Résumé

Le Sommet de la CARICOM sur les maladies chroniques non transmissibles – le premier sommet gouvernemental entièrement consacré aux maladies non transmissibles (MNT) – a été organisé par la Communauté des Caraïbes (CARICOM) à Trinité-et-Tobago en septembre 2007. Les dirigeants présents ont publié la déclaration de Port-of-Spain, un appel pour la prévention et la lutte contre les quatre principales MNT et leurs facteurs de risque.

Un instrument de responsabilisation pour le contrôle du respect des engagements du sommet a été développé pour la CARICOM par l'Université des Antilles en 2008 et modifié en 2010. L'instrument – une grille de codes couleur tenant sur une page et comportant 26 indicateurs de progression – est mis à jour chaque année par points focaux dans les ministères de la Santé des Caraïbes, vérifié par le chef du service médical de chaque pays et présenté au Conseil annuel des ministres de la Santé de la Communauté des Caraïbes. Dans cette étude, les méthodes du Groupe de recherche G8 pour évaluer la conformité ont été appliquées à la grille de rapport de 2009 pour évaluer la performance de chaque pays.

Compte tenu du succès du Sommet de la CARICOM, une réunion de haut niveau des Nations unies de l'Assemblée générale sur la prévention et la lutte contre les MNT a eu lieu en septembre 2011. En mai 2013, l'Assemblée mondiale de la santé a adopté 9 objectifs mondiaux et 25 indicateurs afin de mesurer les progrès dans le domaine de la lutte contre les MNT. Cette étude montre que la grille de contrôle de la CARICOM peut être utilisée pour rendre compte des progrès sur ces indicateurs de manière rapide et compréhensible. Un mécanisme de rapport annuel est essentiel pour encourager les progrès constants et mettre en relief les zones nécessitant des corrections. Cet article souligne l'importance des mécanismes de responsabilisation pour encourager et contrôler le respect des engagements politiques collectifs acquis au plus haut niveau.

Resumen

En septiembre de 2007 la Comunidad del Caribe (CARICOM) convocó en Trinidad y Tobago la Cumbre de CARICOM sobre enfermedades crónicas no transmisibles, la primera cumbre gubernamental dedicada a las enfermedades no transmisibles (ENT). Los líderes que asistieron publicaron la Declaración de Puerto España, un llamamiento a la prevención y el control de cuatro ENT principales y sus factores de riesgo.

En 2008, la Universidad de las Indias Occidentales desarrolló un instrumento de rendición de cuentas para supervisar el cumplimiento de los compromisos de las cumbres para CARICOM, el cual se revisó en 2010. Los centros de coordinación de los ministerios de salud del Caribe actualizan cada año dicho instrumento, una red con código de color de una página con 26 indicadores de progreso, mientras que el director médico de cada país lo verifica y se presenta al Grupo anual de Ministros de Salud de la Comunidad del Caribe. En este estudio, se aplicaron los métodos del Grupo de Investigación del G-8 para la evaluación del cumplimiento a la red de información de 2009, a fin de evaluar la actuación de cada país.

A raíz del éxito de la Cumbre de CARICOM, en septiembre de 2011 se celebró una reunión de alto nivel de la Asamblea General de las Naciones Unidas sobre la prevención y control de las ENT. En mayo de 2013 la Asamblea Mundial de la Salud adoptó nueve objetivos globales y 25 indicadores para medir el progreso en el control de las enfermedades no transmisibles. Este estudio muestra que la red de vigilancia de CARICOM puede utilizarse para documentar el progreso de forma rápida y clara en base a estos indicadores. Es esencial disponer de un mecanismo de presentación de informes anual para impulsar un progreso constante y resaltar las áreas que deben corregirse. Este documento destaca la importancia de los mecanismos de rendición de cuentas para promover y controlar el cumplimiento de los compromisos políticos colectivos adquiridos al máximo nivel.

ملخص

عقدت الجماعة الكاريبية (CARICOM) في ترينيداد وتوباغو في أيلول/ سبتمبر 2007 قمة الجماعة الكاريبية بشأن الأمراض غير السارية المزمنة - أول قمة حكومية على الإطلاق يتم تخصيصها للأمراض غير السارية (NCD). وأصدر القادة الحضور إعلان بورت أوف سبين، وهو دعوة لتوقي ومكافحة أربعة أمراض من الأمراض غير السارية الرئيسية وعوامل اختطارها.

