding complications and global financial crisis. Implementing a more comprehensive preventing the progress of the disease. 11 • Address the gender dimension when targeting. Women and men are exposed to risk factors to a different degree. Men are more likely to use tobacco and consume alcohol in excess, while women are more likely to be obese and physically inactive. Health promotion programs need to target gender-specific risk factors using tested methodologies. • Reorient the health services delivery system of physical, human, and financial resources to adopt new care models. Learn from other countries how they are using Disease Management Programs and integrated care models that hold promise for more effective approaches towards improving health outcomes of NCD patients, as well as potentially containing costs and increasing patient satisfaction. • Adopt a multisector approach for NCD prevention and control by involving non-health ministries, civil society organizations, and the private sector. Jamaica has a wealth of experience in controlling the HIV/AIDS epidemic and this knowledge can be applied in NCD prevention and control. Civil society organizations and the private sector can play critical roles in preventing unhealthy diets, encouraging physical activities, and discouraging tobacco use and excessive use of alcohol. The business communities can contribute to both financing and implementing NCD prevention. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 12 INTRODUCTION Jamaica1 was selected as a typical country in the Caribbean for the purpose of preparing the NCD Study in the Caribbean Region. Like most Caribbean countries, Jamaica is transitioning This Introduction sets out the objectives and structure of this demographically and epidemiologically from the earlier Report. communicable disease phase to what is now a predominantly NCD phase. Nevertheless, it still has to cope with two chronic communicable diseases: HIV/AIDS and tuberculosis. Jamaica Objectives of the Report was selected for this case study because Jamaica has created This report aims to extend the World Bank’s existing knowledge mechanisms, notably the National Health Fund, 2003, (NHF) to base on NCDs by analyzing how NCDs are impacting Caribbean assist individuals to purchase prescription drugs for managing countries. The report is part of the multi-year Non Lending and treating chronic illnesses and has since 2003 subscribed to Technical Assistance (NLTA) program, which began in the 2009 the United Nations Framework Convention on Tobacco Control. fiscal year and is continuing through the 2011 fiscal year. The Jamaica has a rich database from the last twenty years – the Jamaica NLTA and this report in particular aim to provide knowledge Survey of Living Conditions (JSLC) – that provides an opportunity and evidence for designing policies and interventions to prevent to assess level of access and cost of care for NCDs before and after and control NCDs. This study focuses on Jamaica’s experience establishment of the NHF. Lessons can be learned from Jamaica’s in addressing major NCDs and their related risk factors with the experience that may be useful to other Caribbean islands as well as objective of learning from Jamaica and providing policy options to middle-income countries in other regions. to Jamaica to improve its programs. This forms part of the overall objective of the NLTA program to support Caribbean countries in Structure of the Report addressing the growing threat posed by the major NCDs by: This report is structured in nine chapters. Chapter 1 briefly • increasing the understanding of current strategies and reviews the global burden of NCDs. Chapter 2 lays the groundwork programs for NCD prevention and control in the region, for a detailed analysis of NCDs in Jamaica. It introduces the including an assessment of their adequacy and likely conceptual framework for this study and reviews the demographic impacts; and epidemiological transitions that have occurred in the past decades. Chapter 3 presents the current burden of disease in the • identifying good practices for addressing NCD risk factors; context of past trends of NCDs. Major risk factors contributing to NCDs in Jamaica are analyzed in Chapter 4. Chapter 5 presents • providing policy recommendations to improve prevention Jamaica’s response to NCDs with a focus on the role of the NHF and and treatment programs; and the Healthy Lifestyles Prevention Program. Chapter 6 assesses how NCDs affect people’s lives and evaluates the impact of the NHF on • advising on improvements in financing mechanisms to their lives. Chapter 7 examines the economic implications of NCDs. cope with the rising costs due to NCDs. Chapter 8 draws upon the experience of other countries to combat NCDs and, finally, Chapter 9 suggests policy options that would The World Bank’s interest in recent years in improving this further strengthen Jamaica’s National NCD Strategy and Programs. knowledge base results from the impact that NCDs are having on the health, population, and economies of developing countries. The Bank recognizes the economic and social urgency for preventing and controlling NCDs globally and has accumulated knowledge and experience to support countries in understanding the risk factors contributing to NCDs and in taking action to address them. This report adds knowledge from the Caribbean region on NCDs to various reports already compiled, including the seminal World Bank report published in 2007 entitled “Public Policy and the challenge of non-communicable diseases� (Adeyi, Smith and Robles 2007); an early analysis of Chile (The World Bank 1995); and studies on NCDs in Brazil (Danel, Kurowski and Saxenian 2005), the Russian Federation (The World Bank 2005), the MENA region (The World Bank 2010), and the South Asia region (The World Bank 2010); as well as a survey in 25 countries in Latin America and the Caribbean that made policy recommendations for further regional action (Godinho 2006). 1 Jamaica is an island nation established as an independent state in 1962 within the Commonwealth of Nations. With 2.8 million people, it is the third most pop- ulous Anglophone country in the Americas, after the United States and Canada. THE GLOBAL AND REGIONAL BURDEN OF NON-COMMUNICABLE DISEASES 13 1. THE GLOBAL use, and overweight and obesity. Table 1 shows the ten leading risk factors that cause death in middle-income countries. AND REGIONAL TABLE 1. TEN LEADING RISK FACTORS BURDEN OF NON- CONTRIBUTING TO DEATH IN MIDDLE INCOME COUNTRIES, 2004 COMMUNICABLE RISK FACTOR DEATHS % OF DISEASES (MIL- TOTAL LIONS) 1. High Blood Pressure 4.2 17.2 2. Tobacco Use 2.6 10.8 This chapter sets out the burden of NCDs 3. Overweight And Obesity 1.6 6.7 both worldwide and on the Caribbean 4. Physical Inactivity 1.6 6.6 region and describes a regional approach 5. Alcohol Use 1.6 6.4 for dealing with NCDs. 6. High Blood Glucose 1.5 6.3 7. High Cholesterol 1.3 5.2 8. Low Fruit and Vegetable Intake 0.9 3.9 NCDs are the leading cause of morbidity and mortality 9. Indoor Smoke From Solid Fuels 0.7 2.8 worldwide. The top causes of death in the world include coronary 10. Urban Outdoor Air Pollution 0.7 2.8 heart disease, stroke and other cerebrovascular diseases, cancer, and chronic obstructive pulmonary disease. NCDs affect human capital, Source: Global Health Risks (World Health Organization 2009) cause direct losses to productivity, and increase healthcare costs. Urbanization, changing lifestyles, globalization, and living longer NCDs have a negative economic impact on individuals and increase the demand on health services, increase the resources society. The costs of NCDs include both the direct costs for individual allocated to prevent and treat NCDs and place a hefty burden on health expenditure as well as the indirect costs derived from loss of health systems. Figure 1 shows the decrease in traditional risks and earnings and the economic burden on families, communities, and the vast increase in modern risks.2 private and public healthcare systems. NCDs are responsible for a growing portion of health spending and, as the increasing trend FIGURE 1. THE TRANSITION2 OF RISKS of their prevalence continues, it will become progressively more difficult to sustain current healthcare systems (Alleyne 2007). A Traditional Risks 2005 World Bank study on NCDs in Brazil estimated that economic costs over the 2005–2010 period would equal approximately Tobacco 10 percent of GDP (International Diabetes Federation n.d.); Risk productivity losses are estimated at US$71.5 billion, and treatment Size Physical Inactivity costs at US$34 billion. These account for 50 percent of hospital Overweight costs and 70 percent of national health service costs. Urban Air Quality Road Traffic Satefy Occupational Risks THE BURDEN OF NCDS IN THE CARIBBEAN REGION Undernutrition, Indoor Pollution, Water, Sanitation Modern Risks and Hygiene The burden of NCDs has escalated in the Caribbean region with five times as many people dying from NCDs as from all other Time illnesses combined. Ten times more people are dying from NCDs than from HIV/AIDS. NCDs represent not only the major causes of death, but are responsible for the greatest share of the burden Source: (World Health Organization 2009) of disease in the Caribbean region (65 percent) (PAHO/CARICOM 2006). The four leading causes of death in the Caribbean in 2000 NCDs are also among the leading risk factors contributing to were all NCDs – heart disease, cancer, stroke, and diabetes. These mortality in middle-income countries. Risk factors associated with four conditions accounted for 47 percent of deaths in 1980 and 51 NCDs are well known and have been studied extensively. The most percent in 2000 (PAHO/CARICOM 2006). In 2004, cardiovascular notable ones on a global scale include high blood pressure, tobacco disease alone was responsible for 35 percent of all deaths and 68 percent of the total disease burden in Latin America and the 2 Over time, major risks to health shift from traditional risks (e.g. inadequate Caribbean region (Glassman, et al. 2010). Partly as a result of the nutrition or unsafe water and sanitation) to modern risks (e.g. overweight and obesity). Modern risks may take different trajectories in different countries, de- demographic and epidemiological transitions, NCDs have shown an pending on the risk and the context. upward trend in being the most common cause of death from 1985 NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 14 to 2000 (Ivey, et al. 2008). The major NCDs in the Caribbean share common underlying risk factors, such as unhealthy eating habits, lack of physical activity, obesity, excessive tobacco and alcohol use, and inadequate utilization of preventive health services. A SUPPORTING AND ENABLING ENVIRONMENT TO ADDRESS NCDS IN THE CARIBBEAN The governments across the Caribbean region have acknowledged the threat of NCDs. On September 15, 2007, the heads of government of the CARICOM Community subscribed to the Port-of-Spain Declaration titled “Uniting to Stop the Epidemic of Chronic NCDs�, which outlined 15 actionable points to stem the tide of NCDs in the Caribbean. This commitment at the highest levels is supported by a base of technical and human resources directly targeting NCD issues and serving as regional focal points. A Regional Strategic Plan on NCD Prevention Control for the Caribbean Community 2011–2015 has been developed, after a comprehensive consultation process, and examines components crucial to curtailing the epidemic of NCDs in the Caribbean. These include risk factor reduction, health promotion, surveillance, disease management, public policy, advocacy, communications, patient education, and program management. The Plan helps to guide regional and country-level responses to NCDs. These factors, along with the strong interest from international organizations in supporting the region in its response to NCDs, provide an enabling environment to support efforts to respond effectively to NCDs in the region. Having considered the global and regional situation, the next chapter will consider the effect of the demographic and epidemiological transitions in Jamaica as a basis for future chapters which deal with the burden placed on the country by NCDs THE EFFECT OF DEMOGRAPHIC AND EPIDEMIOLOGICAL TRANSITIONS ON NCDS IN JAMAICA 15 2. THE EFFECT OF Key Findings DEMOGRAPHIC AND 1. Jamaica faces a double burden of disease: the EPIDEMIOLOGICAL continued challenge of communicable diseases coupled with the emergence and preponderance of TRANSITIONS ON NCDs. Communicable diseases were the greatest contributor to Jamaica’s burden of disease in the NCDS IN JAMAICA 1960s and 1970s but were surpassed by NCDs in the 1980s and 1990s. NCDs are currently the leading causes not only of mortality but also of morbidity, and their prevalence increased in the last decade. This chapter deals directly with the situation of NCDs in Jamaica, setting out 2. Women in Jamaica are having fewer children than in previous generations. Jamaica’s total fertility rate the conceptual framework to be used for has reduced from nearly 6 children per woman in the analyzing NCDs in the country, and gives 1960s to 2.4 in 2008. details of Jamaica’s demographic and 3. Jamaicans are living longer lives with life expectancy epidemiological transitions. doubling and death rates declining. Life Expectancy at Birth was an average of 38 years in the 1900s, which has almost doubled to 74.1 years in 2008. 4. Jamaica’s population is aging as reflected in the changing age structure of the population, with a declining 0–14 age group, an increasing working age population (15–64), and a growing dependent elderly age group (65+). 5. With Jamaicans living longer and death rates declining, this longer-living population will have greater lifetime exposure to NCD risk factors. 6. Jamaica has advanced significantly in its epidemiological transition with 63 percent of the burden of disease (measured by Disability Adjusted Life Year) due to NCDs and 13 percent due to injuries. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 16 CONCEPTUAL FRAMEWORK FOR ANALYZING NCDS include socioeconomic and demographic factors while secondary IN JAMAICA determinants encompass biological and lifestyle factors (Kosteniuk and Dickinson 2003). Sassi and Hurst, in their Economic Low- and middle-income countries struggle to adapt their Framework for the Prevention of Lifestyle-related Chronic Diseases, healthcare systems to address the now-predominant burden of emphasize the importance of interactions between individual NCDs. Vertical disease programs have been successful in controlling factors and specific socioeconomic environmental influences; the and even eliminating some communicable diseases but are not framework they developed focuses on preventing lifestyle-related necessarily effective in tackling NCD conditions. Lessons learned NCDs (Sassi and Hurst 2008). The various conceptual frameworks from some high- and middle-income countries show that the developed by researchers provide relevant structures and elements strategy for NCD control has to be comprehensive, multilevel, and for analyzing the determinants of NCDs. multisectoral. FIGURE 2. CONCEPTUAL FRAMEWORK FOR Understanding of disease prevention and control has evolved ANALYZING DETERMINANTS OF NCDS from being a narrowly defined medical responsibility to one that is a more complex social phenomenon. First, the determinants of HEALTH OUTCOMES  NCDs lie in behaviors and social conditions, rather than being the  result of single biological causes. Second, these chronic conditions are not once-off or episodic events; they build up over long periods UNDERLYING DETERMINANTS INDIVIDUAL DETERMINANTS of time leading to disease progression that is accelerated with Epidemiological Context Health Profile aging or cumulative exposure to health risks. Third, people who • Pattern of diseases • (Biological) • Prevalence rates acquire multiple risk factors and diseases need lifelong disease  Personal health practice management. Fourth, the complexity of managing and preventing Socioeconomic and Political • (Behavioral) Environment these diseases requires interventions at multiple levels from multiple • Family/Community Exposure to risk factors • Cultural Values and Norms • Living and working conditions actors, ranging from behavior changes to tertiary medical care. An • Use of services effective response to NCDs requires the involvement of the entire Structural Factors • Educational attainment • Health Systems Financing healthcare system. • Access A conceptual framework has been used to help identify the major determinants of NCDs, clarify the relationships among different determinants, and examine the scope and limitation of This study adopts a framework that groups the factors that policy interventions. This approach enables further assessment influence health and the burden of disease into “underlying� of relationships, identification of gaps, and understanding of the and “individual� sets of determinants. Underlying determinants impact on final outcomes. In such a framework, those aspects of affect the health of the population at the macro level while the health system and social environment that can influence the individual determinants affect individual health at the micro overall health status of the population are illustrated in Figure 2. level. This distinction highlights the role that individuals can Here, both health policy and health profile can be seen to directly play in the prevention and control of NCDs while identifying the affect the use of health services, which in turn influences health socioeconomic environment that influences individual behavior outcomes for individuals. The organization of primary care settings and which can be changed by policy interventions. The aim of determines the responsiveness of countries to their health situation, this framework is not to capture the comprehensive relationships yet this relationship can be modified by the social environment, between the determinants of NCDs nor to test these relationships, represented here by characteristics of the patients and personal but rather to raise awareness of them for a better understanding of health practices. It may not be possible to delimit with absolute the pathways that lead to NCDs. certainty the health system from the social environment, but it is possible to identify determinants of both systems. In applying this framework to the Jamaica case, this study identifies three elements that are emphasized in the National The conceptual framework for this case study builds upon Strategy for addressing NCDs. These are: (a) strengthening a previous analyses of diseases and pathways through which public network of health services to increase access to care; (b) social and environmental conditions as well as individual factors establishing a drug subsidy program to facilitate treatment of influence health outcomes. A vast amount of literature has been chronic conditions; and (c) conducting health promotion programs developed in recent years on the determinants of health (Evans, to influence personal health practice and prevent disease as well et al. 2001), (Lurie and McLaughlin 2003), (Solar and Irwin as progression of disease. This study attempts to provide a better 2007). The role of individual and social determinants and the understanding of whether these policies have increased the use of interactions between them have been identified. The impact of health services and ultimately affected health outcomes. different determinants has been further distinguished by the role of structural and intermediary determinants (Solar and Irwin 2007) and primary and secondary determinants. Primary determinants THE EFFECT OF DEMOGRAPHIC AND EPIDEMIOLOGICAL TRANSITIONS ON NCDS IN JAMAICA 17 The study is also guided by the PAHO/WHO framework on annual population growth rate has remained consistently below Essential Public Health Functions “to improve, promote, protect, and 1.0 percent since 1998. The gender composition has remained restore the health of the population through collective action.� PAHO/ unchanged since 2004 but the male/female ratio starts decreasing WHO defined the following eleven Essential Public Health Functions: after the 0–14 age group. 1. Monitoring, evaluation, and analysis of health status Women in Jamaica are having fewer children than in previous 2. Surveillance, research, and control of the risks and threats generations. Jamaica’s total fertility rate was reported to be 2.4 in to public health 2008, similar to the rate for the whole Caribbean region. 3. Health promotion 4. Social participation in health Jamaicans are living longer lives. Contributing to the 5. Development of policies and institutional capacity for epidemiological transition is a reduction in mortality and illness public health planning and management from infectious diseases that has increased life expectancy at birth 6. Strengthening of public health regulation and enforcement from 38 years in 1900 to 74.1 years in 2008. The crude death capacity rate was 35.7 per 1,000 population and the infant mortality was 7. Evaluation and promotion of equitable access to necessary 174.3 per 1,000 live births in the 1900s (Figueroa, 2001). The health services rates declined to 6.3 deaths per 1,000 population and to 21.3 8. Human resources development and training in public infant deaths per 1,000 live births in 2008 respectively (Ministry of health Health Jamaica 2009). The net effect of increasing life expectancy 9. Quality assurance in personal and population-based health and falling crude death rates and infant mortality rate is a longer- service living population affected by an increased mortality and morbidity 10. Research in public health burden due to NCDs. 11. Reduction of the impact of emergencies and disasters on health The age dependency ratio has continued to decline as reflected in a ratio of 73 dependent persons per 100 persons of working age Finally, the study reviews policy options under two levels of in 1997, compared with 66 per 100 in 2007. prevention: The demographic transition has important health • Primary prevention is directed at the prevention of consequences. A longe- living population will have greater lifetime illnesses by removing their causes. The target group for exposure to risk factors such as tobacco, alcohol, and fatty foods, primary prevention is people who are healthy with respect which contribute to heart disease, stroke, and various forms of to the target disease. Population-based interventions cancer. In addition, a lifestyle of limited exercise may contribute cover the whole population and aim to prevent the adverse to deteriorating health in later years through osteoporosis, muscle health event from occurring in the first place. These thinning, and inadequate cardiac condition (Butler 1997). programs promote lifestyle changes to reduce obesity, smoking, and excessive alcohol consumption, promote THE EPIDEMIOLOGICAL TRANSITION IN JAMAICA3 physical activity, and reduce other related risk factors that contribute to NCDs. Jamaica faces a double burden of disease: the continued • Secondary prevention aims at identifying the disease at challenge of communicable diseases coupled with the emergence an early stage so that it can be treated. This enables cure, and preponderance of NCDs. Communicable diseases were the or prevents further deterioration. The target group for greatest contributor to Jamaica’s burden of disease in the 1960s secondary prevention consists of people who are already and 1970s but were surpassed by chronic diseases in the 1980s and ill without being aware of it or those who are at increased 1990s. Epidemiological transitions occur through urbanization risk or who have a genetic predisposition. Individual and lifestyles changes as living standards improve, education clinical interventions for high-risk patients with several levels rise, access to health services increases, and morbidity and risk factors present include medical attention, treatment, mortality patterns change with people living longer lives. and follow-up in order to prevent an existing condition from deteriorating into an incapacitating or fatal result. Changing lifestyles contribute to high rates of NCDs. More than 50 percent of Jamaicans can be categorized as overweight THE DEMOGRAPHIC TRANSITION IN JAMAICA and obese with higher rates among women. In addition, using waist circumference measurements, women are at higher risk of Jamaica’s population is aging as reflected in the changing age cardiovascular disease than men; 70 percent of women have an structure of the population. Three trends characterize Jamaica’s increased waist circumference compared to 20 percent of males population structure: a declining 0–14 age group, an increasing (Wilks, et al. 2008). Policies and programs focusing on NCDs need working age group (15–64), and a growing 60+ age group 3 The primary data sources for the analysis of the epidemiological transition and that is now the fastest-growing segment of the population. The of the morbidity and mortality caused by NCDs are from the Ministry of Health, population was estimated at 2,692,400 at the end of 2008 and the WHO, and peer-reviewed journals. