In a show of commitment to the well-being of citizens, the government allocated TT$6.03bn ($894.4m) to the health sector in the FY 2018 budget, placing it in the top-three publicly funded areas of the economy behind education and national security. While this figure represents a decline from FY 2017, when the allocation was TT$6.25bn ($927m), health funding has risen since 2010. The sector’s allocation first crossed TT$5bn ($741.6m) in 2013 and $TT6bn ($889.9m) in 2016.
Recognising the importance of the health sector and funding it appropriately is a major step towards tending to the needs of the population; however, Trinidad and Tobago is up against the rise of certain ailments and lifestyle issues among its residents.
Threats to Health
Globally, non-communicable diseases (NCDs) are a significant cause of morbidity and mortality. The Ministry of Health (MoH) recognises that T&T has a relatively high occurrence of NCDs, accounting for more than 60% of deaths each year. Based on mortality figures from 2015, heart disease and diabetes are the top causes of death, with the former accounting for 25% of all deaths and the latter accounting for 14%. Cancer is responsible for 13% of all deaths, representing one of the highest rates in the Caribbean, while 10% of deaths are attributed to cerebrovascular disease. Additionally, the country has a high rate of diabetic complications, such as foot infections, which account for 14% of all hospital admissions.
The 2016 report “Economic Dimensions of Non-communicable Diseases in Trinidad and Tobago” by RTI International, a non-profit research institute, estimates that the economic burden attributable to hypertension, diabetes and cancer is TT$8.7bn ($1.3bn) annually – roughly 5% of GDP. The total economic cost of diabetes is around TT$3.5bn ($519.1m) per year, followed by hypertension at TT$3.2bn ($474.6m) and cancer at TT$2bn ($296.6m). These estimates include both the direct cost of health services and indirect costs, measured as the productivity loss of individuals being unable to work due to death or disability. Productivity loss makes up 90% of the overall annual cost for cancer, 66% for diabetes and 58% for hypertension.
While socio-economic factors, including poverty, can contribute to the rise of NCDs in a given country, four common risk factors with significant influence on the prevalence of NCDs have been identified by global health officials: unhealthy diet, physical inactivity, tobacco use and the harmful use of alcohol. Sustained prevention campaigns with respect to these risk factors can have a considerable effect both on the lives of residents and the economy. For example, if diabetes, hypertension and cancer rates drop by 50%, the economy would save nearly TT$3bn ($445bn) in productivity losses alone, according to the report by RTI International.
Behaviour & Lifestyles
The Caribbean Food and Nutrition Institute undertook a body mass index (BMI) study of T&T’s population in 2010, which revealed alarming trends in children aged five to 18. Some 11% of children in this age group were deemed overweight or obese in 1999, climbing to 23% in 2009. Obese children, specifically, increased from 2.4% of the total to 12.5%. These results, to which lack of physical activity and poor nutrition were named as contributing factors, also point to higher levels of adult obesity in the future if children do not lose the excess weight. The ministry has worked to counteract this trend by implementing a Fight the Fat campaign since 2011.
Terri Raney, the representative for T&T and Suriname at the UN Food and Agriculture Organisation, told OBG that despite being classified as a high-income developing country, T&T still has pockets of poverty and income inequality that is visible in food insecurity and poor diets. “A lot of progress has been made over the past 40 years in terms of ensuring minimum caloric intake is achieved, however, the food system needs to be shaped for more nutritional and healthy diets. People are now getting more than enough calories, but diets are unhealthy, which contributes to obesity and the high rates of NCDs,” she said. Raney added that improvements to the social safety net are needed to reach undernourished groups, and that wider access to affordable fresh fruits and vegetables is required.
Unhealthy habits extend beyond food, with the MoH noting that one-fifth of the population smokes tobacco products. A multi-year survey of school-aged children about tobacco use showed that the prevalence of students aged 13 to 15 who had ever smoked a cigarette fell from 38% in 2000 to 30% in 2011, which is a figure that could still do with addressing. Also in 2011, one-third of students in the same age range were defined as “current drinkers”, meaning they had an alcoholic drink in the month preceding the survey. Over 85% of the respondents had their first drink before the age of 14.
Tackling the Problem
Dr Anton Cumberbatch, associate at the Centre for Health Economics of the University of the West Indies (UWI), provided valuable insights into the realities of tackling local health issues during a discussion with OBG. “We cannot afford the technology and types of facilities that developed countries have as a solution to health problems, so we must concentrate on the things that are in our control to keep NCDs in check, such as prevention and early intervention,” he said. Advocating for a return to a more traditional Caribbean diet based on fresh fruits and vegetables, and starches, Dr Cumberbatch told OBG that the challenge is to make such nutritious foods readily available at a low cost to roll back the popularity of fast food.
