Health and Healthcare in the British Overseas Territories: Regional and UK Government Support mu Ber da a d C icos n I a s s la k n r d u T s man Isla y nd a s C Virgin Is h la is n it d r s B airn Isla tc nd i s P Henderson Ducie Oeno Pitcairn ui Ang lla ontserra M t sl Helen nd I and t. a a s Islan Cunha S l on d a lk si d a n n F a e t c s s i r A T The maps above are not to scale and should not be used for determining the precise location of places or features. September 2010 Health and Healthcare in the British Overseas Territories: Regional and UK Government Support Abbreviations AFRO Africa Regional Office (WHO) AIDS Acquired Immunodeficiency Syndrome BVI British Virgin Islands CAREC Caribbean Epidemiology Centre CARICOM Caribbean Community CARPHA Caribbean Public Health Agency CCH Caribbean Cooperation in Health CDB Caribbean Development Bank CDEMA Caribbean Disaster Emergency Management Agency CHAA Caribbean HIV and AIDS Alliance CHRC Caribbean Health Research Council CIS Confederation of Independent States CPO Country Program Officer DFID Department for International Development DH Department of Health EC European Commission EU European Union ECCS Eastern Caribbean Cooperation Strategy ECDC European Centre for Disease Control EDF European Development Fund EIB European Investment Bank EU European Union FCO Foreign and Commonwealth Office GDP Gross Domestic Product GHP Global Health Partnership GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HIS Health Information System HIV Human Immunodeficiency Virus HMG Her Majesty’s Government HPA Health Protection Agency IFRC Int’l Federation of Red Cross & Red Crescent Societies IHR International Health Regulations JCS Joint Country Strategy MoD Ministry of Defence MOH Ministry of Health NCD Non Communicable Diseases NHS UK National Health Service NICO Northern Island Cooperation Overseas OCPC Office of Caribbean Program Coordination (PAHO) OCTs Overseas Countries and Territories OECC Office for Eastern Caribbean Cooperation (PAHO) OTs Overseas Territories OTCC Overseas Territories Consultative Council OTD Overseas Territories Department OECS Organisation of Eastern Caribbean States PAHO Pan-American Health Organisation ppp purchasing power parity PPS Pharmaceutical Procurement Service PWR PAHO/WHO Representative RCM Regional Coordination Mechanism RST Regional Support Team SPC Secretariat of the Pacific Communities TA Technical Assistant (provision of a specialist) TCI Turks & Caicos Islands UKOTs United Kingdom Overseas Territories UNGASS United Nations General Assembly Special Session UNFPA United Nations Population Fund WPRO Western Pacific Regional Office (WHO) 2 Health and Healthcare in the British Overseas Territories: Regional and UK Government Support Table of Contents Introduction 4 Summary of health priorities 4 Health service provision 5 Common themes and diversity 5 1 DELIVERING HEALTH AND HEALTHCARE IN THE UK OVERSEAS TERRITORIES 6 What the territory governments provide 6 What the UK government provides 6 What the European Commission provides 7 What regional organisations provide: PAHO, CARICOM, OECS, UN agencies and others 8 Coordination mechanisms 9 2 ANALYSIS: SIMilarities, DIVERSITY and UNMET NEEDS 10 Diversity 10 Similarity 10 Unmet needs: Secondary and tertiary care - a critical challenge 11 Analysis of health and health care challenges 11 Factors affecting the take-up of available external support 12 3 MOVING FORWARD TOGETHER Matching needs, demands and supplies 13 Communications, coordination and representation 13 Objectives and priority actions for moving forward 13 Annexes Key features of UK Overseas Territories and their health systems Needs and gaps in the provision of support to territory health and healthcare Regional and international organisations/agencies: missions, resources, and key contacts 3 Health and Healthcare in the British Overseas Territories: Regional and UK Government Support Introduction From Montserrat to Bermuda, St Helena to the Falkland Summary of health priorities Islands and Pitcairn, the United Kingdom has responsibility for 14 Overseas Territories (UKOTs), 11 of which are The OTs are in demographic and epidemiological transition. permanently populated – their histories to a greater or lesser Incidence and prevalence of most communicable diseases extent influenced by the global reach of the British Empire. have fallen dramatically, while non-communicable health Though different in size, economic and social development problems such as cardio- and cerebro vascular hypertensive and systems of governance, most of them share common disease, diabetes and cancer have soared over the last 20 features which include relative isolation, exposure to years or so, often linked with lifestyle. Vehicle accidents