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 18 to understand lifestyle and behavior choices in order to address the Four out of the five leading causes of death in Jamaica conditions leading to these high rates. are NCDs: namely cerebrovascular disease, diabetes mellitus, ischemic heart disease, and hypertensive heart disease (Table 3). Women from poorer segments of the population are more likely The PAHO Country Health Profile (PAHO 2001) indicates that in to be at risk of NCDs. More women with low incomes are uninsured 1999 diabetes accounted for one of every nine deaths, and the or underinsured, and cannot afford preventive screenings for rate of diabetes among women increased from 51.8 per 100,000 high blood pressure, high cholesterol, or diabetes, which limits population in 1990 to 59.9 in 1999. Breast and cervical cancers early detection of cardiovascular and other NCDs. Hypertension, were the leading causes of cancer mortality in the 20–59 age diabetes, and hypercholesterolemia are reported more frequently group. The leading cause of hospital deaths for the elderly in 1999 for adult women than for men at prevalence rates of 29.3 versus was cardiovascular disease, followed by diseases of the respiratory 10.7 for hypertension, 9.1 versus 6.1 for diabetes, and 4.9 versus system. The main NCDs and risk factors affecting the elderly were 2.6 for high cholesterol for women and men respectively in Jamaica hypertension, arthritis, overweight, and diabetes. (Wilks, et al. 2008). TABLE 3. TOP TEN CAUSES OF DEATH, ALL NCDs are now the leading causes of mortality and morbidity. AGES, JAMAICA, 2002 Within the Caribbean, the burden of NCDs is particularly acute in CAUSES DEATHS YEARS OF LIFE Jamaica, where NCDs accounted for 60 percent of the burden of (%) LOST (%) disease in 2002 when the country reported its four leading causes of death to be NCDs. Prevalence of diabetes in Jamaica is 11 percent. All causes 100 100 This surpasses the Caribbean regional prevalence rate, which Cerebrovascular disease 18 11 ranges from 6 to 8.5 percent, already higher than world estimates Diabetes mellitus 11 8 of 6.8 percent (International Diabetes Federation n.d.). On a global Ischemic heart disease 10 6 scale, Jamaica ranked 59th in the percentage of Years of Life Lost due to NCDs and ranked fourth in the Caribbean, together with Hypertensive heart disease 6 4 Grenada, at 66 percent of years of life lost, after Cuba, Antigua and Lower respiratory infections 4 4 Barbuda, and Dominica (Table 2). HIV/AIDS 4 9 Stomach cancer 3 2 TABLE 2. YEARS OF LIFE LOST TO NCDS (%), 2002 RISK COUNTRY GLOBAL RANKING % OF YEARS OF Nephritis and nephrosis 3 3 (OUT OF 195 LIFE LOST (PER COUNTRIES) 100,000 POP.) Perinatal conditions 2 8 Cuba 43 73 Breast cancer 2 3 Antigua and 50 69 Source: (World Health Organization 2002) Barbuda Dominica 53 68 NCDs account for the highest number of hospital discharges. In Grenada 58 66 2007, the highest number of hospital discharges (including deaths) were patients with circulatory diseases, malignant neoplasms, Jamaica 59 66 endocrine and nutritional diseases, respiratory diseases, injuries Barbados 60 65 and accidents, and infectious and parasitic intestinal diseases. Of St. Lucia 69 63 these six, the top four diseases share nutrition and lifestyle behavior St. Kitts and Nevis 71 62 as underlying determinants. Diseases of the respiratory tract, including upper and lower respiratory tract infections and asthma, St. Vincent and the 78 60 were the leading cause for out-patient visits. Grenadines Trinidad and 102 50 Of the burden of disease as measured by Disability Adjusted Tobago Life Years (DALYs), 63 percent is due to NCDs and 13 percent to Bahamas 106 45 injuries. Table 4 highlights the percentage of DALYs caused by Suriname 108 45 NCDs in Jamaica, roughly threefold that caused by communicable Belize 118 41 diseases. Table 5 provides further details on the NCDs most affecting the Jamaican population by displaying a list of the top ten specific Dominican 129 33 causes of DALYs. Republic Guyana 131 30 Haiti 153 15 Source: WHO Data at http://data.un.org THE EFFECT OF DEMOGRAPHIC AND EPIDEMIOLOGICAL TRANSITIONS ON NCDS IN JAMAICA 19 TABLE 4. ESTIMATED DALYS PER 100,000 Overall, the health of Jamaicans as measured by Healthy Life POPULATION, 2004 Expectancy (HALE)4 is below that of developed countries. Jamaica’s DALYs % HALE places it below developed countries such as Canada and ALL CAUSES the United Kingdom, as well as its regional neighbors Barbados 16,314 100 and Mexico. Nevertheless, it scores above various countries from Communicable, maternal, perinatal 3,893 24 different regions, including some countries from the Caribbean and nutritional conditions (based on the WHO 2002 HALE data for all member states). As Infectious and parasitic diseases 2,001 12 with all other countries, HALE data for Jamaica reveal consistently Respiratory infections 395 2 higher data for females (65.9) than males (64.2). According to the Maternal conditions 458 3 2007–8 Jamaica Health and Lifestyle Survey data, NCDs such as hypertension, diabetes, and high cholesterol are more frequently Perinatal conditions 792 5 reported for women than men at disease prevalence rates of Nutritional deficiencies 247 2 29.3:10.7 for hypertension, 9.1:6.1 for diabetes, and 4.9:2.6 for NCDs 10,250 63 high cholesterol for women and men respectively (Wilks, et al. Neuropsychiatric conditions 3,477 21 2008). At particular risk are women with low incomes, many of Cardiovascular diseases 1,744 11 whom are uninsured or underinsured and cannot afford preventive screenings for high blood pressure, high blood cholesterol, and Malignant neoplasms 1,043 6 diabetes, which would help with early detection of cardiovascular Respiratory diseases 952 6 and other NCDs (Figure 3). Sense organ diseases 859 5 Other* 2,175 13 Injuries 2,170 13 Unintentional injuries 807 5 Intentional injuries 1,363 8 Source: World Health Organization 2004 (World Health Organization n.d.) *includes other neoplasms, diabetes mellitus, endocrine disorders, digestive diseases, genitourinary diseases, skin diseases, musculoskeletal diseases, congenital anomalies, oral conditions. TABLE 5. TOP 10 CAUSES OF DALYS, JAMAICA, 2004 CAUSES % Neuropsychiatric conditions 21.3 Infectious and parasitic diseases 12.3 Cardiovascular diseases 10.7 Intentional injuries 8.4 Malignant neoplasms 6.4 Respiratory diseases 5.8 Sense organ diseases 5.3 Unintentional injuries 5.0 Perinatal conditions (h) 4.9 Musculoskeletal diseases 2.9 Source: World Health Organization (WHO), 2004 4 HALE combines mortality (life expectancy) and morbidity (disability) measures and is most easily understood as a lifespan in full health, without disability NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 20 FIGURE 3. LIFE EXPECTANCY AT BIRTH IN JAMAICA COMPARED TO SAMPLE COUNTRIES FROM DIFFERENT REGIONS, 2002 Canada United Kingdom Barbados Mexico Jamaica Georgia Peru Thailand Total Egypt Females Iran Males Azerbaijan Guyana Bangladesh India Ghana Laos Cote d'Ivoire 0 10 20 30 40 50 60 70 80 Source: (World Health Organization 2003) The demographic and epidemiological transitions described in this chapter have an impact on the NCD burden on Jamaica; this will be considered in the next chapter. THE BURDEN OF NCDS IN JAMAICA 21 3. THE BURDEN OF Key Findings NCDS IN JAMAICA 1. NCDs have increased steadily across the entire Jamaican population over the last twenty years but much more in the last decade. This chapter takes an in-depth look 2. Estimated NCD prevalence rates increased across at the trends and current burden of all five expenditure quintiles from approximately 4 percent in 1994 to 15 percent in 2007. disease in Jamaica caused by NCDs. 3. Hypertension is the most frequently reported NCD in An analysis of time trends over the nearly all population quintiles, followed by diabetes and asthma. past decade is presented to determine whether disparity in chronic disease 4. Gender disparity in NCDs persists and the gap between women and men is widening over time, with trends exists among individual women at higher risk. socioeconomic and demographic 5. The prevalence of NCDs among women has increased sub-groups. A detailed analysis of much faster than among men; women have shown higher prevalence in most NCDs, such as asthma, the current situation disaggregated diabetes, hypertension, and arthritis. by socioeconomic variables (gender, 6. NCDs are rising substantially and rapidly as the population ages. age, education, region of residence, economic status) was also undertaken to provide a more comprehensive picture of NCDs. The primary sources of data for the analysis are the 1990– 2009 JSLC, complemented by data from the Ministry of Health, WHO, and peer-reviewed journals. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 22 Analytical Approach FIGURE 4. OBSERVED AND ADJUSTED TIME TREND OF NCD PREVALENCE AMONG A time-trend analysis on the prevalence of NCDs among adults JAMAICAN ADULT POPULATION in Jamaica was carried out. Historical chronic disease data are 18% derived from the JSLC 1994–2007. The sample for this analysis was 16% restricted to adults aged 18 years and older because adults are the 14% population group most at risk for NCDs worldwide. Individual adult 12% 10% NCD status is self-reported by respondents in a four-week reference 8% period5. The time-trend analysis method used here is also adopted 6% throughout this report (see the Annex on Time-Trend Analysis for 4% details). A regression model was used to estimate the impact of time 2% 0% changes on the pattern of NCDs, controlling for other factors such 1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 200 5 2 0 0 7 as age, gender, region of residence, and expenditure quintile. The primary goal was to capture other factors which affect NCDs, which obs erv ed adjus t e d could not be controlled, such as overall socioeconomic development and environmental changes over time. * Individual basic socioeconomic and demographic characteristics were controlled for adjusted prevalence Source: Study estimates based on Jamaica Surveys of Living Conditions Data from the 2008 JSLC were used to analyze the current 1994–2007 NCD situation in Jamaica. The 2008 JSLC was the first survey that collected information from all respondents on the current status of There was a significant increase in estimated NCD prevalence major NCDs. Compared with the previous surveys, the 2008 survey rates among all five expenditure6 quintiles from approximately is more comprehensive because: (i) its sample size is the largest 4 percent in 1994 to 15 percent in 2007. The parallel increase among most recent surveys (about 22,294 individuals and 6,513 of NCD prevalence rates among the five expenditure quintiles households); (ii) the NCD questions were asked of each respondent indicates that NCDs affected every socioeconomic group. The regardless of his/her last four-week illness status; and (iii) specific gap between the poorest and richest quintiles was constant, types of diseases were identified. ranging from a prevalence rate of 1.37 to 2.11 percent over the last 15 years. The prevalence of asthma and arthritis is more or Overall Increase of NCDs among the Total Population less the same in all population quintiles. Hypertension is the most frequently reported NCD in nearly all socioeconomic groups but is NCDs increased progressively among the entire Jamaican more prominent among the richer population, while mental illness population in the last decade and the prevalence rates vary is more of an issue among the poorer groups. Diabetes and asthma significantly by socioeconomic group. Hypertension, diabetes and follow hypertension as the most frequently reported NCDs among asthma are currently the most prevalent NCDs in Jamaica. Patterns nearly all socioeconomic groups. The percentage of the population of specific diseases vary considerably by socioeconomic groups and that reported NCDs by disease type and socioeconomic group is gender as well, with women, seniors, rural residents, and the richest provided in Table 6. Roughly 10 percent of the population indicates group reporting higher prevalence rates of NCDs. The results from that they currently have hypertension, 4.8 percent have diabetes, the analysis provide policy makers with a basis for better targeted and 4.34 percent have asthma. interventions to address inequalities. The prevalence of NCDs increased dramatically in the last decade in Jamaica. Figure 4 shows a clearly upward trend of both observed and adjusted NCD prevalence among Jamaican adults (age 18 years and older) during the last decade. After controlling for major individual socioeconomic characteristics including individual age, gender, region of residence, and population expenditure quintile, the adjusted percentage of people were suffering from at least one type of NCD disease was, based on this time-trend analysis, found to have gone up from 4.16 percent to 14.88 percent in 15 years between 1994 and 2007, and NCDs are predicted to account for 25.85 percent of the population in 2015 if this time trend continues and the population composition continues as in 2007. 5 It should be noted that the definitions of NCD before and after JSLC 1999 are somewhat inconsistent. We acknowledge such difference and introduce a time variable to minimize the incomparability issue in these two periods. 6 Expenditure data are used as a proxy for income. THE BURDEN OF NCDS IN JAMAICA 23 TABLE 6. PERCENTAGE (%) OF THE FIGURE 5. ADJUSTED TIME TREND OF NCD POPULATION REPORTING NCDS BY DISEASE PREVALENCE BY GENDER AMONG JAMAICA TYPE AND SOCIOECONOMIC SUBGROUPS ADULT POPULATION ASTHMA DIABETES HYPER- ARTHRITIS MENTAL 20% TENSION ILLNESS 18% All 4.34 4.80 9.97 4.20 0.69 16% %chronic illness 14% Gender 12% 10% Male 4.28 3.21 5.99 2.63 0.78 8% 6% Female 4.40 6.33 13.78 5.71 0.60 4% 2% Age 0% 0–17 6.50 0.17 0.06 0.00 0.06 4 5 6 7 8 9 0 1 2 3 4 5 6 7 9 9 9 9 9 9 0 0 0 0 0 0 0 0 9 9 9 9 9 9 0 0 0 0 0 0 0 0 18–29 3.83 0.60 1.18 0.16 0.63 1 1 1 1 1 1 2 2 2 2 2 2 2 2 year 30–59 2.64 5.66 12.97 2.78 1.21 fem ale m ale 60+ 3.33 21.70 42.75 25.61 1.18 *These time trends of NCD prevalence rates among adult population Region were adjusted by individual socioeconomic and demographic characteristics. KMA* 6.24 4.81 9.51 3.63 0.52 Source: Study estimates based on Jamaica Surveys of Living Conditions Rural 3.40 4.34 9.97 4.69 0.85 1994-2007 Urban 4.58 5.65 10.32 3.76 0.52 Pop Gender disparity in NCDs persists and confirms the disparity quintile observed in the trend analysis. This disparity was confirmed by a Poorest 4.09 3.20 8.11 3.87 1.11 cross-sectional data analysis of the 2008 JSLC Survey. NCDs were 2nd 4.33 3.89 7.88 3.69 0.77 found to be more frequently reported for women than for men at quintile prevalence rates of 20.44 percent for adult men and 33.25 percent for adult women according to the 2008 JSLC Survey as shown in 3rd 4.42 4.30 9.98 4.23 0.68 Figure 6. The information from the Jamaica Health and Lifestyle quintile Survey indicated that women with low income were at higher risk 4th 4.15 6.09 11.09 4.54 0.58 of developing NCDs (Wilks, et al. 2008). Females reported higher quintile prevalence in most NCDs such as asthma, diabetes, hypertension, Richest 4.71 6.48 12.71 4.68 0.31 and arthritis. The gender gap is largest for hypertension (7.79 Source: Study estimates based on Jamaica Survey of Living Conditions percent), and minimal for asthma and mental illness (less than 0.2 2008. percent). Current data reveal minor differences in NCD prevalence among FIGURE 6. ADJUSTED NCD PREVALENCE urban and rural areas. People in the Kingston Metropolitan Area RATES BY GENDER OVER TIME (KMA) reported slightly more asthma cases (6.24 percent) than rural and urban residents, while diabetes, hypertension, arthritis, 35% and mental illness are at about the same level in all regions. 30% The Gender Disparity in the Burden of NCDs 25% 20% The rapidly increasing trends among subgroups exhibit important disparities in Jamaica, especially between men and 15% women. The prevalence of NCDs among women has increased 10% much faster than among men. In 1994, the difference in prevalence rates between women and men, adjusted by basic individual 5% demographic and socioeconomic characteristics, was only a 1.96 0% percentage point, whereas the difference surged to 8.92 percentage female male points after 15 years. Further examination of the NCD trends reveals substantial regional disparities. Unlike some countries Source: Study estimates based on Jamaica Survey of Living Conditions 2008 where males are at a disadvantage in terms of NCD prevalence, women in Jamaica were on average at a significantly higher risk and this gap has diverging continuously during the last decade (Figure 5). NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 24 The Age Disparity in the Burden of NCDs As expected, age is a major factor contributing to NCDs even after controlling for other demographic and socioeconomic changes. As Figure 7 illustrates, a larger share of the senior population (age 60+) reported NCDs compared to younger adults, and the general difference across age bands became larger over time. The prevalence of NCDs in seniors in the early 1990s was around 13.19 percent and it nearly tripled (40 percent) after only 15 years. The increase of NCD prevalence among adults of 30–50 years old and those of 18–29 years old is only 3.78 percent and 8.56 percent respectively. As the population in Jamaica ages, the trend in NCD prevalence is likely to continue increasing. The elderly population, representing 11 percent of Jamaica’s total population, is indicated by the projections in Figure 7 and is a growing segment of the population. Aging will contribute to the increasing burden of disease from NCDs and places greater demand and economic pressure on households, the health sector, and the economy at large. Profiles by age group consistently suggest that prevalence of most NCDs is rising rapidly as people are aging. For example, 0.17 percent of children and adolescents aged 0–17 reported that they were suffering from diabetes, but this number increased to 21.70 percent in the elderly (60+) group. A similar pattern is found for hypertension, arthritis, and mental illness. The only exception is asthma, which is more prominent in the 0–17 age group (6.50 percent) and least reported in the adult (30–59) and elderly (60+) groups. The age profile of NCDs in 2008 shows that NCDs were present in 8.21 percent of children aged 0-4 years ; 24.05 percent in adults between 40 and 49 years, and 68.46 percent in persons 65 years and over (Figure 7). FIGURE 7. AGE PROFILE OF NCDS IN JAMAICA 2008 68% 70% 60% 55% 50% 40% 39% 30% 24% 20% 14% 10% 8% 10% 8% 9% 0% 0-4 5-9 10-19 20-29 30-39 40-49 50-59 60-64 65+ age Source: Study estimates based on Jamaica Survey of Living Conditions 2008 This chapter has considered the burden of NCDs on Jamaica. The following chapter will consider the risk factors which lead to this burden. RISK FACTORS CONTRIBUTING TO THE BURDEN OF DISEASE 25 4. RISK FACTORS Key Findings CONTRIBUTING TO THE BURDEN OF 1. Obesity is the most prevalent chronic disorder in Jamaica. DISEASE • Women are most affected but this is growing in the overall population and accounts for a major share of morbidity, disability, and healthcare costs. • Jamaican culture favors weight, which may This chapter discusses and analyzes contribute to increasing obesity rates and partially explains the lack of action to reduce weight and the five major risk factors that increase obesity. • Globalization and growing urbanization have the prevalence of NCDs in Jamaica. introduced a culture of eating out, coupled with a diet already consisting of a large proportion of staple The trends over time and current foods and sweets. profile of NCDs are influenced by 2. A large percentage of the Jamaican population in all multiple determinants and interactions age groups, particularly women, are either inactive or have low levels of physical activity. among them. Obesity, unhealthy diet, • Levels of physical activity are lower among those with a lower educational level, older people, and the physical inactivity, smoking, and alcohol unemployed. consumption are globally acknowledged 3. The level of tobacco smoking in Jamaica is not high individual risk factors that play key roles compared to countries like China and Russia, but smokers form their addictive habit at very young ages in developing chronic diseases. A good in Jamaica. • Smoking is more prevalent among men and the understanding of these risk factors poorer segments of the population but rich and poor households alike show a growing trend of tobacco provides a robust foundation for policy consumption. makers to design targeted interventions • Expenditure on tobacco per household has risen 1.5 times between 2000 and 2008. for prevention. 4. Men consume more alcohol than women and Jamaicans start to drink alcohol as early as the age of 12. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 26 OBESITY TABLE 7. PREVALENCE OF WEIGHT STATUS OF JAMAICANS BY AGE AND GENDER, 2008 Obesity is the most prevalent chronic disorder in Jamaica. NUTRITION 15– 25– 35– 45– 55– 65– The number of obese people in Jamaica is alarmingly high, STATUS 24 34 44 54 64 74 particularly among adult women. Using WHO criteria for Body Underweight Mass Index (BMI)7, only 7.6 percent male adults in Jamaica are (<18.5kg/m²) obese (BMI>=30 kg/m²) while 23.9 percent female adults fall in Male 8.4 3.4 2.1 2.0 4.8 9.3 this category (Figure 8). Obesity is an increasing health threat globally; WHO estimated that in 2002 more than one billion adults Female 12.6 2.4 2.4 1.4 1.3 2.6 worldwide were identified as overweight and at least 300 million Total 10.5 2.9 2.3 1.7 3.1 5.8 were clinically obese (BMI>=30 kg/m²). Normal(18.5– 24.99kg/m²) FIGURE 8. OBESITY PREVALENCE IN THE Male 70.0 65.8 47.0 43.6 47.7 49.6 CARIBBEAN REGION (%) Female 49.5 35.5 19.3 17.2 17.5 22.9 H a i ti Total 59.7 49.9 32.6 30.6 32.8 35.7 Cuba Overweight(25– B ra z il A rg e n tin a 29.99kg/m²) Tr in id a d & T o b a g o Male 12.6 21.5 36.7 32.9 35.4 29.1 Jamaica Guyana female Female 21.5 24.5 27.8 33.9 33.1 33.3 Bahamas male Total 17.0 23.1 32.1 33.4 34.3 31.3 St Lucia Chile Obese B a rb a d o s (>=30kg/m–) USA D o m in ica n R e p u b li c Male 9.0 9.4 14.2 21.6 12.1 12.1 0 5 10 15 20 25 30 35 40 Female 16.5 37.7 50.5 47.6 48.0 41.2 Total 12.8 24.2 33.0 34.4 29.8 27.3 Source: International Obesity Taskforce, International Association for Source: JHLSII 2008 Report (Wilks, et al. 2008) the Study of Obesity The gender disparity for obesity remained through all age Data from the Jamaica Health and Lifestyle Survey reaffirm the groups and it was more severe among middle-age groups. The conclusions drawn from the JSLC that prevalence of obesity is not JSLC indicated that more than 60 percent of Jamaicans aged 35 only increasing among women, but also in the overall population. to 54 were either overweight (BMI between 25 to 29.9 kg/m²) or Compared with the Jamaica Health and Lifestyle Survey for 2000, obese (BMI>=30 kg/m²) in 2008, and the majority of them were it is clear that the number of people of normal weight decreased women (Table 7). Almost half of women in the 35–54 age group and the obese population increased by 5 percent (Figure 9). are obese; adding overweight women in this group, more than 80 percent are above normal weight. Even among younger age groups FIGURE 9. CHANGES (%) IN NUTRITIONAL (15–24), almost 40 percent of women were either overweight or STATUS OF JAMAICANS 15-74 YEARS obese compared with only 22 percent of men. While overweight DURING 2000–2008 and obese among men decreased over age, obesity among women seems to persist in older ages (Wilks, et al. 2008). 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% underw ei ght nor mal ov er w ei gh t obese (< 18. 5k g/ m2) (< 18. 5-24. 9 9 ( 25- 29. 99 (>=30kg/m2) k g/ m2) k g/ m2) 2000 2008 Source: JHLSII 2007-8 Report (Wilks, et al. 2008) 7 BMI is defined as weight in kilograms divided by square of the height in me- ters (kg/m²), RISK FACTORS CONTRIBUTING TO THE BURDEN OF DISEASE 27 International comparative analysis reveals that the obesity risk versus 60.6 percent of overweight men, perceived their weight to in Jamaica is on the high end of the global scale. A study done by be acceptable (Durazo-Arvizu 2008, Ichinohe 2005). Durazo-Arvizu (Durazo-Arvizu 2008) analyzed obesity prevalence in the United States, Nigeria, and Jamaica and showed that the UNHEALTHY DIET unadjusted weight gain per year in Jamaica was four times higher than that of Americans and Nigerians. The average BMI of the 40– Unhealthy diet is one of the main risk factors for high blood 44 year old Jamaican is 27.7, which makes it 2.7 units higher than pressure, raised blood glucose, abnormal blood lipids, and the globally recognized overweight level of BMI 25. Projecting five overweight or obesity, and is associated with the major NCDs such years forward, Jamaicans will on average increase by 2.5 BMI units, as cardiovascular disease, cancer, and diabetes. Over the past 20 compared to 0.925 units in the US. A study by Luke (Luke 2007) years, Jamaicans’ food consumption patterns have changed due indicates a big gender difference in weight characteristics for the to easy access to fast food as a consequence of liberalization of the urban adult Jamaicans sample. Mean BMIs for females (BMI 29) economy and removal of international trade barriers. Transnational were greater than males (BMI 27), and females gained on average food companies have increased the supply of unhealthy food and more weight (7.4 kg during a six year follow-up) than males (6.1 beverages to the local market. By contrast, there are few incentives kg) (Table 8). for fruit and vegetable production, with alarming prevalence of unhealthy diets. The 2007–8 Jamaica Health and Lifestyle Survey TABLE 8. WEIGHT CHARACTERISTICS OF shows that 98 percent of 10–15 year old Jamaicans regularly URBAN ADULT JAMAICANS consume sugar-saturated soft drinks, and over 80 percent of the 15–74 age group consume fast food more than twice a week. MEN WOMEN TOTAL Age (y) 38.2 37.7 37.9 Globalization and urbanization in Jamaica have introduced a Weight (kg) 83.1 76 79.4 culture of “eating out� and increased consumption of street foods. BMI (kg/m²) 27 29 28 Chains of fast food outlets are rapidly expanding and Jamaica has Body fat (%) 24.5 38.5 31.7 the largest network of fast-food restaurants in the region for the first time, further raising the population’s cholesterol; powerful Weight change (kg) 6.1 7.4 6.8 marketing strategies influence the youth particularly (Tackling the Weight change per year 1.1 1.2 1.1 Obesity Epidemic, the Impact of Food Trade and Commerce 2009). (kg/y) Source: (Luke 2007) The Jamaican diet consists of a large proportion of staple food and sweets with only a small number of the population consuming Obesity poses a serious threat to the nation’s health and fruits. In the 2007–8 Jamaica Health and Lifestyle Survey (Table 9), economy. Unless effective prevention and control measures are more than 60 percent of individuals reported that they consumed taken, the society will bear high direct (treatment) and indirect 6–12 servings (3–6 times a day) of staples per day, with rural males (loss of productivity) costs. Obesity is one of the leading causes and females consuming the largest quantity of staples and legumes. of diabetes mellitus and cardiovascular diseases in the country Fast-food consumption was higher among urban residents (more and contributes to the major share of morbidity, disability, and than 2 times a week) (14.1 percent for urban residents versus healthcare costs (Durazo-Arvizu 2008). 7.4 percent for rural residents), but more than 80 percent of individuals reported consuming fast food less than once per week Jamaican culture favors weight, which may contribute to the or not at all. A higher proportion of rural males than urban males increase in obesity. Adult weight is often culturally associated with (13.2 percent versus 9 percent) and urban women compared to prosperity and is thus a desirable feature in partners and spouses8. rural women (15.2 percent versus 13.1 percent) consumed pastry Moreover, parents in Jamaica believe that chubby babies are one or more times per day. Three-quarters or more of Jamaicans healthier and tend to overfeed their children, unaware of the real aged 15–74 consumed one or more bottles or glasses of sweetened health impact of doing so. This conception could be an important beverages per day, with more rural than urban dwellers consuming factor contributing to increased obesity among children – 11 these amounts. Among all age groups, a high percentage of 15–19 percent of teenagers in the 10–15 age group and 35 percent in the year olds prefer fast food (66 percent), pastries (85 percent), and 15–18 age group are overweight or obese (FAO 2002). Clinical and sugar beverages (96.9 percent) and only small numbers consume population studies in Jamaica found that obesity was significantly fruits (9.7 percent). associated with individuals’ socio-demographic characteristics such as age, gender, race, education, and economic status, and interacted with individual behavior as to physical activity and diet. Studies found that 19.2 percent of obese women versus 25.7 percent of obese men, and 42.2 percent of overweight women 8 Jamaican men favoring full-figured women was listed as one of the factor contributing to obesity during the Bank team’s consultation on the report in November 2010. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 28 TABLE 9. DISTRIBUTION (%) OF FOOD CONSUMPTION BY SEX AND PLACE OF RESIDENCE, 2008 DIETARY PATTERNS MALE FEMALE TOTAL U R T U R T U R T *Staples <3 times per day 33.7 26.5 31.1 39.0 28.3 35.2 36.4 27.4 33.2 3-6 times per day 64.3 69.5 66.1 58.7 70.0 62.7 61.5 69.8 64.4 >6 times per day 2.1 4.0 2.7 2.3 1.7 2.1 2.2 2.8 2.4 Legumes <2 times per week 60.7 51.6 57.5 56.7 48.8 53.9 58.7 50.2 56.7 2-3 times per week 37.4 46.7 40.7 41.5 49.5 44.3 39.5 48.1 42.6 >3 times per week 1.9 1.7 1.8 1.8 1.8 1.8 1.8 1.7 1.8 Fast-food Consumption None 54.4 73.1 61.0 58.5 65.4 61.0 56.4 69.2 61.0 4 times per week 4.3 1.2 3.2 2.8 2.5 2.7 3.5 1.9 2.9 Pastry consumption <1 times per day 91.0 86.8 89.5 84.8 86.9 85.6 87.9 86.8 87.5 1-3 times per day 9.0 13.2 10.5 14.7 12.9 14.0 11.9 13.1 12.3 >3 times per day 0 0 0 0.5 0.2 0.4 0.2 0.1 0.2 Sweetened beverage consumption <1 bottle/glass per day 23.7 18.0 21.7 25.9 18.8 23.4 24.8 18.4 22.5 1 bottle/glass per day 26.9 22.8 25.5 20.6 20.3 20.5 23.7 21.5 22.9 >1 bottle/glass per day 49.4 59.2 52.9 53.5 60.9 56.2 51.5 60.1 54.5 *One time per day is equated to a minimum of 2 servings of staples using 24 hr recall data Source: JHLSII 2007-8 Report (Wilks, et al. 2008) Dietary intake of high levels of salt is thought to contribute to A small improvement was observed over an eight-year period the progression of a number of chronic diseases9. Salt consumption (2000–08) thanks to government efforts to promote healthy is linked to an increased incidence of cardiovascular disease nutrition and social wellbeing through school nutrition programs. and death among overweight people. Low-salt diets seem to be There was a 14-percent increase in the share number of cooked especially important for people with hypertension. In Jamaica, meals eaten whose nutritional value and preparation guidelines however, only 1.2 percent of men and 2.6 percent of women were developed by the Caribbean Food and Nutrition Institute, consume low portions of salt in their meals. Among adult patients which ensured well-balanced and healthy menu composition. As with chronic disease, only 5.7 percent with hypertension reported a part of the school feeding program, children are taught nutrition low salt intake, and among patients with obesity, diabetes, and high education that promotes healthy eating habits (Figure 10). cholesterol only 4.0 percent, 5.8 percent and 4.8 percent reported low salt intake respectively (Wilks, et al. 2008). People do not see a need for dietary management in Jamaica. Ninety-seven percent of the obese people are not on diet and less than 5 percent of Jamaicans reported themselves as ever having being on a special diet to reduce health complications. Ninety-four percent of hypertensive people do not follow a low salt diet and 95 percent of patients with hypercholesterolemia are not on a low fat/ cholesterol diet. Only 16 percent of diabetic patients were reported as being on a diabetic diet (Wilks, et al. 2008). 9 The recommendation for sodium in the Dietary Guidelines for Americans from the U.S. Department of Health and Human Services is 2,400 milligrams (mg) daily for adults. This is about the amount in 1 teaspoon of salt (2,300 mg, to be exact). RISK FACTORS CONTRIBUTING TO THE BURDEN OF DISEASE 29 FIGURE 10. DISTRIBUTION OF SCHOOL FEEDING PROGRAM IN JAMAICA (% SCHOOL REPORTING PROGRAM ENROLLMENT) 50.0% 47.5% 45.0% 40.0% 33.8% 35.0% 29.9% 29.5% 30.0% 25.0% 17.8% 2000 20.0% 2008 15.0% 11.4% 10.6% 10.0% 5.9% 7.1% 6.5% 5.0% 0.0% Yes (milk/nutribun) Yes (cooked meal) Yes (both) No Do not know Source: Study estimates based on JSLC 2000 and 2008 PHYSICAL INACTIVITY FIGURE 11. CHANGES (%) IN PHYSICAL ACTIVITY LEVELS OF JAMAICANS 15-74 In addition to dietary factors, low levels of physical activity are YEARS 2000-2008 another strong predictor of obesity. While the transition to more affluent and modern lifestyles relieves people of physical work 50% 45% (with easy access to transportation, the replacement of manual 40% labor with machinery, and mostly sedentary jobs), this reduces 35% 30% energy needs and potentially leads to people being overweight, 25% 20% obese, and having diabetes, cancer, and cardiovascular concerns. 15% Promoting regular physical activity and creating an environment 10% 5% that supports physical activity can reduce the epidemic of obesity 0% (Fogelholm and Kukkonen-Harjula 2000) and risk of heart attack, i n a cti ve low mo d e ra te h igh colon cancer, diabetes, and high blood pressure, and may reduce 2000 2008 the risk of stroke. It also contributes to healthy bones, muscles, and joints; reduces falls among older adults; helps to relieve the Source: JHLSII 2007-8 Report (Wilks, et al. 2008) pain of arthritis; reduces symptoms of anxiety and depression; and is associated with fewer hospitalizations, physician visits, and medications. Females are far less physically active relative to males in all age groups. The age and gender profiles of levels of physical activity in A large percentage of the Jamaican population reports either 2008 are listed in Table 10. The proportion of females classified being inactive or having low levels of activity10. According to the as physically inactive exceeds that of males in all age groups, and Jamaica Health and Lifestyle Surveys of 2000 and 2007–8 (Figure the proportion of males who are moderately or highly active is 11) the proportion of the Jamaican population in the 15–74 year significantly larger than all ages of females. The variation across age group who reported being inactive doubled in the interval (30 age groups within genders is not substantial. Females tend to be less percent versus 17 percent), and the proportion of people being active at younger (15–24) and older ages (65–74) but more active highly active has dramatically dropped from 47 percent in 2000 to in the age group 25–64. 33 percent in 2008. The proportion of people who reported having low levels of activity did not change significantly but the proportion of moderately active people slightly increased. 10 Physical activity was examined by questionnaire in the Jamaica Health and Lifestyle Survey 2007-8, which included both occupation and recreation. A com- posite score on a four-point scale was derived (Wilks, et al. 2008). NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 30 TABLE 10. PHYSICAL ACTIVITY LEVELS (%) percent of Jamaican women are unemployed, stay primarily at OF JAMAICANS BY AGE AND GENDER, 2008 home and expend minimal energy. An average of 90 percent of the 15-24 25- 35- 45- 55- 65- 15–74 age group report leading mostly sedentary lifestyles with 34 44 54 64 74 limited participation in physical activities. Less than 10 percent Low of the population made efforts to increase their activity levels, of activity which group the majority are men (Wilks, et al. 2008). Male 12.0 12.1 16.0 11.2 5.0 16.1 The educational level is positively associated with the level Female 22.0 17.1 17.1 24.0 17.0 19.0 of physical activities (Wilks, et al. 2008). Adults with higher Moderate educational attainment are more likely to be physically active – activity about 39 percent of people with post-secondary education report Male 28.0 22.4 22.4 20.1 31.0 23.1 high levels of exercise versus 34.1 percent of those with only primary or lower education and 30.85 percent of those with Female 19.3 21.1 21.1 16.1 23.0 20.0 secondary education. High activity The habit of staying physically inactive develops at a young Male 47.0 54.0 46.0 55.4 41.4 31.3 age in Jamaica, particularly among girls. The analysis of the 2001 Female 12.0 21.0 22.0 24.4 30.0 8.0 JSLC, which collected information on physical activities of 17–29 Source: JHLSII 2008 Report (Wilks, et al. 2008) year olds, found that 64 percent of youth did not participate in any activity (79.3 percent of women and 46.3 of men), 11.5 percent did occasionally (13.8 percent of men and 9.6 percent of women) There is a close correlation between levels of energy expended, and only 24 percent exercised on a regular basis or often (39.9 as well as lack of weight management, and obesity in adult percent of men and 11.1 percent of women) (Figure 12). Jamaicans. Clinical multi-year surveys (Luke 2007) identified that energy expenditure11 of Jamaican women is significantly lower FIGURE 12. FREQUENCY OF PHYSICAL than that of men. More than 44 percent of Jamaicans report being ACTIVITY OF 17–29 AGE GROUP, 2001 physically inactive with a high gender disparity: 48 percent of men are reported as physically active, whereas 43 percent of women Do you participate in any physical activity? do not engage in any physical activities whatsoever. The negative correlation between BMI/fat mass and physical activity level is 39.9% relatively stronger for males. Yes 11.1% TABLE 11. ACTIVITY ENERGY EXPENDITURE Occassionaly 13.8% Male 9.6% OF URBAN ADULT JAMAICANS Female MEN WOM- TOTAL 46.3% No EN 79.3% Total daily energy expenditure 13.23 9.94 11.54 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% (MJ/d) Resting expenditure (MJ/d) 6.56 5.5 6.02 Source: Study estimates based on JSLC 2001 Activity expenditure (MJ/d)) 5.42 3.32 4.34 Activity expenditure (kJ/kg.d) 66.3 46.4 56.1 Levels of physical activity for adults (aged 15–74) are Physical activity level (times/ 2.03 1.76 1.89 associated with work status. Employed males of higher economic week) status tend to be more physically active. The Jamaica Health and Source: (Luke 2007) Lifestyle Survey 2007–8 also indicates that employed people (36.2 percent) are more likely to be in high or moderate physical-activity A relatively higher energy expenditure of men is due to the categories than unemployed people (31.4 percent). Approximately more physical work performed and more miles walked regularly 40 percent of Jamaicans reported the nature of their work as being (37 percent of men versus 8.5 percent of women). A total of 41 sedentary, and doing mainly non-strenuous walking, while a much 11 Energy expenditure refers to the amount of energy (calories) that a person higher proportion of males are involved in strenuous walking or uses to breathe, circulate blood, digest food, and be physically active. To pre- heavy physical work than women (37 percent versus 8.5 percent). vent weight gain, energy intake must be balanced with energy expenditure. Meanwhile, unemployment among women is more than double Total daily energy expenditure in this study was measured using the doubly that of men (41 versus 18 percent). labeled water method, resting energy expenditure using indirect calorimetry and activity expenditure calculated as the difference between daily energy expendi- ture and resting energy expenditure. Refer to (Luke 2007) for details. RISK FACTORS CONTRIBUTING TO THE BURDEN OF DISEASE 31 Jamaican culture influences the perception of body shape boards, T-shirts, or manipulation with menthol, fruit and other and fitness not to perceive overweight or obesity as unhealthy or flavors, are having their intended impact on teenagers. Adolescent unflattering. Data collected in the Jamaica Health and Lifestyle perceptions of the health risks posed by tobacco show lack of Survey 2007–8 shows that for adults and seniors (15–74) the information and understanding of harm of smoking. This group majority of males (74 percent) report that they are either “very fit� is misled by positive images of smokers in youth social networks. or “fit� and 62 percent of females, even though a large proportion of them are overweight or obese. Only a small percentage of both FIGURE 14. TOBACCO USE AMONG 13–15 males (5.3 percent) and females (9.4 percent) reported being “not AGE GROUP, 2001 AND 2006 fit� even though data from the same survey show a high percentage of women either over-weight or obese. Use of tobacco, excluding cigarettes male (last 30 days) female SMOKING 15.0% 11.1% 12.2% 10.1% 10.0% Tobacco smoking is a serious public health risk due to its 5.9% association with cardiovascular diseases and chronic respiratory 5.0% problems. Smoking prevalence is relatively high in all age groups 0.0% in part because of Jamaica’s long tradition of tobacco production, 2001 2006 it being one of five countries producing brand-name tobacco. The Use of cigarettes (last 30 days) population has easy access to local tobacco. Data from the Jamaica among 13-15 age group Health and Lifestyle Survey 2007–8 show that current use of 25.0% 21.8% 19.3% tobacco is highest among the 45–54 age group (20.7 percent), 20.0% followed by the 25–34 age group (15.2 percent) and the 55–64 15.0% 11.7% 10.1% male 10.0% age group (15.2 percent). About 10 percent of teenagers and female 5.0% young adults in the 15–24 age group smoke. Fourteen percent 0.0% of participants of the survey reported smoking more than 20 2001 2006 cigarettes per day (males 12.2 percent and females 18.2 percent) while 75 percent smoke 1–5 cigarettes a day (Wilks, et al. 2008). Source: WHO, Jamaica: Global Youth Tobacco Survey 2006 (World Health Organization n.d.)) FIGURE 13. SMOKING BEHAVIOR BY AGE GROUP, 2008 The high prevalence of teenage smokers in Jamaica is associated with serious social threats; smokers are relatively more inclined 30% towards behavior such as unsafe sex, alcohol, and illicit drug 25% abuse. According to the Jamaican National Council on Drug Abuse, tobacco is identified as the major first-time harmful substance used 20% by the population and accounts for 37.7 percent of cases (Figure 15% 15). 10% FIGURE 15. PERCENTAGE OF FIRST-TIME 5% USERS IN JAMAICA 0% 15-24 2 5- 34 35- 44 45- 54 55- 64 65- 74 40.0% 37.70% 35.0% 32% current smoking past smoking 30.0% 27.80% 25.0% Source: JHLSII 2008 Report (Wilks, et al. 2008) 20.0% 15.0% 10.0% The survey data also indicate that smokers form their addictive 5.0% habit at a very young age. Of current smokers, 37 percent report 0.0% starting smoking at 15 years of age or younger. Even though data Tobacco Alcohol Marijuana from this survey did not show the increase of prevalence of teenage smoking, the WHO analysis of tobacco use among teenagers in Source: (Jamaica National Council on Drug Abuse 2004) 2001 and 2006 identified a relatively higher increase of smoking among women (4.2 percent) than among men (1.1 percent) among 13–15 year olds. Modern marketing strategies used by tobacco companies and the diversification of their products through, for example, the distribution of small gifts with logos, flashy street NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 32 The Ministry of Health of Jamaica is committed to controlling FIGURE 16. OBSERVED AND ADJUSTED PER- tobacco use in the country. Efforts started in the mid-1990s, when CAPITA ANNUAL HOUSEHOLD TOBACCO preventive strategies were integrated into healthy lifestyle and EXPENDITURES (2008 JMD) chronic-disease-prevention programs. Since the early 2000s, more comprehensive anti-tobacco policies have been in effect: tobacco 70 advertising was prohibited in the mass media and smoking was 65 banned in all health institutions and some private companies 60 55 (The Gleaner 2009). Currently, legislation is under parliamentary 50 review for a total ban on advertising, promoting, and sponsorship 45 of all forms of tobacco (Caribbean360 2011). 40 35 The first formal legislation of the tobacco industry was proposed 30 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 to Cabinet on November 19, 2001, and approved on November observed adjusted 26 of the same year. The legislation set retail price adjustments, taxation policies, health messages, registration of imports, licensing businesses, contributions to the NHF, etc. On September *adjusted for major household demographic and socioeconomic 24, 2003, Jamaica formally signed the Framework Convention on characteristics. Source: Study estimates based on JLSC 2000–2009 Tobacco Control spearheaded by the WHO, and the excise tax on cigarettes was increased by 23 percent. On April 18, 2005, there was a further increase of tobacco product taxation that brought Rich households spent much more on tobacco but poor the excise tax up to 49.3 percent. and rich households alike showed a growing trend of tobacco use from 2000 to 2009. All households experienced a parallel Per-capita expenditure on tobacco collected in JSLC panel trend of increasing tobacco expenditure, with an increase of surveys was used as a proxy for analyzing the changing trend of approximately 20 to 25 percent (adjusted) in all five household tobacco consumption over time. In the survey, tobacco goods include quintiles. Nevertheless, the richest ones (upper 5th quintile of cigars, cigarettes, chewing tobacco, pipes, etc. Similar to other time households) spent more than double the amount on tobacco trend analyses (details are in the Time-Trend Analysis Annex), a than the other four quintiles (Figure 17). regression model is used to control for household characteristics and to capture pure time effect. Figures 16 and 17 illustrate a time FIGURE 17. ADJUSTED PER CAPITA trend of tobacco expenditure net of other household demographic EXPENDITURE ON TOBACCO BY HOUSEHOLD and socioeconomic changes. Expenditure data were adjusted to ECONOMIC QUINTILES (2008 JMD) constant 2008 Jamaican dollars. This analysis does not intend to capture the policy impact of tobacco control during this period. 90 A more rigorous study of the relationship between income and 80 tobacco, inflation, and other price effects is needed to analyze the 70 60 real impact of excise tax regulations and the effectiveness of excise 50 200 8 J MD 40 tax policies. 30 20 10 Household tobacco expenditure has shown a steady increase 0 between 2000 and 2009. Figure 16 shows an overall increasing 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year trend in household per-capita expenditure on tobacco goods after quint 1 quint 2 quint 3 quint 4 quint5 controlling for residential region and population quintiles. Between 2000 and 2009, the adjusted per-capita annual consumption of tobacco increased by roughly 21 percent. While excise tax *adjusted for household demographic and socioeconomic increased in 2003 and 2005, and evidence found in this analysis characteristics. Source: Study estimates based on JLSC 2000–2009 suggests that household tobacco consumption declined in response to the price increases, there is insufficient evidence to conclude that increased tobacco tax did have the intended effect of reducing Smoking is more prevalent among men and the poorer smoking. segments of the population. A cross-sectional analysis of the most recent household data (JSLC 2008) was conducted to identify the socio-demographic characteristics of current tobacco users at the individual level. Unmarried males of 30–59 years from rural areas and with low income are more likely to smoke. The noteworthy finding is that smoking is becoming more prevalent among the poorest households. Patients with chronic illness and the beneficiaries of health insurance are less likely to smoke. Overall, RISK FACTORS CONTRIBUTING TO THE BURDEN OF DISEASE 33 smoking is more prevalent in males, the 30–50-year age group, FIGURE 19. PERCENT OF JAMAICANS AGED and poorer households. 15-74 WITH DRINKING BEHAVIOR 90% Figure 18 illustrates the gender, age, and population quintile 80% profile of individual smokers. Only 4.26 percent of females are 70% current smokers compared with 25 percent of males. Unlike the 60% information from Jamaica Health and Life Style Survey, the JSLC 50% shows that smoking is most prevalent among 30–50 year old 40% Jamaicans (18.51 percent), followed by young adults of 18–29 30% (12.91 percent), and seniors (12.70 percent). While household 20% per-capita tobacco expenditure in the richest households is 10% approximately four times that of the poorest (Figure 17), the 0% proportion of current smokers in the poorest households is actually 15-24 25-34 35-44 45-54 55-64 65-74 larger than that in the richest households (16.61 percent versus current drinking past drinking 13.78 percent). Source: JHLS 2008 Report (Wilks, et al. 2008) FIGURE 18. PROFILE OF TOBACCO USERS IN JAMAICA The national surveys indicate that Jamaicans start drinking alcohol as early as the age of 12. Despite the high level of awareness 25 % of the causes and consequences of alcohol and other substance 20 % abuse, regular alcohol drinking (more than twice a month) is 15 % reported by 20 percent of 12–17 year olds and 50.2 percent of 10 % 16–17 year olds. Two percent of adolescents younger than 17 are reported as being heavy drinkers (Figure 20). 5% 0% f em al e m al e 0-17 18-29 30-59 60+ poorest 2n d 3rd qu i n t i l e q u i n t i l e 4th q ui nti l e r i c hes t FIGURE 20. PREVALENCE OF ALCOHOL USE gender age bands pop quintil e BY AGE GROUPS, 2001 Source: Study estimates based on JSLC 2008 6% 35-55 y.o. 36% ALCOHOL USE 25-34 y.o. 7% 42% The current prevalence of alcohol consumption in Jamaica is Heavy 4% drinkers alarming with males consuming more alcohol than females. Figure 18-24 y.o. 39% 19 presents the proportion of the population with their drinking behavior by age and gender. More than 75 percent of people aged Under 17 y.o. 2% 17% 15–44 are current drinkers – the proportion reduces somewhat as people get older. Nevertheless, almost 50 percent of elderly people 0% 10% 20% 30% 40% 50% aged 65–74 drink. In terms of gender, 80 percent of males and 49.2 percent of females are current drinkers. Over 50 percent of males Source: : WHO, Jamaica country fact sheet: Youth drug use and abuse report daily or weekend drinking compared with only 18 percent of 2004 (World Health Organization 2004) females. 14.8 percent of males have five or more drinks in a single day compared to 3.2 percent of females (Wilks, et al. 2008). The current trends of alcohol consumption reflect the poor regulations and generally relaxed social attitudes, including those of youth, to it. The laws that do exist are not enforced for locals and are mostly observed in resort areas populated by foreigners. Liquor is easily available and sold in almost all grocery stores where teenagers can purchase it openly and are not checked for proof of age. Teenagers are allowed to purchase and consume alcohol as long as this is not done on store premises. Among adults, considerably NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 34 more men than women consume alcohol – 66.8 percent of males FIGURE 22. ADJUSTED ANNUAL PER-CAPITA and 29.5 percent of females regularly consume (Ichinohe 2005). EXPENDITURE ON ALCOHOL BY HOUSEHOLD QUINTILE (2008 JMD) The analysis of time trends reflects a slight drop in alcohol consumption in early 2000 but an increase in recent years. Household level per capita expenditure on alcohol during 120 1990–2009 shows a “U� shape (Figure 21), after controlling for 100 residential region of household and population quintiles. A slight 80 2 0 0 8 JM D drop in alcohol expenditure was observed around early 2000. In 60 recent years, however, alcohol expenditure has increased with 40 the highest levels observed at 60 JMD/per capita per year. There 20 is as yet no explanation for the decline around the early 2000s 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 and subsequent increase. Alcohol excise tax increased in 2003, year but current evidence is insufficient to indicate an impact. A more thorough investigation with detailed data collection at individual quint1 quint2 quint3 quint4 quint5 level is required. *adjusted for household demographic and socioeconomic characteristics. FIGURE 21. OBSERVED AND ADJUSTED Source: Study estimates based on JSLC 1994-2009 HOUSEHOLDS’ ANNUAL PER-CAPITA EXPENDITURE ON ALCOHOL (2008, JMD) The risk factors examined in this chapter give a good understanding of the need for action to prevent the behavior that contributes to the 70 burden of NCDs. The following chapter considers the response taken by 60 50 the government of Jamaica to this burden. 40 30 20 10 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 obser v e d a d j u s te d *adjusted for household demographic and socioeconomic characteristics. Source: Study estimates based on JSLC 1994–2009 All quintiles experienced a slight drop in alcohol consumption in the 1990s, which picked up in the early 2000s. Further analysis of alcohol consumption by household quintiles in 1990–2009 provided trends consistent with tobacco-related expenditure: the wealthiest households spend most on alcohol and at an essentially higher per-capita amount relative to the lower four quintiles (Figure 22); all quintiles showed a more or less parallel trend that dropped slightly in the late 1990s but increased from the early 2000s. The poorest households spent very little during the early 2000s. There are limitations in using expenditure data to determine levels of alcohol consumption as the number of people drinking remains unknown and a lack of price and quantity data make it difficult to assess consumption trends. Since JSLC does not capture data on home-made alcohol, the reported expenditure on alcohol consumption is likely to be underestimated. JAMAICA’S RESPONSE TO NCDS 35 5. JAMAICA’S Key Findings RESPONSE TO NCDS 1. Recognizing the importance of NCD prevention and control, the government of Jamaica created the National Health Fund (NHF) to reduce the costs of This chapter documents how the treatment for NCDs by providing free or subsidized medicines to patients with more than one NCD. country has responded to the growing prevalence of NCDs. It provides an 2. Residents aged 60 and over suffering from one or more of nine eligible diseases receive medication overview of the National Health Fund free of charge under the Jamaica Drug for the Elderly Program (JADEP) of the NHF. and some prevention programs in 3. All Jamaican residents with one or more of 15 eligible Jamaica, and describes the benefits of diseases receive subsidized medication through the NHF Card Program. the program and the level of program awareness among the population. 4. About 350,000 people, 13 percent of the population, are enrolled in the NHF. 5. More females than males in all age groups are aware of the two Programs. 6. NHF is financed by tobacco excise tax, special consumption tax (imposed on petrol, alcohol, and motor vehicles), and payroll tax on annual earnings paid by employees and employers. 7. The tobacco excise tax caused the major tobacco company to relocate to another Caribbean country. 8. The private sector dominates the pharmaceutical market and about 92 percent of all claims were filled by private pharmacies. 9. Those better off economically are more likely to utilize the Programs than the poor. 10. All socioeconomic groups benefited from the abolition of the user-fee but the major beneficiaries are the poorest population and children, adolescents, and seniors. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 36 The government of Jamaica has recognized the importance of FIGURE 23. (A) RATES OF APPROVAL AND NCD prevention and control. The number-one national goal in the DISBURSEMENT OF INSTITUTIONAL BENEFIT Vision 2030 Jamaica is “A Healthy and Stable Population�. National PROJECTS, 2004-2008 AND (B) NUMBER Strategies call for better performance by the healthcare system as OF (INSTITUTIONAL BENEFITS) PROJECTS well as a greater responsibility on the population for maintaining APPROVED, 2004–2008 their own health. The National Policy for the Promotion of Healthy Lifestyles in Jamaica and the Healthy Lifestyles Program (A) val Approv and Disb bursement were developed in 2004. Their main objectives are to decrease the 2 n) (JM$ Billion incidence of chronic diseases through changing high-risk behavior. 