Opinión y análisis / Opinion and analysis Primary health care (PHC) is defined as “essential Health sector challenges health care based on practical, scientifically sound, and socially acceptable methods and technology and responses beyond made universally accessible to individuals and fam- the Alma-Ata Declaration: ilies in the community through their full participa- tion and at a cost that the community and country a Caribbean perspective can afford to maintain at every stage of their de- velopment in the spirit of self-reliance and self- determination” (1). Its effectiveness is also a mea- sure of the extent to which the availability of Jasneth Mullings1 resources, successful integration with other sectors and Tomlin J. Paul 1 (e.g., education, agriculture), and a broad-based community partnership is achieved (2, 3). The guiding principles of PHC and “Health for All by the Year 2000” speak to the right every citizen has to health care as a means of leading a safe and productive life. Integral to the provision of this right is equitable access to health services based on needs, and the key role of the State in en- suring this right for all (1). The State, therefore, partners with local and international agencies and its citizens to meet this objective, ensuring that ap- propriate policies and programs are in place along- side reliable structures for sustained socioeconomic development (1, 4). For the effective delivery of PHC to occur, it must be undergirded by a national health system infrastructure that has five key components: (1) de- velopment of health resources, such as manpower, facilities, equipment, and supplies; (2) organized arrangement of health resources through the es- tablishment of national health authorities, the pro- vision of national health insurance, and the in- tegration of public and private health services; (3) delivery of health care through the media of primary, secondary, and tertiary health services; (4) economic support through sources, such as pub- lic financing and foreign aid; and (5) management through strong leadership, policy formulation, reg- ulation, and monitoring and evaluation (5). EARLY BEGINNINGS OF PRIMARY HEALTH Key words: primary health care, health care eco- CARE IN THE CARIBBEAN nomics and organizations, health services accessi- bility, delivery of health care, Caribbean. The earliest organization of health services in the Caribbean occurred during the post-emancipation 1 The University of the West Indies, School of Nursing, Mona, Ja- period of the early 1900s and was influenced by maica. Send correspondence and reprint inquiries to: Jasneth high mortality rates from major infectious diseases Mullings, The UWI School of Nursing, Mona, University of the West Indies, Kingston 7, Jamaica; telephone: (876) 970-3304; fax: (876) 927- (malaria, syphilis, tuberculosis, yaws, and yellow 2472; e-mail: [email protected]. fever) (2). Infant and maternal mortality rates were Rev Panam Salud Publica/Pan Am J Public Health 21(2/3), 2007 155 Opinión y análisis • Opinion and analysis TABLE 1. Death rates and infant mortality rates (IMRs) in selected Caribbean territories, in 1928, 1932, and 1937a Territory Statistic 1928 1932 1937 Barbados Death rate 30.1 19.0 18.5 IMR 331.0 198.0 217.0 British Guiana Death rate 27.9 21.1 21.9 IMR 185.0 139.0 121.0 Jamaica Death rate 19.7 17.2 15.3 IMR 157.0 141.0 118.5 Nevis Death rate 19.4 11.1 14.9 IMR 286.6 102.2 107.1 Saint Kitts Death rate 39.8 27.5 36.5 IMR 308.3 166.7 209.0 Source: Moyne L. West Indian Royal Commission Report (6). a The death rates are per 1 000 population, and the infant mortality rates are per 1 000 live births. particularly high during this period (Table 1) (6). for PHC and served as the linchpin for the call to The Caribbean benefited from the concern of the “Health for All by the Year 2000” (1, 7). The Decla- colonial authorities who appointed a series of com- ration highlighted the value of intersectoral link- missions to investigate these diseases. The Rocke- ages and political commitment and responsibility feller and Moyne Commissions and the Irvine to attain this goal. Of key importance was the con- Committee are notable investigative mechanisms cept that socioeconomic development is critical to established during the early to mid-1900s. Their re- health care delivery and reform. In response to this search made recommendations that revolutionized call for action, Caribbean ministers of health, health care services in the Caribbean. through the assistance of the Pan American Health Table 1 depicts deaths and infant mortality Organization (PAHO), the United Nations Chil- rates (per 1 000) for select Caribbean territories dur- dren’s Fund, the United States Agency for Interna- ing the early 1900s. During this period, health care tional Development, and the University of the West expenditure in the Caribbean ranged from a low of Indies (UWI), among others, convened a workshop 8.9% of total expenditure in British Honduras