In 1981, at the end of the report on the Barbados National Health And Nutrition Surveys 1969, 1980, Dr Frank Ramsay, director of Barbados’ National Nutrition Centre, wrote: “Measures for its [obesity’s] prevention and control need to be urgently implemented”.
What was the health landscape back then?
In 1980, already 20 per cent of “older teenagers” were “too big for their heights” –– a term coined because weights, heights were compared to standard tables. Over the age of 35 years, more than half of all adults were already “too big for height”.
With this information in hand, the authors of this national report suggested that obesity needed to be tackled with some effort and enthusiasm.
Thirty-four years later, another report, the Health Of The Nation (HotN) Report, was published in 2015. This is the most recent “national” report since the last annual Chief Medical Officers Report of 2007 to 2009.
In looking at “body size”, the age groupings in HotN are different from the 1981 publication, and BMI –– body mass index –– was used as the criteria here to identify overweight and obese individuals. In the 1980 chart, the 60 per cent line was the highest needed. In the 2015 chart, the 60 per cent line was the lowest one needed. In all the age groups in the 2015 survey of adults 25 years and over, over 60 per cent of the individuals were overweight or obese.
As a society, we had grown/are growing, and our obesity figures have more than doubled since the first call for “urgent” attention to obesity was made in 1981.
In 2014, the World Health Organization (WHO) ranked Barbados as the 13th “fattest country” in the world, based on our percentage of obese persons. Perhaps we will keep moving up the charts.
In the Executive Summary of the HotN Report, the authors also used the word urgent: “urgent action is required to address the high levels of biological risk present in Barbadian adults”.
Thus these medical studies, presented decades apart, both concluded that action was needed urgently. Coincidence? Sir George Alleyne, former director of PAHO, regional office of the World Health Organization, noted in 2005 that “urgent and sustained response is needed to deal with the alarming increase in chronic non-communicable diseases”.
(Notice that he also used the word “urgent”, and this comment was about the Caribbean as a whole.) He also noted that it was “bad practice” to ask people to make healthy choices when there is a lack of agricultural policies and other initiatives to help them do so”.
But there are other perspectives on health, and health care, in Barbados.
In announcing a series of town hall meetings to discuss health care financing, the Ministry of Health noted that they [we] are seeking ways to sustain Barbados’ high-quality health care services.
So while many who use the system and complain of, for example, a shortage of resources at the local polyclinics or long waiting times at the Accident & Emergency Department of the Queen Elizabeth Hospital, would hardly care to characterize the service as “high-quality”, the Ministry of Health has hung its hat on that rack.
The Ministry of Health spends just over $400 million annually to offer free physician visits, free medications, a variety of free investigations, including blood tests and radiology, and even free access to a number of specialists in tertiary care. On the other hand, individuals spend $285 million in out-of-pocket expenses on health.
Who in their right minds would turn away from public health services and spend $285 million on health, unless they perceived there was some problems with the “high-quality, free services” offered in the public health arena.
Our Prime Minister Freundel Stuart, in the ceremony to launch Barbados’ 50th Anniversary Independence Celebrations on January 6, described health care here as “affordable, assessable and acceptable”. If the prevailing view of Government (and finance officials) over the last half-century that our health care is acceptable, then the views of our senior health officials armed with a harmful of health statistics will continue to have no bearing on financial (and political) decisions in health.
Indeed, just two months previously, in November, 2015, the Prime Minister opened another polyclinic to offer more “free” services to members of the Barbadian population, just ten months after the HotN Report noted significant limitations in the quality of health care –– if defined by health outcomes –– available here. Almost in the same breath that the Government is suggesting health care costs are exorbitant and unaffordable, and health care financial reform is needed, it has rushed ahead and offered more “free” services.
This suggests that, to date, decisions about health may not have been based on scientific data, at least data based on health indices. The inertia exhibited by the Ministry of Health in responding to calls for “urgent change” by senior health officials, officials within their own ministry, may not be solely caused by factors confined to the Ministry of Health.
A crystal ball is needed to see whether this trend will be reversed any time soon, and what may happen in the next 50 years. In the meantime, the population is suffering.
It is likely that the state of the national finances, rather that the state of national health, is driving the need to consider health-care financial reform. Government’s recurrent spending on health nowadays is upward of $400 million. The chief programme manager of the National Productivity Council noted about a year ago that businesses here had lost over $1 billion to productivity in 2012 and 2013. This averages $1/2 billion per year.
Much of this lost productivity is due to absenteeism (“sick leave”), a lot of which is related to the large numbers of individuals affected by one or more of the chronic non-communicable illnesses, although the available data on this is not extensive.
Since there has been no major initiative to tackle this problem, at least announced publically, it seems likely that our annual lost productivity remains in this vicinity. But the figures are mind-boggling: Government’s annual spending of $400 million on health, yet still losing $500 million in lost productivity. Is this acceptable? The country using (or losing) $900 million per year –– is this affordable?
In spite of the pleas of some of our senior health care officials to consider the need to improve the health of our people, the current debate on health sector financial reform is focused on finances –– not health. Sir George Alleyne also noted that while we (in the Caribbean) have (at least a version of ) Free Universal Health Care which we inherited from Britain at Independence, our mortality rates from diseases like diabetes and hypertension are five to ten times higher than those of Britain. Implied in this is that we need to focus more on the health care of our people, and the chronic non-communicable diseases in particular.
In the Free Universal Health Care model practised here, any individual can walk up to a public health care facility and request (or demand) free health care, which then has to be paid out of the public purse. So the demand for health care services dictates the funds needed to provide medical care.
In this scenario, an important cost-controlling measure would include measures to reduce the numbers of individuals coming forward seeking attention.
Improving primary care and, in particular, focusing on health promotion and disease prevention offer the opportunity to both lower health care costs and to improve the health of our people. It can significantly reduce the numbers that need to access expensive tertiary (hospital) care. And it can improve national productivity.
To be continued next week.
(Dr Colin V. Alert, MBBS, DM, is a family physician.)