7 1.67 The Healthy Lifestyles Program promotes physical activity, healthy diet, production and marketing of healthy foods, and the 1.5 1.34 1.15 1.14 reduction of alcohol and tobacco use. The Program also addresses reproductive health, violence, and injury. 1 0.9 5 0.85 0.47 NATIONAL HEALTH FUND 0.5 0.2 23 0.28 0 0.09 One of the major steps the government of Jamaica has taken to 0 deal with NCDs is the establishment of the NHF. This was created 04-05 05- -06 06-07 07-08 9 08-09 under the National Health Fund Act in 2003. Its main objective APPROVED ED DISBURSE is to reduce the cost of treatment for NCDs by providing free or subsidized medicines to patients with a number of NCD conditions. (B) The NHF also finances prevention programs, principally the rojects Approved umber of Pr Nu Healthy Lifestyles Program administered through the Ministry of 60 Health and Environment (MOHE). 49 50 42 Institutional Benefits 36 40 The NHF provides grants to public and private institutions to 30 support activities related to health promotion and chronic disease 20 15 5 prevention. Institutions must submit a project proposal to the NHF 9 to become eligible for institutional benefits; this is evaluated by an 10 NHF committee using the national healthcare priorities defined by 0 government. 04-05 05-06 06-07 07-0 0 08 08-09 Source: 2008 Annual Report, National Health Fund (NHF, 2008 The NHF also provides institutional benefits in the form of Annual Report 2008) grants to two sub-funds under the institutional benefits program: the Health Promotion Fund and the Health Support Fund. The During 2008, JMD842.02 million was approved for institutional Health Promotion Fund finances public and private-sector health- benefit projects. Of this, JMD763.37 million was approved for promotion and disease-prevention programs and takes up at least twenty-five new projects while additional funding of JMD78.65 10 percent of NHF revenues. The Health Support Fund assists million was approved for existing projects (Figure 24). Seven public agencies by financing infrastructure development such as projects in Construction and Infrastructure received JMD529.56 the purchase of equipment and renovation, and the refurbishment million, the lion’s share of the funding for approved projects. Health and construction of health facilities. The operations of the Health Promotion received JMD123.29 million, Equipment JMD121.84 Support Fund take up at least 15 percent of annual NHF revenues. million, and Research JMD67.33 million. Non-Governmental Figure 23 shows the number of projects approved and their rate of Organizations had the greatest number of grants approved with approval and disbursements. 14 projects, the Ministry of Health had 10 projects approved, and 4 projects were approved for the South East Regional Health Authority, 2 for the Western Regional Health Authority, and one for the Southern Regional Health Authority. JAMAICA’S RESPONSE TO NCDS 37 FIGURE 24. NHF APPROVAL BY PROJECT vascular disease, and hypertension). The selection of medicines TYPE FOR THE PERIOD 2004–2008 to be subsidized or provided free of charge was based on the most common NCD conditions and their potential financial implications APPROVAL BY PROJECT TYPE (JM$Million) for patients. $355.11 : 8% $72.15 : 2% $990.14 : 23% As part of the individual benefits package, JADEP was launched in 1996 by the Ministry of Health as a national social assistance $840.94 : 19% program to cover Jamaicans who are sixty years of age or older with a diagnosis of one or more chronic diseases. The NHF took over the JADEP Program from the Ministry of Health and has been $1,214.51 : 28% running it smoothly. The Program’s main objectives are to provide $861.33 : 20% basic drugs to the elderly, improve access to pharmaceuticals, and EQUIP. FACILITIES INFRA HEALTH PROMO RESEARCH TRAINING promote rational drug use. JADEP beneficiaries can also join the NHF Card program. The JADEP Program covers the cost of 72 Source: 2008 Annual Report, National Health Fund (NHF, 2008 prescription items and 8 medical-surgical supplies. The average Annual Report 2008) monthly expenditure for the Program is about JMD20 million (US$2.68 million). By the 2009 fiscal year, 18,364 beneficiaries In 2007, health promotion projects accounted for the largest were enrolled in the JADEP Program, and a total of 344 pharmacies share of approved financing – JMD185.20 million (US$2.47 provided JADEP benefits. The major share of JADEP beneficiaries million). This amount was reallocated to projects related to Research (65.9 percent) are in the 65–74 age group, with females accounting (JMD25.63 million; US$0.34 million), Training (JMD24.45 for approximately two-thirds (62 percent). Beneficiaries of the NHF million: US$0.32 million), Construction and Infrastructure Card are automatically enrolled in the JADEP program at the age (JMD27.24 million: US$0.36 million), and Equipment (JMD16.20 of 60. million; US$0.22 million). In the 2007 fiscal year, 34 projects were completed and funds worth JMD502.07 million (US$6.71 million) The NHF Card program was developed as part of the individual were disbursed (NHF, 2008 Annual Report 2008). benefits package to provide subsidies for specified drugs to help beneficiaries meet the costs of medicine. Subsidies are based on Individual Benefits market prices from the most economical sources and beneficiaries are often required to co-pay. Initially, NHF beneficiaries were The NHF responded to the need for public-sector support to help eligible to purchase 182 drugs at a subsidized price in 200 Provider individuals address their NCD needs. The macroeconomic recession Pharmacies across the country. By the 2009 fiscal year, the total at the beginning of this decade caused high unemployment and number of items on the NHF Drug list had reached 1,288 and the escalated global healthcare costs; this made it increasingly difficult total number of Provider Pharmacies had increased to 422; the for households where family members have multiple chronic total number of Active Pharmaceutical Ingredients was 201. In conditions to afford the high cost of medicine to treat and control November 2005 the NHF Board approved an average of 57 percent them. More than half of total health expenditure went on private out of a total of 1,887,739 prescriptions filled for the subsidy, the health services, of which 83 percent was out-of-pocket expenditure, total value of which was JMD 2,386 billion, and the NHF paid out mainly for pharmaceuticals (World Health Organization 2009). JMD 1,371 billion in subsidies. Figure 25 illustrates the NHF Card subsidy rates in the 2008 fiscal year. One of the major functions of the NHF is to provide an Individual Benefit Package and at least 50 percent of the NHF budget has been NHF Card beneficiaries registered for 546,285 cases of illnesses allocated for individual benefits. All residents of Jamaica (except in the 2008 fiscal year, which is an average of 2.62 cases per tourists, in-transit passengers, and temporary workers with a work individual (Figure 26). Hypertension has the highest enrollment permit for less than one year) suffering from NCDs are eligible for with over a quarter (26 percent) of the total number of cases, enrollment into the Jamaica Drug for the Elderly Program (JADEP) followed by arthritis (16 percent), diabetes (14 percent), and high and/or NHF Card Program. Beneficiaries over 60 years of age cholesterol (12 percent). enrolled in the JADEP program are provided with free drugs to treat 10 chronic diseases that are most prevalent among the elderly More people are taking advantage of the Program with an (hypertension, diabetes, glaucoma, heart disease, arthritis, asthma, increase in the numbers enrolled in the NHF Card Program. In vascular conditions, psychosis, benign prostate hyperplasia, and 2007, the total number of cases of illnesses for which the NHF high cholesterol). The NHF Card subsidizes drugs for people of all Card beneficiaries were eligible reached 436,555 or an average ages and covers 15 chronic illnesses (arthritis, asthma, benign of 2.53 cases per individual. In the 2008 fiscal year, a 20 percent prostatic hyperplasia or enlarged prostate, diabetes, ischemic heart increase in the NHF enrollment rate (from 291,390 to 350,304) disease, breast cancer, epilepsy, high cholesterol, major depression, was observed and it reached a total of 2.4 million claims. rheumatic heart disease, glaucoma, prostate cancer, psychosis, NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 38 FIGURE 25. NHF CARD SUBSIDY RATES of 422 locations. The new scheme also intensified competition among pharmacies that limited price increases for medications on Arthritis the NHF drug list. Asthma Breast Cancer A patient needs to be certified by a public or private provider BPH and be registered with the NHF to be eligible for benefits. By the Diabetes 2009 fiscal year, over 80 percent of those enrolled for the NHF Card Epilepsy Glaucoma were over 45 years of age. There are almost twice as many females High Cholesterol (64 percent) as males enrolled for the NHF Card. Once approved, Hypertension the patient receives a magnetic swipe card with which to purchase Isch Heart Disease drugs from participating pharmacies at rates negotiated by the Major Depression NHF. Beneficiaries may be asked to pay a pharmacy fee of up to Prostate Cancer JM¢60 (US¢0.80) per item. Psychosis RFH Disease Vascular disease Eligible beneficiaries can enroll in the NHF Program at any 0% 10% 20% 30% 40% 50% 60% 70% 80% government health center, the national council for senior citizens, or the NHF head office and its branches by providing the national identification card and documents certifying their age. Application Source: 2009 Annual Report, National Health Fund (NHF, 2009 documents for both JADEP and NHF enrollment are available online Annual Report 2009) through the NHF website. Personal appearance for enrollment in the JADEP program is not required for seniors as long as they FIGURE 26. NHF CARD ENROLLMENT BY submit the required documentation through an entrusted person. CASES The number of JADEP enrollees is gradually increasing owing to active outreach and public information programs. The overall number of claims satisfied for NHF and JADEP during 2008 fiscal year reached 2,601,729 prescriptions (Figure 27). FIGURE 27. NHF INDIVIDUAL BENEFITS BETWEEN 2003 AND 2009 – NUMBER OF CLAIMS PAID BY NHF CARD AND JADEP Thousands Individual Benefits Paid Claims 250 200 150 100 Hypertension High Cholesterol Glaucoma Major Depression 50 Arthritis Vascular Asthma Psychosis 0 Diabetes Ischaemic Heart Benigh Prostatic HYP Prostate Cancer Aug-03 Feb-04 Aug-04 Feb-05 Aug-05 Feb-06 Aug-06 Feb-07 Aug-07 Feb-08 Aug-08 Feb-09 Epilepsy Source: 2009 Annual Report, National Health Fund (NHF, 2009 Source: 2009 Annual Report, National Health Fund (NHF, 2009 Annual Report 2009) Annual Report 2009)) NHF Revenue Sources and Allocations More people are taking advantage of the Program with an increase in the numbers enrolled in the NHF Card Program. In The NHF collects its revenues from tobacco excise tax, special 2007, the total number of cases of illnesses for which the NHF consumption tax (imposed on petrol, alcohol, and motor vehicles) Card beneficiaries were eligible reached 436,555 or an average and payroll tax on annual earnings paid by employees and of 2.53 cases per individual. In the 2008 fiscal year, a 20 percent employers (Strachan 2010). Figure 28 illustrates the distribution increase in the NHF enrollment rate (from 291,390 to 350,304) of NHF revenue sources between fiscal years 2003 and 2008. was observed and it reached a total of 2.4 million claims. The NHF has provided its beneficiaries with flexibility in choosing a pharmaceutical provider, which has raised the demand for private health services. In 2008, over 90 percent of claims were filled by private providers, with a network that expanded to a total JAMAICA’S RESPONSE TO NCDS 39 FIGURE 28. NHF SOURCES OF REVENUE Approximately 36 percent of Jamaicans (33 percent of men and 40 percent of women) reported having heard of JADEP. Awareness was REVENUE ($Million) lowest in the 15–24 age group and highest in the over-65 age group 3,500.00 3,00.00 (52 percent). Within all age groups, there was higher awareness 2,500.00 among females than males. 2,000.00 1,500.00 1,000.00 Small differences exist between urban and rural dwellers in 500.00 0.00 awareness and enrollment for the NHF Card. A higher proportion 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 of urban males than rural ones is aware of the NHF Card but among EXCISE 5%SCT PAYROLL TOTAL females the reverse is true. There are no differences in awareness of the JADEP program between urban and rural groups. Of the Source: National Health Fund presentation to the World Bank team, 2009 60-and-over age group, 23.7 percent (28.5 percent of women and 18.4 percent of men) were enrolled in the JADEP program. The most common reasons for the use of the NHF/JADEP cards were the The tobacco excise tax contributed the largest share (23 desire to save (86.8 percent) and encouragement from a healthcare percent) up to 2006, when the major national tobacco producer professional (14.3 percent). (Carreras Limited) relocated to Trinidad and Tobago. From 2006 to the present, payroll taxes have contributed most of the NHF budget, Enrollment of persons with eligible disease conditions has been namely 50 percent in 2006/07, 53 percent in 2007/08, and 44 relatively low as of 2008. Table 13 shows the proportion of eligible percent in 2008/09. By the end of 2008, payroll taxes contributed persons who access NHF Card and JADEP benefits. Uptake of benefits JMD500 million (US$6.69 million) more than excise and special for eligible conditions under the NHF Card Program was reported in consumption taxes. In 2009, the tobacco excise tax contributions less than 50 percent of cases overall. Benefits were accessed in more increased again, making up 28 percent of the total (Strachan than 50 percent of cases among females only for cases of glaucoma 2010). Meanwhile, the major share of NHF funds is allocated to the (57 percent), diabetes mellitus (52 percent), and high cholesterol Individual Benefits Program (Figure 29). (51 percent), and among males for stroke (59 percent). The highest uptake rates are for diabetes mellitus (50 percent), glaucoma (49 FIGURE 29. NHF INCOME ALLOCATION IN percent), and high cholesterol (47 percent). Conditions with the 2008 (%) lowest uptake of benefits include asthma (12 percent), mental health problems (1 6 percent), and enlarged prostate (26 percent). 70 63 60 55 Less than half of the JADEP eligible population is enrolled in the 50 Program. Only ten percent of those stating they were hypertensive 40 are enrolled in JADEP. The highest uptake of JADEP benefits is 30 for cancer (100 percent of men and 47 percent of women) while 21 18 20 16 there was moderate uptake by both sexes for diabetes mellitus, high 9 10 7 6 4 cholesterol, glaucoma, and circulation and for asthma and arthritis 0 0 1 0 among females and enlarged prostate among males. Trust Fund Institutional Individual Administrative Public Surplus Benefits Benefits Costs Infrastructure Cost Budgeted Actual Source: Formal presentation of the NHF finance and institutional benefits to the World Bank mission Program Awareness and Enrollments Awareness of NHF Card and JADEP among Jamaicans is high. The Jamaica Health and Lifestyle Survey conducted in 2007-8 among 2,848 respondents aged 15–74 years identified that 77 percent of the population (74 percent of men and 80 percent of women) had heard of the NHF Card program and 9.5 percent (7.1 percent of men and 11.9 percent of women) were enrolled in the NHF Card program. A higher proportion of women across all age categories has heard of the NHF Card with older women were more aware of the services than younger women while the proportion of men who have heard of the fund did not vary significantly with age. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 40 TABLE 12. PERCENTAGE OF ENROLLMENT IN NHF CARD AND JADEP PROGRAM BY AGE GROUP AND GENDER NHF CARD JADEP AGE GROUPS EVER HEARD ENROLLED EVER HEARD ENROLLED MALE FEMALE ALL MALE FEMALE ALL MALE FEMALE ALL MALE FEMALE ALL 15–24 69.1 72.3 70.7 2.5 2.9 2.7 14.4 24.3 19.4 0 0 0 25–-34 72.6 77.9 75.4 1.3 2.4 1.8 21.9 35.7 29.2 0 0 0 35–44 74.4 79.5 77.0 4.5 8.7 6.6 44.9 41.0 42.9 0 0 0 45–54 79.3 87.3 83.3 13.0 19.2 16.0 53.0 54.0 53.5 0 0 0 55–64 76.7 89.8 83.1 17.3 29.7 23.4 44.8 56.7 50.7 5.1 8.3 6.7 65–74 74.2 87.9 81.4 28.5 54.5 42.0 45.4 57.5 51.7 22.3 34.3 28.6 Total 73.5 79.7 76.7 7.1 11.9 9.5 32.9 39.6 36.3 1.9 3.0 2.5 Source: JHLSII, 2008 (Wilks, et al. 2008) NHF and JADEP enrollment is increasing considerably over time. TABLE 13. DISEASE CONDITIONS OF NHF CARD According to NHF administrative data (Figure 30), enrollments for AND JADEP BENEFICIARIES NHF increased from 50,000 in December 2004 to 260,000 in July DISEASE NHF CARD PROGRAM JADEP PROGRAM CONDITION 2010 – a fivefold increase in six years. JADEP participants increased MALE FEMALE TOTAL MALE FE- TOTAL MALE from 100,000 to 220,000, resulting in a total of 480,000 program Heart Disease 33.3 33.5 33.4 13.0 52.4 39.1 beneficiaries by the summer of 2010. Diabetes 47.1 51.6 49.8 45.6 37.0 40.7 Mellitus FIGURE 30. NHF CARD AND JADEP ENROLLMENT BETWEEN 2003 AND 2010 Glaucoma 41.5 56.9 49.4 39.1 37.2 37.8 Hypertension 33.0 27.8 29.2 12.6 9.1 10.0 500,000 High 38.9 51.4 47.1 36.7 49.1 45.6 400,000 Cholesterol 300,000 Stroke 58.7 28.6 42.1 17.8 19.3 18.5 200,000 Kidney 11.0 15.1 13.4 0 100 25.0 100,000 Disease - Jun-03 Feb-05 Dec-05 Mar-07 Jan-08 Jun-08 Feb-10 Jul-05 May-06 Jul-10 Apr-04 Sep-04 Aug-07 Sep-09 Oct-06 Apr-09 Nov-03 Overweight/ 6.8 18.9 16.1 22.6 36.6 34.8 Nov-08 Obese Circulation 40.3 38.0 38.6 48.0 33.1 37.6 NHFCARD JADEP ALL Enlarged 26.1 N/A 26.1 45.6 N/A 45.6 Source: NHF 2009 (NHF, 2009 Annual Report 2009) Prostate Arthritis 30.9 42.0 39.7 25.3 41.5 37.2 Sickle Cell 0 11.6 8.7 N/A N/A N/A The JHLSII 2007–8 Report summarized the main reasons given Disease for non-participation by those eligible for NHF. The main reasons Asthma 10.1 12.8 11.7 0 54.6 28.0 given were difficulty with the enrollment process and not wanting to make the effort, while having other health insurance and the Cancer 43.1 48.5 47.1 100 47.1 51.2 lowness of the subsidies were other reasons given. Only very few Mental 8.2 21.6 16.3 0 25.4 17.0 people did not enroll in for lack of qualifying information or birth Health certificate, or because drugs were not covered. Not meeting the age Problems criterion excluded over 70 percent of otherwise eligible people from Epilepsy 0 10.5 7.0 0 37.5 37.5 enrolling in the JADEP Program. Source: JHLSII, 2008 (Wilks, et al. 2008) JAMAICA’S RESPONSE TO NCDS 41 Of the persons participating in the NHF Card or JADEP Programs, for cardiovascular diseases. The programs also address only about a quarter used their NHF and JADEP cards on a regular hypertension. basis (Table 14). There was no significant difference in the amount • Diabetes Mellitus: The efforts in this area are mainly of regular usage of each of these cards: 10 percent more males activities for promoting general awareness of risk factors than females never used their JADEP card, while the proportion was for chronic diseases and guidance to adopt supportive roughly the same for female and male NHF Card participants. Over lifestyles and behavior in communities. 85 percent of those enrolled for the NHF Card and JADEP used their • Cervical Cancer Screening: The MOHE Cervical Cancer benefit cards. Encouragement from a healthcare professional was Screening program targets adult women aged 25–54 given as a common reason for using both cards. years of age at risk for cancer of the cervix. The number of women screened increased by 18 percent from 49,754 in TABLE 14. NHF AND JADEP CARD USAGE 2006 to 58,648 in 2007. Screening is conducted by public AMONG ENROLLEES BY GENDER (%) health nurses and midwives in the field. The Jamaica Cancer Society also screens for cervical cancer, reaching NHF JADEP an additional 24,378 women in 2007. MALE FEMALE TOTAL MALE FEMALE TOTAL • Breast Cancer Screening: The Jamaica Cancer Society also Never 23.5 23.9 23.8 24.6 14.3 18.1 provides breast cancer screening services. In 2007, 7,102 people received mammograms, and 23.2 percent of these Seldom 24.8 19.5 21.4 5.1 9.3 7.7 occurred in a mobile unit. Women aged 40–49 were at the Occasion- 20.2 16.9 18.1 24.6 28.0 26.7 highest risk of breast cancer, accounting for 39 percent of ally those having mammograms. Regular 31.6 39.6 36.7 45.6 48.4 47.4 Source: JHLSII, 2008 (Wilks, et al. 2008) HEALTHY LIFESTYLE PROGRAM The national policy for the promotion of healthy lifestyles CHRONIC DISEASE PREVENTION PROGRAMS in Jamaica is intersectoral. It involves the public and private sectors, government and non-governmental organizations, and The government’s National Strategic Plan, “Vision 2030 communities to address critical health issues. The goal of the policy Jamaica�, 2009, aims to advance the country’s status to developed is to decrease the incidence of chronic diseases, high-risk sexual nation by 2030. With guiding principles of social cohesion, equity, behavior, violence, and injury through behavior change among all and sustainability, its goal is to provide citizens with the best age groups but with a focus on youth and adolescents. quality of life and world-class standards in education, healthcare, nutritional status, basic amenities, access to environmental The government plans to implement healthy lifestyle policies goods and services, civility, and social order. The national health in line with Vision 2030. These policies aim at empowering strategies for 2006–2015 seek to expand the healthy lifespan of its communities, developing healthy lifestyle skills, building more people and encourage the population to take greater responsibility green-zone recreational facilities, encouraging smoke-free for their own health. The MOHE encourages health promotion via environments, supporting school and household nutrition education activities in the national curriculum to influence youth and mental-health programs, taking into account the gender to change behavior to reduce the incidence of chronic diseases, dimension, and providing reproductive health services (Planning high-risk sexual behavior, and violence. The government promotes Institute of Jamaica 2009). physical activity, healthy diet, marketing of healthy foods, and reduction of alcohol and tobacco use through the education sector A government project under the healthy lifestyle national policy and in cooperation with the mass media, NGOs, and other national seeks to improve health status through improved socioeconomic and international avenues. conditions, addressing cultural issues, and changing dietary habits. As part of the overall strategy, the project aims to build The MOHE Chronic Disease Unit is implementing prevention awareness of healthy lifestyles through media shows, educational programs for NCDs, including diabetes, hypertension, cancer, and activities at workplaces, schools, clubs, churches, communities, coronary artery disease (Ministry of Health Jamaica 2009). These sport facilities and health facilities, and the integration of behavior are described below: modification activities into treatment programs for those affected by lifestyle diseases. More specific project objectives will address • Cardiovascular Disease: The Heart Foundation of Jamaica chronic diseases and reproductive health issues, and reduce risky focuses on educational intervention and screening programs behavior. The project promotes higher levels of physical activity, to reduce the incidence of death from heart disease. Services increased availability and consumption of healthy foods, and offered include heart screening, counseling and education, reduced smoking. On reproductive health, the project aims to reach home visits, and tobacco cessation programs. The MOHE pre-adolescents, adolescents, and youth through educational initiated smoking prevention among adolescents but does interventions. The project also seeks to address behavior leading to not have intervention programs specifically designed violence, unintentional injury, and suicide. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 42 A major component of the Healthy Lifestyle Program includes several projects that target specific population groups to promote health: • The Healthy Lifestyle School Program introduces a cheerleading program that goes beyond promoting the physical activity, sharing information on the risks of unprotected sexual activity, drug usage, unhealthy eating habits, conflict resolution, and environmental concerns. • The Healthy Zones Program is the community-based physical-activity-promotion program that encourages its members to work closely with each other to foster a healthy way of life. • The Camp Yellow Bird Program provides children and adolescents affected with diabetes with an active and safe camping experience, offering education on diabetes and management skills. • The Teens “R� Terrific Program trains teens to be promoters through involvement in camps where they develop life skills and develop plans for sharing knowledge when they return to their schools and communities. • The Camp for the Healthy Way is a behavioral intervention targeting obese young people aged 10–19 attending secondary-level schools (primary and junior high, high, and technical) across Jamaica, providing participant follow-up over a period of a year to track improvements in their body mass index (BMI). • The Workplace Wellness Program combines efforts by employers and employees to improve the health and wellbeing of people at work. • Community Health Days, Health Fairs and other sponsored events are interventions to make public information prepared by the NHF to encourage Jamaicans to take responsibility for their own health. There is very little information on the results or impact of these prevention programs in Jamaica. Despite many prevention programs having been implemented or under implantation, there is little data on coverage, results and effectiveness of these programs. This chapter has examined the response of Jamaica to NCDs and considered the success and shortcomings of its policies and programs. The next chapter will assess the impact which some programs have had on the lives of people in Jamaica, distinguishing the impact on the different demographic sub-groups in the country. IMPACT OF NCD-RELATED POLICIES AND PROGRAMS ON PEOPLE’S LIVES 43 6. IMPACT OF NCD- RELATED POLICIES AND PROGRAMS ON PEOPLE’S LIVES This chapter assesses the initial impact of compared to non-chronic disease patients. Jamaica’s NCD Programs on people’s lives. The hypothesis is that, by providing free Previous sections of this study illustrated an or subsidized medicines to eligible NCD effort by the government of Jamaica to assist patients, the NHF would reduce NCD patients’ financially people living with NCDs. No impact out-of-pocket expenditure and make their evaluation has been carried out to assess the treatment more affordable and that therefore effectiveness of these programs. This study NCD patients would be more likely to avail uses available data to measure the impact themselves of health services than those of the NHF. It was established in 2003 and it patients without chronic disease. Because of is still too early to assess the full impact on the government’s policy of abolishing user- NCDs. Data to assess the socioeconomic fees at public health facilities, which was impact of the prevention and control programs introduced in 2008 and which may affect are very limited. Nevertheless, repeated cross- healthcare utilization of both NCD patients and sectional Jamaica Living Conditions Surveys non-chronic disease patients, the analysis of provide nationally representative data on the impact of the NHF applied data for 2007 individual and household healthcare utilization, and earlier so as to rule out the impact on the giving a unique opportunity to assess changes results of removing user-fees in public health in patterns of seeking healthcare before and facilities. There are other confounding factors after the introduction of the NHF. that influence healthcare-seeking behavior, however, which this study cannot control. The chapter considers which population Thus the analysis does not attempt to attribute groups benefit most from the NHF Program healthcare-seeking behavior changes solely to to determine (a) whether its establishment the introduction of NHF, but rather to compare has helped to reduce out-of-pocket spending utilization patterns before and after the on healthcare for NCD patients, and (b) how implementation of the policy. patients with NCDs utilizing healthcare fared NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 44 HAS HOUSEHOLD HEALTHCARE EXPENDITURE Key Findings ON NCDS DECLINED? The analysis has found that expenditure on medicines declined 1. The NHF drug subsidy program has achieved its overall in recent years and faster for households with a member primary goal of making NCD drugs more affordable. with chronic disease than for households with a patient with a NCD patients under the NHF paid less for disease that is not chronic. After ruling out the effect of time trend pharmaceuticals than NCD patients without it. changes on household socioeconomic characteristics, household per-capita healthcare expenditure presents as an inverse U curve 2. Prescribing drugs constitutes treatment and does not (Figure 31), with the turning point around 2001–2002. Although prevent disease. households with patients with chronic disease spent more on medicines in each year, the gap between these and households with a patient suffering from a non-chronic disease reduced 3. NHF and JADEP card coverage remains limited and significantly, from JMD1500 (US$20.07) in 1994 to only JMD600 uneven, despite broad awareness among Jamaicans. (US$8.03) in 2007. While this result does not directly support the conclusion that it was the introduction of NHF and JADEP that led 4. Distribution of NHF benefits is unequal among to reduced medicine expenditure for patients with chronic disease, socioeconomic groups. The rich benefit more from the converging trend for the two types of household suggests at the the drug subsidy program and spent 36 percent less least that the household burden of NCDs experienced in the 1990s on drugs in 2007 than they did in 2000 before the was reduced from the early 2000s. establishment of NHF. They are also more likely to join NHF and JADEP Programs. The NHF has not reached Time trends analysis used to examine household annual health the poor; reduction in drug expenditure of the poor expenditure. The analysis looks at two components: (1) household was less than 2 percent between 2000 and 2007. expenditure on medicine including pills, tonics, drugs, family- planning supplies, herbal medicines, mechanical contraceptive devices, condoms, IUDs, etc.; and (2) household medical service 5. People with NCDs in general spent less on expenditure including doctor’s fees, hospital care, prescriptions, pharmaceuticals but more on medical services. spectacles, and laboratory fees. Historical healthcare expenditure data are derived from JSLC during the period 1994–2007. 6. The total medical expenditure for NCDs did not show a reduction after the introduction of the NHF as the The primary goal in this analysis was to determine whether savings on pharmaceuticals were spent on more households with chronic-disease patients spent more on medical consultations. healthcare than households with a member with a non-chronic disease before and after the introduction of NHF. Similar to other time trend analyses in this report, a regression model was used to 7. The increase in healthcare facility visits is largely adjust for demographic and socioeconomic changes in healthcare due to a huge increase in attendance by the richest expenditures. Explanatory variables included in the regression persons with NCDs. model are region of household residence, population quintile, household member disease type (chronic or non-chronic disease), household member health insurance cover, household sanitation characteristics (toilet, lighting, and water source), and household per-capita alcohol and tobacco use. Time variables captured the trend over time. Household per-capita expenditure instead of individual expenditure is used for this analysis because survey questions at the household level are consistent in JSLC over the study period. The study sample therefore focused on households that have at least one member suffering from chronic or non- chronic diseases12. 12 Households are excluded from regression if both chronic and non-chronic dis- ease members are present IMPACT OF NCD-RELATED POLICIES AND PROGRAMS ON PEOPLE’S LIVES 45 FIGURE 31. ADJUSTED ANNUAL PER-CAPITA NCDs reduced their medicine and prescription drug expenditure on DRUG EXPENDITURE FOR HOUSEHOLD average by roughly 10 percent in 2006 and 2007 after the NHF WITH CHRONIC DISEASE PATIENT AND drug purchase subsidy program was introduced, relative to 2000 HOUSEHOLD WITH NON-CHRONIC DISEASE and 2001. In contrast, medical service expenditure presents an PATIENT (2008 JMD) upward pattern from JMD27,755 (US$371.36) per capita in 2000– 2001 to JMD28,817 (US$385.57) per capita in 2006–2007, an 5000 4500 increase of around JMD1,000 (US$13.38) during this short period 4000 (Figure 33). It should be noted that affordable drugs did not only 3500 result from NHF and JADEP cards; the NHF 2008 Report pointed 2008 JMD 3000 2500 to responsive behavior by pharmaceutical providers as a result of 2000 increased competition that limited price increases, especially as 1500 1000 new generic brands for active ingredients on the NHF Drug List 500 were introduced onto the market. 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 year household with non-chronic patient household with chronic disease patient The absolute difference between poor and rich is narrowing in drug expenditure after NHF implementation but the richest quintile benefited most from the program in terms of reduced spending *adjusted for household socioeconomic characteristics on drugs. Figure 33 also summarizes the healthcare expenditure Source: Studies estimates based on JSLC 1994–2007 pattern for the poorest NCD population (population quintile 1) and richest NCD population (population quintile 5). Although the gap In contrast to the pattern observed in medicine expenditure, between poorest and richest quintiles in spending on prescription the cost of medical services for households with a member with a and other medicines reduced, with a nearly 90 percent decrease chronic disease was consistently higher than for households with from JMD38,700 (US$517.81) to JMD20,480 (US$274.02) from a member with a non-chronic disease. This reflects a time trend 2000 to 2007, this reduction was driven primarily by the cost between households that is generally in parallel. In 1994, the saving among the richest population, while the poorest population cost for a family with a member with a chronic disease was nearly incurred more or less the same expenditure. By contrast, the double that for a family with a member with a non-chronic disease; disparity between poorest and richest in medical service expenditure after 15 years, the cost disparity remains double between the two is greater, with the poorest spending less. types of families (Figure 32). In general, medical services impose an increasingly heavy out-of-pocket economic burden on households FIGURE 33. INDIVIDUAL ANNUAL13 MEDICAL whose members are suffering from any type of disease. EXPENDITURES BEFORE AND AFTER NHF PROGRAM AMONG NCD POPULATION (IN FIGURE 32. ADJUSTED ANNUAL PER-CAPITA 1000 2008 CONSTANT JMD) MEDICAL EXPENDITURE FOR HOUSEHOLD WITH AND WITHOUT CHRONIC DISEASE Richest 20 percent Medical service PATIENT (IN 2008 JMD) expenditure Poorest 20 percent 15000 All Population 12000 prescription drug Richest 20 percent medicine and 2008 JMD 9000 expenditure Poorest 20 percent 6000 All Population 3000 0 $0 $10 $20 $30 $40 $50 $60 $70 $80 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 year 2006 and 2007 2000 and 2001 household with non-chronic patient household with chronic disease patient *adjusted for major household socioeconomic characteristics *adjusted for major household socioeconomic characteristics Source: Studies estimates based on JSLC 1994–2007 Source: Studies estimates based on JSLC 1994–2007 The analysis concludes that people with NCDs in general spent less on medicines and prescription drugs but more on medical 13 Two-year expenditure data were combined and annualized for before-NHF services. Pre- and post descriptive statistics confirm the results of period 2000 and 2001 and after-NHF period 2006 and 2007, in order to expand the time-trend analysis and suggests that individuals suffering from study sample size NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 46 Richer people are the major beneficiaries of NHF card and HAVE HEALTH SERVICE VISITS INCREASED? JADEP Program. More NHF Card and JADEP beneficiaries come from the upper income quintile levels. Among the population Health service visits among NCD patients showed an upward eligible for the NHF Card, the probability14 of enrollment is 11.2 trend as opposed to a fairly flat curve among non-NCD patients. percentage points higher for the richest at 19.0 percent, while the Figure 35 illustrates that NCD patients on average had more probability of enrollment for the poorest is only 7.8 percent; among healthcare visits than non-NCD patients, and this gap was the population eligible for the JADEP Program, the difference in substantially larger, rising from 3.8 percent in 1990 to 18.0 percent probability of enrollment is similar at 11.2 percentage points, with in 2007, almost a six fold increase in 17 years. Although it is hard a probability of 15.4 percent for the poorest and 26.6 percent for to conclude that it is the implementation of NHF programs that led the richest (Figure 34). The disparity in enrollment between poor to this profound change in care-seeking behavior, NCD patients are and rich implies that NHF has not effectively targeted the poor. obviously accessing healthcare services more. The data also show that females, the elderly, urban residents, those currently of poor health status by their own report, and those who FIGURE 35. ADJUSTED HEALTH SERVICE already have medical insurance are more likely to enroll in NHF. VISITS (%) FOR INDIVIDUALS WITH AND WITHOUT NCDS FIGURE 34. PROBABILITY OF NHF AND 80% JADEP ENROLLMENT AMONG ELIGIBLE 75% POPULATION BY EXPENDITURE QUINTILES 70% 65% % visit 60% 30% 55% 50% 25% 45% 40% 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20% year non-chronic chronic 15% *adjusted for major household socioeconomic characteristics Source: Studies estimates based on JSLC 1990–2007 10% The analysis given above in respect of health services followed 5% the same methodology to determine whether individuals with and without NCDs had the same level of visits over time, especially 0% before and after NHF introduction in 2003–2004. Explanatory Poorest 2nd 3rd 4th Richest variables included in the regression model include age, gender, quintile quintile quintile education, region of residence, disease type (chronic disease or non-chronic disease), health-insurance cover, population quintile, NHF eligible JADEP eligible and marital status. Again, time variables captured the trend over time. The primary goal of this analysis was to determine whether Source: Studies estimates based on JSLC 2008 individuals with and without NCDs had the same level of health service visits across time, especially before and after NHF. Therefore NHF funds did not achieve their desired goal in reducing drug the study sample focused on all adult individuals suffering from cost, viewed from a welfare-economics perspective. The richest chronic or non-chronic diseases. Healthcare service visits include population who could afford drug expenditure before the program any visit to a doctor, nurse, pharmacist, midwife, healer, or any were actually better off, and the poorest quintile that are the policy other health practitioner. JSLC 1990–2007 served as the data target remained in the same situation with or without NHF funds. source for this analysis. The JSLC survey did not provide enough data to evaluate the reasons behind the substantial decrease in medicine and drug costs and the Pre- and post-descriptive statistics confirmed the time-trend increase of medical service expenditure for the richest. A possible analysis results that people with NCDs in general increased their interpretation is that the NHF and JADEP Programs attracted more utilization of health services. The proportion of people living with rich than poor; hence, the overall drug cost reduction is larger for NCDs has increased over time. The NCD population visiting health the rich. Although the reason for the poor to opt out is unclear, co- service facilities increased by approximately 5–6 percent, from 70 payment and concerns over application processes may play a role. percent in 2001 to 76 percent in 2006, after implementation of the Program (Table 15). The average number of visits per patient 14 Probability of enrollment is predicted by a binary choice model, controlling for slightly decreased (1.6 versus 1.3) before and after NHF. The individual basic socioeconomic characteristics including gender, age, self-re- ported health status, population quintiles, marital status, and medical insurance proportion of public-facility visits, including public hospitals and coverage public centers, did not reveal a significant change (45 percent IMPACT OF NCD-RELATED POLICIES AND PROGRAMS ON PEOPLE’S LIVES 47 versus 44 percent). With regard to prescription drug purchases, pre- and post-descriptive statistics for the whole NCD population did not show a noticeable difference either. During this period health insurance coverage expanded rapidly, however, from only 13 percent for NCD patients in 2001 to 24 percent in 2006, almost doubling in 5 years. TABLE 15. INDIVIDUAL HEALTH SERVICE UTILIZATION BEFORE AND AFTER THE NHF PROGRAM AMONG NCD POPULATION 2000 AND 2001 2006 AND 2007 ALL NCD POOR- RICHEST ALL NCD POOR- RICH- POPULA- EST 20% POPULA- EST EST TION 20% TION 20% 20% Health 70 71 69 76 73 77 service visits (%) Number of 1.6 1.7 1.5 1.3 1.3 1.2 visits Public 45 69 31 44 64 28 facility visits (%) Medication 79 66 85 78 72 81 purchase (%) Insurance 13 4 26 24 17 35 Coverage (%) Source: Studies estimates based on JSLC 2000, 2001, 2006 and 2007 This chapter has examined the impact of the country’s policies and programs on the different groups of people in Jamaica; the following chapter turns to a consideration of the economic impact of NCDs on society and on the individuals in these different groups. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 48 7. ECONOMIC Key Findings IMPLICATIONS OF 1. NCDs have resulted in a large direct and indirect NCDS economic burden for individuals in Jamaica. An average individual suffering from NCDs uses approximately one-third of household income (JM$55,503) on healthcare services and medicine This chapter estimates the economic purchases. burden of NCDs on individuals, 2. Direct healthcare costs associated with NCDs were including direct costs from outpatient regressive, imposing a greater burden on poor households than on better-off households. visits, inpatient care, purchase of 3. Hypertension was by far the most costly chronic medicines, and indirect costs from condition, followed by diabetes and arthritis, while income loss associated with the indirect income loss associated with arthritis was the largest. disease. The analysis in this chapter 4. The richest population quintile incurred an economic includes an assessment of the burden from NCDs almost seven times the national aggregate compared to the poorest. economic burden resulting from the four most prevalent, costly, and 5. National aggregate out-of-pocket health expenditure amounted to JM$33,813 million (US$452 million), or disabling chronic conditions in Jamaica: 3.08 percent of Jamaica’s GDP. The total economic burden on individuals including indirect income loss asthma, diabetes, hypertension, and is estimated at JM$47,882 million (US$641 million) annually in Jamaica in the period 2006–2007. arthritis. This chapter also includes a trend analysis of household out-of- pocket expenditure owing to NCDs during the period from 1994 to 2007. ECONOMIC IMPLICATIONS OF NCDS 49 NCDs not only adversely impact quality of life through NCDs have resulted in an enormous direct and indirect economic morbidity or mortality, but also impose an economic burden on burden for individuals in Jamaica. In 2006 and 2007, average households and on society as a whole. For example, a 1999 study annual individual direct out-of-pocket healthcare costs accounted in Jamaica found that nearly 57 percent of persons diagnosed with for 71 percent of the total economic burden associated with NCDs cancer, diabetes, or a mental health illness had to forego treatment (Figure 36), and on average amounted to JMD55,503 (US$742) per due to their inability to pay (Henry-Lee and Yearwood 1999). person per year, or approximately one-third (36 percent) of annual Understanding the economic implications of NCDs on individuals household per-capita expenditure for NCD patients. Among three and on society is essential for policy-makers for the design of categories of direct out-of-pocket expenditure for healthcare, the interventions for prevention and treatment. most costly component is the purchase of medicines (33 percent of the average economic burden), followed by outpatient visits (20 Disparities in the economic burden of NCDs exist by age, gender, percent), and inpatient care (18 percent). Another 29 percent of income group, insurance cover, and type of disease. An average the economic burden of NCDs comes from indirect income loss of individual suffering from NCDs spends approximately one-third individuals resulting from work absenteeism, about JMD23,008 of household per-capita expenditure on healthcare services and (US$307.80) per person per year. purchases of pharmaceuticals. National aggregate out-of-pocket health expenditure amounted to JMD33,813 million (US$452 FIGURE 36. AVERAGE INDIVIDUAL ANNUAL million), or 3.08 percent of Jamaica’s GDP. The 2006 and 2007 ECONOMIC BURDEN OF NCDS IN JAMAICA annual average total economic burden of NCDs on individuals, 2006 AND 2007 (2008 CONSTANT JAMAICA including indirect income loss, is estimated at JMD47,882 million DOLLARS) (US$641 million). The poorest, the elderly, and persons with hypertension spent more on healthcare, indicating important targets for government intervention. It should be noted that the estimates of the economic burden Indirect Outpatient of NCDs in this chapter have several limitations. First, the data on income loss visits, 155217 health condition and medical expenditure are self-reported. Second, $23,008 2% the estimates focus on a finite number of conditions listed in the 29% survey, excluding other conditions such as cardiovascular disease. Inpatient Third, although household per-capita expenditure is a good proxy care, 142429 for individual annual earning, the measure of income loss suffers 4% from a lack of information on individual work status. Fourth, the Medicine measure of indirect economic burden does not include reductions purchase, 25 in productivity, cost of years of life lost owing to premature 73812% mortality, and the value of activity days lost owing to disability or morbidity; nor are medical insurance premiums and preventive health-seeking activities included. Finally, the estimation of the economic burden was based on household expenditure and did not Source: Studies estimates based on JSLC 2006, 2007 include the cost of provision for treatment and services. ECONOMIC BURDEN OF NCDS AT INDIVIDUAL Patients spent much more at private facilities for outpatient AND HOUSEHOLD LEVELS visits, inpatient care, and the purchase of pharmaceuticals. As Figure 37 illustrates, NCD healthcare expenditure in private facilities The analysis in this chapter focuses on economic burden at for outpatient visits and inpatient care is threefold the expenditure the individual as well as the household level. The direct economic in public facilities, and tenfold for medication purchases. burden at individual level is the sum of out-of-pocket spending by NCD patients on outpatient visits, inpatient care, and medication. The indirect economic burden of NCDs is from loss of income owing to work absenteeism associated with illness15. 15 Indirect income loss is estimated as the number of days in a year that work- ing patients are unable to carry out normal activities due to chronic conditions, multiplied by household total expenditure, and divided by the number of adults in the households (aged 18–59), as a proxy for individual adult annual earnings. Children and adolescents (0–17), and seniors (60 and older) are assumed not to be economically productive. All monetary values are annualized and adjusted to 2008 constant Jamaica dollars. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 50 FIGURE 37. INDIVIDUAL ANNUAL DIRECT Beneficiaries of the two NHF programs spent significantly HEALTHCARE COST SPENT IN PUBLIC AND less than non-beneficiaries. About 17 percent of individuals with PRIVATE HEALTH FACILITIES ATTRIBUTABLE chronic conditions were enrolled in either the NHF Card or the TO NCDS (2008 JMD) JADEP program in 2006–2007. As shown in Figure 38, NHF or JADEP beneficiaries spent approximately the same amount out of $30,000 pocket on outpatient visits and medication as non-beneficiaries. $25,000 $2,704 Non-beneficiaries incurred five times more for inpatient care than $20,000 NHF/JADEP beneficiaries, however, resulting in considerably $15,000 lower total healthcare costs for NHF/JADEP beneficiaries. The $4,160 $3,445 $10,000 $23,010 huge discrepancy in expenditure on inpatient care is largely $5,000 $11,349 $10,790 explained by more non-beneficiaries using inpatient care service $0 than beneficiaries (6 versus 2 percent). It is important to note Outpatient visits Inpatient care Medicine purchase that although NHF and JADEP beneficiaries did not have reduced Private Health Facility Public Health Facility expenditure on prescription drugs relative to non-beneficiaries, it is premature to conclude that the Program failed its intended Source: Studies estimates based on JSLC 2006, 2007 policy impact. It is likely that patients use the savings from NHF/ JADEP benefits on more frequent outpatient visits or inpatient care. Another possibility is that sicker people are more likely to The presence of insurance cover is associated with only a participate in NHF/JADEP programs than healthier ones, spending limited reduction in out-of-pocket healthcare spending for NCDs. more therefore on out-of-pocket health expenditure. A more Only one-fourth of individuals with NCDs were covered by some rigorous research design is needed to evaluate the policy impact of type of medical insurance in 2006–2007. The impact of medical the NHF and JADEP programs on people with chronic conditions. insurance cover on NCD out-of-pocket health expenditure is limited: individuals with insurance cover incurred a slightly smaller Direct healthcare costs associated with NCDs were regressive (JMD6,431 or US$86.03 less) out-of-pocket healthcare expenditure and imposed a greater burden on poor households than on better- per year than individuals without insurance coverage (Figure 38). off households. The poor in general spent less on medical services owing to lack of access or medical insurance cover, inability The cost of inpatient care showed the largest difference to pay, or greater use of public services which charge less than between insured and uninsured (JMD5,817 versus JMD17,088, private facilities. Their spending amounts to a larger proportion or US$77.82 versus US$228.60), as insured spent three-fold less of household per-capita expenditure, however. During the period (Figure 38). Insurance does not appear to reduce out-of-pocket 2006–2007, the poorest quintile incurred mean direct costs of expenditure on prescription drugs or outpatient visits as insured JMD23,742 (US$317.62) and the richest quintile JMD11,2527 patients actually spent slightly more for these two categories than (US$1508.38), but the proportion of per-capita expenditure was the uninsured. This is probably because patients with insurance 40 percent for the poorest and 33 percent for the richest. This were more likely to use services. As a result, insured patients spent uneven distribution of direct out-of-pocket healthcare costs for 11 percent less than people without health insurance on all three NCDs in relation to economic status suggests the need for social direct healthcare costs. protection policies that favor the poor. FIGURE 38. INDIVIDUAL ANNUAL DIRECT Hypertension was the most costly chronic condition, followed HEALTHCARE COST ATTRIBUTABLE TO NCD by diabetes and arthritis, but indirect income loss was the largest for BY INSURANCE COVERAGE (2008 JMD) arthritis. Because total expenditures provide limited information about the drivers of the economic burden, we examine the $60,000 expenditure pattern for five major chronic conditions by socio- demographic characteristics. Table 16 shows that nearly 37 percent $50,000 $24,956 $24,942 of the total economic burden of four NCD conditions is attributable $40,000 $28,246 to hypertension (JMD86,700 or US$1159,87). This cost is $30,000 $29,548 significantly higher than for the other three conditions. These high $17,088 $17,138 $20,000 $5,817 costs were largely a result of the elevated costs of hospitalization $373 compared with other conditions. The second most costly category $10,000 $15,159 $16,709 $16,065 $12,918 is diabetes, which incurred JMD42,939 (US$574.52) direct $0 No Insurance With Insurance non NHF/JADEP NHF/JADEP healthcare costs and an indirect income loss of JMD13,000 beneficiary beneficiary (US$173.91). Arthritis had a comparable level of direct healthcare Outpatient care Inpatient care Medicine purchase cost to arthritis (JMD36,039 or US$482.13) but had the highest cost from indirect income loss of the four conditions (JMD17,755 Source: Studies estimates based on JSLC 2006, 2007 or US$237.53). Medical insurance and enrollment in NHF or JADEP was most common in patients with diabetes, 40 percent and ECONOMIC IMPLICATIONS OF NCDS 51 32 percent respectively, and least common among persons with ESTIMATED NATIONAL AGGREGATED OUT-OF- asthma. The economic burden of asthma was less than half that of POCKET EXPENDITURE ON NCDS hypertension patients, largely because such conditions did not lead to huge income loss from absenteeism and sick leave, and treatment Population estimates16 show that females, the elderly (age cost for the condition was also relatively lower. 