[Civil society promoting government accountability for health equity in the Caribbean: The Healthy Caribbean CoalitionPromoção, pela sociedade civil, da responsabilização do governo pela equidade em saúde no Caribe: a Coalizão do Caribe Saudável]. / Papel de la sociedad civil en la promoción de la rendición de cuentas de los gobiernos en materia de equidad en salud en el Caribe: la Coalición Caribe Saludable.

Achieving health equity and addressing the social determinants of health are critical to attaining the health and health-related targets of the 2030 Agenda for Sustainable Development and its Sustainable Development Goals. Frameworks for health, including the Sustainable Health Agenda for the Americas 2018 - 2030, emphasize reduction of health inequities and "leaving no one behind" in national sustainable development. Health equity includes advancing universal health and the primary health care approach, with equitable access for all people to timely, quality, comprehensive, people- and community-centered services that do not cause impoverishment. Equally important, and a hallmark of good governance, is accountability for such advances. Governments have primary responsibility for reducing health inequities and must be held accountable for their policies and performance. Civil society has been recognized as a key partner in advancing sustainable and equitable national development. Effective accountability mechanisms should include civic engagement. The Healthy Caribbean Coalition (HCC), the only Caribbean regional alliance of civil society organizations working to prevent and control noncommunicable diseases-a major health priority fueled by inequities-has played a significant role in holding governments accountable for advancing health equity. This case study examines factors contributing to the success of the HCC, highlighting work under its five strategic pillars- accountability, advocacy, capacity development, communication, and sustainability-as well as challenges, lessons learned, and considerations for greater effectiveness.

Conquistar a equidade em saúde e abordar os determinantes sociais da saúde são essenciais para atingir as metas de saúde e as relacionadas à saúde da Agenda 2030 para o Desenvolvimento Sustentável e seus Objetivos de Desenvolvimento Sustentável. As estruturas para a saúde, incluindo a Agenda de Saúde Sustentável para as Américas 2018-2030, enfatizam a redução das iniquidades em saúde "sem deixar ninguém para trás", quando se trata do desenvolvimento sustentável nacional. A equidade em saúde inclui impulsionar a saúde universal e a abordagem da atenção primária à saúde, habilitando o acesso equitativo por todas as pessoas a serviços oportunos, de qualidade, integrais, centrados no atendimento às pessoas e às comunidades de maneira a não causar o empobrecimento. A questão da responsabilidade por tais avanços é igualmente importante, e é um selo de distinção de boa gestão. Os governos são os principais responsáveis pela redução das iniquidades em saúde e precisam ser responsabilizados por suas políticas e por seu desempenho. Reconheceu-se que a sociedade civil desempenha um papel essencial na promoção do desenvolvimento nacional sustentável e equitativo. Para que sejam eficazes, os mecanismos de responsabilização devem incluir a participação cívica. A Coalizão do Caribe Saudável (HCC), a única aliança de organizações da sociedade civil que trabalha na prevenção e no controle de doenças não transmissíveis na região do Caribe ­ uma grande prioridade de saúde movida pelas iniquidades ­ tem desempenhado uma função significativa na responsabilização dos governos pelo avanço da equidade em saúde. Este estudo examina os fatores que contribuem para o sucesso da HCC e destaca o trabalho da perspectiva dos cinco pilares estratégicos ­ responsabilidade, promoção de causa, desenvolvimento das capacidades, comunicação e sustentabilidade ­, bem como os desafios, as lições aprendidas e as considerações para que se torne ainda mais eficaz.

Papel de la sociedad civil en la promoción de la rendición de cuentas de los gobiernos en materia de equidad en salud en el Caribe: la Coalición Caribe Saludable

[RESUMEN]. Alcanzar la equidad en salud y abordar los determinantes sociales de la salud son aspectos fundamentales para alcanzar las metas en materia de salud y relacionadas con la salud de la Agenda para el Desarrollo Sostenible 2030 y sus Objetivos de Desarrollo Sostenible. Los marcos de referencia para la salud, como la Agenda de Salud Sostenible para las Américas 2018-2030, hacen hincapié en la reducción de las desigualdades en salud y en “no dejar a nadie atrás” en el desarrollo sostenible a nivel nacional. La equidad en salud incluye la promoción de la salud universal y el enfoque de atención primaria de salud, con un acceso equitativo de todas las personas a servicios de salud oportunos, de calidad, integrales y centrados en las personas y la comunidad que no ocasionen empobrecimiento. La rendición de cuentas por esos avances es igualmente importante, y un signo distintivo de una gobernanza adecuada. Los gobiernos tienen la responsabilidad primordial de reducir las desigualdades en salud y deben rendir cuentas de sus políticas y su desempeño. La sociedad civil es una parte interesada fundamental para promover un desarrollo nacional sostenible y equitativo, y debe formar parte de los mecanismos eficaces de rendición de cuentas. La Coalición Caribe Saludable —la única alianza regional del Caribe de organizaciones de la sociedad civil dedicada a prevenir y controlar las enfermedades no transmisibles, una prioridad de sanitaria importante acrecentada por las desigualdades— ha desempeñado un papel importante en hacer que los gobiernos rindan cuentas de la promoción de la equidad en salud. En este estudio se examinan los factores que han contribuido al éxito de la Coalición Caribe Saludable, con énfasis en la labor realizada en el marco de sus cinco pilares estratégicos —rendición de cuentas, promoción de la causa, desarrollo de capacidad, comunicación y sostenibilidad— así como los retos, las enseñanzas extraídas y otras consideraciones para lograr una mayor eficacia.

[ABSTRACT]. Achieving health equity and addressing the social determinants of health are critical to attaining the health and health-related targets of the 2030 Agenda for Sustainable Development and its Sustainable Development Goals. Frameworks for health, including the Sustainable Health Agenda for the Americas 2018 – 2030, emphasize reduction of health inequities and “leaving no one behind” in national sustainable development. Health equity includes advancing universal health and the primary health care approach, with equitable access for all people to timely, quality, comprehensive, people- and community-centered services that do not cause impoverishment. Equally important, and a hallmark of good governance, is accountability for such advances. Governments have primary responsibility for reducing health inequities and must be held accountable for their policies and performance. Civil society has been recognized as a key partner in advancing sustainable and equitable national development. Effective accountability mechanisms should include civic engagement. The Healthy Caribbean Coalition (HCC), the only Caribbean regional alliance of civil society organizations working to prevent and control noncommunicable diseases—a major health priority fueled by inequities—has played a significant role in holding governments accountable for advancing health equity. This case study examines factors contributing to the success of the HCC, highlighting work under its five strategic pillars— accountability, advocacy, capacity development, communication, and sustainability—as well as challenges, lessons learned, and considerations for greater effectiveness.

