2012

FROM COMMITMENT

TO ACTION

A REVIEW AND ASSESSMENT OF BRASILIA

DECLARATION IN ST. KITTS AND NEVIS

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Contents Executive Summary ................................................................................................................................. 6

1. Introduction ..................................................................................................................................... 9

1.1 Statement of Problem .............................................................................................................. 9

1.2 Rationale for the Study ......................................................................................................... 10

1.3 Methodology ......................................................................................................................... 11

1.3.1. Data Collection ............................................................................................................. 11

1.3.2 Documentary Review .................................................................................................... 12

1.3.3 Qualitative Review ........................................................................................................ 12

1.3.4 Quantitative Review ...................................................................................................... 12

1.3.5 Analytical Framework ................................................................................................... 12

2.1 Population and Ageing .......................................................................................................... 13

2.2. Socio-Economic indicators .................................................................................................. 15

2.2.1 Poverty and Social Deprivation .................................................................................... 15

2.2.2 Health and Healthcare ................................................................................................... 16

2.2.3. Social Safety Nets ......................................................................................................... 17

2.2.4 Social Insurance ............................................................................................................ 18

2.2.5 Labour Market and Employment ......................................................................................... 18

2.3. Social, Economic and Political Situation .............................................................................. 19

2.3.1 Social Risks and Vulnerability .......................................................................................... 19

2.3.2 Economic Vulnerability ................................................................................................ 20

2.3.3 Political Vulnerability ................................................................................................... 20

2.3.4 Vulnerability to Natural and other Disasters ................................................................. 21

3.0 REVIEW AND APPRAISAL OF NATIONAL ACTIONS TO FULFIL COMMITMENTS TO the BRASILIA DECLARATION 2007 – 2011 .............................................................................. 22

3.1 Economic Security ................................................................................................................ 22

3.1.1 Access to Decent Work in Old Age .............................................................................. 22

3.1.2 Coverage of Social Security System (Contributory and Non-contributory) ................. 24

3.2 Health ........................................................................................................................................ 25

3.2.1 Care of older persons with disabilities .......................................................................... 25

3.2.2 Equitable access to health services. .............................................................................. 28

3.2.3 Monitoring of long-stay institutions ............................................................................. 29

3.2.4 Creation of palliative care services. .............................................................................. 0

3.2.5 Access to health care for older persons with HIV. ........................................................ 31

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3.3 Environment .......................................................................................................................... 33

3.3.1 Promotion of continuing education. .............................................................................. 33

3.3.2 Accessibility of public spaces and adaptation of housing. ............................................ 34

3.3.3 Elimination of discrimination and violence in old age. ................................................ 35

3.3.4 Recognition of the contribution of older persons in the care economy ........................ 36

4.0 Summary and the Way Forward ............................................................................................... 37

4.1 General Comments ................................................................................................................ 37

4.2 Strengths and Weaknesses ........................................................................................................ 39

4.3 Priorities for Future Action ................................................................................................... 39

References ............................................................................................................................................. 41

Figure 1: Main Recommendations of 2007 Brasilia Declaration on Ageing ........................ 11 Figure 2: Work Areas for the Inventory and General Evaluation of Actions Aimed at Older Persons ............................................................................................................................... 13 Figure 3: St. Kitts and Nevis Population Age Pyramid for 1981, 1991, 2001, 2011, 2021 and 2025 .................................................................................................................................... 14 Figure 4: Golden Years Steel Orchestra - Nevis .................................................................. 17

Photo 1: CARICOM Leaders Walk before Meeting - Modeling one Healthy Lifestyle Alternative - July 2011 (Source SKNVIBES.com) ................ Error! Bookmark not defined. Photo 2: Nevis AIDS Secretariat March for World AIDS Day (Source: UNGASS 2010 Country Report ................................................................................................................... 32 Photo 3: Craft Produced by Seniors in the Federation .......................................................... 34

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Acronyms

AIDS Acquired Immune Deficiency Syndrome

ARV Antiretroviral

BNTF Basic Needs Trust Fund

CARICOM Caribbean Community

CPA Country Poverty Assessment

GDP Gross Domestic Product

GOSKN Government of St. Kitts and Nevis

HIV – Human Immunodeficiency Virus

LMIS Labour Market Information System

MDGs Millennium Development Goals

MIPAA Madrid International Plan of Action on Ageing

NACU National Aids Coordination Unit

NACHA National Council for HIV and AIDS

NAS National Aids Secretariat

NCDs Non Communicable Disease

NEMA National Emergency Management Agency

NGO Non-Governmental Organization

NIA Nevis Island Administration

NPRS National Poverty Reduction Strategy

NSTP National Skills Training Programme

OECS Organization of Eastern Caribbean States

PLWAs People Living with Aids

SKNAPD St. Kitts and Nevis Association of People with Disabilities

SSMC St. Kitts Sugar Manufacturing Corporation

SSNA Social Safety Net Assessment

UNFPA United Nations Population Fund

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UNGASS United Nations General Assembly Special Session

VCT Voluntary Counseling and Testing

FACTTS Facilitating Access to Confidential Testing, Treatment and Support

VAT Value Added Tax

WTO World health Organization

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Executive Summary

The Federation of St. Kitts and Nevis underscored its commitment to addressing matters of aging at a regional level by signing the Brasilia Declaration on Ageing in 2007. Five years on a systematic and introspective review of the implementation of the Madrid International Plan of Action on Ageing (MIPAA) has been commissioned to map the overall progress towards achieving stated objectives geared mainly towards improving the overall quality of life of older persons.

Over the next decade and half life expectancy at birth is slated to increase even further thereby expanding the proportion of the population over 65 years of age. Poor and non-poor older persons alike in the society however are considered to be particularly vulnerable not only to poverty but are also at risk for neglect, abuse, discrimination, hunger and loneliness. St. Kitts and Nevis already has in place a raft of actions geared towards older persons across the three main thematic areas of the Brasilia Declaration, namely economic security, health and environment. These measures fall into all the work areas under examination, namely legislative, administrative, programmatic and institutional.

By all indications while some progress have been made in meeting these commitments it is clear that there is much more that must be done if there is to be a society for all ages built on agreed core societal principles. This report outlines the main achievements attained over the period under consideration and highlights existing key gaps and actions.

Key Issues on Aging

• The effect of chronic diseases is having a toll on the quality of life of the population especially the older segment of the population. Halting and reversing the exposure to risk factors and impact of chronic diseases can provide some impetus to the provision of care for older person or for them to become actively engaged in health seeking behaviours.

• There is a lag in ensuring economic security for older persons particularly as it relates to secure employment and the provision of decent pensions. There are currently no specific programmes to facilitate older persons’ integration in the labour market.

• There are still several economic and social barriers to the integration of older persons into society. Removing barriers such as those which affect their sense of security and mobility such as transportation costs will go a long way in opening up new avenues for older person to contribute and participate in social life;

• Legislation which speaks directly to the plight of the aged is virtually non-existent. Legislation and policies can only be effective if they are enacted and implemented.

• There are still gaps that must be filled with respect to programmes aimed at older people. The scope of many still remains limited and some programmes are not properly targeted, monitored or evaluated.

• Advocacy for the aged is weak, especially since there are no advocacy groups for the aged in the Federation;

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• There is still much scope for capacity building and institutional strengthening as it relates to institutional arrangements aimed at older persons. Institutional arrangements have been strengthened in Nevis with the establishment of a Senior Citizens Division but similar arrangements are still required for St. Kitts.

• GOSKN can lose out on the dividends from the age structural transformation if it does not take steps to increase employment opportunities, entrepreneurship development, develop human resource base as well as increased savings and investments. Having well-adjusted, educated and prepared population augers well for successful aging.

Priorities for Future Action

• If action aimed at older people is to be pro-active, cohesive, comprehensive and effective the draft National Policy on Ageing must be enacted and Action Plans developed to guide implementation;

• Current draft Regulations for care homes for the aged must be reviewed, updated and enacted so as to create a facilitative and standardized system of care across care providers;

• Support must be lent to the Social Protection reform process; • Implement recommendations of the National Poverty Reduction Strategy (NPRS);

• Strengthening of the environment within which seniors can have improved access to employment and income by aligning government retirement age to social security age of eligibility thus reducing forced early retirement and lessening the gap between retirement and when social security pension payments kick in.

