David Dean Ellis LL.M MBA BA
The emergence of Chronic non-communicable diseases (CNCDs) throughout the developed world have come with debilitating effects on both the social and economic aspects of these countries and have recently become a very serious concern in many areas of the developing world as well. The World Health Organization estimates that CNCDs account for 59 per cent of deaths globally and almost half, (49.5%), of the global burden of disease. Already 77% of CNCD deaths occur in developing countries. A study of 23 developing countries, of the effects of chronic diseases on the population revealed the following findings:
“…an estimated US$84 billion of economic production will be lost from heart disease, stroke, and diabetes alone in these 23 countries between 2006 and 2015. Achievement of a global goal for chronic disease prevention and control—an additional 2% yearly reduction in chronic disease death rates over the next 10 years—would avert 24 million deaths in these countries, and would save an estimated $8 billion, which is almost 10% of the projected loss in national income over the next 10 years.” (Abegunde et al. 2007)
Statistics like these set the scene for preventative action in a number of developing countries such as Barbados, which created a National Task Force on CNCDs in 2004 in response to this pandemic. The Task Force produced a policy document for the prevention and control of CNCDs, which returned the following recommendations:
• The establishment of a Health Promotion Unit.
• The establishment of the post of Senior Medical Officer of Health (CNCDs).
• The establishment of a National Commission on CNCDs.
These recommendations conferred specific responsibilities to these agencies. The health promotion unit became responsible for raising public awareness to threat posed by Non communicable diseases and for the creation of partnerships with the private sector.
The establishment of the office of Senior Medical Officer was seen as a necessary attempt to create a specialized management structure for the initiative, which had the duty of reporting directly to the chief medical officer and the Minister of Health.
The National commission on NCDs was tasked with the following responsibilities:
1. To advise the Minister of Health on CNCDs policies and legislation, e.g. in relation to food availability, affordability and importation, environmental and work place issues, measures to increase participation in physical activity, tobacco control and other strategies to promote healthy lifestyles.
2. To broker effective involvement of all relevant sectors in program implementation, including the private sector, non-governmental organizations and civil society, including faith based organizations.
3. To assist in the mobilization of resources to facilitate the implementation of prevention and control programs.
4. To recommend relevant research, especially in relation to behaviour change and prevention of CNCDs.
5. To promote the establishment of collaboration and partnerships with UWI, CAREC, CARICOM, PAHO/WHO, CFNI and other regional and international institutions and organizations, as appropriate for the pursuit of these goals.
6. To review the National Strategic Plan for Health (2002-2012) and determine the applicability of priorities, expected results and activities in Barbados relative to CNCDs.
7. To monitor regional and international trends and provide direction for national responses.
8. To facilitate the commissioning of audit and evaluation of aspects of CNCD programs.
9. To recommend to the Minister of Health a framework that encourages and promotes behavior change and the prevention of CNCDs.
(National Commission on NCDs. 2008).
The proposals highlighted in the document were seen as necessary to address a problem, which the Ministry of Health considered a national priority. If implemented the policy would necessarily involve:
- Changes to the administration and operational protocols of the Ministry of Health through the creation of an additional layer of bureaucracy.
- Public and private sector engagement. The creation of a Health promotion unit as a public educational and engagement arm.
- The creation of new and specialized monitoring systems for tracking the progress of this initiative. The establishment of a Barbados National registry for Chronic Non Communicable diseases in 2007 was affected to provide a baseline and ongoing monitoring system by which the progress of the initiative could be measured.
Rationale to support the creation of a national policy on CNCDs
The health situation in Barbados has evolved over time. The social development of the country has come with the price of many health concerns. In the absence of a National Registry for Non Communicable diseases, it is estimated that decade before Barbadian independence in 1966, the major health concern for the population was the prevalence of infectious diseases such as Malaria and Dengue Fever. The population was less susceptible to CNCDs due mainly to the following reasons;
- A greater percentage of the population were involved in physical labor and exercise due to a less developed transit system and the absence of amenities such as automated vehicles which meant the population were forced to move more.
- Less processed food in the Barbadian diet. A greater amount of the island food supply was produced on island through agriculture, which reduced the need for preservatives and salt-based additives.
- There was an absence of many of the social pressures which plague the nation today such as decreased crime rates and the anxiety associated with changing work habits.
