National Policy and Multisectoral Action Plan for the Prevention and Control of Non-Communicable Diseases in Antigua and Barbuda

1 — Strengthening coordination and management of NCD prevention and control

1. Strengthening coordination and management of NCD prevention and control

2 — Health system strengthening to NCDs and risk factors at all levels and all

2. Health system strengthening to NCDs and risk factors at all levels and all sectors

3 — NCD risk factors and protective factors

3. NCD risk factors and protective factors

4 — Healthy and active community through multisectoral policies and

4. Healthy and active community through multisectoral policies and partnership

5 — Surveillance, research, information and education

5. Surveillance, research, information and education This National Policy for the Prevention and Control of Non-Communicable Diseases includes a Plan of Action under each strategic area with specific activities, targeted indicators, time frame, proposed budget and responsible organization(s) for efficient implementation, monitoring and evaluation. 8 SITUATION ANALYSIS The situation analysis, comprising socio-demographic indicators, burden of diseases, risk factors, health response system to NCDs, current health information analysis, provides the context to guide policy development. It presents a summary of the existing situation in relation to NCDs and gives the rationale for the policy decisions. Socio-demographic indicators Total population (thousands) 87.9 Average annual deaths (thousands) 0.5 Life expectancy at birth (years) Total: 75.5 (Male: 73.5, Female: 77.6) Adult literacy rate (%) 99.0 Gross National Income US$ per capita 12,130.0 % of population covered by any type health … insurance: ... PAHO Cancer in the Americas. Country Profile 2013 Antigua and Barbuda faces many challenges in the prevention and management of NCDs. Cardiovascular disease, cancer, chronic respiratory diseases and diabetes continue to be the leading cause of death in Antigua and Barbuda with cancer and heart disease being the top two leading causes. Traditionally, Antigua and Barbuda as a small island developing state with a small economy, predominantly tourism service based has always encountered financial constraints in apportioning the overall annual budget (WTO Trade Policy June 2014). Life-long treatments for NCDs which include dialysis, chemotherapy, medical and surgical interventions, etc. coupled with loss of productivity and disabilities increase the financial burden and continue to weigh heavily on the health budget. Mortality and morbidity due to NCDs in Antigua and Barbuda Premature deaths from NCDs are major concern in Antigua and Barbuda. In examining the reported deaths for 2010 alone, of the 490 deaths reported, there were a total of 83 deaths occurring before age 70 years as a result of chronic diseases – 40 males and 43 females. Cancers alone accounted for more than 50 percent of those deaths with a total of 44 deaths. Premature deaths from NCDs (<70 yrs.) account for 22.0 % of all deaths in Antigua and Barbuda. Loss of people in their productive ages due to premature deaths caused by NCDs negatively affects country’s socio, economic and developmental aspects. It is also observed that while cancer and heart disease have been ranked as the top two leading causes of death, a significant number of deaths from cancer are noted in the younger age groups than that of heart disease. The Mount St. John Medical Centre reported a total of 47 new cancer cases for that year. There were 48 amputations performed in 2010 9 as a result of diabetes, and there are 65 patients currently on dialysis, resulting from NCD complications. For the period 2008 to 2009, there were 359 reported new cases of hypertension and 17 reported new cases of diabetes. Premature Deaths (2007) Source: Pan American Health Organization. Country Profiles on Non-Communicable Diseases. Washington, D.C.: 2012 Risk Factors Reduction of risk factors and strengthening protective factors are keys to reduce avoidable premature mortality and morbidity due to NCDs. Due to lack of implementation of the population-based risk factor survey (WHO STEPwise approach to surveillance: STEPS), no population-based data available for tobacco use, physical inactivity and diet (fruit and vegetable intake) in adults aged 25 + years. The prevalence (%) of overweight and obesity among adults indicated relatively high figure particularly females (see Table 1). The prevalence (%) of tobacco use in adolescents (males 8.2%, females 6.1%) is relatively high as compared to other Eastern Caribbean Countries. The prevalence (%) of low physical activity in adolescents is significantly high (males 63.5%, females 73.0%). The WHO Global School Health Survey (GSHS) conducted in 2009 revealed that 89% of the students who admitted smoking, tried their first cigarette before age 14 years. It was also revealed that 86% of those same students also had their first drink of alcohol before age 14 years. 10 Overweight/Obesity Overweight and obesity, which are major risk factor attributing to NCDs, continue to be a challenge in in the adult population. The main nutrition-related problems among adults and the elderly are obesity and NCDs. On average 63.1% of adults 20 years and over, who were screened in community clinics from 2009 to 2013 were classified as overweight or obese. Although there are some observations in recognizing overweight/obesity in children, Antigua and Barbuda has not established sustainable mechanism for a surveillance system collecting data on overweight, obesity and other risk factors particularly for school-aged children and young adolescents. With regard to the overweight/obesity data, population- based data for children over 5 years old until 24 years old need to be collected to appropriately address those risk factors by using cost-effective interventions and to develop specific policies and/or regulations for prevention and control of obesity in a timely manner. A study conducted among 4000 students aged 5-20 years (West Indian Medical Journal 2009) shows a prevalence of overweight and obesity to be 25.6% which raised concern overwith the risk for early onset of type 2 diabetes. (Medical Benefits Scheme (MBS) . Table 1 Risk Factors Prevalence (%) of: Total Males Females Current adult tobacco smokers ... ... ... Adolescent