قامت جامعة ويست إنديز في عام 2008 بوضع صك مساءلة لرصد الامتثال لالتزامات القمة من أجل الجماعة الكاريبية وتم مراجعته في عام 2010. ويتم تحديث الصك سنوياً- وهو عبارة عن جدول من صفحة واحدة بترميز لوني يحتوي على 26 مؤشراً للتقدم - عن طريق مراكز الاتصال في وزارات الصحة في منطقة الكاريبي والتحقق منه من جانب كبير المسؤولين الطبيين في كل بلد وتقديمه إلى التجمع السنوي لوزراء صحة الجماعة الكاريبية. وفي هذه الدراسة، تم تطبيق وسائل فريق البحث التابع لمجموعة البلدان الثمانية من أجل تقييم الامتثال بجدول التبليغ لعام 2009 لتقييم أداء كل بلد.

نظراً لنجاح قمة الجماعة الكاريبية، تم عقد اجتماع رفيع المستوى للجمعية العامة للأمم المتحدة بشأن توقي الأمراض غير السارية ومكافحتها في أيلول/ سبتمبر 2011. وفي أيار/ مايو 2013، اعتمدت جمعية الصحة العالمية تسعة أهداف عالمية و25 مؤشراً لقياس التقدم في مكافحة الأمراض غير السارية. ويتبين من هذه الدراسة إمكانية استخدام جدول الرصد الخاص بالجماعة الكاريبية لتوثيق التقدم المحرز في هذه المؤشرات على نحو سريع ومفهوم. كما يعتبر وجود آلية تبليغ سنوية ضرورياً لتشجيع التقدم الثابت وإبراز الجوانب التي تحتاج إلى تصحيح. وتبرز هذه الورقة أهمية آليات المساءلة لتشجيع الامتثال للالتزامات السياسية الجماعية المكتسبة على أرفع مستوى ورصدها.

摘要

加勒比海共同体组织(CARICOM)于2007年9月在特立尼达和多巴哥召开了慢性非传染性疾病CARICOM峰会——这是有史以来第一次致力于非传染性疾病(NCD)的政府首脑峰会。与会领导人发表了西班牙港宣言,号召预防和控制四大NCD及其风险因素。

2008年,西印度群岛大学为CARICOM开发了监控峰会承诺遵从性的问责工具,并于2010年进行修订。此工具是一页纸的颜色编码网格,包含26个进展指标,每年根据加勒比地区各卫生部的焦点问题进行更新,由每个国家的首席医疗长官确认,并呈送加勒比共同体卫生部长年度会议。在本研究中,将评估遵从性的G8研究组方法应用于2009报告网格来评估每个国家的绩效。

鉴于CARICOM峰会的成功,2011年9月召开了预防和控制非传染性疾病的联大高级会议。2013年5月,世界卫生大会通过了9个全球目标和25个指标来衡量NCD控制进展。本研究表明,CARICOM监控网格可用于快速明了地记录这些指标。对于鼓励稳步推进以及突出需要修正的领域来说,年度报告机制至关重要。本文强调问责机制对鼓励和监督最高层所共同达成政治承诺遵从性的重要性。

Резюме

Саммит Карибского сообщества (КАРИКОМ) по хроническим неинфекционным заболеваниям – первый правительственный саммит, посвященный неинфекционным заболеваниям (НИЗ) – был созван правительствами стран Карибского сообщества в Тринидаде и Тобаго в сентябре 2007 года. Лидеры стран-участниц подписали в городе Порт-оф-Спейн декларацию, призывающую к профилактике и борьбе с четырьмя основными НИЗ и их факторами риска

Для саммита КАРИКОМ Университетом Вест-Индии в 2008 году был разработан и в 2010 году пересмотрен инструмент отчетности для наблюдения за выполнением обязательств саммита. Данный инструмент отчетности – одностраничная цветовая таблица с 26 индикаторами исполнения обязательств – ежегодно обновляется координаторами в министерствах здравоохранения стран Карибского сообщества, заверяется главным врачом каждой страны и представляется на ежегодном съезде министров здравоохранения стран-участниц. В данной работе отчетные таблицы 2009 года для каждой из стран обрабатывались с помощью методов исследования аналитической группы G8 Research Group (основана Университетом Торонто) с целью оценки ситуации в каждой стране.

Учитывая успех саммита КАРИКОМ, в сентябре 2011 года состоялось заседание Генеральной Ассамблеи Организации Объединенных Наций по профилактике и борьбе с НИЗ. В мае 2013 года Всемирная ассамблея здравоохранения приняла 9 глобальных целей и 25 индикаторов для оценки прогресса в области борьбы с НИЗ. Данная работа показала, что контрольная таблица стран КАРИКОМ представляет собой быстрый и понятный способ документирования достигнутых успехов по данным показателям и может быть рекомендована к применению. Механизм ежегодной отчетности необходим для поощрения устойчивого прогресса и определения областей, нуждающихся в коррекции. В статье подчеркнута важность механизмов подотчетности для поощрения и контроля за соблюдением коллективных политических обязательств, принятых на самом высоком уровне.