• Review and upgrade social assistance and poor relief payments; • Improve and increase opportunities for learning and supporting older

entrepreneurs; • Foster health seeking behaviours across the life span in general and specifically

among older persons;

• Strengthen the Home Care Programme by improving oversight and monitoring and evaluation as well as expanding coverage of the programme

• Improve focus on discrimination and abuse of older persons and PLWHAs;

• Encourage greater involvement and participation of civil society in issues related to ageing;

• Establish a Senior Citizens Division on St. Kitts to coordinate activities for the aged;

• Seize the golden demographic bonus by increasing employment opportunities, improving the quality of human resources, and encouraging greater saving and investment by the young;

• Encourage the development of older persons associations and advocacy groups; • Older persons must be facilitated to advocate for their own welfare and actively

engage in decision making on matters which concern them. • Emphasis must also be placed on social and recreational activities for elders all

year round across communities;

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• Improve access of older persons to services by reducing barriers such as transportation costs and accessibility to institutions;

• Expand coverage of the meals and wheels programme and improve frequency of distribution of meals;

• Strengthen the legislative framework within which issues of the aged are addressed e.g Elder abuse legislation;

• Improve palliative care offered to frail older persons by having more experts in specialized areas such as geriatrics and podiatry;

• Establish a National Council on Ageing.

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General Information

Country Name: St. Kitts and Nevis

Name of and information about the author of the report:

a. Name: Ms. Lavern Louard-Greaves,

b. Contact details for the author of the report: Lavelou@gmail.com

4. Name and contact details of official national focal point on ageing:

a. Name: Ms. Azilla Clarke, Director Social Services and Community Development

b. Contact details: Victoria Road, Basseterre, St. Kitts

5. Name, reference and date of adoption or status of preparation of national strategy, action plan or similar policy document on ageing:

Recognizing the need to address the issue of an ageing population and to fulfill its obligations under the Madrid Declaration on Aging and the Brasilia Declaration the Government of St. Kitts and Nevis embarked on a partnership with United Nations Department of Economic and Social Affairs (DESA) to develop a National Policy on Ageing. The draft policy was completed in 2009 with large scale consultation of all relevant stakeholders. It was subsequently submitted to Parliament to be read into law. The final review and adaptation of the policy on ageing into a white paper is yet to be completed. As it stands there is no action plan but it is hoped that one will be developed so as to facilitate implementation of the policy.

1. Introduction

1.1 Statement of Problem

Up until recently, population ageing was mostly viewed as a phenomenon of mainly developed countries which were undergoing rapid demographic transition. However, by the advent of the Second World Assembly on Ageing in Madrid in 2002 and the subsequent drafting of the Madrid International Action Plan on Aging, governments in the Caribbean Region were cognizant of the need to empower all their citizens, most notably older persons to fully participate in all aspects of social and economic life. Protection of the aged was seen as just one pillar of a broader strategy to address issues of active ageing. While not at the level experienced by developed countries Caribbean States like St. Kitts and Nevis are already in the throes of marked demographic transition leading to the gradual ageing of the population.

This newfound realization has provided policy makers in the region with a golden opportunity to address ageing head on in a comprehensive and pro-active manner emphasising the importance of active ageing and healthful ageing from of citizens from an

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early age. Ideologically many governments have stepped up to the plate by signing required commitments including the Brasilia Declaration on Ageing in 2007 which outlines the agreed upon obligation of Latin America and the Caribbean Governments to improving the human rights of older persons and to work along with them to improve their quality of life.

Obligations to reaching key targets outlined in the Millennium Development Goals (MDGs) also underscore the need for impetus in this area. Admittedly, reducing poverty across the region and enabling the poor, disenfranchised and vulnerable necessitates that the welfare of older persons be seriously addressed. Mainstreaming concerns of ageing into development planning and engaging these older persons in dialogue and action is a critical success factor.

As St. Kitts and Nevis grapple with a diverse cocktail of important issues keeping all balls in play becomes steadily more difficult as they set new priorities and renegotiate others. This has meant that more often than not there may be a lag in aggressively meeting agreed commitments in keeping with the acknowledgement of the need to transform administrative, institutional, legislative and programmatic arrangements to reflect and confront the more modern realities of the society. Such is the case with the Federation’s commitment to the Brasilia Declaration on Ageing. While some progress have been made in meeting these commitments there is much more that must be done if there is to be a society for all ages built on agreed core societal principles. Box 1 provides further details of the national Vision and core principles outlined in the Green Paper on Ageing for the twin island states and which reflect the sentiments of the state’s regional and international commitment to addressing issues of aging in its society.

1.2 Rationale for the Study

A systematic and introspective review of the implementation of the Madrid International Plan of Action on Ageing (MIPAA) is required every five years to ensure progress towards the overall improvement of the quality of life of older persons in the society. This review process seeks to complement the sharpened focus on ageing by allowing states to examine critically the operationalization of their commitments made under MIPAA. By identifying key success stories and challenges countries are able to highlight progress made on the implementation process. This will act as a reference point to countries such as St. Kitts and Nevis as they outline priorities for the future and forge a closer path towards achieving their main goals.

Information provided through this National report will form the basis of discussions at the Third Regional Intergovernmental Conference on Ageing in Latin America and the Caribbean to be held in San Jose Chile May 9th to 11th, 2012. In signing the Brasilia Declaration the Latin America and the Caribbean reaffirmed their solidarity with the aim to “spare no effort to promote and protect human rights and fundamental freedoms of all older people. Work towards the elimination of all forms of discrimination and violence and creating safety nets for older persons to exercise their rights.” Figure 1 below outlines the

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key recommendations of the Brasilia Declaration which encompass the areas of economic security, health and environment.

Figure 1: Main Recommendations of 2007 Brasilia Declaration on Ageing

Source: José Luis Machinea, “Envejecimiento y desarrollo en América Latina y el Caribe: hacia una sociedad para todas las edades y de protección social basadaen derechos”, 46th session of the Commission for Social Development, New York, 2008 as quoted in UNECLAC TOR

Consequently this report details the main achievements reached in respect of improving the quality of life of older persons in St. Kitts and Nevis during the last five years and identifies existing key gaps and actions. More specifically, it focuses on the following three components:

1. An inventory and assessment of actions aimed at older persons in the legal, administrative, programmatic and institutional aspects;

2. The identification and assessment of best practices from the perspective of the rights of older persons;

3. The definition of key actions to be taken in the next five years to strengthen the protection of the human rights of older persons.

1.3 Methodology

1.3.1. Data Collection

The data collection and preliminary review process entailed a three pronged approach. Documentary research, qualitative and quantitative techniques were utilized to assess the implementation of the commitments of the Brasilia Declaration.

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1.3.2 Documentary Review

Relevant reports and other documentation were collected and reviewed. A combination of national, regional and international reports and policy documents proved useful. Quite a number of research activities were carried out in the last two to three years and provided up to date information on the Federation and the plight of older persons. Information from these reports was analyzed and utilized at various points in the paper.

1.3.3 Qualitative Review

A small number of informal interviews were conducted with key persons who worked at facilitating the improvement in the quality of life of older persons. The wealth of data collected previously by the author through interviews with stakeholders at all levels in the process of drafting of the National Policy on Ageing 2009 and the National Poverty Reduction Strategy (NPRS) 2011 was complemented by findings from this fresh set of questions. The focal points on both Nevis and St. Kitts were included in these interviews.

1.3.4 Quantitative Review

Statistical data were collected from relevant agencies including the National Statistics Office and The Social Security Board. Data was also collected from trusted online sources such as the U.S. Census Bureau. This information was used to supplement findings in this report.

1.3.5 Analytical Framework

On a whole activities were analysed along four lines, namely legislative, administrative, programmatic and institutional so as to determine the extent to which initiatives adequately ensure the realization of the human rights of older persons.

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Figure 2: Work Areas for the Inventory and General Evaluation of Actions Aimed at Older Persons

Source: Economic Commission for Latin America and the Caribbean (ECLAC), “From commitment to action: Guide to the review and evaluation of the Brasilia Declaration in Latin America and the Caribbean”, 2011.

2. NATIONAL AGEING SITUATION

2.1 Population and Ageing

Official findings of the 2001 Census1 for St. Kitts and Nevis revealed that of a total population of 46,325 persons, about 7.9% were 65 years of age or older. Of the overall number of females in the entire population 4.6% were categorized as aged and just about 3.4% of all males were 65 years of age and older. Approximately 57% of the aged were females and 43% were males. Further, when the population data was disaggregated by island evidence suggested that older persons represented 7.3% of the population on St. Kitts. The 65 and over male to female ratio for St. Kitts stood at 76 males for every 100 females. Nevis recorded a higher proportion of its population in the 65 years and older category than did St. Kitts as 9.9% of Nevis’ population fell into that age cohort. The majority of the elderly on Nevis were females with a ratio of 72 men for every 100 women aged 65 years and over.

While St. Kitts and Nevis retains a relatively youthful population its changing population profile indicates that the number of persons in the 35 to 50 age cohort is expanding as highlighted by the differences between the 1991 Population and Housing Census, 2001 Population and the Population and Housing Census for 2001 and mid-year estimates for 2004. Moreover as the birth rate and fertility rate remain below replacement levels, as those between ages 35 and 50 years of age grow older and life expectancy at birth increases it is

1 National Statistical Office indicated that the findings from the 2011 Census are not yet available and may not be available until after April, 2012.