[RESUMO]. Conquistar a equidade em saúde e abordar os determinantes sociais da saúde são essenciais para atingir as metas de saúde e as relacionadas à saúde da Agenda 2030 para o Desenvolvimento Sustentável e seus Objetivos de Desenvolvimento Sustentável. As estruturas para a saúde, incluindo a Agenda de Saúde Sustentável para as Américas 2018-2030, enfatizam a redução das iniquidades em saúde “sem deixar ninguém para trás”, quando se trata do desenvolvimento sustentável nacional. A equidade em saúde inclui impul-sionar a saúde universal e a abordagem da atenção primária à saúde, habilitando o acesso equitativo por todas as pessoas a serviços oportunos, de qualidade, integrais, centrados no atendimento às pessoas e às comunidades de maneira a não causar o empobrecimento. A questão da responsabilidade por tais avanços é igualmente importante, e é um selo de distinção de boa gestão. Os governos são os principais responsáveis pela redução das iniquidades em saúde e precisam ser responsabilizados por suas políticas e por seu desempenho. Reconheceu-se que a sociedade civil desempenha um papel essencial na promoção do desenvolvimento nacional sustentável e equitativo. Para que sejam eficazes, os mecanismos de responsabilização devem incluir a participação cívica. A Coalizão do Caribe Saudável (HCC), a única aliança de organizações da sociedade civil que trabalha na prevenção e no controle de doenças não transmissíveis na região do Caribe — uma grande prioridade de saúde movida pelas iniquidades — tem desempenhado uma função significativa na responsabilização dos governos pelo avanço da equidade em saúde. Este estudo examina os fatores que contribuem para o sucesso da HCC e destaca o trabalho da perspectiva dos cinco pilares estratégicos — responsabilidade, promoção de causa, desenvolvimento das capacidades, comunicação e sustentabilidade —, bem como os desafios, as lições aprendidas e as considerações para que se torne ainda mais eficaz.

Civil society promoting government accountability for health equity in the Caribbean: The Healthy Caribbean Coalition.

Achieving health equity and addressing the social determinants of health are critical to attaining the health and health-related targets of the 2030 Agenda for Sustainable Development and its Sustainable Development Goals. Frameworks for health, including the Sustainable Health Agenda for the Americas 2018 - 2030, emphasize reduction of health inequities and "leaving no one behind" in national sustainable development. Health equity includes advancing universal health and the primary health care approach, with equitable access for all people to timely, quality, comprehensive, people- and community-centered services that do not cause impoverishment. Equally important, and a hallmark of good governance, is accountability for such advances. Governments have primary responsibility for reducing health inequities and must be held accountable for their policies and performance. Civil society has been recognized as a key partner in advancing sustainable and equitable national development. Effective accountability mechanisms should include civic engagement. The Healthy Caribbean Coalition (HCC), the only Caribbean regional alliance of civil society organizations working to prevent and control noncommunicable diseases-a major health priority fueled by inequities-has played a significant role in holding governments accountable for advancing health equity. This case study examines factors contributing to the success of the HCC, highlighting work under its five strategic pillars-accountability, advocacy, capacity development, communication, and sustainability-as well as challenges, lessons learned, and considerations for greater effectiveness.

Alcanzar la equidad en salud y abordar los determinantes sociales de la salud son aspectos fundamentales para alcanzar las metas en materia de salud y relacionadas con la salud de la Agenda para el Desarrollo Sostenible 2030 y sus Objetivos de Desarrollo Sostenible. Los marcos de referencia para la salud, como la Agenda de Salud Sostenible para las Américas 2018-2030, hacen hincapié en la reducción de las desigualdades en salud y en "no dejar a nadie atrás" en el desarrollo sostenible a nivel nacional. La equidad en salud incluye la promoción de la salud universal y el enfoque de atención primaria de la salud, con un acceso equitativo de todas las personas a servicios de salud oportunos, de calidad, integrales y centrados en las personas y la comunidad que no ocasionen empobrecimiento. La rendición de cuentas por esos avances es igualmente importante, y un signo distintivo de una gobernanza adecuada. Los gobiernos tienen la responsabilidad primordial de reducir las desigualdades en salud y deben rendir cuentas de sus políticas y su desempeño. La sociedad civil es una parte interesada fundamental para promover un desarrollo nacional sostenible y equitativo, y debe formar parte de los mecanismos eficaces de rendición de cuentas.La Coalición Caribe Saludable ­la única alianza regional del Caribe de organizaciones de la sociedad civil dedicada a prevenir y controlar las enfermedades no transmisibles, una prioridad sanitaria importante acrecentada por las desigualdades­ ha desempeñado un papel importante en hacer que los gobiernos rindan cuentas de la promoción de la equidad en salud. En este estudio se examinan los factores que han contribuido al éxito de la Coalición Caribe Saludable, con énfasis en la labor realizada en el marco de sus cinco pilares estratégicos ­rendición de cuentas, promoción de la causa, desarrollo de capacidad, comunicación y sostenibilidad­ así como los retos, las enseñanzas extraídas y otras consideraciones para lograr una mayor eficacia.

Civil society promoting government accountability for health equity in the Caribbean: The Healthy Caribbean Coalition

[ABSTRACT]. Achieving health equity and addressing the social determinants of health are critical to attaining the health and health-related targets of the 2030 Agenda for Sustainable Development and its Sustainable Development Goals. Frameworks for health, including the Sustainable Health Agenda for the Americas 2018 – 2030, emphasize reduction of health inequities and “leaving no one behind” in national sustainable development. Health equity includes advancing universal health and the primary health care approach, with equitable access for all people to timely, quality, comprehensive, people- and community-centered services that do not cause impoverishment. Equally important, and a hallmark of good governance, is accountability for such advances. Governments have primary responsibility for reducing health inequities and must be held accountable for their policies and performance. Civil society has been recognized as a key partner in advancing sustainable and equitable national development. Effective accountability mechanisms should include civic engagement. The Healthy Caribbean Coalition (HCC), the only Caribbean regional alliance of civil society organizations working to prevent and control noncommunicable diseases—a major health priority fueled by inequities—has played a significant role in holding governments accountable for advancing health equity. This case study examines factors contributing to the success of the HCC, highlighting work under its five strategic pillars—accountability, advocacy, capacity development, communication, and sustainability—as well as challenges, lessons learned, and considerations for greater effectiveness.