disasters, dependence on one or two key industries, and all and violence have also risen. HIV infection is the one have opted to remain under British sovereignty rather than, communicable disease to have increased significantly where this is an option, seek independence. amongst the Caribbean territories and Bermuda, although it is less than 1%, but is insignificant in the Atlantic and Pacific. While the territories have their own constitutions, As life expectancy has increased, so have the health problems legal systems and most have a democratically elected associated with an ageing population. Government, the Queen is head of state in each territory. Most powers, including provision of healthcare are Among young children, the more important health problems devolved to the Territories, but the UK retains responsibility are occurring in the perinatal period as well as gastro- for good governance, defence, external relations, and intestinal and respiratory infections – all affected by the level has to meet contingent liabilities and fulfil international of poverty and therefore inconsistent across the territories. obligations applying to the Territories. The UK’s Foreign and Commonwealth Office (FCO) leads overall policy and H1N1 and avian flu present potential challenges for the maintains the main UK presence in Territory through the territories, just as they do for the rest of the world. All except Governor with other Government departments leading Pitcairn, St Helena, Tristan da Cunha and Ascension have and supporting the Territories on areas within their reported cases of H1N1. The remoteness of the islands in the responsibilities. Atlantic and Pacific make their populations more susceptible to seasonal outbreaks or pathogens that arrive with visiting The UK’s Global Health Strategy commits the government ships, and the spread of pandemic flu will be a particular to outlining the UK’s current and future support to overseas cause for concern for them. Other vector borne diseases territories. When ministers of health from the territories met reported as of concern to UKOTs are dengue, leptospirosis at PAHO in September 2008, they asked for clarification of and hydatid on Anguilla/BVI, St Helena and Falkland Islands the responsibilities of UK government departments. This respectively. publication addresses those needs. It also aims to clarify how the people of the territories can access regional and HMG On mental health, most territories struggle with how best resources, and to stimulate thinking about how governments to deal with psychiatric patients who may be a threat to and organisations can work together to improve that access. themselves or their communities. Many end up in prisons because there is no other secure place, which raise concerns The UKOTs covered by this paper include 5 Caribbean OTs that the individuals’ human rights are not being met. (Anguilla, British Virgin Islands, Cayman Islands, Montserrat, Turks and Caicos Islands) and Bermuda, 4 South Atlantic OTs (St Helena, Ascension, Tristan da Cunha and Falkland Islands) See Annex 1 for a summary of key features of the and Pitcairn Islands in the Pacific. UKOTs and Annex 2 for a summary of identified needs and gaps in health service provision. 4 Health and Healthcare in the British Overseas Territories: Regional and UK Government Support Health service provision While health systems and methods of service delivery For all of them, however, the cost of accessing off-island vary widely, most provide basic services on-island through expertise is uneconomic. The issue of ‘micro-island a mix of public and private provision, financed through economies’ are set out in the EC’s Green Paper on relations tax revenue, social insurance and private insurance. So, between the EU and the Overseas Countries and Territories. for example, Bermuda, a territory with a high per capita GDP, relies on a mix of social and private insurance, while Access to regional and international development assistance Montserrat whose per capita GDP is low, provides services also varies across the territories, with those in the Caribbean mainly in the public sector, financed through revenue. and Bermuda having a more extensive range of organisations All territories source specialist services off-island in either available to them. Major technical assistance providers and the public or private sectors. This provides a challenge of funders in the Caribbean include HMG, PAHO, CARICOM, increasing scale and complexity, with great variation in how PANCAP, OECS, and the EC, often working in partnership. off-island services are accessed and financed. While the UK Combined, these organisations are a vast resource. By supports limited off-island care through its quota system, contrast, the Atlantic