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likely that the proportion of the population over 65 years of age could balloon over the next decade and a half. The population structure could grow closer to a more rectangular shape similar to that of more developed countries. See Figure 1 displayed below.

Figure 3: St. Kitts and Nevis Population Age Pyramid for 1981, 1991, 2001, 2011 and projections for 2021 and 2025

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Source: Adopted from US Census Bureau International Database, 2012 2

Although population ageing is not expected to be on par with that of more developed countries the 2007 Social Security actuarial report nonetheless forecasts that the aged would account for upwards of 22% of the population by 2045 (Blank, 2009). Life expectancy for Kittitians and Nevisians has significantly increased. Acknowledged improvements in health services, advances in medical technology, progress in education especially of women and the better control of communicable diseases underpin this trend towards greater longevity. For that matter life expectancy moved from approximately 69 years of age in 19913 to an estimated 73 years of age by 20104. Specifically, in 2010 life expectancy stood at 71 years of age for males and 74 years of age for females.

Further as the population age structure shifts upwards one is likely to see an increase in the phenomena of double demographic ageing as the proportion of the population aged 80 and above grows. An ageing population signals increased demands being placed on the social protection system inclusive of social security and the social safety net as well as healthcare especially specialized health services. In many instances this population transition represents a direct increase in old age dependency ratios which would point to a sharpening of the burden on the working segment of the population. In addition, with the increased cost of health care provisioning the Government is exploring the introduction of a National Health Insurance Scheme which would also be expected to be financed by the segment of the population that is productively employed.

2.2. Socio-Economic indicators

2.2.1 Poverty and Social Deprivation

The majority of the elderly are doing well however the 2007/2008 Country Poverty Assessment (CPA) Report indicated that about 2.6% of the poor were aged 65 and older. Poor and non-poor older persons alike in the society however are considered to be particularly vulnerable not only to poverty but are also at risk for neglect, abuse, discrimination, hunger and loneliness. These are issues which the Federation must vigilantly guard against as it seeks to scale up protection for its most vulnerable sections of the population. On a whole the government ensures that a network of basic social services and amenities are available and relatively accessible to older persons across sectors in both rural and urban areas. This is a key element of it social protection and risk reduction mechanism.

Improved quality of life of citizens has been an enduring goal since the recommendations of the Moyne Commission in the late 1930’s and 1940’s. Special emphasis has been placed on housing, education and healthcare. In particular the aged have benefited from evolving housing schemes over the years which have helped many to become homeowners. A special home repair programme managed through the Social Assistance programme has been

2 http://www.census.gov/population/international/data/idb/country.php

3 US Census Bureau, Census data base 4 National Statistics Office, St. Kitts and Nevis.

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ongoing and has helped disadvantaged elderly persons to make essential repairs or upgrades to their home. Programmes such as the Basic Needs Trust Fund have also helped to eradicate the use of pit toilets in a few areas where they proliferated and where older persons were affected.

2.2.2 Health and Healthcare

There is general agreement in St. Kitts and Nevis that no one should be excluded from accessing necessary health care because of his or her inability to pay. Older persons in the twin island state benefit tremendously from exemptions for services in the secondary and primary health care sector. In particular they receive free health screenings, medications (a one-time EC$ 10.00 processing fee is charged when first prescription is presented), dental and vision checks.

It has been advanced that perhaps one of the most significant scientific discoveries of this century is the knowledge that most lifestyle diseases can be halted and even reversed when enduring lifestyle and dietary changes are made. Recognising this, health promotion through the Diabetic Associations as well as the community health centres is the cornerstone of the Health thrust in St. Kitts and Nevis. Free care and medication are provided for chronic diseases across the board inclusive of HIV/AIDS.

Assessments of the incidence of HIV/AIDS among older persons are not captured as the main focus remains on the 15-49 age categories. They however continue to be infected and affected by the disease although at a significantly lower rate than individuals in the younger age cohorts. The 2010 United Nations General Assembly Special Sessions (UNGASS) Report for St. Kitts and Nevis noted that the prevalence of reported HIV positive reported cases in the Federation for the period 1984 to 2008 was highest for men in the 25-49 and the 50 plus age segments of the population. There have been approximately 21 positive reported cases in the 50 plus age category for the same period. The fact however that the majority of cases cluster in the 25-49 age cohort requires close attentions the age profile of the population continues to shift from young to old and as fewer persons die from AIDS because of accessibility to treatment.

Anti-retroviral treat is available to all citizens in the Federation without cost through the public health system. Caring for Persons Living with Aids (PLWAs) remains a challenge. A key objective of the draft National Strategic Plan on HIV and AIDS 2010-2013 is to get more NGOs involved in the care of PLWAs.

There is some special assistance from the Department of Social Assistance available for the purchase of eyeglasses and special exemptions. Funding is also granted on a case by case basis to persons in the lower socio-economic bracket who may need specialist care any of the main hospitals or tertiary care overseas. The elderly are able to benefit from these last few measures especially due to the provisioning of the Social Assistance Act of 1998.

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2.2.3. Social Safety Nets

Under the Social Assistance Act of 1998 indigent individuals which include the aged and other categories of people are eligible to receive Poor relief assistance and/or food vouchers. Some older individuals who have come into difficult times have also received a rent subsidy. Until recently the elderly also received a discount on their electricity bill through the state.

The Ministry of Social Services, Community Development and Gender Affairs in St. Kitts is undergoing a period of transition and a key aspect of this transition is the development of a Social Protection Policy for the Federation to help them to effectively manage the level of risk to which their clients are exposed and to better protect the most vulnerable in a proactive manner. This recalibration resulted from findings of recently conducted Social Safety Net Assessment (2009) and Country Poverty Assessment (2007/2008) which highlighted some shortfalls and inefficiencies in the loose network of social programmes and services which are geared towards not only assisting the poor but towards helping them to springboard out of poverty. The ongoing economic uncertainty at all levels mandates that policies and programmes be executed with smooth precision so as to mitigate the negative fallout on those whose can’t do for themselves.

Approximately 68 elderly persons and disabled are provided with meals through the state run Hot Meals Kitchen on Nevis. On St. Kitts a non-state agency the St. Christopher Outreach Center5 continuing on from the Red Cross which undertook this task for 25 years now serves as a preparation, distribution and feeding centre for meals for seniors and homeless across the island.

On Nevis a number of ongoing recreational activities are organized for the aged inclusive of a Golden Years Steel Orchestra, Zumba exercise classes, beachnics, tours and other activities. While there are some activities on St. Kitts especially in October for the month of the Elderly the momentum has slowed compared to the level of activity prior to 2010.

Both islands provide Home Care Officers for seniors who need added assistance in their homes. In this regard they assist with personal hygiene, light house work, visitations, preparation of meals and monitor emotional and physical health of the aged. The Home Care Program is in fact considered to be the flagship programme for the aged on St. Kitts and employs 18 women to carry out these duties. Attempts are made to keep the skills of these persons up to date so that

5 Started in 2010 and the Building, equipment, 2 staff and Food provided by Rams Supermarket

Figure 4: Golden Years Steel Orchestra - Nevis

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they can provide adequate care and support at all times to their clients.

2.2.4 Social Insurance

Many older persons continue to live on a fixed income and find it difficult to meet their obligations particularly where already high prices for fuel and food constantly fluctuate. Social Security Benefits provides a necessary layer of protection for older persons. At the age of 62 years individuals are able to draw down on this benefit. There are three main categories under which the elderly may qualify to receive benefits from the Scheme namely, Old-age Pension, old-age Grant and Old-age Social Assistance.

• Old-age pension (social insurance): Age 62 with at least 500 weeks of paid or credited contributions, including at least 150 weeks of paid contributions.

• Old-age grant (social insurance): Age 62 with at least 50 weeks of paid or credited

contributions but does not satisfy the qualifying conditions for the old-age pension.

• Old-age social assistance (means-tested): Older than age 62, not in gainful employment, and does not satisfy the qualifying conditions for the old-age pension.

The “2008 Social Security Statistics Review” showed that there were a total of 1,858 active pensioners in the Federation, 1,546 on St. Kitts and 312 on Nevis. By every indication therefore less than 49% of seniors benefit under the Social Security Scheme. ApproximatelyEC$17,791,950 was paid out to old age pensioners, EC$492,314 was paid for old age grants and a total of EC$1,337,095 was disbursed for old social assistance. (SSecurity, 2010) Interestingly, while the amount of EC$1,138,097 was paid out for Survivor’s benefit to widows only EC$128,517 was paid to widowers perhaps underscoring that women generally tend to outlive the men.