[RESUMEN]. Alcanzar la equidad en salud y abordar los determinantes sociales de la salud son aspectos fundamentales para alcanzar las metas en materia de salud y relacionadas con la salud de la Agenda para el Desarrollo Sostenible 2030 y sus Objetivos de Desarrollo Sostenible. Los marcos de referencia para la salud, como la Agenda de Salud Sostenible para las Américas 2018-2030, hacen hincapié en la reducción de las desigualdades en salud y en "no dejar a nadie atrás" en el desarrollo sostenible a nivel nacional. La equidad en salud incluye la promoción de la salud universal y el enfoque de atención primaria de la salud, con un acceso equitativo de todas las personas a servicios de salud oportunos, de calidad, integrales y centrados en las personas y la comunidad que no ocasionen empobrecimiento. La rendición de cuentas por esos avances es igualmente importante, y un signo distintivo de una gobernanza adecuada. Los gobiernos tienen la responsabilidad primordial de reducir las desigualdades en salud y deben rendir cuentas de sus políticas y su desempeño. La sociedad civil es una parte interesada fundamental para promover un desarrollo nacional sostenible y equitativo, y debe formar parte de los mecanismos eficaces de rendición de cuentas. La Coalición Caribe Saludable —la única alianza regional del Caribe de organizaciones de la sociedad civil dedicada a prevenir y controlar las enfermedades no transmisibles, una prioridad sanitaria importante acrecentada por las desigualdades— ha desempeñado un papel importante en hacer que los gobiernos rindan cuentas de la promoción de la equidad en salud. En este estudio se examinan los factores que han contribuido al éxito de la Coalición Caribe Saludable, con énfasis en la labor realizada en el marco de sus cinco pilares estratégicos —rendición de cuentas, promoción de la causa, desarrollo de capacidad, comunicación y sostenibilidad— así como los retos, las enseñanzas extraídas y otras consideraciones para lograr una mayor eficacia.

Evaluating policy responses to noncommunicable diseases in seven Caribbean countries: challenges to addressing unhealthy diets and physical inactivity

[ABSTRACT]. Objective. To identify, assess, and compare existing policies on noncommunicable diseases (NCDs) in the Caribbean, gaps in policy responses, and the factors influencing successful policy development and implementation following the Port of Spain Declaration of 2007. Specifically, to examine policies that target the upstream determinants of two NCD risk factors—unhealthy diets and physical inactivity. Methods. A total of 76 semi-structured interviews with 80 relevant stakeholders in government, the private sector, and civil society were complemented by policy document analysis. Interviews were analyzed pragmatically, framed by the CARICOM government commitments, the WHO NCD Action Plan, a Multiple Streams framework approach, and realist evaluation ideas. Results. The most widely-reported policy successes involved health promotion activities (e.g., school meal programs) that leveraged multisectoral collaboration among government ministries, such as Health, Education, and Agriculture. Large policy gaps still exist around creating legislative, physical, and social environments to support healthy eating and physical activity at the population level. Multisectoral NCD commissions successfully reached across sectors, but had limited influence on policy development. Different policy levels emerged with national-level policies considered a lengthy process, while “On-the-ground” programming was considered faster to implement than national policies. External barriers included a reliance on food imports enabled by international trade agreements limited availability, quality, and affordability of healthy foods. International pushback limited legislation to reduce food imports and the absence of an international/regional framework, similar to the Framework Convention on Tobacco Control, further impedes efforts. Conclusions. Regional collaboration and political support across sectors are essential to accelerating the pace of action to support healthy eating and active living environments. Policy “blueprints” could accelerate the process of development. Regional “NCD champions” could spearhead such responses and approaches.

[RESUMEN]. Objetivo. Identificar, evaluar y comparar las políticas existentes sobre enfermedades no transmisibles (ENT) en el Caribe, las brechas en las respuestas políticas y los factores que influyeron en el desarrollo y la implementación de políticas exitosos luego de la Declaración de Puerto de España en 2007. Específicamente, examinar las políticas que se enfocan en dos factores de riesgo de ENT: las dietas no saludables y la inactividad física. Métodos. Se efectuaron 76 entrevistas semiestructuradas a 80 interesados relevantes pertenecientes al gobierno, el sector privado y la sociedad civil, y la información obtenida se complementó con un análisis de los documentos sobre las políticas. Las entrevistas se analizaron pragmáticamente en el marco de los compromisos de los gobiernos del CARICOM, el Plan de Acción sobre las ENT de la Organización Mundial de la Salud, un enfoque del marco de Flujos Múltiples e ideas de evaluación realistas. Resultados. Los resultados positivos de las políticas más reportados incluyeron las actividades de promoción de la salud (por ej., los programas de comidas escolares) que consiguieron la colaboración multisectorial de diferentes instituciones gubernamentales tales como los ministerios de salud, educación y agricultura. Todavía existen grandes brechas políticas relacionadas con la creación de entornos legislativos, físicos y sociales que apoyen la alimentación saludable y la actividad física a nivel de la población. Las comisiones multisectoriales dedicadas a las ENT presentaron un alcance adecuado en todos los sectores, pero tuvieron una influencia limitada en el desarrollo de políticas. Se observaron diferentes niveles de políticas y las de nivel nacional fueron procesos prolongados; los programas “en el terreno” fueron más rápidos de implementar. Las barreras externas incluyeron la dependencia de las importaciones de alimentos permitidas por los acuerdos comerciales internacionales, que limitan la disponibilidad, la calidad y la asequibilidad de los alimentos saludables. La limitada legislación a nivel internacional para reducir las importaciones de alimentos y la ausencia de un marco internacional o regional, similar al Convenio Marco para el Control del Tabaco, dificulta aún más los esfuerzos. Conclusiones. La colaboración regional y el apoyo político en todos los sectores son esenciales para acelerar el ritmo de acción en apoyo de una alimentación saludable y entornos que favorezcan una vida activa. Los “proyectos” de políticas podrían acelerar el proceso de desarrollo. Los “campeones regionales contra las ENT” podría liderar las estrategias y respuestas.