At present Barbados is the island most affected by these generational lifestyle changes and the effects of debilitating CNCDs. These include diabetes, obesity and hypertension and their complications, cerebrovascular disease, cancer and heart disease. As a result of the increased prevalence of these “lifestyle based” diseases, the Queen Elizabeth Hospital (QEH) has seen an unprecedented increase in the number of patients being diagnosed with NCDs. The facility reported 1760 newly diagnosed patients for the year 1999 alone. (QEH. 2011)
Also in recent years CNCDs have consistently accounted for a significant portion of all reported deaths in Barbados. Between 1999-2001, heart disease, diabetes and cerebrovascular disease were the principal causes of death per thousand population.
The Barbados Food Consumption and Anthropometric Survey
(2000/2001), a self-reported survey, has indicated that 24.2% of men and 37.5%
of women, based on a sample size of 1051 households (i.e. 1% of total
households of that year), had been diagnosed with one or more CNCD. For
individuals over 50 years of age, the prevalence rose to 39% in men and 61% in women.
It is also significant that from the entire sample studied in the 2000/2001
surveys, hypertension was the most frequently reported CNCD (17.3% in men and
28.8% in women), followed by diabetes (10.1% in men and 15.2% in women).
Barbados has seen numerous attempts over the years to control the spread of CNCDs. These efforts were primarily concerned with the improvement of clinical care and efforts to educate medical and support staff on the nature of these diseases. These efforts however were met with marginal success.
The Barbados risk factor surveys, conducted in 1993 and 2002 showed that there was a considerable increase in the level of awareness of disease risk factors among clinical staff. Individuals interviewed also demonstrated knowledge of disease management and methods of controlling the disease. This however did not arrest the trend of CNCDs spreading within the region.
In 1996 the ministry of health attempted to address the problem by appointing National Advisory Council on Chronic Diseases. Its function was
“…to help to inform policy by guiding the development of comprehensive programs for effective prevention, equitable mangement and optimal control of chronic diseases”.
(National Advisory Council, Ministry Of Health BARBADOS. 2004 pg.3)
The council however was ineffectual due to the lack of official support and the inability to implement programs independently of Ministerial approval.
In 2004 on the Barbados Government formulated a strategy document for the control of CNCDs in the island, as the foundation of a much larger framework and the formulation of an official policy on responding to CNCDs in the island. The document contained only one goal, which was,
“To reduce the mortality rate of selected CNCDs by 15% by 2012”.
(National Advisory Council, Ministry Of Health BARBADOS. 2004 .pg. 37)
In addition the stated objectives of the document included,
- Increase the proportion of the population taking regular physical activity from 47% to 67% in 3 years and to 80% in five years
- Decrease obesity prevalence in women from 30% to 25% in 3 years and to 20% in 5 years
- Decrease overweight prevalence in men from 30% to 25% in 3 years and 20% in 5 years
- Reduce poor diabetes control to 30% in 3 years and 20% in 5 years
- Increase the proportion of hypertensives treated from 66% to 75% in 3 years and 80% in 5 years
- Increase the proportion of hypertensives controlled from 30% to 50% in 5 years
The National Commission on CNCDs was formally created in January 2007 and had as its mandate the development and implementation of strategies aimed at reducing the incidence of CNCD’s in Barbados.
Evidence to support the need for this change came from a variety of sources. The Healthy Caribbean Coalition, a non-profit organization, which promotes health and wellness in the Caribbean, reported that treatment of hypertension and diabetes in selected Caribbean countries (Bahamas, Jamaica, Barbados, and Trinidad and Tobago) was estimated to consume a range of 1.4 to 8.0 % of Gross Domestic Product for these countries. (Healthy Caribbean Coalition. 2011).
This economic impact was further reiterated in 2012 by the then Minister of Health, Donville Inniss while addressing the nation on the matter of CNCD’s
“The first burden is the cost of absenteeism due to illness. Every hour lost because of illness is revenue taken from employers and taken from the Government purse. Without that revenue, Government cannot pay for the goods and services it provides for its citizens. Second, the more people fall ill, the more Government has to spend on health services. CNCDs, therefore, add unnecessary costs to the running of a country. It is for these reasons that development specialists have argued that ‘the health of a nation is the wealth of the nation”. (Public speech transcript given at Lloyd Erskin Sandiford Centre. Ministry of Health. 2012).