In addition, Lawerence Jaisingh, director of research, policy and planning at the MoH, says the current approach of using laws and fiscal measures to dictate consumer behaviour may be falling out of favour. “Legislation and taxes will only get us so far with respect to deterring the consumption of sugar, alcohol and tobacco. Eventually substitutions come into play, so we must make it easier for people to make healthy choices in every facet of their lives. A multi-sectoral approach is required,” he told OBG.
National Strategy
After analysing the state of health in the country and identifying needs, the National Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2017-21 was launched by the MoH in May 2017. The strategy outlines efforts to tackle the four modifiable risk factors of NCDs, and calls to action key stakeholders, including the public and private sectors, non-governmental organisations and civil society. The plan further advocates for improving the well-being of vulnerable and underserved populations.
Previous initiatives to reduce alcohol and tobacco use, bring down childhood obesity rates, eliminate unhealthy diets and increase physical activity are revisited and built upon within the strategy. Such past efforts included legislation to increase public awareness of the dangers of smoking as per the Tobacco Control Act of 2009, installing exercise equipment in community parks and, most recently, the ban on soft drinks in schools introduced in 2017.
The strategy established the primary goal of reducing premature deaths – described as passing before the age of 70 – due to heart disease, diabetes, cancer and stroke by 25% by 2025. Supplementary aims were included to help achieve this goal, such as working towards a 20% reduction in the prevalence of high blood pressure, high cholesterol and high blood sugar among the population by 2021. In addition, overweight and obesity rate targets were set for adults, adolescents and children, with reductions of 10%, 12% and 15%, respectively.
“Risk factor reduction and health promotion” is listed as the top priority area to help achieve the overarching goal of the strategy, with set targets to increase fruit and vegetable consumption, lower salt intake, increase physical activity, and reduce alcohol and tobacco use. The second priority area, “Comprehensive and integrated care and management for NCDs”, includes targets to reduce the rate of heart attacks and stroke-related hospital admissions by 30%, and reduce diabetes-related lower-limb amputations by 20%. The third priority area is “Surveillance, monitoring and evaluation, and research”, while the fourth and final area is “Governance, policy and advocacy”.
The national strategy is being implemented in three phases, with phase two running from 2018 to 2020. In 2021 the plan will be evaluated and another strategy will be created for the period through to 2025. Funding for these efforts will be drawn from a $48.4m loan from the Inter-American Development Bank. To ensure continuity of the initiatives, an NCD unit with an appropriate governance structure is to be established. The unit will take up responsibility for NCDs once the strategy has been executed.
90-90-90: In addition to addressing the high rate of NCDs, T&T has committed to realising the World Health Organisation (WHO) goal to end the AIDS epidemic by 2030. Towards this end, the local target has been set to achieve “90-90-90” by 2020, whereby 90% of residents living with HIV know their status, 90% of these persons are on treatment and 90% of those on treatment have suppressed viral loads. Terrence Deyalsingh, minister of health, told local press in March 2018 that T&T had attained rates of 75-83-75 in 2016 – which is a significant improvement over the 2015 score of 60-50-40 – and that 2017 data was still being analysed. The Pan American Health Organisation report “Core Indicators: Health Situation in the Americas 2017” shows that T&T had an HIV diagnosis level of 51.5 per 100,000 persons in 2015. It is estimated that 1700 infected persons remain to be identified to attain the awareness score of 90%.
Rene Franklin, a public health consultant, says that alerting 90% of those with HIV can be challenging because many fear being tested and dealing with the stigma of the disease. “Persuading HIV-positive people to participate in the treatment programme and keeping them enrolled in the programme is a challenge,” Franklin told OBG. “Treatment is demanding on the body, and basic needs such as transportation and meals become an issue. Lower-income persons are particularly affected.”
The government has been able to access funding under the US programme President’s Emergency Plan for AIDS Relief, which has been used to implement various measures including an after-hours clinic to increase patients’ access to services, thus resulting in the return of over 500 people who had gone off treatment. The government accesses treatment drugs via a revolving fund with the WHO, and the drugs are then given to patients enrolled in treatment programmes free of charge.