2.2.5 Labour Market and Employment

The task of ensuring that the ageing and the aged have access to secure employment remains a challenge. The employment situation for the aged has worsened as they are among the first categories of workers to be let go when the economy is not doing so well. Older persons faced with redundancies, early retirement, low levels of transferrable skills and a tight job market are increasingly forced to re-evaluate their situation. As a result of the need to strengthen its financial and fiscal position the Government of St. Kitts is enforcing previously dormant retirement rules which require persons 55 years and older to retire or request special permission to continue their duties. Given that the Government is the number one employer and that the labour market is shrinking many persons in the affected age category are faced with significantly reduced incomes and increased insecurity.

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The fact that social security benefits are not accessible until age 62 means that the gap in income for some is even more pronounced. Many of these persons still have mortgage payments, children in school and/or University and other obligations which even gratuity payment and pensions may not be able to offset. Persons who may not have been well prepared for this eventuality face notable financial and psychological pressures to cope. Asset preservation and reintegrating older persons into economic activity and actively contributing to the process of economic development as long as they are able and willing to require innovative and pragmatic solutions which focus on areas such as re-training, entrepreneurship development and access to credit.

2.3. Social, Economic and Political Situation

2.3.1 Social Risks and Vulnerability

Money, food, health care and medication, adequate housing with amenities, respect, companionship and independence are among the major concerns of older persons (Kairi, 2007/2008). Further, the 2007/2008 CPA Report indicated that the elderly participated in a number of social activities in the Federation; however, the participation of men remains low. Alcoholism proved to be a crutch for many older men in society and for many their downtime involved spending time with their drinking buddies. The high cost and uncomfortable mode of transportation to and from activities lends a level of difficulty which inhibits seniors’ ability to participate in social and recreational activity.

There is recognition that apart from being a burden to caregivers and members of their household, older persons contribute to the wellbeing of the family by making financial contributions as well as helping with housework and care for other members of the family. Approximately 75% (Kairi, 2007/2008) of the seniors in St. Kitts and Nevis live in extended or multigenerational families. Evidence suggests further that older women especially widows and single women still have singular or shared responsibility for their families and have significant care duties for young members of the family, housework and paid work.

As noted in the 2009 Social Safety Net Assessment (SSNA) report the disease burden in the Federation is growing. The impact of chronic diseases is widely felt as lifestyle diseases become entrenched. A significant proportion of the aged suffer from chronic non-communicable diseases such as hypertension and diabetes which may have an impact on their quality of life as these illnesses tend to lead to reduced mobility and sometimes to disability. Modern assistive devices are not as common as they should be.

Feelings of increased personal insecurity continue to mar the lives of the entire population as crime and criminality increase. Violence and gang wars occur with sickening regularity tearing at the very fabric of society. In particular, the elderly are concerned about their communities and about the behaviour of the youth (Kairi, 2007/2008). There is a noticeable lack of respect for older persons especially among the youth.

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2.3.2 Economic Vulnerability

St. Kitts and Nevis is a small, vulnerable open economy which has been buffeted like others by the increasingly unpredictable and volatile economic tides in the global arena. Internationally, a combination of events has retarded the recovery of the global economy from the recession and financial crisis. Factors such as the impact of the tsunami on trade, worsening financial situation of the Euro States, instability in oil producing states and fiscal and financial deterioration of the position of the USA along with other factors have added a degree of complexity to the development challenges of small states such as St. Kitts and Nevis as have never been witnessed before.

Regionally, activities within the region and sub-region have remained subdued and recovery lags behind that of Latin America. Despite, these difficulties and restrained outlook efforts are still afoot to consolidate the position of the small states in the Region. Recently, OECS States completed the move to allow free movement within a single economic space thus providing some incentive for increased mobility of capital, goods, services and labour around the region.

On the national front growth contract by about 2.2% and inflation grew to 8.2% in 2010. Official explanation for this increase in inflation points to the pass through effect of the imposition of the Value Added Tax (VAT) and increased utility prices (GOVSKN, 2011). The country’s debt to GDP ratio remain high and has implications for the amount of funds allocated to the social sector. Over the last few years budgetary allocations have remained relatively fixed with only marginal increases to sectors such as health and education.

2.3.3 Political Vulnerability

St. Kitts and Nevis is a relatively new democracy having just attained 28 years of Independence. There is a stable government system through which essential social services are provided especially to the most vulnerable. There is recognition of the need to take a coordinated and measured approach to addressing the needs of the most vulnerable and to improve risk management mechanisms.

A Draft policy on ageing was completed for St. Kitts and Nevis in 2009 and has been used as a blue print for other Caribbean territories. It is geared towards creating a society for all ages by 2020. The Policy has been presented as a Green Paper to Cabinet and is in the final review stage by the entire society. A draft Regulation for the Care of the Aged was also developed through the Ministry of Sustainable Development to regulate operations of state and private entities in that sphere. This however was done over six (6) years ago and was not passed on to Cabinet.

In 2011 a Country Poverty Reduction Strategy was detailed and finalized and aims to improve the plight of the most vulnerable in society and to solidify the resilience of the population in the face of future crises. The National Poverty Reduction Strategy is to be

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launched in the first half of 2012. Lastly a National Health Plan which is cognizant of the interrelationship between ageing and healthful living was drafted and enacted in 2008 covering the period up to 2013. St. Kitts and Nevis has made significant investment in healthcare to ensure that pivotal national health priorities are identified and vigorously pursued.

2.3.4 Vulnerability to Natural and other Disasters

Many older persons are particularly vulnerable during a disaster because of their reduced mobility and sometimes unwillingness to be relocated as well as lack of proper planning by disaster managers. Disasters can potentially deepen the level of deprivation within communities and worsen the plight of the most vulnerable. Timely and effective risk reduction and management is essential to safeguard the wellbeing and strengthen the resilience of communities, families and individuals.

The National Emergency Management Agency (NEMA) has decentralized its planning and response mechanisms to the community level. This allows for those individuals familiar with the community to participate in the management of disaster and to allow for the identification of major risks within the community, and marshaling of some resources ahead of time. This micro level approach to planning redounds in the favour of community members especially older persons as it facilitates the sharing of information. It also allows older persons and first responders to become familiar with each other as special attention is paid to the safety of older more vulnerable individuals in the community who may require assistance prior to, during or after an event.

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3.0 REVIEW AND APPRAISAL OF NATIONAL ACTIONS TO FU LFIL COMMITMENTS TO the BRASILIA DECLARATION 2007 – 2011

3.1 Economic Security

3.1.1 Access to Decent Work in Old Age As underscored by the Brasilia Declaration and organizations such as HelpAge International, access to decent work represents a fundamental human right which promotes development and alleviates poverty. Older persons however tend to be among those who are most vulnerable to working under untenable conditions or experience reduced opportunity for decent employment. For that matter, it is contended that many older persons due to poverty, low levels of education, age discrimination, low levels of earnings over a lifetime and poor health can ill afford to be choosy about the conditions under which they work.

3.1.1.1 Work Areas

Legislative

The Labour Act and the Protection of Employment Act 1986 along with the Country’s Decent Work Programme form the basis of employee protection and collective bargaining. (GOSKN, 2011) Currently there is minimum wage legislation in the Federation. The minimum wage was raised from EC$250.00 weekly to EC$320.00 per week in November of 2008. Stringent monitoring of practices in this area must continue to ensure that employers do not circumvent requirements. The Protection of Employment Act of 1986 acts as a safeguard for workers in the areas of job termination, severance payment and maternity benefits. In particular, severance pay becomes very important given the climate of closure hanging over some businesses especially in the Manufacturing sector.

Administrative

With the ongoing recession and downturn in the economy, older workers have been at the front line of the battle as they are retrenched and forced into early retirement. As noted in an earlier section of this report, with the restructuring of the fiscal and financial space in St. Kitts and Nevis the GOSKN has been fully enforcing the rule of retirement at age 55 as a cost cutting measure and to create opportunity for younger workers. Being the largest employer this decision has been impactful. This measure however is purported to be of a temporary nature. It has been noted that the new Public Service Act which is being prepared has as one of its goals to increase the retirement age. The 7 year gap between the Civil Service Pension Age and the Social Security Pension Age has been identified in the Policy on Ageing and last Actuary report for the Social Security

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Board as being too wide and could possibly lead to hardship for pensioners. Consideration is being given to raising it closer to or on par with the current Social Security Pension Age of 62 years.

Programmatic

St. Kitts and Nevis is party to the Decent Work Initiative put forward by the ILO in 2006. There are four pillars to the Decent Work Programme of St. Kitts and Nevis namely, employment, social protection, rights at the work place and dialogue. It has been purported that major aspects of the programme include policies, pensions, institutional strengthening, legislation and insurance. The aim is to make decent work a national goal as the country seeks to ensure that in the future there is employment and social protection for all. On a whole, the following three strategic objectives of the ILO Decent Work programme provides an opportunity for policy makers and for older persons themselves to ensure that maximum benefit is derived as various aspects of this agreement are developed and implemented on the national front.