Introduction

The Caribbean Community (CARICOM) is composed of 15 member states and five associate members. Most of these are Caribbean islands; three are countries on the mainland of Central and South America.¹1 Caribbean Community Secretariat [Internet]. Caribbean Community Secretariat: members and associate members. Georgetown: Caribbean Community; 2013. Available from: http://www.caricom.org/jsp/community/member_states.jsp?menu=community [accessed 26 November 2013].
http://www.caricom.org/jsp/community/mem... CARICOM members have a combined population of 17 million and an average life expectancy ranging from 70 to 80 years except in Haiti, where it is 62 years.²2 Health situation in the Americas: basic indicators 2012. Washington (DC): Pan American Health Organization; 2012. Available from: http://www.paho.org/hq/index.php?option=com_content&view=article&id=7170&Itemid=2395 [accessed 23 January 2014].
http://www.paho.org/hq/index.php?option=...

The Caribbean region has the highest burden of noncommunicable diseases (NCDs) in the Americas.²2 Health situation in the Americas: basic indicators 2012. Washington (DC): Pan American Health Organization; 2012. Available from: http://www.paho.org/hq/index.php?option=com_content&view=article&id=7170&Itemid=2395 [accessed 23 January 2014].
http://www.paho.org/hq/index.php?option=... In light of this, the Caribbean Cooperation in Health Initiative, approved by health ministers in 1986, made NCDs a priority concern.³3 Caribbean Community Secretariat [Internet]. Caribbean Cooperation in Health Phase III (CCH III): regional health framework 2010-2015. Georgetown: Caribbean Community; 2013. Available from: http://www.caricom.org/jsp/community_organs/health/health_main_page.jsp [accessed 22 January 2013].
http://www.caricom.org/jsp/community_org... In their 2001 Nassau Declaration, the CARICOM heads of government identified human immunodeficiency virus (HIV) infection, NCDs and mental health problems as regional priorities, called for strategies for the prevention and treatment of NCDs and articulated principles and processes to preserve and enhance “the health of the Region which is the wealth of the Region”.⁴4 Hospedales CJ, Samuels TA, Cummings R, Gollop G, Greene E. Raising the priority of chronic noncommunicable diseases in the Caribbean. Rev Panam Salud Publica 2011;30:393–400. PMID:22124699 In 2005, the Caribbean Commission on Health and Development reported that the number of deaths from diabetes, hypertension and heart disease combined was 10 times higher than the number of deaths from acquired immunodeficiency syndrome (AIDS) and declared NCDs a “super priority”.⁵5 Caribbean Community Secretariat [Internet]. Strategic Plan of Action for the Prevention and Conrol [sic.] of Non-communicable diseases for countries of the Caribbean Community 2011-2015. Washington & Georgetown: Pan American Health Organization & CARICOM Secretariat; 2011. Available from: http://www.healthycaribbean.org/publications/strategic-plan-of-action.html [accessed 24 January 2014].
http://www.healthycaribbean.org/publicat...

At the CARICOM Summit in July 2006, leaders received a report on “the macro-economic implications of non-communicable diseases”.⁶6 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the twenty-seventh meeting of the conference of heads of government of the Caribbean Community (CARICOM). Georgetown: Caribbean Community; 2006. Trinidad and Tobago agreed to host a special regional consultation on compliance with specific recommendations pertaining to tobacco, diet and physical activity.⁷7 Caribbean Community Secretariat [Internet]. CARICOM priority necessary to lowering non-communicable diseases. Georgetown: Caribbean Community; 2006. In October of the same year, Sir George Alleyne, director emeritus of the Pan American Health Organization (PAHO) – regional office for the Americas of the World Health Organization (WHO) – called for more attention to NCDs. He argued that although “impressive gains” had been made in stemming malnutrition and infant mortality, “obesity was of growing concern, even among children” and diabetes was the “steady cause of death” among many in the Caribbean.⁷7 Caribbean Community Secretariat [Internet]. CARICOM priority necessary to lowering non-communicable diseases. Georgetown: Caribbean Community; 2006. Sir George’s presentation spurred the decision to hold a summit devoted to NCDs. In February 2007, Prime Minister Denzil Douglas of Saint Kitts and Nevis, in his capacity as CARICOM Minister of Health in the quasi-cabinet of the 18th Inter-sessional CARICOM Heads of Government Summit, urged CARICOM members to develop a “comprehensive regional strategic plan to respond to the chronic non-communicable diseases and the havoc they are wreaking on our Caribbean people”.⁸8 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the eighteenth intercessional meeting of the Conference of Heads of Government of the Caribbean Community (CARICOM) 12-14 February 2007, Kingstown, St. Vincent and the Grenadines. Georgetown: Caribbean Community; 2007.Five months later, leaders agreed to participate fully in the CARICOM Summit on Chronic Non-Communicable Diseases, to be held later in the year. Thus, the world’s first summit of heads of government devoted specifically to NCDs was the product of over a decade of regional discussions.

