The historical development of human resources policies in the health sector of four Caribbean territories: imitated or created?

Health systems are labour intensive, dependent on a mix of professionals to provide health care in both public and private sectors. In this paper, we explore the historical development of human resources, focusing on doctors and nurses, in four Caribbean territories-the Bahamas, Martinique, Suriname and Trinidad and Tobago. All these territories have faced issues around the out-migration of doctors and nurses and tensions between public health, hospital services and private sector policies. Early policies to increase the number of nurses and doctors were costly, because they were implemented against a tide of increasing outward migration. Both push and pull factors were evident. Human resources policies focused on ways to counter pull factors-such as introducing regional medical training-but neglected push factors. These began to be addressed from the 1980s on, although tensions between public health, hospital services and private sector policies led to resistance and conflicts in attitudes to reform among health professionals. Policy responses were the product of many influences, and it is too simple to conclude they were either imported from abroad or internally generated. However, it is clear that in all four territories the medical profession played a dominant role in human resources policy development either directly or indirectly.

Health financing policy formulation in the Eastern Caribbean.

Stakeholders formulating policies on national health insurance (NHI) in the Eastern Caribbean have circled the abstract concept called NHI like the proverbial blind men explaining the elephant. Definitions of NHI have shifted depending on their perspectives and philosophical leanings, their understanding of the issues, and their degree of influence on the process. Based on NHI feasibility studies, market research, and stakeholder analysis conducted in five countries, this article analyses the policy formulation stage of NHI development in these tiny countries. Given the level of economic development and the existing administrative capacity of the governments, this 'phase one' NHI could be a pragmatic first step in introducing a health insurance component into the social security systems of the countries, and gradually reforming other aspects of the health sector. The article is structured around key questions which help to define the positions and relationships of key stakeholders, and then evaluate NHI plans in terms of economic viability, equity, administrative feasibility and efficiency, cost containment incentives, and political palatability. These are the elements that--in combination with economic and political context--will determine the success or failure of NHI in the Eastern Caribbean.