- Promoting and realizing standards and fundamental principles and rights at work, - Creating greater opportunities for women and men to secure decent employment and

incomes, - Enhancing the coverage and effectiveness of social protection for all,

As a first step there was a conference in 2009 to sensitize the public about the conditions of work in the Federation. In 2010 a programming workshop on the Development of a Decent Work Country Programme for the Federation was completed. At that tripartite sitting St. Kitts and Nevis identified the development of a Labour Code as a key legislative action and this process has been initiated. St. Kitts and Nevis was able to establish a Job Assistance Programme with the help of the United States Labour Department in 2004. This is still operational and allows employers to list available jobs on a website established for this purpose. Job seekers are encouraged to register with the Labour Department who helps to match suitable candidates with available jobs.

Institutional

Many older persons work in the informal sector as hucksters, “turn hands” (especially older women), casual labourers, farmers for example and may not have access to benefits. Organizations such as the Development Bank and the Foundation for National Development have strengthened their commitment to small businesses by increasing the level of financial and technical support they provide. The Development Bank has also funded training for persons in technical areas they have also assisted fishers and farmers. Cognizant of the fact that the aged still find it hard to access funding it is still likely that older persons would have benefited from some of these measures. The Labour Department is in the process of implementing a Labour Market Information System (LMIS) aimed at improving the quality of data available to manage critical areas in the economy. As emphasized by the OECS Secretariat the Monitoring of employment shifts,

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unemployment, occupational wages and labour costs as well as mobilizing and developing human resources becomes critical as the Federation strives to meet specific challenges of a globalized world and confront rapid destabilizing changes.

3.1.2 Coverage of Social Security System (Contributory and Non-contributory)

For close to 35 years the Social Security System in St. Kitts and Nevis has provided protection for the aged and some level of security for members of younger generations. Evolving from a Provident Fund which ran for 10 years until 1977 it provides contributory and non-contributory benefits to older persons.

3.1.2.1 Work Areas

Legislative

The Social Security Act was amended a number of times to broaden coverage of excluded groups. In particular the Social Assistance Act of 1998 makes provisions for financial assistance to the indigent. This is paid through the Social Security Scheme. In 2005 the Social Security Board increased pensions so as to ensure that the real value of pensions was maintained.

The Social Security (Relief of SSMC Pensioners) Act 2005 provides relief for pensioners under the St. Kitts Sugar Manufacturing Corporation Pension Scheme which effectively closed following the closure of the sugar industry. This provides coverage for these persons under the Social Security Scheme.

Administrative

A recent pillar of the Social Security Scheme is the Self-Employed category. This allows for the self-employed to be covered for old age pension, cash sickness benefit and maternity benefit. The self-employed are expected to pay 10% of his or her weekly or monthly income on incomes of between E$200.00 to EC$1,500.00.

Programmatic

Older persons in the Federation receive a number of benefits through the Social Security Scheme, mainly in the form of Old Age pensions, old age grants and Old age Social assistance (Means tested). The Minimum monthly pension is EC$300.00 and the maximum is 60% of monthly income or EC$3,900 whichever is less. Old age social assistance amounts to EC$210.00 per month. There is also a funeral grant of EC$2,500 for the insured regardless of age. The SSNA Report noted however that pensions and assistance pension payments remain way below the national poverty line for many persons. Helping the aged to get a decent pension is essential.

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A SSNA completed in 2009 indicated however that on a whole old age pension payments amount to just about 37% of the poverty line while assistance payments stand at approximately 6% of the poverty line (Blank, 2009). Although there has been a decline in the number of persons presenting for old age social assistance there is still only about 49% of population 65 years and older who are covered by social security benefits. This underscores the heightened level of income insecurity which seniors face especially as intra-familial transfers and remittances which elders may have depended upon to make up shortfalls have come under pressure due to the prolonged economic downturn and recession.

Institutional

The last Actuary Report has highlighted the need to protect the fecundity of the fund. Reports indicate that the strength of the fund will be in danger of becoming severely depleted by 2035 if corrective measures are not instituted. Currently persons are eligible to receive old age pensions from the age of 62 years however given that life expectancy in the Twin Island state stands at about 72 years of age it is anticipated that this gap will place undue pressure on the fund as people draw from the fund for a longer period. Ensuring the sustainability of the fund has required that the Social Security Board launch a social security reform process. There has been ongoing dialogue since 2009 on the best way forward for the scheme. Along with feedback from the public recommendations of the 9th Actuary report will fuel the reform process. Consideration is being given to increasing the age of eligibility to receive old age benefits.

3.2 Health

3.2.1 Care of older persons with disabilities

The World Health Organization contends that the number of the disabled is on the increase due to factors such as aging populations, increases in the prevalence of chronic diseases among the elderly, as well as growing numbers of injuries caused by violence, vehicular accidents and work place related incidents. It is generally estimated that more than 10% of a population is likely to experience some level of disability. The disabled are among the most vulnerable sub-population to poverty, discrimination and other hardships and sometimes finds it difficult to access key social services and assistance.

3.2.1.1 Work Areas

Legislative

The Government of St. Kitts and Nevis is not yet a signatory of the UN Convention on the Rights of Persons with Disabilities but is assessing the implications of doing so. The Building Code acknowledges the need for the disabled to have access to services but regulation is not strictly upheld in this area.

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Mental health is seen as an emergent issue and is receiving growing attention. A draft Mental Health Act was drafted in 2007 to replace the act of 1956.

Programmatic

Integrating disabled persons into mainstream life is the main preoccupation of the St. Kitts and Nevis Association of People with Disabilities (SKNAPD) and the St. Kitts and Nevis Association for the blind and visually impaired. The month of May has been celebrated for the last 4 years as the month of the disabled with a view of raising the profile of the disabled in the society. In addition skills-training also forms part of the arsenal of these two bodies as they seek to equip their membership with the necessary skills whereby they can become financially independent. Special Education Units on both St. Kitts and Nevis cater to the unique educational needs of children and young persons with disabilities. An NGO called Ade's Place which was established in 2005 has the mandate for providing special training for older persons with disabilities in an effort to promote independent living and to provide a place for these adults and otherwise shut-ins to participate in daily activities at the centre. The aim is to help the disabled to function in the wider society. Placements are found for those who are able to work independently while an in-house programme has been developed to help empower those who require close supervision and care. The GOSKN and other agencies provide financial support to this agency. There is scope to strengthen and enhance this programme as the GOSKN continues to seek to ensure “Education for all”. Care and support is provided for persons with disabilities and mental issues through the Ministry of Health. The nation’s strategic health plan pledges to pay increased attention to “geriatric care and the physically disabled”, chronic disease management and mental health and substance abuse. While the Ministry of Health tries to assist the disabled in being more independently mobile, it is recognized that modern assistive devices are expensive and are not as common as one would expect. The Mental Health Policy has been drafted and is being reviewed. A Mental Health and Substance Abuse Plan (2008-2012) were developed in 2007. As the plan specifically focused on children and adolescents, it does not address the peculiar needs of the aged, especially older women, who tend to be more prone to emotional and mental dissonance as they grow older. Chronic non-communicable diseases such as cancer, diabetes, heart and lung diseases impose enormous costs to populations and economies and increase the likelihood of an affected person developing a disability or impairment. For example, research show that diabetes causes morbidity and complications and it leads to blindness and amputations which can alter an individual’s life forever (CARICOM, 2011). PANAM STEPS data collected in 2008 show a 35% hypertensive rate for St. Kitts and Nevis with its prevalence increasing in advancing age. It was revealed further that the average Kittitian or Nevisian was 90% likely to develop hypertension over the lifetime (CARICOM, 2011).

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In 2011, world leaders pronounced the impact of chronic non-communicable diseases as a challenge of epidemic proportions. The resolve then was to implement measures to improve efficiencies in the monitoring of the disease, reduction of the risk factors and to strengthen health systems so as to effectively address the problems posed by chronic non-communicable diseases. St. Kitts and Nevis is party to a resolution establishing a Regional Strategy and Plan of Action for an integrated approach to the prevention and control of chronic diseases.

This focuses on diet, physical activity and health. The Federation is also a signatory of the2007 Port of Spain Declaration titled “Uniting to Stop the Epidemic of Chronic NCDs”. The 2011global declaration signed recently at the UN Heads meeting allowed countries like St. Kitts and Nevis in the Caribbean that had already started tackling the problem to unite with global partners in the fight against chronic diseases. Persons 62 years and older in St. Kitts and Nevis are also eligible to see the doctor, receive dental and eye care in the health system

without attracting a fee. Fee waivers are also issued to indigent older persons for other levels of care upon request. All persons suffering from a chronic communicable or non- communicable illness are eligible to access care from community health centres as well access medication from the public pharmacies.