The CARICOM Summit was held in Port of Spain, Trinidad and Tobago, on 15 September 2007. The 11 heads of government and five ministers present agreed that “immediate collective actions were necessary to manage and control NCDs” and issued a 15-point summit declaration titled Uniting to stop the epidemic of chronic NCDs (also known as the declaration of Port of Spain),⁹9 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the Regional Summit of Heads of Government of the Caribbean Community on chronic non-communicable diseases (NCDs), 15 September 2007, Port-of-Spain, Trinidad and Tobago. Georgetown: Caribbean Community; 2007. calling for policies and actions for the prevention and control of the four major NCDs and their common risk factors. Regional and multilateral organizations and the independent, authoritative scientific and academic community were represented at the CARICOM Summit, but there was inadequate representation of nongovernmental organizations. The financial resources to support the Summit were contributed by external actors, including Canada, yet funding for follow-up actions was meagre – less than 2% of the external funding for HIV infection and AIDS.

CARICOM Summit follow-up

Commitments are discrete, specific, publicly expressed and collectively agreed to statements of intent. They are understood to be a “promise” by summit members that they will undertake future action to move towards, meet or adjust to an identified target.¹⁰10 Kokotsis E. Keeping international commitments: compliance, credibility and the G7, 1988–1995. New York: Garland Publishing; 1999. Whether summits succeed and their commitments are complied with depends largely on how quickly and often follow-up occurs. In this case, follow-up took place within a month of the Summit and repeatedly afterwards. In October 2007, CARICOM agriculture ministers discussed the impact of food and agricultural policies on NCDs and made 13 commitments to combat these diseases.¹¹11 Caribbean Community Secretariat [Internet]. Declaration of St. Ann: implementing agriculture and food policies to prevent obesity and non-communicable diseases (NCDs) in the Caribbean Community. Georgetown: Caribbean Community; 2007. At its November 2008 meeting, CARICOM’s Council for Human and Social Development (COHSOD) focused on the connection between health and education and noted the importance of physical activity and healthy school meals.¹²12 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the seventeenth special meeting of the Council for Human and Social Development (COHSOD) – SPORT. Georgetown: Caribbean Community; 2008.

As mandated in the declaration of Port of Spain, the first Caribbean Wellness Day was celebrated on 13 September 2008 to commemorate the anniversary of the CARICOM Summit, with support from PAHO.¹³13 Samuels TA, Fraser H. Caribbean Wellness Day: mobilizing a region for chronic noncommunicable disease prevention and control. Rev Panam Salud Publica 2010;28:472–9. doi: http://dx.doi.org/10.1590/S1020-49892010001200009 PMID:21308174
https://doi.org/10.1590/S1020-4989201000... In July 2009, CARICOM heads of government endorsed the Caribbean Wellness Day slogan of “Love That Body”.¹³13 Samuels TA, Fraser H. Caribbean Wellness Day: mobilizing a region for chronic noncommunicable disease prevention and control. Rev Panam Salud Publica 2010;28:472–9. doi: http://dx.doi.org/10.1590/S1020-49892010001200009 PMID:21308174
https://doi.org/10.1590/S1020-4989201000... ^,1414 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the thirtieth regular meeting of the conference of heads of government of the Caribbean Community, 2-5 July 2009, Georgetown, Guyana. Georgetown: Caribbean Community; 2009. and, during the six years since the CARICOM Summit, the majority of countries have celebrated Caribbean Wellness Day every year.

At the June 2009 meeting of the COHSOD, the chair pointed out that achieving the United Nations Millennium Development Goals (MDGs) by their 2015 deadline would result in reduced rates of NCDs. “The Strategic Plan of Action for the Prevention and Control of NCDs in Countries of the Caribbean Community” was reviewed in November 2009, in a workshop attended by representatives of ministries of health from 10 CARICOM countries, the CARICOM Secretariat’s Health Desk and experts from PAHO and the University of the West Indies. The completed plan was tabled and endorsed at the 2010 COHSOD.⁵5 Caribbean Community Secretariat [Internet]. Strategic Plan of Action for the Prevention and Conrol [sic.] of Non-communicable diseases for countries of the Caribbean Community 2011-2015. Washington & Georgetown: Pan American Health Organization & CARICOM Secretariat; 2011. Available from: http://www.healthycaribbean.org/publications/strategic-plan-of-action.html [accessed 24 January 2014].
http://www.healthycaribbean.org/publicat...