60+), and those in the richest quintile are more likely to suffer from NCDs (Table 17). TABLE 16. ECONOMIC BURDEN OF FOUR MAJOR NCDS (2008 CONSTANT JMD) TABLE 17. ESTIMATED NCD PREVALENCE BY ASTHMA DIABETES HYPERTENSION ARTHRITIS SOCIO-DEMOGRAPHIC CATEGORY Total 37,261 55,939 86,700 53,795 PREVA- RELA- ESTIMATED economic LENCE TIVE POPULATION cost (%) RISK WITH CONDITION Direct 31,911 42,939 69,890 36,039 BY GENDER out-of- (23%) (28%) (37%) (23%) pocket Male 17.02 234,810 health- Female 25.28 1.48 365,627 care cost BY AGE GROUP (% of 0–17 9.31 97,397 house- hold 18–59 18.50 1.98 270,860 per-capita 60+ 66.41 7.13 228,581 expendi- BY POPULA- ture) TION QUINTILE Outpa- 9,321 12,698 15,281 11,7000 Poorest 17.18 97,098 tient visits Richest 26.74 1.55 151,130 Inpatient 1,272 3,027 29,928 0 BY FOUR care MAJOR NCDS Medicine 21,317 27,213 24,680 24,339 AMONG ENTIRE purchase JAMAICA Indirect 5,350 13,000 16,810 17,755 POPULATION income Asthma 4.47 126,318 loss Diabetes 4.90 1.09 138,470 Insurance 22.76% 40.53% 28.19% 28.34% Hypertension 10.41 2.32 294,179 Cover Arthritis 4.57 1.02 129,144 NHF/ 2.76% 32.02% 26.65% 28.19% Source: Studies estimates based on JSLC 2008 JADEP Cover National aggregate out-of-pocket health expenditure amounted Source: Studies estimates based on JSLC 2006, 2007 to JMD33,813 million (US$452 million) per year during 2006 and 2007, 3.08 percent of Jamaica’s annual GDP for that period (US$14.6 billion). The share of out-of-pocket expenditure on NCDs to Jamaican GDP compares with other developing countries such as India, for example. In 2004, Indians spent nearly 3.3 percent of GDP on out-of-pocket healthcare expenses associated with NCDs (The World Bank 2010). At the national level, the aggregate economic burden for females is comparable to that of males despite the fact that the prevalence of NCDs among females is significantly higher than among males. The 8 percent disparity in NCD prevalence between 16 Using the estimated total population of 2.826 million from the Central Intel- ligence Agency World Fact book for Jamaica in 2010 and reported NCDs from the JSLC 2007–8, while the number of people with NCDs was estimated by socio-demographic category. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 52 females and males indicates that the female population is at higher capita household expenditure: income loss for the richest group risk from chronic conditions but females in general accrued far was ninefold that of the poorest (JMD6,679 million versus JMD709 lower annual out-of-pocket healthcare expenditure (JMD44,791 or million or US$89 million versus US$9 million). US$599.21) and indirect income loss (JMD17,444 or US$233.36) than males (JMD74,259 and JMD32,752, or US$993.43 and Hypertension caused considerably higher aggregate direct US$438.15) on a per-capita basis. As a result, the national healthcare expenditure in all three cost categories, as well as aggregate economic burden for females amounted to JMD22,754 higher indirect income loss, than any of the other three conditions. million (US$304 million) per year, approximately the same level This represents 50 percent of the national economic burden of as for males at JMD25,127 million (US$336 million) (Figure 39). the four major NCDs. The primary cost driver for hypertension There are no detailed data to allow more indepth analysis on why is its prevalence, more than twice that of any of the other three females are at higher risk from NCDs, but had lower out-of-pocket conditions. High per-capita medical costs also drive hypertension to healthcare expenditure. such a high level. For persons with diabetes, over half of spending nationally is for prescription drugs; the remaining cost is for medical FIGURE 39. ESTIMATED NATIONAL treatment and indirect income loss. Prescriptions also accounted AGGREGATE ECONOMIC BURDEN OF NCDS for approximately 50 percent of the national aggregate economic BY SOCIOECONOMIC GROUP (2008 JMD IN burden for individuals with arthritis and asthma. Inpatient-care MILLIONS) expenditure for arthritis patients was negligible. $30,000 FIGURE 40. ESTIMATED NATIONAL $25,000 ECONOMIC BURDEN BY FIVE MAJOR NCD CONDITIONS, (2008 JAMAICA CONSTANT $20,000 DOLLARS, IN MILLIONS) $15,000 $45,000 $10,000 $40,000 $5,000 $35,000 $0 $30,000 male female 0-17 18-59 60+ Poorest Richest $25,000 $20,000 Source: Studies estimates based on JSLC 2006, 2007, 2008 $15,000 $10,000 $5,000 High NCD prevalence in the older (60+) population led to $0 Asthma Diabetes Hypertension Arthritis the largest direct healthcare burden in Jamaica. as would be expected. Out-of-pocket expenditure for the working population Outpatient visits Inpatient care Medicine purchase Indirect income loss (aged 18–59) was moderate but indirect income loss resulting from absenteeism and sick leave was very large. The 60-and-over Source: Studies estimates based on JSLC 2006, 2007, 2008 population accounted for only 38 percent of the incidence of NCDs but had the largest aggregate share (54 percent) of national direct This report has shown how the situation and trends of NCDs in healthcare expenditure for NCDs, or JMD17,577 million (US$235 Jamaica has impacted on the various groups in the country, how various million) per year, which puts them at considerably higher financial policies and programs have responded to the challenge of dealing with risk than children and adults. The working age population (18–59) NCDs and how these have impacted on the different groups faced with accounted for healthcare costs of JMD 11,340 million (US$151 these diseases. This study has shown gaps where action is needed and the million), with indirect income loss of JMD 16,297 million (US$218 following chapter turns to a consideration of the experience of dealing million). Not surprisingly, healthcare expenditure for children and with NCDs in other countries which could be applied to benefit Jamaicans adolescents (0–17) was only one-fifth of the expenditure for the burdened with NCDs. elderly, owing to considerably lower disease prevalence and lower medical treatment and medicine cost. The richest quintile with NCDs spent almost seven times as much as the poorest on healthcare. Despite the 9 percent difference in NCD prevalence between richest and poorest, there is a sevenfold difference in healthcare expenditure: JMD17,006 million (US$227 million) for the rich and JMD2,305 million (US$31 million) for the poor group. The indirect income loss between these two economic subgroups is even larger owing to a stunning disparity in per- LESSONS FROM OTHER COUNTRIES THAT ARE APPLICABLE TO TACKLING NCDS IN JAMAICA 53 8. LESSONS FROM Key Messages OTHER COUNTRIES 1. Jamaica is developing a national strategy to control THAT ARE the impact of NCDs and could benefit from the experience of other countries. APPLICABLE TO TACKLING NCDS IN 2. Population-based primary prevention and early detection programs are the most cost-effective way to tackle NCDs. JAMAICA 3. Managing NCDs may require redefining and redistributing responsibilities across health professionals. Nurses can take on greater In the process of developing Jamaica’s responsibilities. Using primary care teams and community-based programs are practical solutions for national strategy to control the impact strengthening the capacity to address NCDs. of NCDs, it could benefit from the 4. Disease management programs (DMPs) have experience of other countries. This developed in the past decade to manage individual NCDs, changing traditional approaches for treating chapter reviews these experiences NCDs. DMPs focus on controlling multiple risk factors of a disease rather than a single risk factor. which could be profitably applied in Jamaica. 5. Integrated care models treat NCDs more effectively than dealing with a single disease. NCDs can rarely be treated in isolation. Patients often have several chronic diseases or conditions and may need care from different providers. Treatment and prevention of these conditions are better integrated across the whole range of care and services. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 54 A literature review of the experience of other countries in controlling HBP, an 85 percent reduction in hospital tackling NCDs identified four intervention strategies (Reinhard admissions for HBP, and net savings for overall HBP care Busse 2010), which are reviewed below, namely: costs (WHO n.d.). 1. Emphasize prevention and early detection of chronic Strategy 2: New provider qualifications diseases 2. Adjust the qualifications and tasks of providers of care and Nurses are taking on greater responsibilities and playing a redefine their functions key role in addressing NCDs, as countries begin to redefine and 3. Coordinate disease management to replace episodic care redistribute responsibilities across health professionals. A new 4. Recognize that patients may have multiple conditions that profession of nurse practitioner has been established in the United require integrated care in managing them rather than Kingdom, the Netherlands, the United States, Canada, Australia, manage single diseases. and New Zealand (Busse R 2007) (CHSRP 2006). These university- trained professionals carry out traditional nursing duties, but Strategy 1: Disease prevention and early detection also assume responsibility for tasks that would traditionally be viewed as part of a doctor’s remit, such as limited prescribing of Primary prevention is directed at the prevention of illnesses by pharmaceuticals and administering the less-complex treatments. removing the causes. The target group for primary prevention is Germany has recently created community nurses, similar to those that are healthy with respect to the target disease. Population- nurse practitioners in other countries. They make house visits based interventions cover the whole population and intend to and are responsible for basic primary care, supported by eHealth prevent the adverse health event from occurring. Programs would equipment. This gives chronically ill people in rural regions better promote lifestyle changes to reduce obesity, smoking, and excessive access to basic medical care. It also relieves family doctors for alcohol consumption, to promote physical activity and to reduce other work (Busse R 2007). Another new professional group is other related risk factors that contribute to NCDs. Here are a few liaison nurses, introduced in several European countries. These examples: carry out follow-ups after discharge, pulmonary rehabilitation for people with COPD, supervision of medication and compliance, 1. The National Health Service (NHS) in the United Kingdom patient education, and service navigation. The redistribution of (UK) launched the Change4Life program in January 2009 responsibilities across the nursing profession (nurse practitioners, under the slogan “Eat Well, Move More, Live Longer� (UK community nurses, liaison nurses) would need to be assessed Department of Health n.d.). The campaign targets families within the current reality in Jamaica and the Caribbean as a whole and adults utilizing strategic placement of advertising where the shortage of highly trained nurses reduces the capacity of on TV, internet, posters, and buses. Change4Life features countries to meet their key health care service needs, especially in tools and ideas to motivate people to manage their weight the areas of disease prevention and care. such as “5 A Day�, “60 active minutes�, “me-size meals�, “cut back on fat� and “sugar swaps� (NHS Choices n.d.). Case managers are an option to complement the work of 2. Mexico approved the “Children Obesity Law� in 2010, physicians and nurses to provide care related to NCD patients. Case which is the first countrywide primary prevention program managers coordinate services for people with long-term conditions for obesity that encourages exercise, drinking more or with complex social and medical needs. Their functions include water and consuming fruits and vegetables (Tuckman assessing people’s needs, developing care plans, helping people 2010). The campaign bans junk food such as soft drinks, access appropriate care, monitoring the quality of this care, and sweetened juices, tamarind candy, and pork rinds in maintaining contact with the person and her/his family (Wilkins school stores and cafeterias. OECD estimates that primary VM 2009). The central role of family caregivers in monitoring, prevention programs such as this one could prevent up to treating, and managing chronic diseases and conditions is also 47,000 deaths from chronic diseases each year in Mexico. increasingly being acknowledged (Wilkins VM 2009). 3. The Tula province in the Russian Federation experimented with primary healthcare level prevention and management Innovative approaches such as the use of primary care teams and of NCDs with the involvement of multidisciplinary health community-based intervention programs can provide a practical teams. The project supported multidisciplinary teams in solution for addressing NCDs. Experiments with primary care five healthcare facilities who were involved in planning teams for NCD patients have led to the reorganization of practices the project. The objective initially was to promote healthy and creation of patient-centered “care teams� that are capable of behavior in order to prevent complications from high blood anticipating patients’ needs and facilitating communication about pressure (HBP); to change the delivery of care for HBP their care. In a pilot practice with patients with hypertension in the according to new guidelines; to develop evidence-based state of Maine in the United States, the percentage of patients with guidelines for HBP care at the primary care level; and to controlled hypertension rose from 55 percent in July 2007 to more reallocate financial and human resources to facilitate than 82 percent in July 2010 (Feder 2011). “Crusade for the quality implementation of these services. The project produced of health services� is a project launched by the Secretariat of Health positive results including a 70 percent success rate in of Mexico in the state of Veracruz to provide better healthcare to LESSONS FROM OTHER COUNTRIES THAT ARE APPLICABLE TO TACKLING NCDS IN JAMAICA 55 people with chronic diseases. A one-year pilot project conducted • Patient management tools e.g. health education, in-service training of primary-care personnel to adopt a quality empowerment, and self-care improvement methodology and also implemented a structured • Use of evidence-based guidelines, clinical protocols, and diabetes education program. Among innovations introduced at care pathways the primary-care level were the organization of diabetes clinics, • Information technology collective medical visits for self-support groups of people with • Continuous quality improvement diabetes, and training people with diabetes to be community health workers. The pilot evaluation identified an 11-percent increase in A number of developed countries are experimenting with DMPs. cases of diabetes that were under good control (28 to 39 percent) Experiences from developing countries are limited. The Centers for in the intervention group, while among those receiving the usual Medicare and Medicaid Services in the US have conducted seven care the proportion only increased from 21 to 28 percent. In the DMPs involving 300,000 beneficiaries in 35 programs (Bott, et treatment group, the proportion of patients using insulin increased al. 2009). Patients with chronic conditions such as heart failure, from 3.5 to 7.1 percent, while it remained at 0.9 percent among diabetes, and chronic obstructive pulmonary disease appeared to be those receiving traditional care (WHO n.d.). motivated and able to engage in improved self-management with the result that chronic conditions could be avoided by better day-to-day Community-based rehabilitation programs have been organized self-management. High costs associated with chronic conditions in Pakistan and India. Multidisciplinary and intensive rehabilitation stem from emergency department visits and from inpatient programs proved effective in reducing stroke, chronic pain, and hospital admissions that could be reduced with coordinated and impaired functioning after myocardial infarction as major causes of comprehensive disease management. Germany has implemented disability, including blindness, lower limb amputation, and motor a nationwide disease management program that is based on and sensory dysfunction. The community-based rehabilitation primary care and sustained physician involvement for patients with program in rural south India supported permanently blind people diabetes mellitus that is currently accessible to around 90 percent through mobility training as well as training to perform normal of the population (Stock, et al. 2010). The program is based in daily activities. The program improved quality of life for some 95 primary-care practices and carried out by physicians, and draws percent of participants. In Pakistan, the program trained volunteer on personal relationships with patients to promote adherence to local supervisors from targeted communities (villages and slum treatment goals and self-management. After four years of follow- areas) to identify and train people with disabilities to perform their up, overall mortality for patients and drug and hospital costs were routine daily activities. One to two years after training, 80 percent all significantly lower for patients who participated in the program of participants showed improvement in function (WHO n.d.). than for other insured patients with similar health profiles that were not in the program. These results suggest that the German Strategy 3: Disease Management Programs for Individual disease management program is a successful strategy for improving NCDs chronic illness care. Disease management programs (DMPs) have developed in the A developing country example comes from China where in past decade that are changing traditional ways of managing NCDs. 1999–2001 the city of Shanghai developed a chronic-disease The standard approach to NCD management is to treat symptoms: self-management program. It was implemented in thirteen diagnose and prescribe a treatment. Medical practitioners have come communities and six districts and conducted by trained volunteer to realize that the underlying causes of the presenting symptoms leaders. The disease-management methods included exercise, are multiple and that effective treatment requires attention to the use of cognitive symptom-management techniques, proper the root causes of a specific disease. DMPs focus on controlling nutrition, fatigue and sleep management, use of medications, multiple risk factors rather than on a single one. Patients often have management of fear, anger, and depression, communication with several risk factors present and need medical attention, treatment, health professionals, and problem-solving and decision-making and follow-up to prevent an existing condition from deteriorating techniques. After six months, the disease self-management program into an incapacitating or fatal result. Diabetes is a leading NCD in significantly improved participants’ health behavior, confidence, Jamaica. The daily injection of insulin for diabetic patients must and health status, reducing the number of hospitalizations. be complemented by other disease management efforts such as physical activity and appropriate diet. This comprehensive and Jamaica needs to move from episodic care based on prescribing multidisciplinary approach to caring for an entire disease cycle also medications to managing NCDs comprehensively. Comprehensive includes active patient management tools such as health education, care programs would control the early stages of a disease condition empowerment, and self-care (Velasco-Garrido M 2003). and prevent its progression through primary prevention before problems arise, such as the Change4Life program in the UK, and Main features of DMPs include the following: secondary prevention to detect potential cases of being overweight • Comprehensive care that is multiprofessional and and obesity early, such as in the National Child Measurement multidisciplinary Program in the UK that measures children’s height and weight • Integrated care, care continuum, and coordination of care and in which 91 percent of English school children participate. components The continuum of care would cover prevention and treatment at NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 56 home, in work places, in schools, in ambulatory settings, and at the inpatient level. Strategy 4: Case Management – Comprehensive Integrated Care Models Integrated care models treat NCDs more effectively than focusing on a single disease. Doctors and researchers admit that they have focused on a straightforward disease-management approach because it was relatively simple. Chronic conditions do not present alone, however, and NCDs can rarely be treated in isolation. Patients often have several chronic diseases or conditions at a time and need care from different providers. These models organize prevention and treatment in such a way that services are better integrated across the whole range of care. Examples of this are the introduction of case management by the NHS in the United Kingdom, and pilot projects in Spain in which the whole care process is provided from only one source. Many developed countries have set up various forms of provider networks and interventions to close the gap between primary care and hospital services. Some countries are experimenting with new models of healthcare delivery through comprehensive integrated care models or provider networks that can achieve more integrated and more comprehensive services. Recent experience in developed countries shows that some are moving towards integrated care models. Integrated care models developed in the United States have been adopted in Europe. The redesign of healthcare services has been guided by approaches taken by the health maintenance organization Kaiser Permanente in the United States; these have been used as the basis for NHS programs since 2003 in the United Kingdom. The 2004 NHS Improvement Plan stipulated the introduction of case management in all Primary Care Trusts by appointing senior nurses by 2007. In Germany, DMPs promote integrated care models based on the family physician as gatekeeper, integrated care contracts, and medical polyclinics. France introduced mechanisms aimed at stimulating local provider networks for ambulatory patients and at improving the interface between ambulatory and hospital care under the heading of health networks (réseaux de santé). These arrangements now include mobile dialysis units, specialized mental healthcare facilities, new cancer centers (combining research, treatment, and prevention) and new centers for managing HIV/AIDS. The Canadian province of Ontario promotes networks of family doctors – family health groups and family health networks – and local health integration networks. The mission of these local care networks is to improve the planning, coordination, and integration of healthcare. Being local organizations, they are expected to be more responsive to local needs. The review of other countries’ experiences in dealing with the challenge of NCDs may be useful for policy-makers in considering the approaches and programs that can be initiated in Jamaica. The following chapter makes recommendations in regard to the policy options which the country faces. POLICY OPTIONS 57 9. POLICY OPTIONS Policy options include prevention actions at primary, secondary, and tertiary levels. Primary prevention aims to prevent exposure to the risk factors that cause disease. These may include policies that are anti-smoking, encourage physical activity, promote a healthy The preliminary analysis of Jamaica’s diet, and reduce harmful use of alcohol. Secondary prevention strategies attempt to diagnose and treat an existing disease in its NCD policy and programs indicates that early stages before it results in significant morbidity. Policy options to be considered at the secondary level of care include adopting the drug subsidy program supported new care models such as DMPs and integrated care models, strengthening the surveillance on NCDs, and using information by the NHF has helped NCD patients and communications technology such as electronic patient records and clinical decision support systems. Tertiary prevention aims to reduce their spending on treatment. reduce the negative impact of an established disease by restoring function and reducing disease-related complications. Activities There is little evidence indicating that at this level would focus on the avoidance of complications and preventing disease progression. the trend of NCDs is likely to increase Priorities to Strengthen the National Response to NCDs and much more needs to be done to Improve efficiency of the NHF by: (1) assessing the effectiveness stop and reverse the increasing trend. of prevention programs financed by the NHF; (2) striking the appropriate balance between prevention and drug-subsidy Prevention programs supported by the programs; and (3) improve targeting of the poor under the drug- subsidy programs. Activities could focus on geographic areas where NHF may not have produced results in poverty, disease, and violence are concentrated, and where the poor reducing the population’s exposure to population should be provided with NHF cover. key risk factors as the emphasis has Improve the financial sustainability of the NHF. Government budgets and the NHF are the primary sources of financing for been on treatment. The following are NCD prevention and treatment. Increasing financing for NCD prevention and treatment is a challenge due to: (i) the impact of policy options and interventions that the global financial crisis; (ii) the increase in the patient enrollment rate (16 percent increase in 2008–09); and (iii) the MOHE request Jamaica may consider for enhancing its to expand the program and add new drugs to the list of benefits. The NHF is facing budget problems and without additional financing NCD prevention and control programs, the program may “collapse in the near future�, according to NHF management. Implementing a more comprehensive NCD strategy with priorities for strengthening the will require more funds. The Ministry of Finance is aware of this and has promised to increase financing using the newly introduced national response. gas tax and setting a new threshold for the National Insurance Scheme. The NHF is a well-organized entity. The primary mitigation measure when