tobacco smokers 7.4 8.2 6.1 Fruit and vegetable intake in adults a ... ... ... Fruit and vegetable intake in adolescents a 26.7 30.7 21.4 Binge drinking among adults ... ... ... Low physical activity in adults b ... ... ... Low physical activity in adolescents c 68.2 63.5 73.0 Overweight among adults 59.0 54.4 63.3 (BMI 25-29.9) Obesity among adults (BMI ≥30) 25.8 18.1 33.1 Overweight among adolescents (BMI>+1SD) ... ... ... Obesity among adolescents (BMI>+2SD) ... ... ... Children <5 overweight ... ... ... Adults with diabetes mellitus ... ... ... Adults with raised BP and/or taking medication 42.4 47.1 37.8 Notes: a: % who eat ≤5 servings of fruit and vegetables per day; b: physically active for <600 met minutes; c: physically active less than 60 min per day in 5-7 of the last 7 days; BP: Blood pressure. BMI: Body Mass Index Source: Pan American Health Organization. Country Profiles on Non-Communicable Diseases. Washington, D.C.: 2012 11 Alcohol A total alcohol per capita (15+) consumption in litres of pure alcohol was 5.4 (average 2008-2010). A total alcohol per capita (15+) consumption, drinkers only (in liters of pure alcohol), 2010 for males (15+) and females (15+) are 10.6 and 5.1, respectively. Recorded alcohol per capita (15+) consumption by type of alcohol beverage (2010) indicated that 47% of consumption is from spirits, 36% from beer and 17% from wine. However, no written national alcohol policy and action plan exist. There are no legally binding regulations on alcohol advertising, product placement, sponsorship and sales promotion which protect adolescents from being targtes for marketing of alcohol in Antigua and Barbuda. Health System Response Accessible and effective health systems are critical to combating communicable diseases, achieving the Millennium Development Goals and tackling the growing threat of NCDs. Equitable and sustainable health improvement for all citizens of Antigua and Barbuda is the ultimate goal. The government maintains a commitment to providing health care for all citizens, as represented by the implementation of a Medical Benefits Scheme (MBS) that offers financial assistance toward the cost of medical services and pharmaceuticals for those living with NCDs. However, an increasing population with NCDs gives new challenges for the Government to provide appropriate health care financing, human resources, health services development, available and affordable essential medicines and health technologies, and to strengthen evidence-based health information and research. Shortage of trained health professionals (health care workers) is a challenge. Although the Ministry of Health provides refresher/capacity training for health professionals to improve their skills, a major challenge is securing finance for human resource development. The primary health care provides a platform as the first entry point for citizens receiving health promotion, prevention, screening for early diagnosis and appropriate treatment for NCDs. Considering limited human resources, it is very important to integrate effective NCDs prevention and control into primary health care to be well harmonized with existing health services such as Expanded Program of Immunization and child and maternal health. While a strong community programme exists, there is a gap in monitoring the health status of 6-19 age group which needs to be strengthened. In addition, it is critical to review and revise the School Health Programme and establish adolescent health programmes in collaboration with the Ministry of Education for early prevention of NCDs through a life- course approach which will prevent early onset of NCDs. Empowering entire nation with appropriate health education throughout their life course is critical. An overall health budget captures the costs for NCD prevention and control. There is no budget specifically allocated for NCDs prevention and control. Thus, effective health financing for an integrated approach for the prevention and control of NCDs including health system response at all levels of health services both in public and private should be emphasized and prioritized. 12 Surveillance, Research, Information and Education One of the major challenges in Antigua and Barbuda is that there is no well-structured surveillance system established yet for monitoring main risk factors for NCDs and health trends in Antigua and Barbuda. In addition, Antigua and Barbuda has never conducted a national survey on risk factors (PanAm STEPS Survey) due to budgetary constraints. Data are collected and maintained mainly on paper-basis and not being effectively utilized for development of health policies, regulations and legislations in a timely manner. The surveillance system in Antigua and Barbuda has been established mainly capturing health information of communicable diseases The current health information system does not allow health professionals to utilize patients’ medical record for effective referral, discharge and follow ups at all levels of health services for improving health outcomes. Although opportunities for the country to conduct national and/or sub-national surveys are provided by different International Agencies such as PAHO, CARPHA, UNAIDS etc., from time to time, there is no budget allocated for development of surveillance, active research and public advocacy and education for NCDs prevention and control. Coordination, Multisectoral Policies and Partnerships for Tackling CNCDs The traditional way of dealing with NCDs was physician-driven, disease-oriented, cure- focused and segmented treatment and care provided by different levels of health services. However, the nature of NCDs and their risk factors (tobacco use, harmful use of alcohol, unhealthy diets, physical inactivity, and overweight/obesity) involves a complexity of social determinants of health which are beyond individuals’ control. Approaches for NCDs prevention and control have been shifting from health sector-focused setting to non-health sector fully engaged settings. There is no existing multisectoral NCDs prevention and control policy, framework and action plan in Antigua and Barbuda. It is urgently requested to establish and implement such a policy and action plan and promote integration of NCDs prevention in sectors outside of health, at the government level and conducted in partnership with