In September 2010 and December 2011, regional NCD meetings were held in Trinidad and Tobago with funding from PAHO and the Inter-American Development Bank. At these meetings, NCD focal points within the health ministries and chief medical officers reviewed and evaluated compliance with the commitments acquired under the declaration of Port of Spain and shared plans to advance the NCD agenda nationally and regionally.

From the Caribbean to the United Nations

Following the 2007 CARICOM summit, CARICOM leaders, actively encouraged a broader range of countries and organizations to take action towards the control of NCDs. In 2008, Guyanese health minister and World Health Assembly president Leslie Ramsammy advocated for NCDs to be given a more prominent place on the global public health agenda and made the subject of an additional MDG.¹⁵15 Ramsammy L. Address to the Sixty-First World Health Assembly, 19 May 2008. Geneva: World Health Organization; 2008.

NCDs were on the agenda of the Fifth Summit of the Americas in Trinidad and Tobago in April 2009. Their leaders declared that they could “reduce the burden of non-communicable diseases (NCDs) through the promotion of comprehensive and integrated preventive and control strategies at the individual, family, community, national and regional levels and through collaborative programmes, partnerships and policies supported by governments, the private sector, the media, civil society organisations, communities and relevant regional and international partners”.¹⁶16 Declaration of commitment of Port of Spain: securing our citizens’ future by promoting human prosperity, energy security and environmental sustainability. Port of Spain: Summit of the Americas; 2009. Available from: http://www.oas.org/psf/docs/Declaration_VSummit.htm [accessed 24 January 2014].
http://www.oas.org/psf/docs/Declaration_... They supported holding a United Nations (UN) high-level meeting on NCDs.

NCDs were highlighted at the November 2009 Commonwealth Heads of Government Meeting, also held in Trinidad and Tobago. Participants specifically called for “the consideration of a Summit on NCDs to be held in September 2011, under the auspices of the United Nations General Assembly (UNGA), in order to develop strategic responses to these diseases and their repercussions”.¹⁷17 The Commonwealth [Internet]. Commonwealth Heads of Government Meeting Secretariat (CHOGM) communiqué. Port of Spain: Commonwealth Heads of Government; 2009. They also supported initiatives to promote accountability, specifically “the monitoring of NCDs in existing national health information systems” and the inclusion of NCD indicators as part of the monitoring of the MDGs.

In February 2010, CARICOM, Brazil and WHO jointly advocated for a UN high-level meeting on NCDs before UN permanent representatives in New York. In May 2010, UNGA approved a resolution, presented on behalf of CARICOM member states, to hold such a meeting.¹⁸18 The NCD Alliance [Internet]. UN votes yes for NCD Summit. 2010. Available from: http://www.ncdalliance.org/node/80 [accessed 26 November 2013].
http://www.ncdalliance.org/node/80... ^,1919 Keeping the promise: united to achieve the Millennium Development Goals. New York: United Nations General Assembly; 2010. Available from: http://www.mofa.go.jp/region/latin/caricom/mc_1009/ps.html [accessed 24 January 2014].
http://www.mofa.go.jp/region/latin/caric...

At the Second CARICOM-Japan Ministerial Conference, held in September 2010, participants called for widespread support for the high-level meeting on NCDs.²⁰20 Ministry of Foreign Affairs of Japan [Internet]. Partnership for Peace, Development and Prosperity between Japan and the Member States of the Caribbean Community (CARICOM). Tokyo: MFA; 2010. Available from: http://www.mofa.go.jp/region/latin/caricom/mc_1009/ps.html [accessed 24 January 2014].
http://www.mofa.go.jp/region/latin/caric... Participants at the UN Summit on the Millennium Development Goals, also held in September 2010, committed themselves to taking action at the national, regional and global levels to control NCDs and to ensuring the success of the UN high-level meeting.¹⁹19 Keeping the promise: united to achieve the Millennium Development Goals. New York: United Nations General Assembly; 2010. Available from: http://www.mofa.go.jp/region/latin/caricom/mc_1009/ps.html [accessed 24 January 2014].
http://www.mofa.go.jp/region/latin/caric...