In addition, Commonwealth Health Online another NGO, which specializes in the collection of data statistics for the countries of the British Commonwealth, reported recently that non-communicable diseases (NCDs) in Barbados accounted for an estimated 82 per cent majority of all mortality in 2008.
These disturbing statistics and the threat of economic retardation have prompted the government to consider an action plan for arresting this trend. The plan was first introduced through an international symposium in 2005, which brought together all the major stakeholders, including members of the private sector. The event was advertised as an opportunity to develop and foster partnerships with the local community and businesses to combat the problem posed by CNCD’s and as a sounding board for ideas from the general public on how the challenge should be met.
The result was the formation of a National task force charged with formulating strategies for combatting this problem as well as raising public awareness.
One of the initiatives was the establishment of a National Commission for Non Communicable Diseases, which became responsible for overseeing preventative and therapeutic strategies against CNCDs. The Commission funded by European Development Fund, contracted the Chronic Disease Research Centre of the University of the West Indies to implement and manage the Barbados National Registry for Chronic Non-Communicable Disease (BNR): the first national, population-based, combined disease registry in the Caribbean.
The commission also contracted the creation of a publication entitled
” Guidelines for Physical activity for the Barbadian Population. The document was
distributed within all primary health care centers and contained information
relating to the resources, which were free and available to the Barbadian
population to promote a healthier lifestyle and diet. A highly publicized
health and fitness campaign on social media and the press also accompanied the
Evaluation of policy: Planning and implementation
The initiative thus far has been successful in that the number of people making use of free public services like nutrition counselling has increased. This however has not stopped the rise of mortality and cases of CNCDs in the country. Indeed in 2010, Dr. Trevor Hassel, Chairman of the National Commission for Chronic Non-Communicable Diseases (CNCDs) announced,
“Chronic diseases account for 50 per cent of all death and disability in Barbados.” (Barbados Advocate 1/29/2010, pg18.)
The failure of these measures to bring bout a lasting positive effect on the situation is further exemplified by the figures collected by the National Registry for Non communicable diseases which placed the number of Myocardial infarctions at 182 and 347 for the years 2009 and 2010 respectively. The number of recorded deaths from strokes and heart attacks combined were 363 (2009) and 533 (2010).
The lack of success of this initiative despite what seems to be a growing awareness among the population has been due to a number of factors:
First is the fallacy that good policy planning must necessarily produce good results. The standardized development of policy, shown in the Strategy for the Prevention and Control of Chronic Non Communicable Diseases (2004) has all the markings of a well-executed plan of action except for the fact that there was an absence of the anticipation of public response to the changes proposed in the strategy itself.
The paper in effect chose not to address the prevalence of cultural norms and beliefs with regard to diet and the difficulty involved in changing traditional attitudes to nutrition. It also did not take into consideration the increasing prevalence of fast food franchises and outlets being brought to the Caribbean and the effect, which the convenience provided, by these fast food outlets has had on a developing and faster paced society. Finally, the document did address the Obesity rate and the general attitude towards obesity at the time,
“Obesity, which is not considered by most of the Barbadian public to be an actual chronic disease, has been directly related to an increase in the prevalence of hypertension and coronary heart disease,” (National Advisory Council, Ministry of Health. PG14),
but failed to suggest methods of addressing this problem.
The document did however provided a framework for mechanisms to combat the socio-economic effects of CNCDs including an inter- ministerial approach, which involved all aspects of the public sector.
Subsequent literature from the Ministry of health also failed to address the prevailing attitudes of the population towards health. The Health Systems Profile (2008) document created by the Ministry of health also made mention of the serious impact of the rise of CNCD’s in the country, but chose to address the issue from the position of greater public sector reform and improvements to the health services as exemplified in it’s executive summary,
“A significant epidemiological trend in Barbados is the increasing prevalence of overweight, obesity, and chronic non-communicable diseases in the general population…The Barbados Drug Service provides drugs and other pharmaceutics listed in the Barbados Drug Formulary free of charge to persons in the public sector and to pre-defined beneficiaries in the private sector.” (Ministry of Health. 2008 pg.3).
Recent literature however on the subject of CNCDs has sought to address this problem by producing advisory publications for the population seeking to change public perceptions and beliefs through education. One such publication was Battling the hidden Enemy (2012) which addressed the attitudes of the Barbadian population with regard to diet, but chose to concentrate primarily on Salt as the culprit for the majority of the CNCDs and not necessarily on the root of the problem which is the cultural and social drivers for poor dietary choices.
