Richard Amenyah | From fragmentation to integration

Across the Caribbean, our health systems face a dual crisis that can no longer be treated in isolation. On one hand, decades of investment in the HIV response have delivered remarkable gains, resulting in more people living with HIV being on treatment, and AIDS-related deaths continue to fall (62 per cent decline since 2010).

On the other hand, non-communicable diseases (NCDs) such as diabetes, hypertension, cancer, and heart disease now account for over 80 per cent of all deaths in the region, with premature mortality hitting our most productive populations.

Yet, despite this shared burden, we continue to treat HIV, tuberculosis (TB), and NCDs in separate silos — different clinics, different budgets, different strategies. This fragmentation is neither efficient nor sustainable. It is time to pursue a people-centred approach, where the same primary healthcare platform can manage chronic diseases holistically, whether communicable or non-communicable.

SHARED EPIDEMIC

Communicable diseases (including HIV, TB, STIs, and Hepatitis) and NCDs may look different, but they share important similarities. Both require long-term treatment, excellent adherence, regular monitoring, and systems that ensure people are retained on treatment as part of chronic care continuum. Both are deeply shaped by social determinants of health — poverty, gender inequality, stigma, and poor access to nutritious food and lack of safe environment, among other factors. And both disproportionately affect the most vulnerable and marginalised in our communities.

A 45-year-old woman living in Kingston or Castries may visit one clinic for her HIV treatment, another for hypertension, and yet another for diabetes, on different clinic days. Each requires time, transport, money and multiple appointments with different providers. This fragmented model drains and impoverishes patients, families, and already overstretched health systems. Integration — bringing communicable and non-communicable disease care together at the primary healthcare level — offers a smarter, more dignified alternative with significant health cost savings for patients.

SUSTAINABILITY THROUGH INTEGRATION

With the current geopolitical shifts with significant funding cuts for global health initiatives, the Caribbean can neither continue to depend on external aid to sustain its health responses, nor can it ignore the growing economic toll of NCDs. Treating these health challenges separately leads to duplication of resources with gross inefficiencies — different supply chains, information systems, and health-worker training streams. By integrating services, we can leverage existing HIV investments — robust laboratories, supply chains for antiretrovirals, and community health networks — to strengthen care for NCDs. Adopting holistic, person-centred healthcare strengthens labour productivity, supports innovation, and reinforces value chains in diagnostics, biotechnology, pharmaceuticals, logistics, and digital infrastructure — making it a critical driver of sustainable development and inclusive growth.

Integration does not mean diluting HIV efforts: it means protecting them by embedding them within stronger, more resilient health systems. For example, the infrastructure used for HIV viral load testing could be adapted for monitoring diabetes (HbA1c) or cholesterol levels. The same trained health workers who provide adherence counselling for antiretrovirals could support patients managing hypertension medication. Community outreach models developed by HIV programmes can be expanded to promote healthy lifestyles and NCD screening.

Policymakers across the region now face a clear choice: continue business as usual with fragmented, vertical programmes, or embrace integration as a pathway to sustainability and, importantly, a healthier society. A primary healthcare model that addresses HIV, TB, and NCDs under one roof aligns with the Caribbean Cooperation in Health framework and the Sustainable Development Goals.

Such a shift would also help tackle inequities. Rural populations, low-income families, and marginalised groups and key populations often face the heaviest burden of multiple chronic conditions. Integrated services reduce access barriers by offering ‘one-stop care’ that saves time, reduces costs, and builds trust.

PRACTICAL STEPS FORWARD

Prevention must be front and centre: Implement WHO’s “best buys” like MPOWER for tobacco control, SAFER for alcohol, SHAKE for salt reduction, and ACTIVE for physical activity. CARPHA’s ‘Caribbean Moves’ initiative can promote regionwide wellness, curbing obesity — a key driver for both NCDs and poor HIV outcomes. Integration need not be overwhelming. Policymakers can begin with practical, incremental steps:

Policy alignment – Revise national health strategies to explicitly mandate integration of Communicable and Non-Communicable Disease care at the primary health care level. There is a need for political will, and this policy alignment must be deliberate to match commitments with significant domestic resource investments. Socially, leverage health laws to regulate marketing of unhealthy products to children with front-of-package labelling and advertising bans to protect vulnerable populations.

Service delivery redesign – Expand existing HIV clinics to include NCD screening and management, starting with hypertension and diabetes which older people with HIV experience because of their age or from other causes. South-south cooperation can be explored to help improve health system redesign for health impact.

Capacity building – Train health workers in multi-disease management, strengthening skills for chronic care and patient-centred counselling. There should be a deliberate attempt to start integration from pre-service training in the medical and nursing schools. Hence, curriculum adjustment may be necessary.

Data integration – Harmonise health information systems to track both CDs and NCDs, leveraging artificial intelligence platforms for data analysis and adopt digital tools like electronic health records for patient monitoring for quality care and to foster effective and efficient resource planning and tracking of health outcomes and impact. Invest in surveillance surveys for real-time data on CDs and NCDs.

Community engagement – Empower communities, including those already mobilised for HIV, to champion healthy lifestyles and NCD prevention.

CALL TO ACTION

To our Caribbean governments and policymakers, strategic investments in health are not just about saving lives — they are a catalyst for the region’s goals of industrialisation, trade integration, and geo-economic sovereignty. By prioritising health within CARICOM’s development agenda, governments can unlock productivity, attract investment, and build resilience, turning health into a driver of sustainable growth and regional independence.

The Caribbean has always been a region of resilience and innovation. We pioneered community-led HIV responses that inspired the world. Today, we must once again lead — by breaking down the artificial walls between communicable and non-communicable diseases and embracing a unified, sustainable health agenda.

Integrating HIV, TB, and NCD services at the primary healthcare level is not just a technical fix; it is a moral and socio-economic imperative. It respects the dignity of every patient, maximises limited resources, and secures the hard-won gains of the AIDS response for future generations.

The choice before us is stark: maintain parallel systems that stretch our budgets and weaken our health outcomes, or build a unified health system that reflects the realities of people’s lives. If we want a healthier, more sustainable Caribbean, integration must start now — at the front line of care, where it matters most. Policymakers must act urgently — convene commissions, pass laws, and invest now. Together, we can turn this burden into a collective triumph: healthier people, stronger economies, and SDG success. Our future depends on it.

Dr Richard Amenyah is an international public health specialist from Ghana and the director of the UNAIDS Multi-Country Office in the Caribbean. Send feedback to columns@gleanerjm.com