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INTRODUCTIONThe National Strategic Plan for the Prevention andControl of Non Communicable Diseases (NSP NCD)outlines the strategic direction for the response to NonCommunicable Diseases (NCDs) in Trinidad and Tobago(TTO), and the strategic outcomes that partners fromgovernment, private sector, and civil society will beengaged to collaborate towards their achievement overthe period 2017-2021. This plan is in alignment withthe national development strategy of the Governmentof the Republic of Trinidad and Tobago (GORTT),which acknowledges that multiple factors and socialdeterminants combine together to affect the health ofindividuals and communities including inter alia, wherepeople live, work, play, the environment, genetics,income, education, and relationship with friendsand family . It utilises key approaches to populationhealth and development including primary health care,universal health coverage, standards of care, integratedmanagement, the Health in All Policies (HiAP), andmultisectoral approaches which involve the whole ofgovernment (WOG) and whole of society (WOS).In order to address the varied determinants of health,many of which are outside of the health sector, the planembraces the following core principles:1. Prevention-focus2. Equity3. Inclusiveness4. People centred5. Evidence-based & results-drivenThe development of the strategic plan includedengagement with partners throughout the process.Through stakeholder consultations, ideas andperspectives of internal and external stakeholders weregarnered to facilitate their contribution to and buy-in forthe proposed approaches to implementation of the plan.2007 Framework Conventionon Tobacco Control (FCTC) CARICOM Heads of GovernmentSummit on the NCD and Declarationof Port of Spain20142010 WHO NCD GlobalMonitoring FrameworkFigure 1:LIMITATIONSComprehensive data on the NCD situation in Trinidadand Tobago was difficult to obtain. Several data sourcesused were dated and the data obtained varied accordingto the source. This was compounded by the absenceof a national NCD surveillance system and lack ofcollation and analysis of data from the Regional HealthAuthorities (RHAs). Several proxies were utilised suchas using hospital admissions to represent morbiditydata. A comprehensive surveillance system will beimportant to the implementation and monitoring ofthe NSP NCD. More peer reviewed, policy-relatedresearch is needed, as well as collation and analysisof data covering five (5) to ten (10) year periods togenerate trends.REGIONAL AND INTERNATIONALDECLARATIONS ON NCDS UTILISEDIN THE NSP NCDMETHODOLOGY2003Data and evidence to guide the development of theplan were gathered from several sources in the Ministryof Health (MOH), the Central Statistical Office (CSO),academia, and research studies on NCDs and their riskfactors. In 2012, the results of the 2011 Trinidad andTobago STEPS NCD Risk Factor Survey (STEPS) werereleased. This data established baseline on key riskfactors, and was utilised in the development of the NSPNCD. The consultative process used in the developmentof the plan also maximised availability of outcomes ofother similar or relevant dialogues, which had takenplace in the recent past.2004The NSP NCD is guided by several international andregional frameworks and declarations, which inform thestrategic approach adopted in the plan to address ournational NCD situation and local determinants of health.These include: WHO Global Strategy on diet,physical activity and health WHO Set of Recommendations onMarketing of Foods and Non-AlcoholicBeverages to Children20132011 UN High Level Meeting on NCDs andUN Declaration on NCDs Strategic Plan of Action for the Prevention andControl of NCDs for countries of CARICOM PAHO Plan of Action for Prevention and Control of NCDsin the Americas 2013-2020 WHO Global Plan for the Prevention and Control of NCDs 2013-2020 Helsinki Health Promotion Conference - Health in All PoliciesDeclarations and International and Regional Frameworks used in the Developmentof the National Strategic Plan for the Prevention and Control of NCDs. Ministry of Planning and Development, Government of the Republic of Trinidad and Tobago. 2016. National Development Strategy 2016-2030 (Vision 2030).Retrieved from 1/V2030-as-at-August-29th-2016.pdfNational Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -20212