[RESUMO]. Objetivo. Identificar, avaliar e comparar as políticas existentes sobre doenças não transmissíveis (DNT) no Caribe, as lacunas nas respostas e fatores que influenciam o desenvolvimento e implementação de políticas bem sucedidas depois da Declaração de Porto Espanha em 2007. Especificamente, examinar as políticas que apontam para dois fatores de risco de DNT: dietas não saudáveis e inatividade física. Métodos. Um total de 76 entrevistas semi-estruturadas com 80 participantes diretos, pertencentes ao governo, ao setor privado e à sociedade civil, foram complementados com a análise de documentos sobre as políticas estabelecidas. As entrevistas foram analisadas pragmaticamente, enquadradas nos compromissos dos governos do CARICOM, no Plano de Ação das DNTs da Organização Mundial da Saúde, numa abordagem do quadro de fluxos múltiplos e em ideias de avaliação realistas. Resultados. Os resultados positivos das políticas mais divulgados incluíram atividades de promoção da saúde (por exemplo, programas de alimentação escolar) que tiveram colaboração multissetorial de diferentes instituições governamentais, como os ministérios da saúde, educação e agricultura. Ainda existem grandes lacunas políticas em torno da criação de ambientes legislativos, físicos e sociais para apoiar a alimentação saudável e a atividade física no nível populacional. As comissões multissetoriais de ENT alcançaram com sucesso todos os setores, mas tiveram influência limitada no desenvolvimento de políticas. Diferentes níveis de políticas foram observados e aqueles em nível nacional foram processos prolongados; os programas “no terreno” foram mais rápidos para implementar. As barreiras externas incluíram a dependência de importações de alimentos permitidas por acordos comerciais internacionais que limitam a disponibilidade, qualidade e acessibilidade de alimentos saudáveis. A legislação internacionalmente limitada para reduzir as importações de alimentos e a ausência de um quadro internacional o regional, semelhante à Convenção-Quadro para o Controle do Tabaco, torna os esforços ainda mais difíceis. Conclusões. A colaboração regional e o apoio político em todos os setores são essenciais para acelerar o ritmo de ação em apoio à alimentação saudável e a ambientes de vida ativa. Os “esquemas” de políticas podem acelerar o processo de desenvolvimento. Os “campeões regionais de ENT” poderiam liderar as estratégias e respostas.

Evaluating policy responses to noncommunicable diseases in seven Caribbean countries: challenges to addressing unhealthy diets and physical inactivity / Evaluación de las respuestas políticas a las enfermedades no transmisibles en siete países del Caribe: desafíos para abordar las dietas no saludables y la inactividad física / Avaliação de respostas políticas a doenças não transmissíveis em sete países do Caribe: desafios para abordar dietas não saudáveis e inatividade física

ABSTRACT Objective. To identify, assess, and compare existing policies on noncommunicable diseases (NCDs) in the Caribbean, gaps in policy responses, and the factors influencing successful policy development and implementation following the Port of Spain Declaration of 2007. Specifically, to examine policies that target the upstream determinants of two NCD risk factors—unhealthy diets and physical inactivity. Methods. A total of 76 semi-structured interviews with 80 relevant stakeholders in government, the private sector, and civil society were complemented by policy document analysis. Interviews were analyzed pragmatically, framed by the CARICOM government commitments, the WHO NCD Action Plan, a Multiple Streams framework approach, and realist evaluation ideas. Results. The most widely-reported policy successes involved health promotion activities (e.g., school meal programs) that leveraged multisectoral collaboration among government ministries, such as Health, Education, and Agriculture. Large policy gaps still exist around creating legislative, physical, and social environments to support healthy eating and physical activity at the population level. Multisectoral NCD commissions successfully reached across sectors, but had limited influence on policy development. Different policy levels emerged with national-level policies considered a lengthy process, while "On-the-ground" programming was considered faster to implement than national policies. External barriers included a reliance on food imports enabled by international trade agreements limited availability, quality, and affordability of healthy foods. International pushback limited legislation to reduce food imports and the absence of an international/regional framework, similar to the Framework Convention on Tobacco Control, further impedes efforts. Conclusions. Regional collaboration and political support across sectors are essential to accelerating the pace of action to support healthy eating and active living environments. Policy "blueprints" could accelerate the process of development. Regional "NCD champions" could spearhead such responses and approaches.

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RESUMO Objetivo. Identificar, avaliar e comparar as políticas existentes sobre doenças não transmissíveis (DNT) no Caribe, as lacunas nas respostas e fatores que influenciam o desenvolvimento e implementação de políticas bem sucedidas depois da Declaração de Porto Espanha em 2007. Especificamente, examinar as políticas que apontam para dois fatores de risco de DNT: dietas não saudáveis e inatividade física. Métodos. Um total de 76 entrevistas semi-estruturadas com 80 participantes diretos, pertencentes ao governo, ao setor privado e à sociedade civil, foram complementados com a análise de documentos sobre as políticas estabelecidas. As entrevistas foram analisadas pragmaticamente, enquadradas nos compromissos dos governos do CARICOM, no Plano de Ação das DNTs da Organização Mundial da Saúde, numa abordagem do quadro de fluxos múltiplos e em ideias de avaliação realistas. Resultados. Os resultados positivos das políticas mais divulgados incluíram atividades de promoção da saúde (por exemplo, programas de alimentação escolar) que tiveram colaboração multissetorial de diferentes instituições governamentais, como os ministérios da saúde, educação e agricultura. Ainda existem grandes lacunas políticas em torno da criação de ambientes legislativos, físicos e sociais para apoiar a alimentação saudável e a atividade física no nível populacional. As comissões multissetoriais de ENT alcançaram com sucesso todos os setores, mas tiveram influência limitada no desenvolvimento de políticas. Diferentes níveis de políticas foram observados e aqueles em nível nacional foram processos prolongados; os programas "no terreno" foram mais rápidos para implementar. As barreiras externas incluíram a dependência de importações de alimentos permitidas por acordos comerciais internacionais que limitam a disponibilidade, qualidade e acessibilidade de alimentos saudáveis. A legislação internacionalmente limitada para reduzir as importações de alimentos e a ausência de um quadro internacional o regional, semelhante à Convenção-Quadro para o Controle do Tabaco, torna os esforços ainda mais difíceis. Conclusões. A colaboração regional e o apoio político em todos os setores são essenciais para acelerar o ritmo de ação em apoio à alimentação saudável e a ambientes de vida ativa. Os "esquemas" de políticas podem acelerar o processo de desenvolvimento. Os "campeões regionais de ENT" poderiam liderar as estratégias e respostas.

Establishing national noncommunicable disease surveillance in a developing country: a model for small island nations.