In July 2010, at the Thirty-first Regular Meeting of the Conference of Heads of Government of the Caribbean Community, UN Secretary General Ban Ki-moon pledged his full support for the high-level meeting and commended CARICOM for raising the critical issue of NCDs.¹⁹19 Keeping the promise: united to achieve the Millennium Development Goals. New York: United Nations General Assembly; 2010. Available from: http://www.mofa.go.jp/region/latin/caricom/mc_1009/ps.html [accessed 24 January 2014].
http://www.mofa.go.jp/region/latin/caric... ^,2121 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the thirty-first regular meeting of the conference of heads of government of the Caribbean Community (CARICOM). Georgetown: Caribbean Community; 2010. The problems posed by NCDs were brought up at the Seoul Summit of the Group of Twenty (G20) in November 2010²²22 Guebert J, Lennox R. Health at the G20: a small but significant step in Seoul. Health Diplomacy Monit 2011;1:9–10. and dealt with during the Asia Pacific Economic Cooperation summit, which was held the same month in Yokohama, Japan. At this summit, leaders agreed on the necessity to “enhance” NCD control.²³23 Asia-Pacific Economic Cooperation [Internet]. 2010 leaders’ declaration: Yokohama declaration – The Yokohama vision – Bogor and beyond. Yokohama: APEC; 2010.

The United Nations high-level meeting

On 19–20 September 2011, 113 member states, including 35 heads of state and government, attended the UN High-level Meeting on Non-communicable Disease Prevention and Control in New York City.²⁴24 World Health Organization [Internet]. United Nations high-level meeting on noncommunicable disease prevention and control. Geneva: WHO; 2013. Available from: http://www.who.int/nmh/events/un_ncd_summit2011/en/ [accessed 24 January 2014].
http://www.who.int/nmh/events/un_ncd_sum... Participants discussed how to better address the burden of NCDs, which annually kill 9 million people under the age of 60 years. Following the meeting, WHO adopted the target of reducing premature mortality from NCDs by 25% between 2012 and 2025, and in May 2013, UN member states adopted an additional nine targets and 25 indicators during the 2013 World Health Assembly.²⁵25 World Health Organization [Internet]. Sixty-sixth World Health Assembly. Geneva: WHO; 2013. Documenting progress on these indicators in an easy-to-read document, similar to the one used to monitor compliance with CARICOM’s commitments in relation to NCDs, can help to achieve the established targets. The accountability mechanisms developed for the CARICOM Summit show how and why this is so and suggest how compliance can be enhanced for this and other summits on NCDs and other health concerns.

Monitoring compliance

CARICOM and PAHO, as the joint secretariat for the Caribbean Cooperation in Health Initiative, were responsible for monitoring and evaluating compliance with the commitments acquired under the declaration of Port of Spain.⁹9 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the Regional Summit of Heads of Government of the Caribbean Community on chronic non-communicable diseases (NCDs), 15 September 2007, Port-of-Spain, Trinidad and Tobago. Georgetown: Caribbean Community; 2007. These activities were central to advancing the NCD agenda. Before they could recommend a global summit on NCDs, CARICOM leaders needed to demonstrate that their regional summit had made a difference in their countries.

Compliance grid

In 2008, one of the authors of this paper (TAS) designed and implemented a one-page reporting grid that was endorsed by the CARICOM heads of government and ministers of health (Table 1). The grid, intended as a tool for monitoring CARICOM members’ compliance with the commitments acquired under the declaration of Port of Spain, presented succinct information to show where countries stood in terms of NCD-related plans and budgets and of activities and policies surrounding smoking, nutrition, physical activity, health promotion, NCD surveillance and the treatment of NCDs. The grid was revised in 2010; the original 21 indicators were expanded to 26 and colour coding was added (Table 2, available at: http://www.who.int/bulletin/volumes/92/4/13-126128). This was done in collaboration with Fitzroy Henry, director of the former Caribbean Food and Nutrition Institute, now part of the Caribbean Public Health Agency. Countries update the grid annually.⁴4 Hospedales CJ, Samuels TA, Cummings R, Gollop G, Greene E. Raising the priority of chronic noncommunicable diseases in the Caribbean. Rev Panam Salud Publica 2011;30:393–400. PMID:22124699 This task is usually performed by NCD focal points and validated by the chief medical officers in the ministries of health of CARICOM countries. Through this self-reporting, governments note the progress made by their ministries and societies in complying with the Declaration’s 15 items, which translate into 27 commitments acquired under the CARICOM Summit. The updated grid is presented to CARICOM ministers of health every September and to the heads of CARICOM governments annually.

The ministers of health are given a detailed presentation on the status of compliance in their respective countries. In subsequent discussions, the ministers of the countries with the poorest performance are encouraged to improve and are offered assistance by other countries and agencies. Competition among countries over grid status is notable and leads to efforts to improve. For example, at the 2010 Caucus of Caribbean Community Ministers of Health, the health minister of Trinidad and Tobago reviewed the grid. When she noticed that her country had not conducted a STEPwise approach to surveillance (STEPS) NCD risk factor survey, she prioritized completion of this survey, which was published in 2012.