THE HEALTH SYSTEMThe MOH is the national authority charged withoversight of the entire health system in TTO.The MOH plays a central role in the protection of thepopulation’s health and in ensuring that all organisationsand institutions that produce health goods and servicesconform to standards of quality, care, and safety .The health system in TTO comprises several entities,which must work as a cohesive and committed whole.These entities include public, private, and civil societyagencies working together to produce the public goodcalled ‘population health’. Through collaboration amongthese entities, public and personal health care servicesare provided to citizens, with a reach to all communities.Table 1:Public health and population based programmes,which focus on wellness and preventive care, aremade available through the MOH, the vertical servicesand national programmes and civil society. Personalhealth care services at the primary, secondary, andtertiary levels are available through the Regional HealthAuthorities (RHAs), civil society, and the private sector.THE REGIONAL HEALTH AUTHORITIESResponsibility for the provision of clinical health careservices in TTO was contracted out from the MOHto the RHAs with the passing of the Regional HealthAuthorities Act No. 5 in 1994. RHAs are autonomousHealth Services Delivery Type of Health lationbasedProgrammesPersonalHealth CareServicesMinistry of HealthPublicSectorMinistry of HealthVertical ServicesRegional Health AuthoritiesOther Ministries, StateAgenciesPrivate for profitPrivateSectorCivil dies that own and operate health facilities in theirrespective Regions . There are five RHAs in TTO,which deliver public health care services to thepopulation of TTO on behalf of the MOH through anetwork of one hundred and five (105) health centreslocated in communities close to the population, andeight hospitals.The MOH is responsible for corporate governance andleadership of the health sector, policy setting, qualityassurance and regulations, monitoring and evaluation,and public health services for the population . TheRHAs provide a basket of primary, secondary, andtertiary health services to the population based onnational health priorities established by the MOHand on continuing assessment of health needs of thecommunities served.NWRHANCRHAERHANWRHA - North West RegionalHealth AuthorityNCRHA - North Central RegionalHealth AuthorityERHA -SWRHASWRHA - South West RegionalHealth AuthorityTRHA -Figure 2:Eastern RegionalHealth AuthorityTobago RegionalHealth AuthorityMap of Regional Health Authorities in Trinidad and Tobago Ministry of Health, Trinidad and Tobago. n.d. “Ministry of Health - Overview.” Ministry of Health, Trinidad and .aspx?id 38). Ministry of Health, Trinidad and Tobago. 2016. The Ministry of Health - Trinidad and Tobago. Retrieved from Ministry of Health, Trinidad and Tobago:http://www.health.gov.tt3National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021

They follow the policy direction of the MOH, provideservices in accordance with the standards ofcare, SOPs, and guidelines from the Ministry. TheMinistry allocates financial resources to the RHAsthrough Annual Service Agreements (ASAs) for theimplementation of these services.These agreements also serve as a mechanism formonitoring and evaluation.ROLE OF COUNTY MEDICAL OFFICERS OFHEALTH IN PREVENTION & CONTROL OFNCDSA key role of the MOH is ensuring that the essentialpublic health functions are delivered to promoteand protect the health of the population. TheCounty Medical Officers of Health (CMOsH), seniorpublic health administrators within the MOH, havea critical function of coordinating and monitoringthe implementation of these essential public healthfunctions. The Ministry retains other nationalprogrammes that are critical to the discharge ofthese functions that are dedicated to the promotionand protection of the health of the population, thuscontributing to social and economic development ofthe country. Coordinating the development of strategies tosupport the delivery of the Ministry’s NSP NCD; Health situation analysis, health risk assessment,and disease surveillance; Primary health care and health promotionprinciples; Social participation and intersectoral collaborationat the community level; and Ensuring the timely implementation of theessential public health functions at thecounty level including:o Public health surveillance, research and reporting;o Monitoring and evaluation of the implementationof MOH policies, programmes, services and healthsituation assessment;o Health promotion;o Facilitating social participation in the response to NCDprevention and control; ando Quality assurance and standards of care to trackprogress in personal and population based services.The role of the CMOH in the implementation of theNSP NCD will involve strengthening and renewingthe primary care approach for NCD Prevention andControl through: Providing leadership for the development anddelivery of the primary health response to NCDsat the community level; Ministry of Health, Trinidad and Tobago. 2011. “Strategic Plan: Fiscal Years 2012-2016.”.National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -20214

SITUATIONAL ANALYSISTrinidad and Tobago has experienced an epidemiologicaltransition over the last 40 years. NCDs are now themajor health problems, replacing the communicablediseases of the 1960s. Several factors have contributedto this, including an ageing population, urbanisation, andsignificant changes in the lifestyle of the population.observed in more than seven other Caribbean countriesfor the same period. Research is needed to determinethe reasons for this. Of note also is the earlier onset ofNCDs in the population.Today onset of NCDs is being observed more frequentlyin the under 45 years age group .DEMOGRAPHY2005to2010uniqtiarMThe country’s population is approximately 1.35 million,with an estimated 8.6% of the population living in urbanareas. Males account for 50.2% of the population, 27udrb25-2977.9GutigAnch40-44oenFrAge 4.89204674.51064.71074.31164.411as.StPopulation pyramids for Trinidad and Tobago for 2000 and 2011 *2000 – orange and blue; 2011 – grey nRcainiitiHaThe 2016 Evaluation of the Port-of-Spain Declarationrevealed that while overall life expectancy in TTOincreased from 64.8 to 69.3 between 1970 and 2010,this increase was far less than the 10-15 year increasesmThe crude birth and death rates are 12.83 births and8.23 per 1 000 population respectively. The fertility rateis 1.71 children per woman and the infant mortality rateis 12.0 per 1 000 live births . Life expectancy at birth is73.9 years for females and 66.5 years for males .Dofemales account for 49.8% . The population pyramids inFigure 3 reveal the continuing demographic transition ofthe ageing population. Between 2000 and 2011, whilethere was growth in the youngest age group (0-4 years),there was significantly more growth in the age group45-80 .92060.72146.321HaitiChanges in life expectancy in the Caribbean Central Statistical Office. 2012. “Trinidad and Tobago 2011 Population and Housing Census: Demographic Report.” Ministry of Planning and SustainableDevelopment, Port-of-Spain. 2011 DemographicReport.pdf).National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021licubepnRcainimDoFigure 4:sdobarBa Central Statistical Office, Trinidad and Tobago. 2016. “Population Mid Year Estimates.” Central Statistical Office. (http://cso.gov.tt/data/?productID age2ha4Ba6aoacrCurbBa5-9aubto60-64Figure 3:baCu70-74P80.1eadMALE8075-79coRitorue

