78596 Non-Communicable Diseases In The Caribbean: The New Challenge For Productivity And Growth June 2013 1 This material has been prepared by Clark Matthews, under the supervision of Shiyan Chao of the Health Unit of the Latin America and the Caribbean Region of the World Bank. The content draws mainly on the following literature: “Promoting Healthy Living in Latin America and the Caribbean: Governance of Multisectoral Activities to Prevent Health Risk Factors�, World Bank (forthcoming in 2013); “Non-Communicable Diseases in Jamaica: Moving from Prescription to Prevention� World Bank (2011) and “The Growing Burden of Non-Communicable Diseases in the Eastern Caribbean, World Bank (2011) The Caribbean Knowledge Series is an occasional series that presents World Bank knowledge in an accessible format. It is meant to assist knowledge sharing across the region and trigger policy dialogue on topics relevant for the Caribbean. This note was prepared to support the participatory policy dialogue in the context of the Caribbean Growth Forum (CGF). The CGF is an initiative facilitated by the Compete Caribbean Program, the Inter-American Development Bank, the World Bank and the Caribbean Development Bank, with the support of the Canadian International Development Agency, the United Kingdom’s Agency for International Development, CARICOM Secretariat, the University of the West Indies, the European Union and Caribbean Export. It aims to facilitate a multi-stakeholder dialogue to identify practical solutions for the growth challenge in the Caribbean. To learn more about the CGF methodology and progress in each Caribbean country visit: http://caribgrowth.competecaribbean.org/ Disclaimer: This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Visit the entire “Caribbean Knowledge Series� collection at: http://worldbank.org/lac Design & Concept by Room Grupo Creativo | www.room.com.do Cover Photo: Jamaica Ministry of Health 2 3 Non-communicable diseases in the Caribbean: the new challenge for productivity and growth Non-communicable diseases (NCDs) falling. During this period there has also been pose significant challenges to individuals, a move towards urbanization as workers often communities, and nations alike, and represent relocate from rural communities to city settings. the major cause of death in the Caribbean. The percentage of urban dwellers varies across NCDs, which by definition are non-infectious the region, with countries such as the Dominican and non-transmissible among people, include Republic (69 percent) and the Bahamas (84 percent) autoimmune diseases, heart disease, some forms having among the highest proportion of citizens of cancers, and diabetes, among others. Over the in urban settings. The result is an increasingly last few decades, NCDs have reached the level of aging population concentrated in high-intensity epidemic in many parts of the world. The severity is locations. Crowded living conditions and significant particularly pronounced in the Caribbean region, environmental pollution are some of many factors and has resulted in both considerable loss of life, that contribute to heightened health risks in the and economic and social costs to individuals, region. families, and their communities. The prevalence of NCDs impacts labor market outcomes, including NCDs are linked to more than 7 out of 10 significant productivity losses due to absenteeism, deaths in the Caribbean region, which exceeds disability, reduced functionality, and less years the global average of nearly 60 percent. In of worker output. Addressing NCDs is no longer contrast, the occurrences of deaths as a result of solely a social protection strategy, but rather is a communicable diseases are on average 8 to 15 requirement to maximize investments in human percent in the region. Compared with the English capital to enhance productivity and achieve speaking Caribbean countries’ rate of death as a sustained economic growth. result of NCDs, non-English speaking Caribbean countries’ rate is particularly high, averaging The Emergence and Predominance 83 percent compared with 71 percent1. Within of NCDs the Organization of Eastern Caribbean States (OECS) countries, the three types of NCDs that Key demographic and migration trends have account for the largest portion of deaths includes: contributed to the predominance of NCDs. cardiovascular disease (30 to 46 percent of deaths), Since 1960, the rate of life expectancy at birth malignant neoplasms (10 to 20 percent of deaths), in the Caribbean region has increased from 61 and diabetes mellitus (3 to 14 percent of deaths)2. to 72 years; all the while, death rates have been Figure 1: Mortality distribution by causes of deaths, Figure 2: Mortality distribution by causes of deaths, Non-English speaking Caribbean English speaking Caribbean Injuries Injuries 8% 10% Ill-defined causes 4% Ill-defined NCDs causes 83% 1% NCDs 71% Communicable Communicable diseases diseases 8% 15% PAHO, 2011 PAHO, 2011 1 English-speaking Caribbean countries include: Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Netherland Antilles, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, and Turks and Caicos. Non-English speaking countries include: Cuba, Dominican Republic, French Guiana, Guadeloupe, Haiti, Martinique, and Montserrat. 1 OECS Countries are a proxy the entire Caribbean region. Data presented in World Bank, 2011. “The Growing Burden of Non-Communicable Diseases in the Eastern Caribbean�. Washington, DC. 4 Risk factors of NCDs NCDs share common underlying, interrelated risk factors, including obesity, physical inactivity, and tobacco and alcohol use. Despite overwhelming evidence of the harmful health consequences associated with these risk factors, the prevalence is on the rise in Caribbean countries. - Obesity: Since the 1970s, the rate of obesity and overweight people in the Caribbean has steadily increased across all countries and age cohorts. Studies indicate that diets include heavy consumption of grains, meats, sugars, oils and sodium, thus rendering it common for the average calorie intake to exceed daily requirements. - Physical inactivity: Physical inactivity is the fourth leading risk factor of global mortality. Country surveys provide moderate insight and demonstrate that populations are insufficiently active. - Smoking: In total, smoking is responsible for at least 10 percent of all deaths in Caribbean countries. Among countries possessing statistical data tracking tobacco usage, the rate is highest in Trinidad and Tobago, where 33 percent of the adult male and 6 percent of the adult female populations smoke cigarettes. - Alcohol: The excessive and harmful use of alcohol is a global problem that compromises both individual and social development, and can result in serious