The grid has been used at regional NCD meetings in September 2010 and December 2011 to compare the progress made by countries, set priorities, and identify areas of poor performance. It has spurred a focus on areas of lower performance and has generated an awareness of the need for regional initiatives.

Some of the data from the grid are publicly available. The grid itself was published in a newspaper supplement on 25 September 2011, soon after the UN high-level meeting.²⁶26 Caribbean Community Secretariat [Internet]. Declaration of Port of Spain: uniting to stop the epidemic of chronic NCDs. Georgetown: Caribbean Community; 2011. Surveillance reports and legislation, such as the STEPS reports on NCDs, are made public. Caribbean Wellness Day celebrations are covered widely in the regional media. Data on tobacco control are publicly available through the Framework Convention on Tobacco Control (FCTC) website. Information on other NCD-related commitments is covered in internal health ministry documents and is not publicly available.

The grid has limitations. It is not used to monitor regional actions, as required under the declaration of Port of Spain, partly because it is not suitable for monitoring the unique inputs from each of the regional entities. In addition, the data are self-reported by the people responsible for the NCD programme area, so respondent bias cannot be ruled out. Some indicators are not precisely defined and are open to interpretation. For example, in the health promotion indicator “…≥ 50% of public and private institutions with physical activity and healthy eating programmes”, “physical activity programme” is not defined and each country can choose its own definition.

The grid illustrates the importance of holding leaders accountable for acting on their commitments and of conducting independent expert assessments. Summits generate declarations that politically bind national leaders to commitments they make personally, publicly and collectively. Independent analysis of compliance with these commitments reveals how well and under what conditions countries comply with them. It also makes it possible to see how compliance by CARICOM member countries has varied over time in different areas and what factors are associated with high and low compliance.⁴4 Hospedales CJ, Samuels TA, Cummings R, Gollop G, Greene E. Raising the priority of chronic noncommunicable diseases in the Caribbean. Rev Panam Salud Publica 2011;30:393–400. PMID:22124699^,2727 Kirton J, Guebert J, Samuels TA. Controlling NCDs through summitry: the CARICOM case. Toronto: University of Toronto; 2011.

Compliance assessment results

The Healthy Caribbean Coalition’s assessment

In March 2010, Trevor Hassell, chair of the Healthy Caribbean Coalition, summarized the contents of the grid to assess compliance with the commitments acquired during the CARICOM Summit (Table 2).²⁸28 Hassell T. Caribbean chronic disease initiatives post summit of Port of Spain. In: 16th Annual International Diabetes Conference, University Diabetes Outreach programme, Ocho Rios, Jamaica, March 25-28, 2010. St Michael: Healthy Caribbean Coalition; 2010. Available from: http://www.healthycaribbean.org/presentations/deadly-duo/Caribbean-Chronic-Disease-initiatives-post-Summit-of-7-march27-2010.pdf [accessed 24 January 2014].
http://www.healthycaribbean.org/presenta... He concluded that, almost three years after the Summit, compliance was modest and mixed. Barbados, Guyana, Jamaica and Trinidad and Tobago showed the highest compliance; Haiti, Montserrat and Turks and Caicos showed the lowest.

The G8 Research Group’s assessment

In 2011, two of the authors (JK, JG) assessed compliance with CARICOM Summit commitments using a standard method developed by the G8 Research Group,²⁷27 Kirton J, Guebert J, Samuels TA. Controlling NCDs through summitry: the CARICOM case. Toronto: University of Toronto; 2011. which is the world’s leading independent source of information, analysis and research on Group of Eight institutions, activities and members. The method built on the compliance methods first developed by Von Furstenberg & Daniels in 1992²⁹29 von Furstenberg GM, Daniels JP. Economic summit declarations, 1975-1989: examining the written record of international cooperation [Princeton Studies in International Finance No. 72]. Princeton: Princeton University Press; 1992. and expanded on those developed by Kokotsis in 1999.¹⁰10 Kokotsis E. Keeping international commitments: compliance, credibility and the G7, 1988–1995. New York: Garland Publishing; 1999. Full compliance with a commitment is assigned a score of +1; a score of −1 indicates a failure to comply with a commitment or that a country did the opposite of what was promised; an “inability to commit” or a “work in progress” is scored at 0.