Institutional

A focal point for Non communicable Diseases (NCDs) has been established in the Health Promotion Unit of the Ministry of Health to coordinate activities aimed at this specific challenge. Moreover as noted before, free care and medications are available through the community health system for all persons suffering with chronic diseases (communicable and non-communicable). Member Governments of CARICOM have been asked to budget up to USD$22, 000 for the promotion and implementation of Caribbean Wellness Day. Caribbean Wellness Day is celebrated every year in St. Kitts and Nevis on the second weekend in September and various agencies organize activities on this day. Overall expenditure on mental Health related services represented just about 1% of the nation’s outlay (WHO, 2009). A 2009 Report on Mental Health Systems in St. Kitts and Nevis indicated that the civil servant insurance covers all mental health disorders but noted however that there is no overage for the general population under any established scheme. Three health centres provide out-patient care for persons with mental disorders, however, there are no homes for mentally-ill persons although a few may be accommodated at the

Photo 1: CARICOM Leaders Walk before Meeting - Modeling one Healthy

Lifestyle Alternative - July 2011 (Source SKNVIBES.com)

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Cardin home, the national home for the aged on St. Kitts or in special cells at the Her Majesty Prison (WHO, 2009). The Government of St. Kitts and Nevis is committed to raising the standard of care offered in the Health Service. As such, the main Hospital on St. Kitts is undergoing an accreditation process. For starters one outcome is to be the Patient Charter which will document a shared understanding about the health system between those who use the system, health providers and the government.

3.2.2 Equitable access to health services. There are no barriers to health care in the Federation. The Ministry of Health’s open access policy guarantees access to those who need. There is a network of seventeen health centres across the twin island state located not more than 3 miles from each home, with eleven centres on St. Kitts and six on Nevis. Services delivered at these centres are free to all. There are four hospitals in the Federation, one large hospital in Nevis and two large and one small hospital on St. Kitts. The second largest hospital on St. Kitts was recently upgraded and now offers expanded medical services.

3.2.2.1 Work Areas

Administrative

Rising health care costs is emerging as a nagging challenge for the Ministry of Health as the health system becomes overburdened and the cost of inputs escalate. Serious consideration is being given to implementing a National Health Insurance System which would allow the productive segment of the population to contribute. In particular, the poor are very reliant on the public health services and very few persons have private insurance coverage. There is some effort to ensure that citizens have access to tertiary health care and where such services are not available, care is sought overseas with the GOSKN assisting where it can do so as well as partnering with counterparts such as Cuba to provide such services. The issue of funding health care remains a challenge and cultivating key partnerships has become necessary in an effort to continue to improve the health system and to maintain a certain level of care to the populace.

Programmatic

At the level of community health there is vibrant diabetic education programme conducted at health centres. The Diabetics Associations are not as active as they should be and as such, are absent from many communities. For the most part it is older persons in the community who attend these sessions at the health centres or participate in the associations. This highlights the need to promote healthy living throughout the life cycle as this in turn leads to more successful and healthful ageing. Older persons especially those over 70 years of age have unique dietary needs. Nutrient dense foods are essential for older persons who wish to maintain optimal health. Limited mobility

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and disability, low levels of income and access to other resources and lack of care and support may predispose some older persons to become nutritionally deficient or experience hunger. The GOSKN of St. Kitts and Nevis along with civil society entities seek to ensure that vulnerable older persons eat healthily and are fed on a regular basis. The Meals on Wheels Programme in Nevis provides meals on a continual basis for the most vulnerable seniors on Nevis several times per week. Meals however are not provided on a daily basis. The St. Christopher Outreach Centre on St. Kitts operated by the St. Kitts Evangelical Association provides meals to elderly, shut-in, disabled and homeless persons. Meals are either taken at the centre or are distributed by various church groups

3.2.3 Monitoring of long-stay institutions

3.2.3.1 Work Areas

Legislative

There are no regulations in place to monitor the operations of long-stay institutions providing care for the aged and infirmed. Draft Standards and Regulations for Care homes were developed and submitted to Cabinet just over six years ago. Not much progress has been made in enacting these rules. The Cardin Home is subject to standards enforced at the Joseph N France Hospital since it falls under its mandate. The number of care homes is growing steadily with not much in place to guide their operations. The draft standards and regulations may require some revision and need to be submitted again to cabinet for enactment and them implementation.

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3.2.4 Creation of palliative care services.

3.2. Work Areas

Legislative

Draft standards and regulations for care homes for the aged have been developed; however these require revision and enactment at the highest level.

Institutional

Caring for older persons requires specialized skills and facilities. A total of three public care facilities are operated by the state. While those on St. Kitts are free, the care home on Nevis is fee for service basis. There are also a number of privately operated care homes for older persons a number of privately established care home for the aged reflecting the growing demand for such services by older persons and their families (PAHO, 2008). There is growing evidence that the state run facilities are running at full or nearly full capacity as citizens live longer. As a result, a number of persons who may require care have not been able to access such care. Privately run care homes continue to be out of the reach of older persons in St. Kitts and Nevis. Undeniably the case can be made for the establishment of a modern care facility for older persons which will offer more places and modern upgraded services for elderly who need specialized care. The belief that quality care matters, underpins policies and regulations aimed at establishing standards of care to be offered to fragile older persons being

Supporting a Culture of Family Care

The Home Care Programme for the Aged was

initiated by the Ministry of Social Services and

Community Development in GOSKN in St. Kitts

in 2001. The programme commenced later in

2009 on Nevis. Overall, this initiative was aimed

at providing some care and support to older

persons in their homes in support of the policy

of ageing in place. It marked the first formalized

approach to home based care for the aged and

has provided some level of support to family

members who were tasked with taking care of

their loved ones.

It is funded mainly by revenue from the GOSKN

although other local and international agencies

often provide technical support, training and

equipment to the home care officers. The

service is provided free of cost to the aged and

their families.

A total of 18 officers are employed in St. Kitts

and 12 in Nevis. More than 352 older persons

benefit under the programme. Visitation,

personal hygiene assistance, light house

cleaning, devotions, light errands, preparation

of meals, washing of wares, reporting of cases

of suspected ill health, neglect and abuse,

malnutrition, change in mood, behaviour, etc.

form the main focus of the programme.

Home Care Officers receive training on an

ongoing basis and now also provide some

measure of health checks such as blood

pressure levels and blood sugar levels.

The majority of communities covered are in the

rural area. The Home Care Programme operates

on a referral system. There is general

satisfaction with the programme. However,

there is recognition of the need to tighten

oversight and strengthen targeting, monitoring

and evaluation as well as expand coverage

especially on Nevis.

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cared for outside their homes. Older persons are particularly vulnerable, thus it is incumbent on the state to ensure that they live with dignity, integrity, independence and free from abuse, neglect, and exploitation, especially when they are outside of their family care circle. Most of these establishments have a team of care professionals who develop individual care plans for their patients and provide some level of palliative care which helps to improve the overall quality of life of patients and their families. There is a cadre of health professionals who care for the aged at the community level including health professionals at the community health centres. Currently, while there is general expertise in care delivery for the aged there are no specialists in geriatric medicine or podiatry or other key areas related to older persons and care. Conditions such as Alzheimer’s are still little understood ailments and many older persons are miss-diagnosed.

Programmatic

The Home Health Care Programme on both islands has been developed to provide added care and support for the aged and shut-ins. Training is provided on an ongoing basis as home care officers are equipped to better care for those in their care. In 2009, each home care officer was equipped with equipment such as a glucometer, test strips, thermometers, blood pressure cuffs and a stethoscope, and provided with the technical knowledge so that they could adequately assist these patients. Although this programme has been in operation for the past ten years, there is still scope for its expansion and increased coverage. An essential ingredient r is consistent monitoring and evaluation of the services provided so as to maintain an acceptable level of care. Despite the existence of care facilities and the Home Health Care Programme, care of the aged still resides for the most part within the realms of the family and wherever possible care duties are shared around family members (Dysart-Gale, 2007). Ageing in place is a key tenet of the policy on ageing reflecting this salient value of the society. Given that family members and other caregivers care for their loved ones for a large measure of time there is scope for offering training in care methods for these individuals. Moreover, addressing issues of care require bridging the gap between ideological values in the professional and the cultural realms in treating with areas such as placement of loved ones in care homes and defining what constitutes respite care for family caregivers. Faith Based Organizations and Churches play an important role in helping older persons to cope with debilitating aspects of ageing. Many churches or faith based organizations offer care and support for older persons in at the community level by providing home assistance, feeding programmes, prayer and visitation. This helps to meet the social, physical, emotional and spiritual need of older persons and helps them to feel connected to their communities and organizations within those communities.