and in 1981 to develop a Caribbean strategy for PHC (8). Montserrat to a high of 18.6% in Saint Kitts and Seven years later, PAHO conducted an evalu- Nevis and 19.6% in Saint Vincent. Other countries, ation of the PHC progress made in four countries, such as Barbados, Jamaica, and Trinidad, spent namely Anguilla, Barbados, Grenada, and Saint 11.3%, 9.8%, and 9.2% of their budgets, respec- Lucia. Most of these countries had embarked on de- tively, on health care (6). veloping an intersectoral approach to the imple- The first half of the twentieth century brought mentation of PHC through convening national in- two important health care milestones to the Carib- tersectoral workshops, and the establishment of a bean: the establishment of the West Indies School of PHC Intersectoral Committee in at least one coun- Public Health to train public health nurses and in- try (8). In Jamaica, where a policy decision had been spectors, and the establishment of the University made in 1977 to expand PHC services, the pace was College of the West Indies to train doctors. A PHC far advanced. The country’s approach was docu- system gradually developed with the concept of the mented in “Primary Health Care: the Jamaican Per- “health team approach,” the creation of medical spective,” and it was through this document that districts, and the development of health centers to key contributions were made to the discussions at provide first-line health care (2). Alma-Ata (9). One of the outstanding goals laid out in this document was that there should be a PHC center within 10 miles (16 km) of every citizen. ALMA-ATA AND THE CARIBBEAN Acknowledging the shortage and poor uti- PRIMARY HEALTH CARE STRATEGY lization of human resources within the health sec- tor, the Jamaican response was to train a cadre of The Declaration of Alma-Ata, made in 1978, community health aides as an “interface between encapsulates the principal processes and strategies the community and the health delivery system for 156 Rev Panam Salud Publica/Pan Am J Public Health 21(2/3), 2007 Opinión y análisis • Opinion and analysis health promotion, health education, disease pre- THE CARIBBEAN COOPERATION IN vention, and follow-up of persons to ensure that HEALTH CONCEPT—A NEW PERSPECTIVE they kept clinic appointments. .” (10). This train- ing experiment was the innovative and visionary The Caribbean countries, acknowledging that work of Sir Kenneth Standard and Olive Ennever of collaboration and cooperation were needed to meet the UWI Department of Social and Preventative health challenges and improve PHC delivery, gave Medicine (now the Department of Community birth to the Caribbean Cooperation in Health (CCH) Health and Psychiatry). Success led to its adoption concept in 1984, and further redefined it in 1996 by several countries, such as Antigua, Barbados, (13). The initiative embraced the World Health Or- Dominica, Grenada, Saint Lucia, and Saint Vincent, ganization’s definition of health as “a state of com- as early as 1967—before the Alma-Ata Conference. plete physical, mental, and social wellbeing, and Other additions to the health care team included not merely the absence of disease or infirmity” (14). the school dental nurse and dental assistant in 1970; It also recognized that there were multiple determi- the nurse practitioner, 1978; and the pharmacy tech- nants of health and that a multipronged approach nician, 1980 (10). was critical to achieving health gains. In 1996, Increased collaboration within the Caribbean health promotion—one of the cornerstones of the community, especially in the area of environmental PHC system—was identified as the major imple- health, was denoted by the development of the mentation strategy, and the tenets of the Caribbean Caribbean Environmental Health Strategy and the Charter for Health Promotion (CCHP) were ap- establishment of the Pan Caribbean Disaster Pre- plied to the priority areas identified. The priority vention and Preparedness Program in the 1980s. areas for the Caribbean included health systems de- The training and placement of national epidemiolo- velopment, human resource development, family gists, the move towards the development of sur- health, food and nutrition, chronic noncommunica- veillance systems and computerized information ble diseases, communicable diseases, mental health, systems (although at an uneven pace across the and environmental health (13). Caribbean), and the development of the advisory role of the Caribbean Epidemiology Center (CAREC) were among the important mileposts since the Alma- EMERGING ISSUES: 1980 TO PRESENT Ata Conference (8). Programs funded through local and interna- Changing demographic profile tional resources to upgrade unsatisfactory health facilities were implemented. Saint Lucia received Overall, increases in life expectancy and de- a grant from the Kellogg Foundation, and Barbados clines in fertility rates have resulted in a shift in the modernized its geriatric hospital (8).