Objective To describe the surveillance model used to develop the first national, population-based, multiple noncommunicable disease (NCD) registry in the Caribbean (one of the first of its kind worldwide); registry implementation; lessons learned; and incidence and mortality rates from the first years of operation. Methods Driven by limited national resources, this initiative of the Barbados Ministry of Health (MoH), in collaboration with The University of the West Indies, was designed to collect prospective data on incident stroke and acute myocardial infarction (MI) (heart attack) cases from all health care facilities in this small island developing state (SIDS) in the Eastern Caribbean. Emphasis is on tertiary and emergency health care data sources. Incident cancer cases are obtained retrospectively, primarily from laboratories. Deaths are collected from the national death register. Results Phased introduction of the Barbados National Registry for Chronic NCDs ("the BNR") began with the stroke component ("BNR-Stroke," 2008), followed by the acute MI component ("BNR-Heart," 2009) and the cancer component ("BNR-Cancer," 2010). Expected case numbers projected from prior studies estimated an average of 378 first-ever stroke, 900 stroke, and 372 acute MI patients annually, and registry data showed an annual average of about 238, 593, and 349 patients respectively. There were 1 204 tumors registered in 2008, versus the expected 1 395. Registry data were used to identify public health training themes. Success required building support from local health care professionals and creating island-wide registry awareness. With spending of approximately US$ 148 per event for 2 200 events per year, the program costs the MoH about US$ 1 per capita annually. Conclusions Given the limited absolute health resources available to SIDS, combined surveillance should be considered for building a national NCD evidence base. With prevalence expected to increase further worldwide, Barbados' experiences are offered as a "road map" for other limited-resource countries considering national NCD surveillance.

Establishing national noncommunicable disease surveillance in a developing country: a model for small island nations / Introducción de la vigilancia nacional de las enfermedades no transmisibles en un país en desarrollo: un modelo para las pequeñas naciones insulares

Objective. To describe the surveillance model used to develop the first national, populationbased, multiple noncommunicable disease (NCD) registry in the Caribbean (one of the first of its kind worldwide); registry implementation; lessons learned; and incidence and mortality rates from the first years of operation. Methods. Driven by limited national resources, this initiative of the Barbados Ministry of Health (MoH), in collaboration with The University of the West Indies, was designed to collect prospective data on incident stroke and acute myocardial infarction (MI) (heart attack) cases from all health care facilities in this small island developing state (SIDS) in the Eastern Caribbean. Emphasis is on tertiary and emergency health care data sources. Incident cancer cases are obtained retrospectively, primarily from laboratories. Deaths are collected from the national death register. Results. Phased introduction of the Barbados National Registry for Chronic NCDs (“the BNR”) began with the stroke component (“BNR–Stroke,” 2008), followed by the acute MI component (“BNR–Heart,” 2009) and the cancer component (“BNR–Cancer,” 2010). Expected case numbers projected from prior studies estimated an average of 378 first-ever stroke, 900 stroke, and 372 acute MI patients annually, and registry data showed an annual average of about 238, 593, and 349 patients respectively. There were 1 204 tumors registered in 2008, versus the expected 1 395. Registry data were used to identify public health training themes. Success required building support from local health care professionals and creating island-wide registry awareness. With spending of approximately US$ 148 per event for 2 200 events per year, the program costs the MoH about US$ 1 per capita annually. Conclusions. Given the limited absolute health resources available to SIDS, combined surveillance should be considered for building a national NCD evidence base. With prevalence expected to increase further worldwide, Barbados’ experiences are offered as a “road map” for other limitedresource countries considering national NCD surveillance.

Objetivo. Describir el modelo de vigilancia que se utilizó para crear el primer registro poblacional nacional de múltiples enfermedades no transmisibles en el Caribe (uno de los primeros registros de esta clase en el mundo), la ejecución del registro, las lecciones aprendidas y las tasas de incidencia y mortalidad desde sus primeros años de funcionamiento. Métodos. Esta iniciativa del Ministerio de Salud de Barbados, realizada en colaboración con la Universidad de las Indias Occidentales e impulsada por la limitación de los recursos nacionales, tuvo por finalidad recoger datos prospectivos sobre los casos nuevos de accidente cerebrovascular e infarto agudo de miocardio en todos los establecimientos de atención de salud de este pequeño estado insular en desarrollo del Caribe oriental. El análisis se centró en las fuentes de datos sobre la atención de salud terciaria y de urgencia. La información sobre los casos nuevos de cáncer se obtuvo de manera retrospectiva, principalmente de los laboratorios. Los datos sobre las defunciones se tomaron del registro nacional de mortalidad. Resultados. La introducción progresiva del Registro Nacional de Enfermedades Crónicas no Transmisibles de Barbados se inició con el componente de los accidentes cerebrovasculares en 2008, seguido del componente de infarto agudo de miocardio en 2009 y el componente de cáncer en 2010. Las estimaciones previstas con base en los estudios anteriores fueron en promedio de 378 casos de un primer accidente cerebrovascular, 900 casos de accidente cerebrovascular y 372 pacientes con infarto agudo de miocardio cada año; los datos del registro mostraron un promedio anual cercano a 238, 593 y 349 casos respectivamente. En el 2008, se registraron 1204 casos de cáncer, frente a los 1395 previstos. En función de los datos del registro se definieron los temas de capacitación en salud pública. El éxito de la iniciativa exigió fomentar el apoyo de los profesionales de salud a nivel local y dar a conocer la existencia del registro en toda la isla. Con un gasto cercano a 148 dólares por episodio y 2200 episodios por año, el programa cuesta al Ministerio de Salud alrededor de un dólar por habitante cada año. Conclusiones. Dada la limitación de los recursos absolutos destinados a la salud en los pequeños estados insulares en desarrollo, es preciso analizar la posibilidad de realizar una vigilancia combinada, con el objeto de crear una base nacional de datos fidedignos sobre las enfermedades no transmisibles. Ante la perspectiva de un aumento continuo de la prevalencia mundial, la experiencia en Barbados se ofrece como una “hoja de ruta” destinada a otros países con recursos limitado

Establishing national noncommunicable disease surveillance in a developing country: a model for small island nations / Introducción de la vigilancia nacional de las enfermedades no transmisibles en un país en desarrollo: un modelo para las pequeñas naciones insulares

ABSTRACT Objective To describe the surveillance model used to develop the first national, population-based, multiple noncommunicable disease (NCD) registry in the Caribbean (one of the first of its kind worldwide); registry implementation; lessons learned; and incidence and mortality rates from the first years of operation. Methods Driven by limited national resources, this initiative of the Barbados Ministry of Health (MoH), in collaboration with The University of the West Indies, was designed to collect prospective data on incident stroke and acute myocardial infarction (MI) (heart attack) cases from all health care facilities in this small island developing state (SIDS) in the Eastern Caribbean. Emphasis is on tertiary and emergency health care data sources. Incident cancer cases are obtained retrospectively, primarily from laboratories. Deaths are collected from the national death register. Results Phased introduction of the Barbados National Registry for Chronic NCDs (“the BNR”) began with the stroke component (“BNR–Stroke,” 2008), followed by the acute MI component (“BNR–Heart,” 2009) and the cancer component (“BNR–Cancer,” 2010). Expected case numbers projected from prior studies estimated an average of 378 first-ever stroke, 900 stroke, and 372 acute MI patients annually, and registry data showed an annual average of about 238, 593, and 349 patients respectively. There were 1 204 tumors registered in 2008, versus the expected 1 395. Registry data were used to identify public health training themes. Success required building support from local health care professionals and creating island-wide registry awareness. With spending of approximately US$ 148 per event for 2 200 events per year, the program costs the MoH about US$ 1 per capita annually. Conclusions Given the limited absolute health resources available to SIDS, combined surveillance should be considered for building a national NCD evidence base. With prevalence expected to increase further worldwide, Barbados’ experiences are offered as a “road map” for other limited-resource countries considering national NCD surveillance.