NCD RISK FACTORSPersonal factors such as age, ethnicity, and geneticfactors are not amenable to change. However, NCDsshare common risk factors that are modifiable. Criticalactions for prevention and control of NCDs must bedirected at the modifiable risk factors which include:The NCD problem is growing rapidly because of thehigh and increasing prevalence of NCD risk factors inthe population. There are several types of factors thatincrease the risk for the development of NCDs.UNDERLYINGSOCIOECONOMICCULTURAL, POLITICALAND ENVIRONMENTALDETERMINANTSCOMMONMODIFIABLERISK FACTORS GLOBALISATION URBANISATION POPULATIONAGEINGNCDs NON-MODIFIABLERISK FACTORSUNHEALTHY DIETPHYSICAL INACTIVITYTOBACCO USEHARMFUL USE OFALCOHOL AGE GENETICSHEART SESFigure 5: Risk factors of NCDs.Table 2:NCDsCommon modifiable behavioural risk factors of NCDs.COMMON MODIFIABLE RISK FACTORSTobaccoUnhealthy DietPhysical InactivityHarmful Useof AlcoholHeart sYesYesStrokeYesYesYesYes Pan American Health Organization. 2015. “Health Situation in the Americas: Basic Indicators 2015.”. (http://www.paho.org/hq/index.php?option comdocman&task doc download&gid 31791&Itemid 270&lang en). PAHO/WHO and CARICOM. (2016). Evaluation of the 2007 CARICOM Heads of Government Port-of-Spain NCD Summit Declaration. Retrieved L-Report.pdf Ministry of Health, Trinidad and Tobago. 2012. “Trinidad and Tobago Chronic Non-Communicable Disease Risk Factor Survey [Pan American .aspx?id 394).National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -20216

Modifiable behavioural risk factors: tobacco use,alcohol abuse, unhealthy diets, and physicalinactivity;TOBACCO USE Modifiable biological risk factors: obesity, high bloodpressure, high cholesterol, and raised blood glucose.When left unchanged, modifiable behavioural riskfactors progress and intermediate biological risk factors(high blood pressure etc.) develop. Without the relevantmanagement and control, these intermediate biologicalrisk factors will progress to chronic diseases such asheart disease, diabetes, cancers, and stroke.NCD risk factors are also influenced by other factorsin the society where people, live, learn, work, love andplay. These are referred to as social determinantsof health (SDH), and include, but are not limited to,socioeconomic, cultural, environmental and politicalfactors, over which individuals have limited control, andfor which action is required by governments, privatesector, and civil society.Data from several national surveys including the 2011STEPS NCD Risk Factor Survey, the Global School HealthSurvey (GSHS - 2007 and 2011), the Global YouthTobacco Survey (GYTS - 2000, 2007, and 2011), and the2011 Evaluation of School Meals Options revealed thatthe prevalence of NCD risk factors in the populationwas high.About one fifth of the population smoke and theprevalence is much higher among men than amongwomen. The average age of initiation to smoking isaround 17 years in both sexes, and manufacturedcigarettes are the preferred form of tobacco use. Theaverage number of cigarettes smoked per day was 11.5cigarettes. In 2004, tobacco was attributable to 7% ofall NCD deaths – 9% of deaths due to ischemic heartdisease, 61% of deaths due to lung cancer .Regarding smoking and youth, while Figure 6 showsthat the prevalence of smoking cigarettes amongstudents has decreased steadily over the period 2000– 2011, there is no room for complacency. The 2011GYTS showed that 30% of students in Forms 1 to 4 hadsmoked a cigarette at least once in their lives and 18%were current smokers. The use of tobacco productsother than cigarettes had increased from 4.8% in 2000to 12% in 2011 .ALCOHOL USEForty percent of respondents to the STEPS survey werecurrent drinkers (defined as having consumed a drinkwithin the 30 days prior to survey implementation),and drinking was found to begin at an early age. The2011 GSHS showed that in TTO among the 13-15year olds, 36.4% of students had an alcoholic drink inthe month preceding the survey, with 86.5% of these50Prevalence (%)4540Boys35GirlsOverall302520200020072011GYTS Survey YearFigure 6:Prevalence of students who ever smoked cigarettes from GYTS 2000, 2007, and 2011 World Health Organization. (n.d.). WHO What is Moderate-intensity and Vigorous-intensity Physical Activity? Retrieved from World Health ty/physical activity intensity/en/7National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021

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Figure 8: Distribution of BMI in secondary school children. Figure 9: Four leading causes of mortality in Trinidad and Tobago. Figure 10: Prevalence of diabetes in Trinidad and Tobago compared to the regional and global prevalences. Figure 11: Cost of cancer, hypertension, and diabetes (TT Millions).