The assessment revealed 27 concrete, discrete commitments emanating from the 15-point declaration of Port of Spain. Application to the 2009 reporting grid showed an overall average compliance score of merely +0.23, equivalent to 61.5%. The average score for the 15 full members of CARICOM was slightly higher, at +0.27 (63.5%). The average score for the five associate members of CARICOM was +0.08 (54%). When applied to the more up-to-date grid results generated for 2011 at the University of the West Indies, which included additional indicators, compliance remained mixed and the average score was +0.06 (53%). The countries with the highest implementation scores were, in order, Barbados (+0.64 or 82%), Trinidad and Tobago (+0.44 or 72%), Bermuda (+0.43 or 71.5%) and Dominica (+0.38 or 69%). The countries with scores below average were Saint Vincent and the Grenadines (−0.45 or 27.5%), Anguilla (−0.61 or 19.5%) and Haiti (−0.83 or 8.5%).

The low average score observed was largely due to the inclusion of indicators for compliance with commitments relating to food and nutrition policy. “Upstream” actions that create healthy food environments are likely to have greater impact than promoting behaviour change around diet and physical activity. Such actions are addressed by items 7, 8 and 9 of the declaration of Port of Spain and include a food supply free of trans-fats, trade agreements conducive to meeting national health goals, and mandatory labelling of packaged foods for nutrition content.⁹9 Caribbean Community Secretariat [Internet]. Communiqué issued at the conclusion of the Regional Summit of Heads of Government of the Caribbean Community on chronic non-communicable diseases (NCDs), 15 September 2007, Port-of-Spain, Trinidad and Tobago. Georgetown: Caribbean Community; 2007. These public and private sector policies and actions were monitored on the grid and received the worst compliance scores across all countries.²⁷27 Kirton J, Guebert J, Samuels TA. Controlling NCDs through summitry: the CARICOM case. Toronto: University of Toronto; 2011.

Factors influencing compliance

Assessing the factors that influence compliance, the ways in which governments comply with their summit commitments and the effects of accountability assessment is a complex and challenging task. Many factors – some well beyond the control of governments or their leaders – can undermine compliance.³⁰30 Kirton JJ, Guebert J. North American health governance: shocks, summitry, and societal support. Rev Norteamericana 2010;5:221–44.Available fromhttp://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S1870-35502010000100008[accessed 27 January 2014]
http://www.scielo.org.mx/scielo.php?scri... Sudden events unrelated to NCDs can distract a country. For example, the 2010 earthquake in Haiti diverted the country’s attention towards the immediate crisis. This weakened governance in the country and pushed NCDs down on the list of priorities. Even without the earthquake, however, compliance with Summit commitments would probably have been minimal. The global economic crisis that started in 2008 has aggravated matters. At the regional level, the recent creation of the Caribbean Public Health Agency as an international institution may have drawn potential financial support away from NCDs.

However, in the case of the CARICOM Summit, some key factors stand out. Countries with a higher gross national income (GNI), a higher gross domestic product (GDP) and a larger population – these are the standard measures of overall national capability – are more likely to follow through on their commitments than those with lower GNIs and GDPs or smaller populations. Commitments supported regionally, such as Caribbean Wellness Day, or internationally, such as commitments related to the FCTC, are also more likely to be fulfilled.⁴4 Hospedales CJ, Samuels TA, Cummings R, Gollop G, Greene E. Raising the priority of chronic noncommunicable diseases in the Caribbean. Rev Panam Salud Publica 2011;30:393–400. PMID:22124699

More generally, there is mounting evidence, especially from G8 summits, that leaders in attendance can use the power of the chair to craft their commitments in ways that improve compliance. They can, for example, add accountability mechanisms.³⁰30 Kirton JJ, Guebert J. North American health governance: shocks, summitry, and societal support. Rev Norteamericana 2010;5:221–44.Available fromhttp://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S1870-35502010000100008[accessed 27 January 2014]
http://www.scielo.org.mx/scielo.php?scri... ^–3232 Kirton JJ. Explaining compliance with G8 finance commitments: agency, institutionalization and structure. Open Econ Rev 2006;17:459–75. doi: http://dx.doi.org/10.1007/s11079-006-0359-5
https://doi.org/10.1007/s11079-006-0359-... Independent assessments conducted by experts for G8 and G20 summits have been reported by the media, discussed by leaders’ representatives at preparatory meetings, and publicly referred to and discussed by leaders at the summits.

In summary, the CARICOM Summit was successful in several ways. It was the first summit of heads of government to focus on the problem of NCDs and it resulted in multiple collective, multilateral commitments for implementation of policies and actions pertaining to NCD control. Although there is room for improvement, countries fulfilled some important commitments acquired at the Summit. The CARICOM Summit sparked interest in a global summit on NCDs and resulted in the UN high-level meeting on NCDs. An accountability mechanism based on annual reporting is critical for monitoring progress and highlighting areas in need of correction.

References

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