RESUMEN Objetivo Describir el modelo de vigilancia que se utilizó para crear el primer registro poblacional nacional de múltiples enfermedades no transmisibles en el Caribe (uno de los primeros registros de esta clase en el mundo), la ejecución del registro, las lecciones aprendidas y las tasas de incidencia y mortalidad desde sus primeros años de funcionamiento. Métodos Esta iniciativa del Ministerio de Salud de Barbados, realizada en colaboración con la Universidad de las Indias Occidentales e impulsada por la limitación de los recursos nacionales, tuvo por finalidad recoger datos prospectivos sobre los casos nuevos de accidente cerebrovascular e infarto agudo de miocardio en todos los establecimientos de atención de salud de este pequeño estado insular en desarrollo del Caribe oriental. El análisis se centró en las fuentes de datos sobre la atención de salud terciaria y de urgencia. La información sobre los casos nuevos de cáncer se obtuvo de manera retrospectiva, principalmente de los laboratorios. Los datos sobre las defunciones se tomaron del registro nacional de mortalidad. Resultados La introducción progresiva del Registro Nacional de Enfermedades Crónicas no Transmisibles de Barbados se inició con el componente de los accidentes cerebrovasculares en 2008, seguido del componente de infarto agudo de miocardio en 2009 y el componente de cáncer en 2010. Las estimaciones previstas con base en los estudios anteriores fueron en promedio de 378 casos de un primer accidente cerebrovascular, 900 casos de accidente cerebrovascular y 372 pacientes con infarto agudo de miocardio cada año; los datos del registro mostraron un promedio anual cercano a 238, 593 y 349 casos respectivamente. En el 2008, se registraron 1204 casos de cáncer, frente a los 1395 previstos. En función de los datos del registro se definieron los temas de capacitación en salud pública. El éxito de la iniciativa exigió fomentar el apoyo de los profesionales de salud a nivel local y dar a conocer la existencia del registro en toda la isla. Con un gasto cercano a 148 dólares por episodio y 2200 episodios por año, el programa cuesta al Ministerio de Salud alrededor de un dólar por habitante cada año. Conclusiones Dada la limitación de los recursos absolutos destinados a la salud en los pequeños estados insulares en desarrollo, es preciso analizar la posibilidad de realizar una vigilancia combinada, con el objeto de crear una base nacional de datos fidedignos sobre las enfermedades no transmisibles. Ante la perspectiva de un aumento continuo de la prevalencia mundial, la experiencia en Barbados se ofrece como una “hoja de ruta” destinada a otros países con recursos limitados que planean introducir la vigilancia nacional de las enfermedades no transmisibles.

Implications of hypertension in Barbadians: findings from the Barbados Eye Study Group

Hypertension is the most significant chronic disorder in the Caribbean, affecting approximately 45 percent of adults aged 45 years and older. This condition has significant clinical and public health implications, as elevated blood pressure is associated with considerable morbidity and mortality in populations of black African descent. Here we report some of the cardiovascular implications of blood pressure in Barbadians. The Barbados Eye Study commenced in 1988 and included 4 709 participants or 84 percent of a simple random sample of the island's population aged 40 to 84 years. Measurements included blood pressure (two random zero sphygmomanometer measurements), anthropometry including weight, height and body circumferences, visual acuity, perimetry and applanation tonometry measured by trained observers, and assay of glycated haemoglobin. The median age of the study population was 58 years, 57 percent were female and 93 percent reported their race as black. Among black participants the overall prevalence of hypertension (mean systolic blood pressure > 140 mmHg and/or mean diastolic blood pressure > 90 mmHg and/or a history of antihypertensive treatment) was 55.4 percent with 49.8 percent of men and 59.6 percent of women being affected. The prevalence of self-reported angina in men (based on the Rose questionnaire) was 1 percent in normotensives, 1.3 percent in untreated hypertensives, and 1.5 percent in treated hypertensives. Corresponding prevalences of angina were higher in women, being 2.0 percent, 2.4 percent and 4.5 percent, respectively. The prevalence of self reported myocardial infarction in men was 1.3 percent in normotensives, 2.3 percent in untreated hypertensives and 5.7 percent in treated hypertensives; and, in women, 2.2 percent in normotensives, 2.1 percent in untreated hypertensives and 5.0 percent in hypertensives. The prevalences of cerebrovascular accidents was higher in men than in women: 1.4 percent in normotensive men vs 0.9 percent in normotensive women; 2.3 percent in untreated hypertensive men vs 1.6 percent in untreated hypertensive women; and 6.5 percent in treated hypertensive men vs 4.4 percent in treated hypertensive women.(AU)

Work site heart health promotion and practice: a pilot project of the Heart Foundation of Barbados

The workplace has long been recognised as an important setting in which to promote the practice of healthy living since most individuals spend more than one-third of their day in such situations which might be considered a "captive environment". The Heart Foundation of Barbados, aware of the significantly high prevalence of lifestyles related illnesses and the opportunities and potential for effecting positive change in the workplace, embarked on a worksite heart pilot project aimed at determining the feasibility of establishing such a programme in Barbados and determining its impact and effect on health practices of workers in the workplace and elsewhere. The study was conducted among the staff of a local professional services firm. It consisted of risk factor screening of staff members, teaching of and certification in Cardiopulmonary Resuscitation (CPR), and facilitating regular related activities. Two years after the initiation of the project an anonymous knowledge, attitudes and practice questionnaire was administered to participants. 116 (88 percent) members of staff was taught and certified in CPR, and a further 3 persons were trained and certified as CPR instructors. Anthropometric and blood pressure measurements were performed on the 116 participants. Over the two years of the project the company developed a significantly enhanced health consciousness and profile, as evidenced by the formation of a health club, active participation in national healthy lifestyles activities and the conducting of a regular related seminars, lectures and associated and related activities. Finally, among those responding to the knowledge attitudes and practices survey 60 percent of 60 participants returning completed questionnaires reported a positive change in their lifestyle as a direct result of the programme. Among 63 percent there was an enhanced personal attitude to the company. 36 participants (60 percent), reported that they would provide assistance in an emergency situation, of which 64 percent expressed confidence in doing so, and 58 percent attributed their confidence to their involvement in the programme. Preliminary results suggest that the introduction and implementation of a work site heart health promotion and practice programme is acceptable to workers in Barbados, is feasible, and results in improvement of worker health attitudes and practices.(AU)