Mental Health
There is increasing global recognition of mental health being as significant an issue as physical health. Highlighting the trends of violence perpetrated through school shootings in the US and familial abuse in T&T as examples, Dr Cumberbatch noted that these were expressions of mental health issues via extreme behaviour, stressing that such problems can manifest themselves along a spectrum of responses. Franklin agrees that global health care must direct more attention and resources to mental health, and focus on methods to reduce the stigma associated with getting help.
According to Jaisingh, the MoH is working to develop a draft policy on mental health, which once approved by the appropriate committee, will lead to an action plan for improving T&T’s mental health care. The ministry is examining how to decentralise the system and shift to a more community-based model of care, which would require capacity building among the various regional health authorities. It is expected that the plan will also address screening, registries and comprehensive training for those who work with persons suffering from mental health issues, such as police officers. Furthermore, several upgrades to St Ann’s Psychiatric Hospital in Port of Spain are scheduled for FY 2019.
Public Infrastructure
Indeed, hospitals and clinics are integral to ensuring the population is mentally and physically healthy. According to Jaisingh, the public hospitals under construction in Arima and Point Fortin were 41% and 45% complete, respectively, as of March 2018. The ministry has been able to save around TT$250m ($37.1m) on the cost of Arima hospital – without changing the infrastructural design or capacity of the 150-bed facility – by reviewing each line item with the state agency responsible for executing the project, the Urban Development Corporation of Trinidad and Tobago. Both hospitals are expected to come on-line in 2019. Staffing for these facilities has already been examined, with the 100-bed Point Fortin facility expected to generate 1000 jobs. Arima hospital is forecast to serve 150,000 citizens in the north-eastern district of Trinidad, while Point Fortin hospital will serve 100,000 citizens in the south-west.
Construction of the Couva Children’s Hospital, along with its Medical and Multi-Training Facility, was completed in May 2018. It is expected to have operational costs of TT$430m ($63.8m) per year once fully up and running, and will be jointly owned by the government and UWI. In the mid-year budget review, published the same month, InterHealth Canada was announced as the international operator of the facility. There is also ongoing discussion with the government of India to possibly conduct training in traditional Indian medicine at the facility. In addition to its role as a teaching hospital, the centre is expected to contribute to a broader economic vision of developing medical tourism in the country.
The Public Sector Investment Programme Trinidad 2018, published by the Ministry of Planning and Development in September 2017, provided details on how the TT$25m ($3.7m) allocation under the Hospital Refurbishment Programme was utilised in 2017. Works that year included the beginning of construction of a second operating room for the maternity department at the Port of Spain General Hospital. A new building to accommodate a pharmacy and the medical records department at Sangre Grande Hospital was also under construction.
An allocation of TT$45m ($6.7m) was laid out for 2018 to complete some 2017 projects and commence new works, such as the upgrade of the accident and emergency department at the Eric Williams Medical Sciences Complex in Champ Fleurs.
Private Sector
In the private sector, hospitals must pay annual operating fees to the government. The FY 2018 budget outlined increases to these fees, moving from a standard flat fee of TT$150 ($22.25) per year to a structure based on the number of beds in a given private hospital. Facilities classified as medical, surgical or maternity hospitals with less than 30 beds are now required to pay TT$25,000 ($3710), those with 30 to 59 beds are charged TT$50,000 ($7420) per year, and such hospitals with 60 or more beds pay TT$100,000 ($14,800). The new structure does not apply to facilities for the convalescent, chronically ill or elderly, nor to facilities designated for specified diseases, disorders or illnesses. These will all continue to pay the existing annual fee of TT$150 ($22.25).
Data from the MoH shows the bed count of 14 private hospitals that fall under the new fee structure, with six having less than 30 beds, seven in the range of 30 to 59 beds and one facility with over 60 beds. Given the fees outlined and the distribution of beds across these facilities, the state can expect to collect a total of TT$600,000 ($89,000) in licence fees on an annual basis from the private hospitals, which provide a total of 423 beds. For comparison, the state provides 2167 beds for overnight stays across its eight public hospitals and complexes.
Outlook
In formalising the approach to NCDs with a dedicated national strategy, the MoH has committed to promoting lifestyle changes that can result in an overall healthier population. However, most essential to this strategy is ensuring participation at the individual level. “We must encourage people to treat their individual health as a sacred resource and do what is required on a daily basis to protect it, rather than seek care when a health concern manifests; this is the mindset required for building individual health resilience,” Franklin told OBG.
T&T health officials are also honing their strategy to better equip the system to care for mentally ill patients and erase the stigma associated with certain disorders. Pursing a body-and-mind line of action should ultimately yield the desired outcomes.
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