3.2.5 Access to health care for older persons with HIV.

3.2.5.1 Work Areas

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Administrative

A Human Rights Desk has been established to address issues of discrimination and to encourage PLHIVs to be more open about their status so as to help facilitate better planning for their needs. This measure is not being utilized as it should as there is some fear regarding confidentiality.

Programmatic

Persons infected and affected by HIV/AIDS require home-based, psychosocial and nutritional care (NACHA, 2011). One of the main aims of the Ministry of health and the National HIV/AIDs Secretariat is to provide universal care for person infected and affected by HIV/AIDS. Anti-retroviral therapy is available to patients free of charge and a clinical care coordinator for HIV/AIDS has been in place for a number of years. However, first and second line drugs are more readily available than third line drugs as the cost of the drugs increases dramatically as persons further in their illness. In 2009 there were approximately 40 persons receiving Antiretroviral (ARV) treatment. Given that men over 50 are among the categories of the population with the highest prevalence it would follow that these older men are able to receive adequate care and treatment once they access that care. Special Outreach programmes are carried out to increase the number of men tested – Special Father’s Day Voluntary counseling and testing VCT, Informational Sessions and VCT at Men’s health clinic especially on Nevis. Health centres provide VCT services and many Community nurses have been trained to be counselors. Persons are still slow to access this programme as there are perceived problems on the part of members of the society as it relates to confidentiality. There are also community testing days where community members are encouraged to know their HIV/AIDS status. An annual HIV/AIDS march and rally is executed each year where awareness is raised and information is shared with the public. For the most part, home-based care has not been shown to be required on a large scale as most often those who require such care are hospitalized. It was noted in the UNGASS 2010 Country Report that the availability of psychosocial care and support for the infected and affected may not be readily accessed by those who need it because of stigma and discrimination attached to the disease. A Nutrition Assistance Programme was launched in 2009 by the Ministry of Health to assist PLHIVs/AIDS meet their nutritional needs. By 2011 20 persons were receiving groceries on a monthly basis, 16 on St. Kitts and 4 on Nevis. Initially funded by the World Bank and the Global fund there is now some uncertainty whether this assistance will be able to continue beyond February 2012.

Photo 2: St. Kitts AIDS Secretariat March for World AIDS

Day (Source: UNGASS 2010 Country Report

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There is a National HIV/AIDS Prevention and Control programme aimed at supporting the recommendations enshrined in the St. Kitts and Nevis HIV/AIDS Strategic Plan 2010-2013. The dual aim of the plan is to reduce the spread of HIV infections and to reduce the impact of the disease on individuals, families, communities and the society as a whole. Care, treatment and support encapsulate one of the five strategies aimed at achieving these National goals (NACHA, 2009).

Institutional

A supportive group called Facilitating Access to Confidential Testing, Treatment and Support (FACTTS) was formed in 1999 and has been expanding the scope of support it offers to PLHIV/AIDs. In 2008 and 2009 FACTTS was involved in peer counseling, human rights advocacy, and coordination of the Nutrition Assistance Programme. While the NACU is more established in St. Kitts the Nevis NAS is being strengthened so as to ensure that effective services and support are provided on that island. Research has become critical as the NAS and NACU seek to better identify those who require care and support and fine tune their policies and programmes. Stigma and Discrimination associated with the disease and the lifestyles of some of the more vulnerable groups make this particular difficult. Partnering with civil society groups who have connections with target population has become an invaluable tool in the fight against the disease. The Caribbean HIV/AIDs Alliance is one such key organization which facilitates research on hard to reach segments of the vulnerable population.

3.3 Environment

3.3.1 Promotion of continuing education.

Current models of concentrating education efforts on those under age 25 neglect to take into consideration the transitions societies are undergoing. As persons are forced to make adjustments later in life it is argued that lifelong learning will become a key pillar of any development strategy (McNair, 2009). Such a focus is particularly valuable in a society whose life expectancy is on the increase and as a larger proportion of the population becomes eligible to receive pensions It is recognized further that with the volatility of the economy, the need for continuous learning becomes a requisite as some older persons may need to sharpen their skills so that they can continue to provide for their dependents and themselves or to keep their skills current even if they are volunteers.

3.3.1.1 Work Areas

Programmatic

On a whole, some effort has been exerted by the Federation to ensure education for all. An Adult and Continuing Education Unit was established at the College of Further Education and is geared towards addressing the needs of the proportion of the population 40 years and

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over who have not benefited from a strengthened education system. Recently there have been efforts to decentralize training to the community level so that the training could be more accessible to more persons. The closure of the Sugar Industry in 2005 heralded the later transformation of the National Youth Skills Programme into the National Skills Training Programme (NSTP) which broadens the mandate of that organization to target older persons with specific training programmes. Ex-sugar workers benefited from some of the training. As the region considers free movement of labour, it allows for skilled artisans to upgrade their qualifications or gain some level of certification.

Administrative

The Federation has had universal primary and secondary education for over 40 years. The Education Policy and Plan for the current period is focused on improving the quality of education as well as increasing the competitiveness of workers, thereby equipping them to effectively compete in a world marked by uncertainty, rapid change and hyper-globalization. There is recognition that a better educated young person is likely to enjoy a better quality of life in later on in the lifecycle.

Programmatic

In Nevis a Retired Professionals and Skills Corp was established so as to ensure that older persons remain productively engaged. Exhibitions are held to display and sell items produced. There are no retired persons associations in St. Kitts. Golden Age Clubs operate in St. Kitts however many communities remain without activities for older persons. Activities for older persons are more centralized in Nevis as they tend to meet in one location.

Photo 3: Craft Produced by Seniors in the Federation

3.3.2 Accessibility of public spaces and adaptation of housing. Many older persons are vulnerable and at risk of social exclusion. Planning processes must take on board the special needs of older persons. Impediments to pedestrians should be removed. Work Areas Programmatic

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A project to create ramps on sidewalks in Basseterre that would facilitate the mobility of older persons as well as the disabled was carried out by the BNTF. It is also advised that poor-quality pavements, inadequate street lighting, noise and pollution, threats to safety and inconsiderate behaviour towards the aged should be addressed. If these persons did not feel comfortable or safe, it is likely that they would curtail their activities and this could lead to them becoming further isolated. Access to trouble free and low cost transportation facilitates the independence of older persons. Transportation costs emerged as a barrier to older persons’ participation in certain activities in the 2001 Country Poverty Assessment. There is no public bus system nor is there a specific bus in the Ministry of Social Services which is dedicated to transporting the aged. The lack of a public bus system makes it difficult to implement cost reduction or removal for older persons. There has long been a recognized need for a mode of transportation for the aged and disabled so as to enhance their mobility, independence and integration into social life. The Ministry of Social Services provides assistance to older persons to repair their homes and to adapt houses to their needs. As housing conditions improve the quality of life of individuals also improves. The Government has a low and middle income housing programme through which older persons have been able to benefit. Administrative The current Building Code acknowledges the commitment of the GOSKN to construct buildings that are accessible to all. This, however, is not fully enforced. Some existing businesses have constructed ramps leading to their premises to facilitate the disabled and elderly who find it difficult to negotiate steps. A few government buildings such as the Government Headquarters have been fitted with ramps and elevators which can accommodate wheelchairs. Handrails have also been installed along steps leading to some health centres.

3.3.3 Elimination of discrimination and violence in old age. The GOSKN guarantees its citizens the right to equality and non-discrimination through its constitution. Although age is not specifically singled out the spirit of the law prohibits the practice of discrimination against any person.

3.3.3.1 Work Areas

Legislative

There are no specific regulations which speak specifically to protecting the aged from abuse or exploitation. However the laws of the land offer some level of general coverage for the entire citizenry and offers protection from criminal acts.

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Programmatic

St. Kitts and Nevis has ratified the Declaration on the Elimination of Discrimination against women as well as the Declaration on the elimination of Violence Against women. A Multi-sectoral National Action Plan on Sexual and gender-based violence, which is aimed at improving coordination and response to sexual and gender-based violence, was crafted for the Federation in 2010... The recently drafted National Policy on Ageing has outlined various safeguards and areas to deal with elder abuse along with other critical areas pertaining to the wellbeing of older persons. Enactment of this policy will go a long way help safe guard the welfare of older persons. Regulations which will make the commitments of the policy assume legal weight and breadth are yet to be developed and submitted to Cabinet.

Institutional

A Senior Citizens Division was established on Nevis recently within the Department of Social Services to coordinate activities for the seniors and to advocate on their behalf. A similar office has not yet been established in St. Kitts. Currently, the Supervisor of Social Assistance in the corresponding Ministry in St. Kitts over sees the coordination of activities for the elderly along with other duties. There is no civil society group which actively advocates on behalf of the aged.

3.3.4 Recognition of the contribution of older persons in the care economy

The contribution of older persons in the provision of social care often goes unrecognized. However, there is no doubt that older persons especially older women, play a significant role in the care economy either through the care of dependents, spouses or through voluntary work in their communities.