Factors associated with hypertension in Barbadians: findings from the Barbados Eye Study cohort

Although hypertension has emerged as the most common chronic non-commuciable disease in the Caribbean, affecting approximately 45 percent of those aged 40 years and older, few studies have attempted to elucidate the contribution of risk factors to the burden of hypertensive disease. The Barbados Eye Study commenced in 1988, and included 4709 participants or 84 percent of a simple random sample of the island's population, aged 40 to 84 years. Measurements included applanation tonometry, visual acuity and perimetry, blood pressure with a random zero sphygmomanometer, anthropometry including weight, height, and body circumferences performed by trained observers, as well as the assay of glycated haemoglobin. The median age of the cohort was 58 years, 57 percent being female, with 93 percent reporting their race as Black. In patients not receiving treatment for hypertension, mean systolic and diastolic pressures were significantly higher in Blacks compared to Whites or others, mean systolic pressure: 132.1 ñ 21.1 mm Hg vs 129.6 ñ 19.8 mm Hg, respectively (p=0.021); mean diastolic pressure: 79.4 ñ 11.3 mm Hg vs 76.1 ñ 10.8 mm Hg, respectively (p=0.001).(AU)

An investigation of some risk factors for severe leptospirosis on Barbados

Between November 1979 and the end of December 1986 (7.17 years), 248 cases of leptospirosis were confirmed among hospital patients on Barbados (mean 35 per year; range 25-57). Considering the 235 who were greater than or equal to 15 years of age, the annual incidence of leptospirosis was 19.2/100,000 population (14.0 for all age groups). There were 173 males and 62 females, and for cases aged 15-34 leptospirosis was 9.6 times more common in men than women. Among men, incidence increased fairly steadily with age, and an even steadier increase was apparent in women up to age 64, with some decline in later years. The incidence of disease was much higher among agricultural than other workers and the un-employed. Highest case numbers were recorded in the parishes of St Michael (65 or 28 percent) and Christ Church (36 or 15 percent), though the incidence was lowest in these two parishes (13.1/100,000 and 17.4/100,000, respectively). The highest incidence rates were in St Andrew and St Joseph ((50.2 and 36.1/100,000, respectively). The incidence in areas with rainfall greater than or equal to 1600 mm (32.6/100,000) was nearly twice that in areas with rainfall less than 1600 mm (17.3/100,000). There is a clear link between cases of severe disease and recent rainfall. Using 134 patients greater than or equal to 15 years of age with fever due to other illnesses as controls, a higher proportion of cases than controls came from rural areas. The risk of contracting leptospirosis was increased for all categories of manual workers relative to the group at lowest risk (non-manual indoor workers). Sugar-cane workers were five times more likely to contract leptospirosis than were non-manual indoor workers, while those with rodents in their garden/yard were 1.8 times more likely to do so. Other risk factors examined did not show significant associations with the disease. Despite increasing mechanization and the use of more protective clothing, agricultural workers are still at high risk from leptospirosis. The annual range of cases is likely to stay much as it is in the foreseeable future. (AU)

Cardiovascular abnormalities in the acquired immune deficiency syndrome - abstract

Serious organ system failure has been documented in the pulmonary, gastrointestinal, renal and central nervous systems in patients with cquired immune deficiency syndrome (AIDS). Clinical cardiac involvement has received little attention world-wide until the last few years, and in particular there has been no documentation or assessment of the cardiac involvement in patients with AIDS either in Barbados or the Caribbean. This study aims to assess the clinical cardiovascular findings in AIDS patients. A retrospective review and analysis of the case notes of AIDS patients who had died at the Queen Elizabeth Hospital, Barbados, in 1990 was undertaken. Prospective clinical assessment, including electrocardiography and echocardiography, was performed on a further set of patients admitted to hospital with HIV-related illness. The case notes of 31 (91 per cent) of the 34 patients with AIDS who died durng 1990 were reviewed. These patients were admitted to hospital on 77 occasions for AIDS-related illness. All patients were stage 3 or 4 according to the revised CDC/WHO classification. A clinical suspicion of cardiac involvement was entertained in 7 patients, 4 of whom were subsequently diagnosed as having a pericardial effusion - 2 of which were determined to be related to the presence of severe renal failure. Electrocardiography was performed on 7 patients; S-T segment elevation was noted in 2 of these patients. T-wave inversion in 1 patient and the effects of hyperkalaemia in 1 patient. Cardiac manifestations demonstrated in the AIDS patients studied prospectively will be presented. Cardiac involvement among AIDS patients admitted to hospital in Barbados is not clinically overt. A truer and higher incidence of cardiac manifestations in these patients will become evident by more detailed and systematic assessment (AU)

Acute myocardial infarction in Barbados - abstract

This project set out to establish the accurate documentation of patients presenting with acute myocardial infarction (AMI) to the medical wards of the Q.E.H., with investigation of putative factors, as well as to establish the feasibility of a prospective AMI register. Prospective analysis was carried out with daily review, and entry of data on prepared forms, of patients admitted with suspected AMI. Assessment of risk factors was made by questionnaire, anthropometric measurements and biomedical indices, with documentation of AMI by standard criteria. Initial results for the 3-month period commencing November 1, 1990, showed 26 patients with AMI. Three patients were visitors and 23 were Barbadian. Four of the Barbadian patients died within 24 hours of admission and a further 3 died before discharge from hospital. Of the 19 Barbadians surviving > 24 hours (11 males, 8 females), 18 were black and 1 white, 5 having previously had AMIs. Eight were known to be hypertensive, 7 were diabetic and of these, 3 suffered from both disorders. Over the study period a further 11 patients were admitted with anginal episodes, 9 of whom were known to have ischaemic heart disease. A further 18 patients admitted with suspected AMIs were not subsequently shown to have ischaemic myocardial disease. Extrapolation of preliminary data suggests an incidence of 100 cases of AMI annually. The accuracy of this estimate will be clarified by continuation of this study. Inherent problems and their relevance to the accurate documentation of AMI will be discussed. A prospective register is an important method of accurately documenting AMI (AU)

