Creating a more inclusive, equitable and resilient health-care system post COVID
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TO successfully plan a resilient health-care delivery system for the Caribbean basin, it is critical to have a sober reflection to determine what can appropriately be characterised as an adequate level of care for the region consistent with the best available medical evidence and advances in science and technology.

Furthermore, we must review our decision-making process to integrate the social determinants of health, including social values, security, education, economic positions, and the built environment into our health-care planning for the region. It is only through a cohesive integration of these intersecting determinants that we can truly determine what services should be made available to our citizens, how they should be made available, how they would be paid for, and how to develop the human capital to provide these services to improve the human development indices for the region.

Our health-care value chain in the Caribbean must include the upstream and downstream variables that impact access, affordability, and outcomes and must consist of measures that provide social safety nets to ensure a minimum floor of an acceptable level of health care that citizens in the region do not fall below. These measures must apply to the entire population without socio-economic discrimination. Whether in the private or public sector, citizens in the Caribbean should expect a minimum acceptable standard and level of care consistent with international best practices. This will form the basis for health equity in the region. To achieve this lofty goal, we must consider uniform standards of care and consistent monitoring and compliance. We require a structure that ensures accountability in all sectors of the health-care ecosystem (public, private, and payers) and other factors that influence the quality, cost, and access to health care, including workforce, supplies, and capital, among other things. Equally important is the regulatory framework and the implied economic cost of compliance with onerous requirements with no proven benefit to the quality of care or patient outcomes.

The health-care value chain must become less asymmetric to offer the best benefit to the region. It must integrate the various elements that impact the ecosystem to improve access, affordability, and quality of care for all citizens. We must review our circumstances and consider our population's unique experiences and healthcare needs in determining appropriate healthcare standards for the region. This would require dialogue and consultation with stakeholders, including medical experts and opinion leaders, civic society groups, religious leaders, social scientists, consumers, and policymakers, to ensure adaptability, sustainability, and uniform application.

The Caribbean health-care workforce is an area of significance that has not received adequate attention. The Caribbean remains a net exporter of high-value health-care workers, widening the region's access gap and worsening health inequity. With the novel coronavirus pandemic driving the demand for health-care workers globally, the Caribbean has become a hunting ground for wealthy nations resulting in the poaching of high-value health-care workers and teachers from the region. The current workforce shortages and ongoing recruitment from more affluent countries will devastate the human development indices in the Caribbean in decades to come unless we assess its potential impact and take proactive steps to address the issue. The human capital deficit in health care is a significant regional problem, which we expect to worsen. The public and private health-care systems are often critically understaffed. According to the World Health Organization (WHO), Jamaica, for example, has 0.807 nurses and midwives per 1,000 population compared to 17.6 nurses and midwives per 1,000 population in the United States and an average of 14.6 nurses and midwives per 1,000 in other highly developed countries. Concerning the physician population, in Jamaica, there are 1.31 physicians per 1,000 compared to 2.9 physicians per 1,000 in the United Kingdom and 2.6 physicians per 1,000 in the USA. The deficit becomes more pronounced when we consider specialised skills in nursing and medicine. So, most citizens are denied access to highly technical skills and services, resulting in a significant exodus of capital from the region to the USA as those with means seek specialised care at a high economic and social cost.

Need for health equity and uniform standards

The Caribbean must reposition to improve access and quality of care for our citizens. This requires evolving a paradigm that places a high premium on health equity, leveraging the capacity in both public and private health-care sectors to improve access to optimal services for citizens within a set of uniform standards and regulations to achieve optimal outcomes. The WHO defines "Health as a state of physical, psychological, and spiritual well-being, and not merely an absence of diseases. Health is impacted by the complex interaction of many social and economic variables as a state and outcome. The human capital perspective recognises an initial endowment of health, which can be maintained, and enhanced by health production processes, including but not limited to health care". In seeking to provide optimal health care for citizens, we must be guided accordingly.

In search of answers and to provide guidance for the region, a high-level Caribbean Health Summit was convened in Kingston, Jamaica, on September 15, 2022. The summit, which was attended by more than 40 opinion leaders drawn from across the Caribbean, including medical experts, civic society leaders, social scientists, economists, business leaders, policymakers, and religious leaders, sought to review the current state of health care in the Caribbean and explore the future of health care service delivery in the region. The summit explored the underpinnings of health-care delivery in the region to identify friction points and recommend creative approaches to building a more resilient healthcare system in the post-COVID era. The engagement of a diverse group of healthcare stakeholders, including providers, payers, and consumers of healthcare services, is essential to developing an effective and non-discriminatory health-care delivery system. Robust deliberations during the summit identified common ground amongst stakeholders in the region that could serve as the basis of future collective action to advance the process of health-care transformation in the region.

Understanding the nexus between healthcare and economic development reinforces the need for collective action to ensure that the health-care value chain in the Caribbean is appropriately aligned to take advantage of current advances in health-care delivery, recognising that this is only possible when we holistically address other determining factors that impact the healthcare value chain.

We are encouraged and optimistic that this high-level summit will begin a meaningful dialogue between the stakeholders, and ultimately lead to actionable items that improve access to and quality of health care for citizens in the Caribbean basin with the goal of ensuring health equity and inclusion.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to or call 876-906-2107

Dr Paul Edwards and Dr Ernest Madu

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