facing a serious financial difficulty would be to cut the number of institutional projects financed but not the number of enrollees (The Gleaner 2009). It may be possible to finance the NHF out of general taxation or linking its financing to payroll taxes. These measures would make the fund more sustainable and able to meet the increasing needs for prevention and treatment. Other methods for mobilizing resources could be expanding public- private partnerships. Build a comprehensive National Strategy for NCDs. The determinants of NCDs are entrenched in behavior and social conditions and require a comprehensive, multilevel, and multisector strategy. Reversing the NCD epidemic in Jamaica requires a National Strategy that combines the three levels of prevention. The focus so far has been on clinical interventions mainly to NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 58 subsidize medications (prescribing) and much less on population- based primary prevention. The National Strategy will need to put population-based prevention at center stage and define achievable and measureable goals with specified time frames. Improve the surveillance system to monitor the risk factors and NCDs. A dearth of reliable registration and reporting of cause-specific mortality and morbidity makes targeting difficult. Improving the information on risk factors is a necessary first step for feeding data into the NCD policy dialogue. Health Information systems need to be developed to collect and report data on risk factors, mortality, morbidity, and the determinants of NCDs. Reduce the risk factors through policy interventions. Legislation and regulations are needed to control tobacco and alcohol production and use, and to reduce trans-fat and salt intake by working with manufacturers and the food-production industry to ensure healthy food supply. Address the gender dimension when targeting. Women and men are exposed to risk factors to a different degree. Men are more likely to use tobacco and consume alcohol in excess while women are more likely to be obese and physically inactive. Health- promotion programs need to target gender-specific risk factors using tested methodologies. Evaluate the effectiveness of policies, strategies and interventions, refine targeting groups, and accelerate, adjust, or change interventions as necessary, learning from results on the ground. Reorient the health-services delivery system with its physical, human, and financial resources to adopt new care models. Learn how other countries use DMPs and integrated care models that hold the promise of more effective approaches to improve health outcomes for NCD patients, as well as potentially contain costs and increase patient satisfaction. Adopt a multisector approach to NCD prevention and control by involving non-health ministries, civil society organizations and the private sector. Jamaica has a wealth of experience in controlling the HIV/AIDS epidemic and such knowledge can be used for NCD prevention and control. Civil Society Organizations and the private sector can play critical roles in preventing unhealthy diet, encouraging physical activity, and discouraging tobacco use and excessive use of alcohol. The business community can contribute to both financing and implementation of NCD prevention. This report has attempted to contribute to the body of knowledge on the situation regarding NCDs in Jamaica. It has considered the trends, impacts, and costs associated with NCDs, examined the policies undertaken to deal with them together with their results, and referred to lessons from other countries. It is hoped that policy-makers in Jamaica will be able to benefit from this information to generate and apply policies that will improve the NCD situation in the country and that other countries will also benefit from the information and conclusions arising out of this study. ANNEX A 59 ANNEX A: TIME- To understand disparities in health outcome and health-related expenditure in Jamaica, we conducted time-trend analysis across TREND ANALYSIS socioeconomic groups over time. Our goal was to examine whether population differences in time trend are primarily associated METHODOLOGY with individual and household socioeconomic and demographic characteristics. We employed data from the Jamaica Survey of Living Conditions (JSLC)17, a cross-sectional face-to-face annual survey done since 1988. This national survey was implemented to establish baseline measures of household welfare and then to monitor the impact of Jamaica’s Human Resource Development Program on health, education and nutrition. With the exceptions of 2003 and 200518, the JSLC linked to the quarterly Labor Force Survey (LFS), and provided specific information on all six modules – demographic characteristics, household consumptions, health, education, housing, and social welfare and related programs. The JSLC randomly chose one-third of households on a circular systematic basis with a random start from the LFS, the sampling strategy of which is a two-stage stratified process designed to select approximately one-and-a-half percent of the dwellings in Jamaica. The LFS sample is self-weighted, that is, each household in Jamaica is equally likely to be included in the survey sample. The table below shows JSLC individual and household sample size for each interview year between 1990 and 2009, the primary data sources our time-trend analysis relied on. Among those years, 1992, 1998, 2002 and 2008 contained the largest sample with approximately 20,000 individuals interviewed. Dependent Variables To examine health outcome and expenditure time trend in recent decade, several dependent variables were selected for regression analysis, including individual-level chronic-illness status, and healthcare access, and household-level medicine expenditure, medical-service expenditure, alcohol consumption, and tobacco consumption. For individual-level analysis, the sample focused on adults aged 18 years and older, reflecting the fact that the adult population is at considerably higher risk of NCD than children and adolescents; while household-level analysis included all households in the JSLC sample unless otherwise specifically stated. Because of the nature of the JSLC survey, all information relied on respondents’ recollection of past behavior in a given period, and was therefore subject to self-report biases. Underreporting was especially likely to occur in risky behavior questions owing to social desirability. Despite these limitations, data from the JSLC still provided a general picture of NCD and NCD-related outcome for entire population in Jamaica. 17 Publicly available at http://salises.mona.uwi.edu/databank/JSLC.htm. For de- tailed information, please refer to the JSLC annual report, a joint publication of the Planning Institute of Jamaica and the Statistical Institute of Jamaica 18 The 2003 and 2005 surveys did not ask individual health module questions NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 60 YEAR INDIVIDUAL HOUSEHOLD Healthcare access is a dummy variable indicating any visits to OBSERVATIONS OBSERVATIONS a doctor, nurse, pharmacist midwife, healer or any other health 1990 7,233 1,828 practitioner in the past 4 weeks. The sample being analyzed are all 1991 7,197 1,786 adult respondents suffering from illness in the reference period. 1992 18,250 4,485 Two variables were generated to examine the trend of household 1993 7,317 1,963 medical expenditure in past 12 months. Household expenditure 1994 7,109 1,940 on medicine covered pills, tonics, drugs, family planning supplies, 1995 7,535 1,976 herbal medicines, mechanical contraceptive devices, condoms, IUDs, etc.; household medical-service expenditure consisted of 1996 6,997 1,825 doctors’ fees, hospital care, prescriptions, spectacles, and laboratory 1997 7,282 2,020 fees. The wording of questions was quite consistent across years. 1998 26,504 7,375 Both expenditure data were divided by household size to obtain per- 1999 6,554 1,876 capita values. Regression samples comprised all households that 2000 6,309 1,800 reported at least one member suffering from illness in the past 4 weeks in order to explore time-trend differences in the household 2001 5,713 1,668 burden for NCD patients and non-NCD patients. 2002 24,382 6,976 2003 6,720 2,037 Tobacco and alcohol consumption are leading risk factors 2004 6,680 1,981 of NCD. Unfortunately, the JSLC did not provide risky behavior questions for individuals. We captured such information instead by 2005 6,299 1,997 using household per-capita tobacco and alcohol expenditure data, 2006 6,297 1,917 which were collected in daily expense and food expense modules. 2007 6,611 1,994 Monetary value of the last 7 days’ purchase of tobacco products 2008 22,294 6,513 (cigars, cigarettes, chewing tobacco, pipes, etc.) and alcoholic 2009 6,108 1,787 beverages (rum, whiskey, wine, beer, sherry, etc.) were multiplied by 4.33*12 to achieve an annualized amount. Household per- capita expenditure was the total expenditure per household divided Individual chronic illness dummy variable was derived based on by the household size. self-report last-4-week illness status. Before 2008, each respondent was asked in the health module whether they had suffered from All monetary values in time-trend analysis were adjusted to any illness in the reference period; this was then followed up with 2008 Jamaica constant dollars using World Bank historical CIP a question on the type of illness, which was the key information data. to identify chronic-illness status. The wording of the question varied across years, particularly before and after the year 200019. Independent Variables In general, respondents who reported any illness in the reference period were assigned with chronic illness dummy value 1 if To investigate the time trend by specific characteristics net the illness had begun before the past 4 weeks or the illness was of other demographic changes, we adjusted trends based on a recurring or chronic, and value 0 otherwise. We acknowledged regression model and weighted to correspond to the population the inconsistency and inaccurateness of the survey questions in in the 2008 study. Individual and household socioeconomic terms of chronic illness definitions. Nonlinear functional forms characteristics included in regression analysis when appropriate of time trend were therefore introduced to partly account for such were: gender, age group, marital status, education categories, region issues, as explained in the regression methodology section. Instead of residence, household per-capita expenditure quintiles. Age was of being restricted to respondents who reported illness in a very grouped into three categories (18–29, 30–59, 60+) to represent short period of time in the 1988–2007 survey years, the surveys in differences in risk/behavior among the younger adult, older adult, 2008 and 2009 made inquiries about current chronic illness status and senior population. Value 1 was assigned to households located for each individual regardless of their past record or disease time in Kingston Metropolitan Area and other towns, and 0 to rural frame. Because 2008 had a much larger sample than 2009, 2008 areas. Population consumption quintiles (quintile 1 being the cross-sectional data were used to show national representative poorest and quintile 5 being the wealthiest) were derived based on prevalence statistics on NCD; data before 2008 were utilized to annual household per capita expenditure. perform time-trend regression analysis. Time trend was specified as year and year squared to capture nonlinear changes over time. As a sensitivity test to this functional 19 Surveys up to and incuding1999: “did this illness begin within or before last form, analysis using linear time trend, but allowing for different 4 weeks?� 2000, 2001: “is this illness recurring?� From 2002, each type of se- lected chronic illness was probed, including diarrhea, asthma, diabetes, hyper- slopes before and after year 2000 was conducted to capture tension, arthritis, and others potential different magnitude of changes for the periods of 1990– ANNEX A 61 1999 and 2000–2007. Interactions between time trend and key socioeconomic factors were captured by interactions between year and gender, year and education, year and region, year and household quintiles. These interactions examined changes of health outcome or expenditure among different subgroups. Gender (male=1, female=0) is a dummy variable, and year is calendar year, years is year quadratic. The two interactions terms between gender and time would therefore be gender with calendar year and gender with year square. If coefficients of both interactions terms after regression simultaneously equals to 0, this indicates that in each and every period, change of dependent variable was the same for male and female and no difference in time trend between genders. Empirical regressions showed that time functional forms did not affect general pattern of time trend for every outcome, the report thus only presented the results by year and year squared. Besides common independent variables summarized above for individual-level outcomes, we also included several other variables in regression as the case required. For example, alcohol and tobacco consumption are suggested as the leading causes of NCD; we therefore added household expenditure data on these two types of risky behavior in NCD-prevalence regression. Another example is medical expenditure. To understand the differences in medical-expenditure time trend between NCD patients and non- NCD patients, we incorporated household-member disease type dummies in regression so that households with at least one NCD member and households with at least one non-NCD member could be compared with each other. Regression details were listed in table below. Statistical Method Ordinary least squares or binary choice probit regressions were performed depending on the outcome being analyzed. Joint tests of interaction terms were conducted for the null hypothesis that no differences in weight gain exist across socioeconomic groups. Statistical significance level was defined as p<0.05. We summarized adjusted time trend across years in following steps: (1) Regression results were obtained using full sample in all study periods. (2) Adjusted outcome for the year 2008 (reference year) were predicted based on regression results. (3) Predicted outcome in all other years were generated based on 2008 sample characteristics and full model coefficients except for the time value replaced with that particular year. For instance, to predict the conditional mean of NCD prevalence in the year 1999, all observations in 2008 were retained but year values were changed to 1999. (4) Average annual conditional mean of outcome was then plotted each year by socioeconomic subgroups. Regressions and summary statistics were all weighted to correct for inequality of non-response across enumeration districts so as to represent national population characteristics. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 62 DEPENDENT INDEPENDENT VARIABLE REGRESSION STUDY SAMPLE VARIABLE TECHNIQUE PERIOD NCD status Age, gender, education, region of residence, population quintile, Probit 1994– Adults household per-capita alcohol and tobacco consumption, marital 2007 status, year, year quadratic Healthcare Age, gender, education, region of residence, illness type, health Probit 1994–- Adults who reported access insurance coverage, population quintile, marital status, year, 2007 illness in last 4 weeks year quadratic Medicine Region of residence, population quintile, household member OLS 1994– Households with at least expenditure illness type, household member health insurance coverage, 2007 one member reporting household sanitation characteristics, year, year quadratic illness in last 4 weeks Medical Region of residence, population quintile, household member OLS 1994– Households with at least service illness type, household member health insurance coverage, 2007 one member reporting expenditure household sanitation characteristics, year, year quadratic illness in last 4 weeks Alcohol Region of residence, population quintile, year, year quadratic OLS 2000– All households expenditure 2009 Tobacco Region of residence, population quintile, year, year quadratic OLS 1994– All households expenditure 2009 ANNEX B 63 ANNEX B: The objective of economic burden of chronic disease study is to estimate the direct healthcare cost attributable to chronic illness ECONOMIC BURDEN and the indirect cost attributable to productivity in Jamaica. Direct out-of-pocket healthcare costs include expenditure on outpatient OF DISEASE visits, inpatient care, and purchase of medicines among chronic disease patients. Indirect costs are income loss associated with METHODOLOGY the disease. The analysis includes an assessment of the economic burden resulting from the four most prevalent, costly and disabling chronic conditions in Jamaica: asthma, diabetes, hypertension, and arthritis. The cost estimates are derived from the Jamaica Survey of Living Conditions (JSLC) 2006 and 2007. We are concerned with the economic impact at the level of individuals. Owing to data restrictions, we limit our study sample to individuals who reported one of four chronic conditions: asthma, diabetes, hypertension, and arthritis. Total direct out-of-pocket healthcare costs for each patient are the sum of three components: outpatient visits, inpatient care, and purchase of medicines. The costs are further disaggregated into expenditure at private and public facilities to make possible a comparison between facility types. Indirect income loss for each patient is estimated as the number of days in a year that working patients are unable to carry out normal activities owing to chronic conditions, multiplied by household total expenditure then divided by the number of adults in the household aged 18–59, which proxies adult individual annual earnings. Income loss was estimated for working-age adults only (age 1859). Children and adolescents (0–17), and seniors (60 and older) are assumed not productive. All monetary values are adjusted to 2008 constant Jamaican dollars using the consumer price index. After computing direct healthcare out-of-pocket cost and indirect income loss due to chronic illness for each NCD patient, we report the average annual cost in 2006 and 2007 in the study population. To understand the economic burden among the entire Jamaica population, we also obtain an aggregate individual economic burden by multiplying the individual average cost by the total number of NCD patients (asthma, diabetes, hypertension, and arthritis) in Jamaica. NCD prevalence was estimated from JSLC 2007-8. The number of NCD patients in Jamaica is the product of NCD prevalence and the estimated total population of 2.826 million taken from the Central Intelligence Agency World Fact book for Jamaica in 2010. It should be noted that the estimates of the economic burden of NCDs have several limitations. First, the health conditions and medical expenditure are self-reported data. Second, the estimates focus on a finite number of conditions listed in the survey; therefore, some other conditions such as cardiovascular disease were excluded. Third, although household per-capita expenditure is a good proxy for individual annual earning, income-loss measure is still subject to bias owing to lack of information on individual work status. Fourth, the measure of indirect economic burden does not include productivity reduction, cost of years of life lost owing to premature mortality, and the value of activity days lost owing to disability or morbidity. Medical insurance premiums NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 64 and preventive-health-seeking activities are not considered either and, finally, the estimation of the economic burden was based on household expenditure and did not include the cost of provision for treatment and services. ANNEX C 65 ANNEX C: The Jamaica Survey of Living Conditions (JSLC) was first conducted in 1988. The JSLC was originally conceived to be a semi- THE JAMAICA annual survey. Early on the schedule was interrupted by Hurricane Gilbert and national elections. In 1990, an annual survey was SURVEY OF LIVING deemed to be sufficient and an annual schedule was adopted. Twenty-two rounds of the survey were completed from 1988 to CONDITIONS 2008: 1988, 1989-1, 1989-2, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, and 2009. The nationwide survey was implemented to establish baseline measures of household welfare and then to monitor the impact of Jamaica’s Human Resources Development Program on health, education and nutrition. The JSLC differs from other Living Standard amd Measurement Surveys in its relatively narrow focus and greater emphasis on immediate policy impact. The JSLC is linked to the ongoing quarterly Labor Force Survey (LFS). The households are visited once for the standard LFS. Then a subset of households is revisited about a month later for the JSLC. When the data sets are merged, the LFS serves as the employment module of the combined LFS/JSLC. To avoid respondent fatigue, the JSLC household questionnaire is short enough to be administered in one interview (as compared to two interviews in the typical LSMS survey). In general, each JSLC questionnaire has included modules on health, education, nutrition, consumption, and housing. On a rotating basis, designated topics have received additional emphasis. To date, expanded modules for Health, Poverty, Education, Housing, Consumption, Household Finances, Employment, Aging, and Coping Strategies have been carried out. The JSLC surveys contain no data on agricultural activities, non-agricultural household activities, or migration. Only the 1989-2 survey has a fertility module. Data are publicly available at http://salises.mona.uwi.edu/ databank/JSLC.htm. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 66 REFERENCES Dominica News Online. University of the West Indies Open Campus Dominica. 2010 13-December . http://dominicanewsonline.com/ dno/third-annual-dr-bernard-a-sorhaindo-memorial-lecture-set- for-thursday/ (accessed May 15, 2011). Abu-Raddad, L, F Akala, I Semini, G Riedner, D Wilson, and O Tawil. Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Time for Strategic Action. Washington, DC: The World Bank, 2010. Adeyi, O, O Smith, and S Robles. Public Policy and the Challenge of Chronic Non-communicable Diseases: Directions in Development. Washington DC: Human Development, World Bank, 2007. Agency for Healthcare Research and Quality . Preventing Disability in the Elderly With Chronic Disease. n.d. http://www.ahrq. gov/research/elderdis.htm (accessed June 8, 2011). Alberto, Barcelo, and Rajpathak Swapnil. “Incidence and prevalence of diabetes mellitus in the Americas.� ev Panam Salud Publica, 2001: 300-308. Alleyne, G. “The Silent Challenge of the Chronic Non- Communicable Diseases in the Caribbean.� Draft paper, 2007. Ammar, W. Health System and Reform in Lebanon. Cairo and Beirut: World Health Organization Regional Office for the Eastern Mediterranean and Entreprise Universitaire d’Etudes et de Publications, 2003. Anderson, Gerard F., Hugh Waters, Patricia Pittman, Robert Herbert, Ed Chu, and Kristina Das. Non-Communicable Chronic Diseases In Latin America and the Caribbean. Baltimore, Maryland, USA: Bloomberg School of Public Health, Johns Hopkins University, 2009. Assad, R., and F. Roudi-Fahimi. Youth in the Middle East and North Africa: Demographic Opportunity or Challenge? Cairo: Population Reference Bureau, 2007. Barker, DJP. “Fetal Origins of Coronary Heart Disease.� British Medical Journal 311 (1995): 171-174. Barr, V. et all. “The Expanded Chronic Care Model: An Integration of Concepts and Strategies From Population Health Promotion to Chronic Care Model .� Hospital Quarterly 7, no. 1 (2003): 73-82. Barrett, Raphael D., and Stanley Lalta. “Health Financing Innovations in the Caribbean:EHPO and the National Health Fund of Jamaica.� Inter-American Development Bank Sustainable Development Department Technical Papers Series, November 2004. REFERENCES 67 Baswell, Allen. “Smoking ban draws compains .� Grenada Star . “Caribbean360.� Plan to ban public smoking, tobacco ads in 2009 13-January . http://www.grenadastar.com/v2/content.aspx Jamaica Read more: http://www.caribbean360.com/index.php/ ?module=ContentItem&ID=109859&MemberID=1218 (accessed news/jamaica_news/464528.html#ixzz1QV9FpUgp. June 8, 2011 18 -April ). 2011. http://www.caribbean360.com/index.php/news/jamaica_ Bleich, S., Cutler, D., Adams, A., Lozano, R., Murray, C. “Impact news/464528.html#axzz1QV80FFEi (accessed June 27, 2011). of Insurance and Supply of Health Professionals on Coverage of Treatment for Hypertension in Mexico: Population Based Study.� CDC. Fact Sheet: Region of the Americas, Saint Lucia. 2008 4-April BMJ, October 27, 2007. . http://www.cdc.gov/tobacco/global/gyts/factsheets/amr/2001/ saintlucia_factsheet.htm (accessed April 21, 2011). Blum, K. “Nurse practitioners in eastern Germany. Health Policy Monitor.� University of Auckland, Centre for Health Services National Center for Chronic Disease Prevention and Health Research and Policy. October 8, 2006. http://www.hpm.org/survey/ Promotion . n.d. http://www.cdc.gov/excite/skincancer/mod13. de/b8/3. htm (accessed June 2011). Boaden, R. “Evercare evaluation: Final report.� National Central Intelligence Agency. “CIA World Factbook.� the World Primary Care Research and Development Centre, Manchester, Factbook. n.d. https://www.cia.gov/library/publications/the-world- 2006. factbook/ (accessed May 2011). Bodenheimer, T, E Wagner, and K Grumbach. “Improving Chobanian, AV. “The seventh report of the joint national primary care for patients with chronic illness: The chronic care committee on prevention, detection, evaluation, and treatment of model.� JAMA, 2002: 1909–1914. high blood pressure: The JNC 7 report.� JAMA 289 (2003): 2560– 2572. Bonhauser, M., Fernandez, G., Püschel, K., Yañez, F., Montero, J., Thompson, B., Coronado, G. “Improving Physical Fitness and CHSRP. “Development of nurse practitioners. Health Policy Emotional Well-Being in Adolescents of Low Socioeconomic Monitor.� University of Auckland, Centre for Health Services Research Status in Chile: Results of a School-Based Controlled Trial.� Health and Policy. October 8, 2006. Promotion International, 2005: 113–122. Daar, Abdallah S. “Grand Challenges in Chronic Non- Bott, David M., Mary C. Kapp, Lorraine B. Johnson, and Linda Communicable Diseases.� Nature, November 2007. M. Magno. “Disease Management For Chronically Ill Beneficiaries In Traditional Medicare.� Health Affairs, 2009: 86-98. Daar, AS, PA Singer, and DL Persad. “Grand Challenges in Chronic Non-Communicable Diseases.� Nature 450 (2007): 494-6. Bryce, J, D Coitinho, I Darnton-Hill, D Pelletier, and P Pinstrup- Andeersen. “Maternal and Child Undernutrition: Effective Action Danel, I, C Kurowski, and H Saxenian. Brazil – Addressing the at National Level.� The Lancet, 2008: 371:510-26. Challenge of Non Communicable Diseases. Washington DC: World Bank, 2005. Busse R, Schlette S. “Health policy developments 7/8. Focus on prevention, health and aging, new health profession.� Gütersloh, Dubois C-A, Singh D, Jiwani I. “The human resource challenge Verlag Bertelsmann Stiftung, 2007. in chronic care.