Indeed most recent publications by the Commission have avoided dealing with the psychosocial aspects, which underpin the rise of CNCD’s in the region. The resolving of this issue is assumed to be a direct by-product of proper and structured planning and there has not been a concerted effort on the part of the Ministry to address this issue to date.
Second is the problem associated with most centralized “top-down” systems. Heavy bureaucracy makes for an inefficient response to changing circumstances. The structural changes to the administration proposed by the Strategy for the Prevention and Control of Chronic Non Communicable Diseases (2004) included the creation of an alternate administration for this initiative, placing additional layers to the administrative structure (Senior Medical Officer of Health (CNCDs), Senior Health Promotion Officer) and new sublevels (Behavioural Specialist, Research Officer, Administrative Officer, Health Promotion officers).
The result of the restructuring of these systems would mean the slowing down of the overall system as staff and new personnel began adapting and entering learning curves in their new positions and to the new structure.
The Ministry of Health however held a national symposium on CNCDs the following year (2005), which sought to create a forum for the public and private sector before the new proposed structure was fully in place. This symposium invited all the stakeholders concerned with CNCDs and a discussion forum was opened concerning the fostering of partnerships with the private sector. This was not efficient, as the working structure proposed in the 2004 document would essentially have to come into these “partnerships” at a later date. The official creation of the National Commission for CNCDs was officially announced in 2007, three years after the publishing of the document and 2 years after the first attempts were made at engaging the private sector. The commissioning of the Barbados National Registry for CNCD’s whose data was to be used as a baseline for monitoring the progress of the initiative was also started in 2007.
The effect of creating these partnerships before the necessary structural agencies were effectively set up and running smoothly was the slowing down of the effective administration of all relevant resources. Government for instance did not anticipate what the cost of a drastic change in fiscal resources could have on government programs and failed to adjust effectively. The 2008/2009 global economic contractions for instance saw a subsequent declining of 3.6% of GDP of the Barbados economy. Government approved estimates for health was $458,773,151 with an actual expenditure on health of $418,822,559. The real expenditure at the start of the global economic crisis was recorded at $406,510,095. (Ministry of Finance, 2009-2010 pg.4).
It is little wonder therefore that newer programs in the ministry suffering from reduced funding yielded mediocre results. The Barbados National registry recorded an increase in the number of Stroke and Heart attack incidents in the years succeeding the Global economic slump with total hospital intake rising from 532 to 658 in 2009 to 2010 respectively. Whereas no direct correlation can be made between the level of funding to the Ministry and its programs and the rising trend of CNCDs, the effect of decreased funding to any public sector change system would necessarily limit the performance of that system.
Finally, public involvement in public sector policy planning is a crucial element of successful implementation. The creation of a framework in 2004 represented the administrative fallacy of “if you build it, they will come”. Although there had been many attempts to engage the public at large as partners in the fight against CNCDs the Ministry of Health should have taken into consideration that its traditional position as the sole.
“…executing agency for the delivery of health care in the public sector and has responsibility for planning, regulation and evaluation across the public, private and NGO sectors. It is headed by a Minister who has overall responsibility for policy-making and political direction. Decision-making is centralized and there are no local authorities.” (Ministry of Legal Affairs, Health Services Act, 1969. Cap 44 pg.1),
meant that the public expected that full accountability and responsibility for their health lay with the Minister of Health and his agents.
This concept of a centralized government with ultimate authority and responsibility for public health represents, in effect “the way things were done in Barbados” and the government should have considered the effects of cultural norms on the population before attempting to implement changes, which would have repercussions on the way this initiative was received.
Regardless, attempts were made after the formulation of the 2004 framework, in the form of a Health and fitness campaign in 2012. These efforts however were mediocre in their results as there was little emphasis placed on public involvement and more placed on public participation. In contrast, the level of public involvement and engagement executed in Scotland’s Detect Cancer early campaign saw a developed media and social campaign which had a monitoring process already structured into every activity.