health concerns. Data from a subset of Caribbean countries shows that the total per capita consumption of pure alcohol per year is in excess of 5 liters in most countries. Studies show that overconsumption of alcohol increases the risk for more than 60 types of diseases and injuries. Economic Impact of NCDs Reducing the prominence of NCDs is an important that over the 18-year period, the percentage of economic growth strategy. Along with the social health care visits by patients without NCDs was and human merits for intervention, there are strong relatively stable, whereas the rate for patients economic motives for addressing NCDs. Countries with NCDs increased 20 percentage points3. in the Caribbean were negatively impacted by the These visits are labor intensive and require costly 2008 financial crisis and have not fully recovered. technology and physical space, which results in the They are heavily indebted, and economic growth diversion of limited financial and human resources has slowed. NCDs are costly, and have a direct and away from other pressing needs in the medical significant impact on economies, health systems, system. For example, in the OECS the total public and households and individuals. health expenditure per diabetic patient ranges from USD 326 in St. Vincent and Grenadines to Public health systems bear a significant portion of as high as USD 776 in Antigua and Barbuda per direct costs as a result of NCDs. People with NCDs year. In total, this expenditure equates to USD 1.8 have higher utilization of health care services. Data million and USD 2.4 million in the two countries for Jamaica from the period 1990 to 2007 shows presented, respectively. 3 Data presented in World Bank, 2011. “Non-Communicable Diseases in Jamaica: Moving from Prescription to Prevention�. En Breve Series, Number 171. Washington, DC. 5 The economic burden of NCDs on individuals is supply and less hours worked. Although there is high. Both direct and indirect economic burdens insufficient information to accurately assess the full must be examined in order to estimate the total extent in the Caribbean region, data from select economic burden of NCDs to individuals. The South American countries shows that individuals direct economic burden can be defined as the sum with NCDs work less hours than do average of out-of-pocket spending by NCD patients on workers, and have more pronounced working life outpatient visits, inpatient care, and medication. cycles (greater share of hours are worked mid- In contrast, an evaluation of the indirect economic career compared with early and late stages of a burden measures the reduction of productivity career). Anecdotal evidence also suggests that due to illness. A 2006 study estimates the total individuals with NCD-related disabilities are less average private economic burden of NCDs to be able to undertake a full spectrum of work duties, approximately USD 1,320 in St. Lucia per year, or which limits employment opportunities. roughly 1/4th of GDP per capita. The implications of this high level of expenditure can be seen in International evidence shows that individuals with many different ways. Allocating scarce financial NCDs have lower income. Studies undertaken in resources to treat NCDs can impoverish families, Brazil and Chile find that workers without NCDs diverting financial resources from other important earn higher incomes than those with NCDs by areas, such as extracurricular activities for children a measure of 30-40 percent4. Research further and quality of life activities. shows that there is a relationship between income and productivity, however it can be difficult to Addressing NCDs to Enhance measure because labor earnings are a result Productivity of several factors, including education, ability, industry, technological factors, amongst others5. Reducing the prevalence of NCDs can lead to To assess the full implications of NCDs on income positive labor market outcomes. NCDs create requires detailed analysis in the Caribbean region. barriers and impediments that limit employees’ Individuals suffering from NCDs in the Caribbean abilities to perform duties in the work place, which are already at a disadvantage. Reduced income in turn affects the level of labor force participation potential, coupled with the high private cost, and type of employment, and results in lower labor leads to reduced quality of life for individuals with NCDs and a diminished stock of human capital. Figure 3: Adjust Health Services Visits for individuals with Employers may then suffer from reduced profits as and without NCDs (%) a result of higher labor costs and inefficiencies, and each level of government receives less revenue from taxation (from both business and personal taxation). 4 World Bank, 2013. “Promoting Healthy Living in Latin America and the Caribbean: Governance of Multisectoral Activities to Prevent Health Risk Factors�. Washington, DC. 5 World Bank, 2013. “Promoting Healthy Living in Latin America and the Caribbean: Governance of Multisectoral Activities to Prevent Health Risk Factors�. Washington, DC. 6 For example, see: World Bank, 2013. “Promoting Healthy Living in Latin America and the Caribbean: Governance of multi-sectoral activities to prevent health risk factors�. Washington, DC. P125372; World Bank, 2011. “Non-Communicable Diseases in Jamaica: Moving from Prescription to Prevention�. Washington, DC; World Bank, 2011. “The Growing Burden of Non- Communicable Diseases in the Eastern Caribbean�. Washington, DC. 6 Conclusions Addressing NCDs should be at the forefront of the through various policy mechanisms, such as taxes economic growth agenda in the Caribbean. and incentive-based systems. These efforts require involvement from a wide range of stakeholders in Tackling NCDs requires an integrated, multi- the planning and implementation of strategies, disciplinary and sustained approached. The primary including the public and private sectors, and other challenge to addressing NCDs is there is no singular organizations. The prevalence of NCDs is rampant, action that will lead decrease the prevalence of the and the consequences well documented. From diseases, but rather a multiple pronged approach an economic perspective, addressing NCDs is that combines education, policy actions, and a necessity to increase labor productivity and interventions is required. Investing financial and achieve sustained economic growth. human resources wisely in the health care system through prevention and rehabilitation, such as screening, treatment, and care, is a necessity. Interventions – Healthy Caribbean, Caribbean Tobacco Control Project, amongst others – are environmental-based strategies to encourage and support behavioral change and can be supported 7 worldbank.org/lac 8