� In Caring for people with chronic conditions: A health system perspective, by McKee M Nolte E, 143–171. Maidenhead: Busse, R, and N Mays. “Paying for chronic disease care.� In Open University Press, 2008. Caring for people with chronic conditions: A health system perspective, by McKee M Nolte E, 195–221. Maidenhead: Open University Durazo-Arvizu. “Rapid increase in obesity in Jamaica, compare Press, 2008. to Nigeria and the United States.� BMC Public Health, 2008: 8-13. Busse, R, M Blumel, D Scheller-Kreinsen, and A Zentner. EarthTrends Database, World Resources Institute . n.d. http:// Tackling Chronic Disease in Europe: Strategies, Interventions and earthtrends.wri.org (accessed 2011). Challenges. Observatory Studies Series, European Observatory on Health Systems and Policies, 2010. “Economic and Social Survey, Jamaica.� 2008. Butler, R. “Population aging and health.� British Medical El-Zanaty, F, and A Way. Egypt Demographic and Health Survey. Journal, 1997: 1082-1084. Cairo: Ministry of Health, 2008. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 68 Ergo, A, M Shekar, and Gwatkin DR. Inequalities in Malnutrition Food and Agriculture Organization. The State of Food Insecurity in Low- and Middle Income Countries: Updated and Expanded Estimates. in the World: Economic Crises - Impacts and Lessons Learned. Rome: Washington, DC: The World Bank, 2008. United Nations, 2009. European Commission. EURODIET Core Report – Nutrition & Framework Convention Alliance. “Updated Status of the WHO Diet for Healthy Lifestyles in Europe, Science & Policy Implications. FCTC as of October 29, 2010.� Framework Convention Alliance . n.d. Crete: European Commission and University of Crete School of http://www.fctc.org/images/stories/ratification_latest_Saint%20 Medicine, 2000. Vincent%20and%20Grenadines.pdf (accessed May 2, 2011). “EURODIET, Nutrition and Diet for Health Lifestyles in Francis, Debbie. Caribbean News Portal Caribarena Antigua . Europe, Science and Policy Implications, DG-SANCO.� 2004. 2009 10-January. http://caribarena.com/antigua/health/diet-a- http://ec.europa.eu/health/ph_determinants/life-style/nutrtion/ fitness/1436-obesity-in-children-on-the-rise-.html (accessed April report01_en.pdf. 12, 2011). European Training Foundation. Employment Policy Reforms in Gakidou, Emmanuela. “Management of diabetes and associated the Middle East and North Africa: Selected Issues on the Functioning of cardiovascular risk factors in seven countries: a comparison of data the Labor Market. Luxembourg: ETF, 2006. from national health examination surveys.� Bulletin of the World Health Organization, 2011: 172–183. Evans, T, M Whitehead, F Diderichsen, A Bhuiya, and M Wirth. Challenging inequalities in health: from ethics to action. Oxford Gardner, Kim. Overweight and Obesity in Five-Year-Old Children University Press, 2001. in Saint Lucia. Community Child Health Service, Ministry of Health, Saint Lucia , Castries: Centre of Excellence for Children FAO. “Antigua and Barbuda: Nutrition Country Profile .� United and Adolescents with Special Needs Memorial University of Nations , 2003. Newfoundland, Canada, 2009. FAO. Dominica Country Summary Profile on Smoking Prevalence. Glassman, Amanda, Thomas A Gaziano, César Patricio Bouillon FAO, 2001. Buendia, and Frederico C Guanais de Aguiar. “Confronting The Chronic Disease Burden in Latin America and Caribbean.� Health FAO. “Dominica: Nutrition Country Profile.� 2003. Affairs, 2010: 2142-2148. FAO. “Grenada: Country Summary Profile on Smoking Godinho, J. Non-communicable Diseases in Latin America and the Prevalence.� 2001. Caribbean Living Longer, Healthier lives. Draft report, Washington DC: Latin America and the Caribbean Region, World Bank, 2006. “Nutrition country profile: Jamaica.� 2002. ftp://ftp.fao.org/ es/esn/nutrition/ncp/jammap.pdf (accessed January 22, 2010). Gordon-Strachan, Geogriana. Rapid Assessment of the Impact of the Economics Crisis on Health Spending in Jamaica. Draft report, FAO. “St. Vincent and Grenadines: Country Profile. Food Washington DC: World Bank, 2010. security indicators .� 2002. GoSL. “Government moves to ratify Framework Convention Feder, J. Lester. “At Martin’s Point In Maine, Primary Care Teams on Tobacco Control.� 2005 9-November. http://www.stlucia.gov. For Chronic Disease Patients.� Health Affairs 30, no. 3 (2011): 394- lc/pr2005/november/government_moves_to_ratify_framework_ 396. convention_on_tobacco_control.htm (accessed May 14, 2011). Figueroa, J. “Health trends in Jamaica: significant progress an Government of Jamaica Website. March 04, 2009. http:// da vision for the 21st century.� West Indian Medical Journal, Sep www.jis.gov.jm/health/html/20090303T180000-0500_18703_ 2001: 15-22. JIS_USER_FEES_MAJOR_IMPEDIMENT_TO_POOR_ACCESSING_ HEALTH_CARE__SPENCER.asp (accessed June 15, 2010). Fogel, R. “Economic growth, population theory, and physiology: the bearing of long term processes on the making of economic “Government of St. Lucia.� OECS calls for protection of its policy.� The American Economic Review, 2004. pharmaceutical market from counterfeit Drugs. 2004 2-November. http://www.stlucia.gov.lc/pr2004/november/oecs_calls_for_ Fogelholm, M., and K. Kukkonen-Harjula. “Does physical protection_of_its_pharmaceutical_market_from_counterfeit_ activity prevent weight gain – a systematic review.� Obesity Reviews, drugs.htm (accessed 2 May 15, 2011). 2000: 95-111. REFERENCES 69 Green, Tarnia. Dominica News Online. 2011 30-March. http:// Ivey, MA, G Legall, EV Boisson, and A Hinds. “Mortality trends dominicanewsonline.com/dno/diabetes-and-hypertension- and potential years of life lost in the English and Dutch-speaking leading-causes-of-death-in-dominica/ (accessed April 12, 2011). Caribbean, 1985–2000.� West Indian Med.J, Mar 2008. Grenada Nutrition Country Profile. FAO, 2003. Jamaica National Council on Drug Abuse . 2004. Gwatkin, DR, S Rutsten, K Johnson, E Suliman, A Wagstaff, Jamison, D, and A Bremen. Disease Control Priorities in Developing and A Amouzou. Socio-Economic Differences in health, nutrition and Countries, Second Edition. Oxford: Oxford Press, 2006. population within developing countries: an overview. Washington, DC: The World Bank, 2007. Jenkins, C, and DA Robalino. HIV in the Middle East and North Africa: The Cost of Inaction. Orientations in Development Series, Ham, C. “The Ten Characteristics of High Performing Chronic Washington, DC: The World Bank, 2003. Care System.� Health Economics, Policy and Law 5 (2010): 71-90. Kosteniuk, J, and D H Dickinson. “Tracing the social gradient Hanson, Kara, and Peter Berman. “Private Health Care in the health of Canadians: primary and secondary determinants.� Provision in Developing Countries: A preliminary analysis of Social Science and Medicine, 2003: 263-276. levels and composition.� n.d. http://www.hsph.harvard.edu/ihsg/ publications/pdf/No-76.PDF (accessed 2010). Laith, JA, FA Akala, I Semini, G Riedner, D Wilson, and O Tawil. Characterizing HIV/AIDS Epidemic in the Middle East and North Africa Henry-Lee, A, and A Yearwood. Protecting the poor and the Region: A Time for Strategic Action. Washington, DC: The World medically indigent under health insurance. Partners for Health Sector Bank, 2010. Reform,IDB, 1999. Lancet. Lancet. April 6, 2011. www.thelancet.com (accessed Hensley, Daniel. A Plan of Action for Localising and Achieving the April 2011). Millennium Development Goals (MDGs). Castries, St. Lucia: OECS Secretariat, 2006. Leatherman S, Berwick D, Iles D. “The business case for quality: Case studies and an analysis.� Health Affairs, 2003, 22 ed.: 17–30. Hogan, Margaret C., et al. “Maternal Mortality for 181 Countries 1980-2008: a Systematic Analysis of Progress towarsd Leatherman, S. “Applying Performance Indicators to Health Millennium Development Goal 5.� The Lancet, 2010: Published System Improvement.� In Measuring Up - Improving Health System online April 12, 2010 www.thelancet.com. Performance in OECD Countries. Paris: OECD Publishing, 2002. Horton, R. “Chronic Diseases: the Case for Urgent Global Lieberman, SS, and A Wagstaff. Health Financing and Delivery in Action.� Lancet 370 (2007): 1881-2. Vietnam: Looking Forward. Washington, DC: The World Bank, 2009. Horton, S, and J Ross. “The Economics of Iron Deficiency.� Food Luke, A. “Activity, Adiposity and Weight Change in Jamaican Policy, 2003: 28:517-5. Adults.� West Indian Medical Jouranal, 2007: 398. Hyder, A. Road Traffic Injuries in the Middle East and North Africa: Lurie, N, and J McLaughlin. “In pursuit of the social A Regional Assessment. Unpublished report commissioned by the determinants of health: the evolution of health service research.� World Bank. , 2009. Health Services Research, 2003: 1641-3. Ichinohe, M. “The prevalence of obesity and its relationship Madrigal, Lorena. “Human Biology of Afro-Caribbean with liifestyle factors in Jamaica.� The Tohoku Journal of Experimental Populations.� Cambridge University Press , 2006: 44-45. Medicine, 2005: 21-32. Maternal and Chlid Undernutrition Study Group. “Maternal International Development Research Centre. n.d. http://www. and Child Undernutrition: Global and Regional Exposures and crdi.ca/uploads/user-S/11577246161tobacco_jamaica_eng.pdf Health Consequences.� Lancet, 2008: 243-60. (accessed January 22, 2010). Mathers, C, A Lopez, and C Murray. “The Burden of Disease International Diabetes Federation. n.d. www.earlas.idf.org and Mortality by Condition: Data Methos and Results for 2001.� In (accessed October 12, 2009). Global Burden of Disease and Risk Factors, by AD Lopez, M Ezzati, JT Jamison and C Murray, 47-95. New York: Oxford University Press, IDF DIABETES ATLAS. n.d. http://www.diabetesatlas.org/ 2006. (accessed May 2011). NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 70 Mathers, CD, and D Loncar. “Projections of Global Mortality Obegunde, DO, CD Mathers, T Adam, M Ortegon, and K Strong. and Burden of Diseases from 2002 to 2030.� PLoS Med, 2006: “The Burden and Costs of Chronic Diseases in Low-income and e442. Middle-income Countries.� Lancet 370 (2007): 1929-38. Micronutrient Initiative. “Investing in the Future: A united Observer, Antigua. OBSERVER News. February 9, 2011. http:// call to action on vitamin and mineral deficiencies, Global Report www.antiguaobserver.com/?p=54200 (accessed April 12, 2011). 2009.� Ottawa, 2009. OECD. The Prevention of Lifestyle-related Chronic Diseases: An Ministry of Health Jamaica. Annual Report 2007. Jamaica Economic Framework. OECD Working Papers, DELS/HEA/WD/ Ministry of Health, 2009. HWP(2008)2, Paris: OECD, 2008. Ministry of Health Jamaica. “Health Sector Performance PAHO. Country health profile. 2001. http://www.paho.org/ Improvement Programme.� 2002. English/sha/prfljam.htm (accessed July 20, 2010). MOH. National Business Plan for Health 2008-2010 . July 7, “Epidemiological Bulletin.� The Global Youth Tobacco Use Survey: 2011. http://www.healthresearchweb.org/files/National_Health_ Status of Implementation in LAC counrties. June 2001. http://www. Policies-Antigua_Barbuda-Business_Plan_Health_2008-10.pdf paho.org/english/sha/be_v22n2-GYTS.htm. (accessed May 15, 2011). “Epidemiological Bulletin.� June 2001. http://www.paho.org/ MOHE, St. Vincent and Grenadines. “St. Vincent and Grenadines english/sha/be_v22n2-cover.htm (accessed April 15, 2011). Strategic Plan for Health 2007-2012.� 2007. PAHO. “Health in the Ameircas: Grenada country profile .� Monteiro, C, EC Moura, LC Wolney, and BM and Popkin. 2007. “Socioeconomic status and obesity in adult populations of developing countries: a review.� Bulletin of the World Health PAHO. “Health in the Americas .� Volume II, World Health Organization, 2004. Organization , Washington DC, 2002. Mufti, MH. Healthcare Development Strategies in Saudi Arabia. PAHO. Health in the Americas. PAHO Scientific Publication, New York: Kluwer Academic/Plenum, 2000. 2007. Nassar, H, and S El-Saharty. “Chapter 5: Egypt.� In Global PAHO/CARICOM. “Report of the Caribbean Commission on Marketplace for Private Health Insurance - Strength in Numbers, edited Health and Development.� 2006. by A Preker, P Zweifel and OP Schellenken, 163-188. Washington, DC: The World Bank, 2010. PAHO/WHO. Essential Public Health Functions as a Strategy for Improving Overall Health Systems Performance. n.d. http://www. NHF. 2008 Annual Report. National Health Fund, Jamaica who.int/pmnch/topics/health_systems/paho_who_ephf2007/en/ Ministry of Health and Environment, 2008. index.html (accessed June 3, 2011 ). NHF. 2009 Annual Report. National Health Fund, Jamaica Pan America Health Organization. Health in the Americas 2007. Ministry of Health and Environment, 2009. Washington, DC: Pan American Sanitary Bureau, Regional Office of the World Health Organization, 2007. NHS Choices. n.d. http://www.nhs.uk/change4life/Pages/ change-for-life-families.aspx (accessed June 2011). Peden, M, R Scurfield, D Sleet, D Mohan, A Hyder, and E. Jarawan. World Report on Road Traffic Injury Prevention. Geneva: Nolte, E, and CM McKee. “Measuring the Health of Nations: World Health Organization, 2004. Updating an Earlier Analysis.� Health Affairs 27 (2008): 58-71. PIOJ. Revised National Population Policy. United Kingdom: Nolte, E, and M Mckee. “Integration and chronic care: A PIOJ, 1995. review.� In Caring for people with chronic conditions: A health system perspective, by McKee M Nolte E, 64–91. Maidenhead: Open Planning Institute of Jamaica . “Vision 2030: National University Press, 2008. Development Plan, Planning for a Secure and Prosperous Future.� Kingston, 2009. Novotny, TE. “Preventing chronic disease: Everybody’s business.� In Caring for people with chronic conditions: A health Planning Institute of Jamaica. the Economic and Social Survey of system perspective, by McKee M Nolte E, 92–115. Maidenhead: Open Jamaica (ESSJ). Jamaica: Planning Institute of Jamaica, 2008. University Press, 2008. REFERENCES 71 Population projections Jamaica 2000-2050. STATIN, Kingston: Strachan, G. “Rapid Assessment of the Impact of the Economic STATIN, 2008. Crisis on Health Spending in Jamaica.� Draft , World Bank, 2010. Rajaratnam, JK, et al. “Neonatal, postneonatal, childhood, and Stromberg A, Martensson J, Fridlund B. “Nurse-led heart under-5 mortality for 187 countries, 1970-2010: a systematic failure clinics improve survival and self-care behavior in patients analysis of progress towards Millennium Development Goal 4.� with heart failure: Results from a prospective, randomized trial.� The Lancet, 2010: Published online May 24, 2010 DOI:10.1016/ European Heart Journal, 2003: 1014–1023. S0140-6736(10)60703-9. Sturm, R. “The Effects of Obesity, Smoking and Drinking on Reinhard Busse, Miriam Blümel, David Scheller-Kreinsen, Medical Problems and Costs.� Health Affairs 21 (2002): 245-253. and Annette Zentner. “Strategies against chronic disease: what is being done?� Chap. 4 in Tackling chronic disease in Europe - Strategies, Suhrcke, M, RA Nugent, D Stuckler, and L Rocco. Chronic interventions and challenges, by Miriam Blümel, David Scheller- Disease: an Economic Perspective. Oxford Health Alliance, 2006. Kreinsen, and Annette Zentner Health Reinhard Busse. World Health Organization, 2010. Swann, C, et al. Health Systems and Health Related Behavior Change: a Review of Primary and Secondary Evidence. National Rocco, L. Chronic Diseases and Labor Market Outcomes in Egypt. Institute for Health and Clinical Excellence (NICE) and WHO Amman, Jordan: unpublished report, presented at the Middle East Regional Office for Europe, 2010. and North Africa Forum Conference, June 7-8, 2010, 2010. “Tackling the Obesity Epidemic the Impact of Food Trade Rothman, A, and E Wagner. “Chronic Illness Management: and Commerce.� 2009. http://72.249.12.201/wordpress-mu/ What is the Role of Primary Care?� Annual Internal Medicine 138, jamaica/? (accessed February 25, 2010). no. 38 (2003): 256-61. Talevani, L. Middle East and North Africa Gender Overview. Rothman, AA, and EH Wagner. “Chronic illness management: Washington, DC: The World Bank, 2007. what is the role of primary care?� Annual Internal Medicine, 2003: 256-61. “The Gleaner .� Smoking Ban Looms . February 3, 2009. http:// jamaica-gleaner.com/gleaner/20090203/news/news2.html Roudi-Fahimi, F, and MM Kent. “Challenges and Opportunities (accessed June 27, 2011). - The Population of the Middle East and North Africa.� Population Bulletin, June 2007. The Gleaner . NHF could collapse - Cash problems loom, says CEO. 2009 6-September . http://jamaica-gleaner.com/ Samuels, Alafia. “Caribbean Wellness Day: mobilizing a region gleaner/20090906/lead/lead7.html (accessed June 8, 2011 ). for chronic noncommunicable disease prevention and control.� Rev Panam Salud Publica 28, no. 6 (2010): 472-279. The World Bank. A Note on Disability Issues in the Middle East and North Africa. Report, Washington DC: The World Bank, 2010. Sassi, F, and J Hurst. “The prevention of lifestyle related chronic diseases: an economic gramework.� Working Paper, OECD, 2008. The World Bank. Better Governance for Development in the Middle East and North Africa: Enhancing Inclusiveness and Accountability. Smith, P, E Mossialos, I Papanicolas, and S Leatherman. Washington, DC: The World Bank, 2003. Performance Measurement for Health System Improvement: Experiences, Challenges and Prospects. Cambridge: Cambridge The World Bank. Capitalizing on the Health Transition: Tackling University Press, 2009. Non Communicable Diseases in South Asia. Report, Washington DC: The World Bank, 2010. Solar, A, and A Irwin. “A conceptual framework for action on the social determinants of health.� Comission on Social Determinants The World Bank. Chile: the Adult Health Policy Challenge. of Health, WHO, 2007. Washington DC: World Bank, 1995. “St. Kitts and Nevis Drug Information Network Annual Report The World Bank. Dying Too Young. Report, Washington DC: The .� 2003. World Bank, 2005. Stock, Stephanie, et al. “German Diabetes Management Dying Too Young. Washington, DC: The World Bank, 2006. Programs Improve Quality Of Care And Curb Costs.� Health Affairs, 2010: 2197-2205. Middle East and North Africa 2007 Economic Developments and Prospects: Job Creation in an Era of High Growth. Washington, DC: The World Bank, 2007. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 72 Middle East and North Africa 2009 Economic Developments and UNICEF. State of the World’s Children. New York: United Nations, Prospects: Navigating through Global Recessions. Washington, DC: 2009. The World Bank, 2009. State of the World’s Children 2009. New York: UNICEF, 2009. Repositioning Nutrition as Central to Development: a Strategy for Large-Scale Action. Washington, DC: The World Bank, 2006. UNICEF, and WHO. Countdown to 2015 Decade Report (2000- 2010) with Country Profiles: Taking Stock of Maternal, Newborn and The World Bank. Sri Lanka: Addressing the Needs of an Aging Child Survival. Washington, DC: WHO and UNICEF, 2010. Popluation. Washington DC: The World Bank, 2008. United Nations. World Population Prospects: The 2008 Revision The World Bank. The Adult Health Policy Challenge. Report, Population Database. n.d. http://esa.un.org/unpp/ (accessed Washington DC: The World Bank, 1995. September 7, 2010). The World Bank. The economic implications of non-communicable UNODC. UNODC. n.d. http://www.unodc.org/pdf/barbados/ disease for India. Discussion Paper, Washington DC: Health, st_kitts_and_nevis_2002.pdf (accessed May 16, 2011). Nutrition and Population, World Bank, 2010. Van Beeck, E, G Borsboom, and J Mackenbach. “Economic World Development Report 2009: Reshaping Economic Geography. development and traffic accident mortality in the industrialized Washington, D.C.: The World Bank, 2009. world, 1962-1990.� International Jornal of Epidemiology 29, no. 3 (2000): 503-9. Youth - an Undervalued Asset: Towards a New Agenda in the Middle East and North Africa - Progress, Challenges and Way Forward. Velasco-Garrido M, Busse R, Hisashige A. Are disease management Washington, DC: The World Bank, 2007. programs effective in improving quality of care for people with chronic conditions? Copenhagen: WHO Regional Office for Europe, 2003. Thorpe, KE, DH Howard, and K Galactionova. “Differences in Disease Prevalence as a Source of the US-European Health Care Victora, CG, et al. “Maternal and Child Undernutrition: Spending Gap.� Health Affairs 26 (2007): 678-686. Consequences for Adult Health and Human Capital.� The Lancet, 2008: 371: 340-57. Tobacco News and Information. March 2008. http://www. tobacco.org/articles/country/antigua/ (accessed 2011 13-May). Vilamoska, C. “Improving Patient Safety: Addressing Patient Harm Arising from Medical Error.� Policy Insight (RAND Tsounta, Evridiki. “Universal Health Care 101: Lessons for the Corporation) 3, no. 2 (April 2009). Eastern Caribbean and Beyond.� IMF working paper, 2009. Vrijhoef, HJ. “Undiagnosed patients and patients at risk for Tuckman, Jo. “Mexico Bans Junk Foods in Schools.� The COPD in primary health care: Early detection with the support of Guardian, May 27, 2010. non-physicians.� Journal of Clinical Nursing, 2003: 366–373. U.S.Census Bureau, International Data Base. n.d. http://www. Wagstaff, A. “Measuring Financial Protection in Health.� census.gov/ipc/www/idb/country.php (accessed December 20, In Performance Measurement for Health Systems Improvement: 2009). Experiences, Challenges and Prospects, by PC Smith, E Mossialos and S Leatherman. Cambridge: Cambridge University Press, 2009. UK Department of Health. Change4Life – Eat Well, Move More, Live Longer. n.d. www.dh.gov.uk/en/MediaCentre/Currentcampaigns/ Wagstaff, A, and M Lindelow. “Can Insurance Increase financial Change4life/index.htm (accessed June 2011). Risk? The Curious Case of Health Insurance in China.� Journal of Health Economics 27, no. 4 (2008): 990-1005. UN General Assembly. “Follow-up to the outcome of the Millennium Summit: Prevention and control of non- Wagstaff, Adam, and Mgnus Lindelow. “Can insurance increase communicable diseases.� Vers. Agenda item. 2010 28-April. financial risk? The curious case of health insurance in China.� http://www.google.com/url?sa=t&source=web&cd=6&ved=0CD Journal of Health Economics, 2008: 990-1005. oQFjAF&url=http%3A%2F%2Fnew.paho.org%2Fbra%2Findex. php%3Foption%3Dcom_docman%26task%3Ddoc_downlo WHO . Chronic Diseases and Health Promotion . n.d. http://www. ad%26gid%3D981%26Itemid%3D&rct=j&q=Antigua%20 who.int/chp/chronic_disease_report/part3_ch2/en/index12.html and%20Barbuda%20national%20response%20to%20non- (accessed May 28, 2011). communicable%20diseases&ei=--vPTfqoGtCtgQfzjri8DA&usg= AFQjCNEF6zfWWOVhFn_70rl5CNBKrg8-aQ (accessed May 15, WHO. 2004. http://www.who.int/tobacco/mpower/2009/ 2011). Appendix_VIII-table_1.pdf (accessed April 21 2011). REFERENCES 73 WHO. “Alcohol Consumption Country Profile .� 2004. Wilkins, VM, ML Bruce, and JA Sirey. “Caregiving tasks and training interest of family caregivers of medically ill homebound WHO. “Global Alcohol Consumption Report.� 2006. older adults.� Journal of Aging Health, 2009: 528–542. “Global Database on BMI .� n.d. http://apps.who.int/bmi/ Wilks, R, N Younger, M Tulloch-Reid, S McFarlane, and D index.jsp?introPage=intro_3.html (accessed April 12 , 2011). Francis. Jamaica Health and Lifestyle Survey 2007-8 Technical Report. Jamaica National Health Fund, 2008. WHO. “Global Health Risks: Mortality and Morbidity Attributable to Selected Major Risks .� 2009. World Bank. Development Committee Global Public Goods: A Framework for the Role of the World Bank. Washington DC: World WHO. Global Health Risks: Mortality and Morbidity Attributable Bank, n.d. to Selected Major Risks. WHO, 2009. World Health Organization. n.d. https://apps.who.int/infobase/ WHO. Global Recommendations on Physical Activity for Health. and https://apps.who.int/infobase/Indicators.aspx. WHO, 2010. “Death and DALY Estimates by Cause.� 2002. http://www. WHO. “Grenada – Global Youth Tobacco Survey .� 2001. who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls (accessed August 18, 2010). WHO. Obesity: Preventing and Managing the Global Epidemic . Geneva : WHO, 2000 . Disease and injury country estimates. n.d. www.who.int/ healthinfo/global_burden_disease/estimates_country (accessed WHO risk factors database. n.d. http://www.who.int/topics/ December 29, 2009). physical_activity/en/ (accessed April 14, 2011). World Health Organization. Global Health Risks: Mortality WHO. “Saint Lucia: Smoking Prevalence Tobacco Economy .� and Burden of Disease Attributable to Selected Major Risks. Report, 2002. http://www.who.int/tobacco/media/en/Saint_Lucia.pdf Switzerland: World Health Organization, 2009. (accessed April 21, 2011). Global Prevalence of Vitamin A Deficiency in Populations at Risk WHO. “Saint Vincent and Grenadines: Global Youth Tobacco 1995-2005. Geneva: World Health Organization, 2009a. Use Survey .� 2001. Global Status Report on Road Safety. Geneva: WHO, 2007. “Updated Status of the WHO FCTC: Ratification and Accession by Country.� October 29, 2010. http://www.fctc.org/images/ Global Status Report on Road Safety. Geneva: WHO, 2009b. stories/ratification_latest_Saint%20Vincent%20and%20 Grenadines.pdf (accessed May 12, 2011). Global Tobacco Epidemic. Geneva: World Health Organization, 2009c. “WHO Department of Measurement and Health Information.� December 2004. http://www.who.int/healthinfo/statistics/ Jamaica. 2009. www.who.int/nha/country/jam/en (accessed bodgbddeathdalyestimates.xls. 2010 15-May). WHO. WHO, Global status report on noncommunicable diseases Jamaica Country Health Profile. 2008. http://www.who.int/ 2010. WHO, 2010. countries/jam/en/ (accessed June 2010). “Jamaica: Global Youth Tobacco Survey.� n.d. https://apps.who. “World Health Statistics 2008.� n.d. http://www.who.int/ int/infobase/report.aspx?rid=115&dm=8&iso=JAM (accessed whosis/whostat/2008/en/index.html. January 20, 2010). WHO/AMRO. “Alcohol Consumption Country Profiles.� 2010. World Health Organization. Prevention and Control of Non- http://www.who.int/substance_abuse/publications/global_ Communicable Diseases: Implementation of the Global Strategy. alcohol_report/msbgsramro.pdf. Document WHA63/12, Geneva: World Health Organization, 2010a. Wilkins VM, Bruce ML, Sirey JA. “Caregiving tasks and training interest of family caregivers of medically ill homebound older World Health Organization. Reducing Risks, Promoting Healthy adults.� Journal of Aging Health 21, no. 3 (2009): 528-542. Life. World Health Organization, 2002. NON-COMMUNICABLE DISEASES IN JAMAICA: MOVING FROM PRESCRIPTION TO PREVENTION 74 World Health Organization. The Global Burden of Disease: 2004 update. World Health Organization, 2008. World Health Organization. The Global Burden of Disease: 2004 Update. Geneva: World Health Organization, 2008a. World Health Organization. The World Health Report 2003: Shaping the Future. World Health Organization, 2003. “WHO Department of Measurement and Health Information.� December 2004. http://www.who.int/healthinfo/statistics/ bodgbddeathdalyestimates.xls. World Health Report 2005: Preventing Chronic Diseases; a Vital Investment. Geneva: World Health Organization, 2005. World Health Report 2008: Primary Health Care - Now More than Ever. Geneva: World Health Organization, 2008b. “World Health Statistics 2008.� n.d. http://www.who.int/ whosis/whostat/2008/en/index.html. World Health Statistics 2010. Geneva: World Health Organization, 2010b. www.diabetesatlas.org. n.d. diabetesatlas.org. REFERENCES 75