The Ministry of Health chose to use the National Symposium on CNCDs (2005) as the “priming campaign” for it’s activities and members of the public were encouraged to present any suggestions they may have, but the framework and the method of implementation had already been created and decided by the Ministry and the symposium represented a mere formality to it’s implementation. Further public engagement came only in the form of public awareness campaigns with no monitoring structures in place to assess their effectiveness. Indeed the wording of the 2004 document suggests a number of surveys be conducted to assess the effectiveness of the program but was not specific as to how and when the program should be evaluated,
“The success of any program for the control of CNCDs which are already established in the population will only become evident with the passage of time…. An audit of the program would ensure that the components of the program are monitored and constantly upgraded, allowing all stakeholders to:
1. Appreciate what a good program entails
2. Understand the benefits of such a service to persons with CNCDs
3. Review the program’s effect on health and productivity”.
(National Advisory Council, 2004. Pgs. 40-41).”
The vagueness of this wording resulted in inefficiencies in actual implementation of evaluation policies. The Barbados National registry for CNCDs, which was to be used as the Baseline for statistical evaluation, began publishing their annual reports in 2009. Thus most attempts at actual implementation of informed evaluation methods and support services began after this date.
not to understate the effect that a reduction in funding had on the efficiency
of the new systems. Initiatives such as the commissioning of “Guidelines for
Physical activity and Exercise” a Barbadian publication had to be put off till
2012 because of lack of funding. This publication was supposed to be the
flagship initiative for encouraging public engagement and education on what
constitutes adequate physical exercise and healthy activity, however the
unexpected shortfall in government financial allocation to health services
meant that programs such as these needed to be put on hold in light of the
global economic contraction.
Recommendations and alternatives
The essentials of change management do not differ greatly when applied on a nationwide scale. In the case of the Barbadian government a problem had been identified and a policy had to be implemented to redress it.
Basic Change management protocols should have been implemented from the onset however to handle the responses which were inevitable in the following ways:
- Anticipation of resistance and support to the proposed change should have been considered in the planning stages of the initiative. The effect of this change for example, would ultimately mean alterations in Barbadian food choices and activity and as such a certain percentage of the business places such as fast food restaurants and snack producers would necessarily be negatively affected by this policy. It would have been advisable to attempt to reach out to these businesses and in an effort to negotiate healthier food options for the public. The proposed strategy however did not take into consideration the responses of these businesses to what would have been perceived as a threat to their profitability.
- Consideration of the soft aspects of change management in the planning stages. The creation of a hard structural approach to health policy to combat CNCDs in Barbados was ill advised and the initiative should have began with an attempt to shift the awareness and consciousness of the Barbadian public away from traditional patterns of nutrition to more positive and constructive lifestyle choices. The decision to create a framework first with the hopes that attitudes would change if there were a system in place to change them ignores the realities of a society with established norms albeit erroneous, as to what constitutes good health.
- The creation of contingencies and better operational logistics for unexpected circumstances in the form of small attainable goals in pursuit of the larger goal stated in the framework would have alleviated some of the difficulties associated with an unexpected lack of funding. The initiative should have been handled as a bundled project with smaller to medium sized goals, which would continue to function with a decreased budget instead of having to reprioritize major initiatives and compromising the momentum of the entire project.
- Specialized managers experienced in change management should have been brought in to oversee the project. While it was important to emphasize evaluation and monitoring of the program, the implementation phase should have been considered as equal priority and should have been built into the framework of the program.
The creation and implementation of public policy in Barbados has traditionally been a top-down centralized affair with little or no pubic engagement. The Campaign to reduce the effects of CNCDs on the Barbadian population represented a new precedent in the implementation of public policy. The campaign began as a reaction to the rising trend of CNCDs among the population but brought elements such as structural changes to the administration as well as systems approach for establishing a baseline and future monitoring systems.
There were however shortfalls in the preparations such as the lack of public engagement and unforeseen circumstances in the amount of public funding which affected the effectiveness of the campaign.
Subsequent iterations however on the original framework of 2004 made by the National Commission on CNCDs have sought to resolve the initial problems associated with the “soft” aspects of change management. The success of these corrections however will depend entirely on how the public responds to the changes in the administration and the culture of health services as well as the level of consistent effort put forward by the agencies and stakeholders involved.
The Barbados Strategic plan for health 2002-2012 states the Health of a nation is the Wealth of a Nation. This is certainly literally the case when considering the economic impact which CNCDs. Estimates places the global loss in production due to CNCDs at 47 trillion over the next two decades. (Bloom et. al 2011). It is for this reason Barbados must establish itself as a useful partner in the global campaign against CNCDs.
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