Blood pressure in blacks: twin studies in Barbados

We have recently reported that there are significant genetic influences on the population variation in blood pressure in black twins in Los Angeles. The present cross-sectional study was undertaken to replicate these findings in a black twin population that lives in a different biosocial environment. We chose the Caribbean island nation of Barbados, where 96 percent of the population is black, the literacy rate is 99 percent, and the access to health care is guaranteed. The goals were 1) to test the feasibility of twin studies in blood pressure research in a developing country and 2) to estimate the relative contribution of genes and environment to blood pressure variability in blacks in the Caribbean. The names of 200 twin sets were obtained with the assistance of community resources including a twin club, by media advertisement, and by asking people at public blood pressure screenings if they knew any twins. By using these methods, we identified 200 sets of twins. Of these, 37.5 percent (75/200) met our criteria for study. Although 97 percent of the sets of twins (73/75) said they were willing to participate, only 69 percent (52/75) were able to be scheduled during the 1 week of the study when the full team of investigators was in Barbados. Of those scheduled, 83 percent (43/52) were examined. Examination included medical history, physical examination, recumbent blood pressure measurements by two observers, anthropometric measurements, 24-hour urine collections for sodium and potassium tests, and blood tests for zygosity. (ABSTRACT TRUNCATED AT 250 WORDS) (AU)

Leptospirosis in Barbados: a clinical study

A 39-month clinical study of leptospirosis was undertaken at the Queen Elizabeth Hospital, Barbados. Eighty-eight patients had a confirmed diagnosis of the disease during the period. The major serogroups identified were autumnalis (including a new serovar bim), icterohaemorrhagiae, ballum and canicola. The majority of patients presented with jaundice (95 percent), anorexia and headaches (85 percent), fever (76 percent) and conjunctival suffusion (54 percent). While abnormal creatinine levels were seen in 49 percent of patients on admission, only 16 percent were judged to have renal failure. The urine to plasma urea ratio showed high sensitivity and specificity in the diagnosis of pre-renal azotemia. Cardiac arrthymias and myocarditis occurred in 18 percent of patients and pericarditis in 6 percent. An elevated serum amylase was found in 65 percent of cases. The bilirubin level took 5.5 weeks to return to normal. Thrombocytopenia was shown not to be due to a disseminated intravascular coagulation, and a randomised trial dose penicillin did not reveal any benefit to jaundiced patients. The overall mortality during the study was 5.7 percent (AU)

Urinary diagnostic indices in the management of leptospirosis: selection of patients for dialysis therapy

Cases of leptospirosis admitted to the Queen Elizabeth Hospital (QEH), Barbados, were assessed for the presence of "pre-renal azotaemia" (NON-ARF) as opposed to "acute renal failure" (ARF). Distiction between the two diagnoses was made on the basis of clinical course. Peritoneal dialysis was inappropriately utilised in 26 percent of patients receiving such therapy. This study evaluates diagnostic tests for pre-renal azotaemia, and acute renal failure in leptospirosis, and indicates guidelines for the management of azotaemia in such patients. U/P urea and osmolar ratios show high sensitivity and specificity in diagnosing pre-renal azotaemia. While "early" dialysis is essential for patients with acute leptospiral renal failure, in those with plasma creatinines less than 600 umol/litre on entry and indices indicating NON-ARF, decisions regarding dialysis can safely be delayed for 48-72 hours while the effect of rehydration is assessed (AU)

Permanent pacemaker implantation and follow-up programme: the Barbados and Eastern Caribbean experience - abstract

Fifty-four years after the first pacemaker implant was carried out on humans, the first successful implantation of a permanent pacing system was performed in Barbados in 1986, through the collaborative efforts of the Pacemaker Industry, Rotary International and Rotary Barbados, The Watson Clinic Foundation of Florida and The Queen Elizabeth Hospital, Barbados. In a programme in which pacemakers are supplied and implanted, free of cost to indigent individuals, 26 pacemaker systems have been implanted in 16 males and 10 females, average age 64 years, and age range 27-86 years. There were 17 Barbadians, 4 Antiguans, 2 St. Lucians and one each from Dominica, St. Vincent and Montserrat. The major indication for implantation was symptomatic third degree atrio-ventricular block, which occured in 11 (42.3 percent) of patients. Recurrent dizziness and/or loss of consciousness was the most common symptom - in 21 (80 percent) of patients, and the most common underlying cardiac conditions were myocardial ischaemia in 10 patients, and fibrosis in 7 patients. Cephalic vein cut down and subclavian vein puncture were performed on fourteen (14) and twelve (12) patients respectively. All pacemakers implanted were of the "ventricular pacing and sensing type (VVI)", of which 13 were programmable. Seventeen of the systems were provided by The Intermedics Pacemaker Company and nine by American Pacemakers. Twenty-three (88.5 percent) patients had an entirely successful outcome post implantation with complete resolution of symptoms. One patient died 5 weeks after implantation as a direct result of the procedure, another died within hours of emergengy implantation which had been carried out following several episodes of cardiac arrest, the pacing system was functioning normally at the time of death. A third suffered a cerebro-vascular accident with a progressively poorly functioning left ventricle some months after implantation, again the pacing system was functioning normally. Finally, one patient with previously diagnosed ischaemic heart disease suffered an acute myocardial infarction two months post implant from which he made an uneventful recovery with the pacing system intact. Two patients contracted insignificant wound infections. Pacemaker follow-up programmes aim by continued long-term follow-up to reduce the incidence of sudden and unpredicted pacemaker system failure and detect sub-standard performance of some models. Such a computer-assisted follow-up programme was started at the Queen Elizabeth Hospital, Barbados, on April 3, 1985, with more recently an associated programme at Holberton Hospital, Antigua. Sixty-five patients are registered in the clinic, 33 of whom are males and 32 females, average age 60 years, range 6-88 years. Forty (61.5 percent) patients in the pacemaker follow-up clinic have pacemaker systems in situ with 18 systems being from Intermedics Company, 9 American, 6 Medtronic, 4 Teletronics and one each from Vitatron and Cordis. During the follow-up period two patients had premonitory symptoms and electro-stimulogram derived data to suggest impending system failure, which duly occurred in both patients, one of whom had the successful implantation of a new pacing system while the other had a change of the battery system. Of the 25 patients registered and considered potential candidates for pacemaker implantation, one with asymptomatic complete atrio-ventricular block died. The successful implementation of a permanent pacemaker implantation and follow-up programme for Barbados and the Eastern Caribbean has been established. The major indication for implantation has been symptomatic acquired complete atrio-ventricular block. The main challenge of the computer-assisted pacemaker follow-up programme has been the need to monitor, be familiar with, and have programming equipment appropriate for pacemakers manufactured by several companies. The clinic has been particularly successful in the early detection of pacemaker system failure and the meticulous development of statistical patient data (AU)