3.3.4 Work Areas

Programmatic

The International Day for Older Persons is celebrated in St. Kitts and Nevis each year in October in recognition of the contribution of older persons to the society. In fact activities are held over the entire month of October. Birthday celebrations for elderly persons are held throughout the year by the Ministry of Social Services and Community Development and special attention is paid to centenarians and other “older” older persons. An annual march and rally is held in both St. Kitts and Nevis to raise the profile of older persons.

Care and support for caregivers is very important if they are to continue to provide quality care to their charges. The provision of affordable day care services outside the home helps to alleviate the burden of care for younger members of the family often placed on seniors. St. Kitts and Nevis has a well-established system of government-operated nurseries and day care

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centres that provide affordable care services for children. This has served to relieve the burden of care older persons face with respect to the care of children. The Adopt an Elderly initiative was recently launched in the Federation to encourage intergenerational sharing and to strengthen social support systems for older persons in the Twin Island state.

In addition addressing the living conditions of older persons and meeting their needs is fundamental to reducing poverty and improving the quality of life which the aged enjoy. This is true not only because of their right to an acceptable standard of living but also because of their broader contributions in terms of providing care to their dependents or the general upkeep of their households and communities. A National Poverty Reduction Strategy (NPRS) that speaks to the plight of vulnerable older persons and offers critical solutions to improving their plight has been developed. The Strategy which was developed under the ambit of the Ministry of Sustainable Development should be launched early in 2012.

4.0 Summary and the Way Forward

4.1 General Comments

GOSKN has made significant progress in addressing the human rights of older persons and improving their quality of life, thereby making noticeable inroads towards meeting their obligations under the Brasilia Declaration. There is obvious commitment to this end. There is a raft of actions geared towards older persons across the three main thematic areas of the Brasilia Declaration, namely economic security, health and environment. Arguably progress in the area of health is more marked than in others as the Federation boasts an excellent health care system which is geared towards eliminating barriers such as cost, ineffective health systems and under-developed human resources which could impede access to much needed care. The renewed focus on health promotion, halting and reversing the exposure to risk factors and impact of non-communicable chronic diseases provide some impetus to the provision of care for older person or for them to become actively engaged in health seeking behaviours.

There is a lag in ensuring economic security for older persons particularly as it relates to secure employment and the provision of decent pensions. Older persons who are disadvantaged due to poverty or low levels of qualification face greater risks of reduced incomes, unemployment and early retirement. Labour markets are undergoing noticeable transformations that heighten the level of insecurity for all and call for the productive segments of the population to be flexible and adaptable to meet these modern challenges. There are currently no specific programmes to facilitate older persons’ integration in the labour market. With the increase in longevity and the squeeze of the recession the Federation faces the prospect of a social security scheme that is under pressure. Having embarked on social security reform, the GOSKN is laying a more secure foundation for the future for its populace.

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Creating the right environment so that persons can survive and thrive in their old age requires steadfastness. St. Kitts and Nevis has made uneven progress in this area. Measures and policies in this area tend to be broad-based in nature and do not specifically address the needs and peculiarity of older members of the society. While there is potential for older persons to benefit, there is much scope to fine tune actions to cater to the situation of older persons and to ensure broader participation and maximum benefit. Enforcing the building code and removing barriers to the integration of older persons into society, such as those which affect their sense of security and mobility such as transportation costs will go a long way in opening up new horizons.

From a legislative perspective there is still much to be realized. Legislation which speaks directly to the plight of the aged is virtually non-existent. Commendably the GOSKN has been proactive in treating with the issue of an ageing population by developing a draft National Policy on Aging which has had its first introduction to Cabinet ahead of many of its Caribbean counterparts. Speedy adoption of the policy is of paramount importance if the GOSKN is to stay on track with its agenda to develop a society for all ages. Developing a strategic action plan to operationalize this regulation is also critical. While the Constitution and other legislation make provisions for the general population, they do not refer to age as a characteristic like sex, race, nationality that attracts non-discrimination. There is no legislation that deals with elder abuse. While draft regulations for care homes for the aged were developed, there is still a lot to be done in terms of the enactment and implementation.

For the most part older persons have access to a wide array of services especially in the area of health care. However, while there may be opportunities in other areas such as adult and continuing education there may be a lack of incentives for older persons to participate. Coverage of some programmes is still limited due to finances, limited human resources and scope of activities and has given rise to the problem of exclusion of some older persons from being able to benefit. Older persons are generally satisfied with the programmes that they are able to access. Some programmes such as the Home Care Programme as well as recreational programmes require strengthening. Nonetheless, there are still gaps that must be filled. The fiscal and financial imbalances of the GOSKN create unique challenges at a time when there is need for greater investment in social services in the Federation. The recalibration of the Social Safety Net and the drafting of the Social Protection Strategy, which are currently in process, will ensure that programmes are relevant, effective and efficient and that the needs of those who are most vulnerable in the society are met.

The public sector and civil society are both engaged in meeting the needs of the aged but there is scope for greater involvement and partnerships. Participation of older persons in advocating for their own good is low as there are no advocacy groups aside from assigned government seniors departments or focal points. There are also limited opportunities for older persons to work as volunteers. Whether this is from lack of opportunity or the will on the part of seniors to do so is unclear.

There is much scope for capacity building and institutional strengthening as it relates to institutional arrangements aimed at older persons. St. Kitts and Nevis has the beginnings of a

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strong institutional framework in support of work on ageing. The Department of Social Services and Community Development serves as the focal point on matters of ageing in St. Kitts. The Nevis Island Administration (NIA) however has taken it a step further and established a Senior Citizens Division within the Department of Community Service with a Director assigned. A national council on ageing has not yet been established to monitor and evaluate actions aimed at improving the quality of life of the aged.

The GOSKN is on the thresh hold of reaping enormous dividends as a result of the age-structural transformation that is taking place within its population. The greying of the population presents the country with significant opportunities. Additionally, as the population structure shifts from a largely young population to greater concentration of older persons, meeting the challenge of facilitating its graceful and successful transition into the third and fourth age becomes an imperative. Success in this would demand that the country increase employment opportunities, entrepreneurship development, develop human resource base as well as increased savings and investments (Hakkert, 2007). Opportunities to learn must be available to all segments of the population if they are to be globally competitive and flexible. Such actions will prevent the development of a population that could become a grave burden.

4.2 Strengths and Weaknesses

The GOSKN has already established a strong platform of social services aimed at the aged upon which a more diverse and expanded response to their unique requirements can be built. In drafting the policy on ageing the GOSKN has shown it commitment to providing a better quality of life for older persons. In reforming its social security scheme and recalibrating its social safety net will strengthen its ability to provide a more secure future for its population.

On the other hand, the weak policy and legislative environment which exists weakens the value which can be gained from having clearly articulated parameters for action and the delineation of roles and responsibilities. Bridging the gap from policy to action remains a challenge as the necessary institutional framework is still under construction.

4.3 Priorities for Future Action

• If action aimed at older people is to be pro-active, cohesive, comprehensive and effective the draft National Policy on Ageing must be enacted and Action Plans developed to guide implementation;

• Current draft Regulations for care homes for the aged must be reviewed, updated and enacted so as to create a facilitative and standardized system of care across care providers;

• Support must be lent to the Social Protection reform process; • Implement recommendations of the National Poverty Reduction Strategy (NPRS);

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• Strengthening of the environment within which seniors can have improved access to employment and income by aligning government retirement age to social security age of eligibility thus reducing forced early retirement,

• Review and upgrade social assistance and poor relief payments; • Improving and increasing opportunities for learning and supporting older

entrepreneurs; • Foster health seeking behaviours across the life span in general and specifically

among older persons;

• Strengthen the Home Care Programme by improving oversight and monitoring and evaluation as well as expanding coverage of the programme;

• Improve focus on discrimination and abuse of older persons and PLWHAs; • Encourage greater involvement and participation of civil society in issues related

to ageing; • Establish a Senior Citizens Division on St. Kitts to coordinate activities for the

aged; • Seize the golden demographic bonus by increasing employment opportunities,

improving the quality of human resources, and encouraging greater saving and investment by the young;

• Encourage the development of older persons associations and advocacy groups; • Older persons must be facilitated to advocate for their own welfare and actively

engage in decision making on matters which concern them; • Emphasis must also be placed on social and recreational activities for elders all

year round across communities;

• Improve access of older persons to services by reducing barriers such as transportation costs and accessibility to institutions;

• Expand coverage of the meals and wheels programme and improve frequency of distribution of meals;

• Strengthen the legislative framework within which issues of the aged are addressed e.g Elder abuse legislation;

• Improve palliative care offered to frail older persons by having more experts in specialized areas such as geriatrics and podiatry;

• Establish a National Council on Ageing.

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