a wide range of non-state actors, as appropriate, (e.g. agriculture, trade, education, labor, development finance, urban planning, environment and transportation). This requires strong leadership and commitment led by the Government, a high level of coordination among all concerned stakeholders, a wide range of proactive partnerships and multisectoral approaches via “Whole-of-Government” and “Whole-of Society”) to combat NCDs. In an effort to address the complexity of NCDs prevention and control, the Ministry of Health has appointed a National NCD and Wellness Committee Chaired by the Chief Medical Officer, and a National Non-Communicable Diseases (NCD) Focal Point to assist with the coordinated efforts and initiatives in preventing and controlling NCDs. The Ministry of Health gained strong commitment, support and partnerships from other Ministries, civil society, NGOs, Faith-based Organizations (FBOs), academic institute, private sectors, media, International Agencies such as PAHO, WHO, CARPHA, FAO, UNFPA etc. It is time for 13 Antigua and Barbuda to strengthen a high level coordination mechanism and its operation to maximize all efforts to improve the nation’s health status. LIMITATIONS AND CONSTRAINS Following are identifying limitations and constraints: Due to lack of experience in development and implementation of multisectoral policies, it is observed that these imitations and constraints exists. · Lack of appreciation for multisectoral policy · Need for national prioritization, collaboration and coordination · Need for dedicated national financial commitment on NCD prevention and control POLICY FRAMEWORK The policy framework sets out the scope and positions on key strategic areas for the prevention and control of NCDs in Antigua and Barbuda. This section identifies the policy issues that will inform the policy. SCOPE This policy provides a strategic framework to support improving health outcomes for people at risk of, or living with, all NCDs (cardiovascular diseases, diabetes mellitus, cancer, chronic respiratory diseases), significant co-morbidities (overweight and obesity, mental health conditions, especially depression and dementia, and oral and renal diseases) and major risk factors (tobacco use, harmful consumption of alcohol, unhealthy diet, physical inactivity). It covers all sectors and involves all the main stakeholders in the prevention and control of NCDs in Antigua and Barbuda. This Policy provides a framework within which the activities of the health sector can be coordinated to address health promotion, primordial, primary, secondary and tertiary prevention and control. It covers both the public and private sectors and involves all concerned main actors including various Ministries, civil society, NGOs, media, Faith-Based Organizations, academic institutes and professional associations. The programmes for the prevention of NCDs must have a financial foundation to support and sustain their service. An appropriate allocation of the national budget must include funding for health promotion, prevention, management (treatment and control), sustainable surveillance system, and research and information dissemination. In addition, appropriate budget should be allocated for a National NCD and Wellness Commission, which is an oversight body for effective policy implementation. The National NCD Prevention and Control Policy also reinforces the Government of Antigua and Barbuda and the Ministry of Health’s compliance with Global and Regional Initiatives, Resolutions and Mandate such as: 14 · Alma Ata and Primary Health Care Declaration 1978 · Ottawa Charter on Health Promotion 1986 · WHO Global Strategy for Prevention and Control of NCDs (2000) · WHO Global Action Plan for the Prevention and Control of NCDs (2013-2020) · WHO Global Monitoring Framework and Global Action Plan (2013-2020) · WHO Framework Convention of Tobacco Control (2005) · PAHO Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and Control of Chronic Diseases, 2007 · PAHO Plan of Action for the Prevention and Control of Noncommunicable Diseases in the Americas (2013-2019) · PAHO Plan of Action for the Prevention of Obesity in Children and Adolescents, 2014 · United Nation NCD Resolution, 2010 · United Nation High Level Meeting: Political Declaration, 2011 · CARICOM Port of Spain Declaration, 2007 · Caribbean Cooperation in Health Phase III (CCH III): Regional Health Framework (2010 – 2015) POLICY LEGISLATIVE FRAMEWORK Legislation is an important mechanism for supporting initiatives to reduce the incidence of NCDs as well as to promote healthy lifestyle by controlling tobacco use, harmful alcohol consumption, elimination of trans-fat and reduction of salt and sugar consumption. The mental health and aging policies are important supporting elements as these conditions are related to NCDs. Some supporting policies and legislation include but are not limited to the following: · Public Health Act, 1957 · The Pharmacy Act 2007 · Aging Policy 2012 · Mental Health Policy 2014 · Mental Treatment Act, 1957 · Food and Nutrition Security Policy 2012 · National Tobacco Control Act 2014 (draft) VISION, MISSION, GOAL, CORE VALUES AND OBJECTIVES The VISION of the National Policy for Prevention and Control of Non-communicable Diseases is to make all citizens and residents enjoy healthy, happy and productive lives free from NCDs. The MISSION is to lead a collaborative effort that engages all stakeholders to effectively prevent, control and manage NCDs and their associated risk factors. The CORE VALUES guiding this policy are: · Equity 15 All persons will be treated and considered fairly and justly. · Respect The dignity and diversity of all persons, groups and communities will be embraced and preserved. · Sustainability Programs and interventions will be structured and implemented in a manner that ensures that they can be maintained. · Solidarity There will be the promotion of shared interests and responsibilities and collective efforts to achieve common goals. · Integrity Transparent, ethical and accountable performance will be mandated. · Excellence All efforts will be made to ensure the highest quality programmes and interventions. The GOAL of the NCD Policy is to reduce preventable morbidity and premature mortality due to NCDs and control of the risk factors attributed to these diseases. The OBJECTIVES are to:

1 — Promote healthy lifestyles by creating a supportive healthy environment;

1. Promote healthy lifestyles by creating a supportive healthy environment;

2 — Improve overall quality of life in persons with NCDs;

2. Improve overall quality of life in persons with NCDs;

3 — Reduce exposure to risk factors that contribute to NCDs;

3. Reduce exposure to risk factors that contribute to NCDs;

4 — Prevent and delay early onset of NCDs for individuals and population groups;

4. Prevent and delay early onset of NCDs for individuals and population groups;

5 — Reduce incidence and prevalence of NCDs; and

5. Reduce incidence and prevalence of NCDs; and

6 — Reduce morbidity associated with NCDs

6. Reduce morbidity associated with NCDs. GUIDIG PRINCIPLES: Having the guiding principles derived from key International Commitments, Resolutions, Mandates and Declarations, the Government of Antigua and Barbuda is committed to the following operational guiding principles:

1 — Raising NCDs as a priority on the national health and development agenda;

1. Raising NCDs as a priority on the national health and development agenda;

2 — Addressing the social and environmental determinants of health that impact

2. Addressing the social and environmental determinants of health that impact NCDs through advocacy and action for a whole of society response;

3 — Creating sustainable, coordinated efforts/initiatives to address the NCD

3. Creating sustainable, coordinated efforts/initiatives to address the NCD epidemic in Antigua and Barbuda; 16

4 — Promoting cost-effective interventions to reduce the risk factors for NCDs and

4. Promoting cost-effective interventions to reduce the risk factors for NCDs and health promotion through life-course approach such as tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol;

5 — Promoting partnerships and resource mobilization for the prevention and

5. Promoting partnerships and resource mobilization for the prevention and control of NCDs re-orienting the primary health care (PHC) services response by applying an integrated conceptual framework for improving quality of care (such as Chronic Care Model); and

6 — Monitoring NCDs and their complications and evaluating progress made at

6. Monitoring NCDs and their complications and evaluating progress made at community and national levels. PROCESS With technical support provided by Pan American Health Organization (PAHO), the Ministry of Health started the process for development of a National Policy for Prevention and Control of NCDs with wide range of stakeholders, various Ministries (Ministries of Education, Agriculture, Social Transformation, Transport, and Trade), MBS, civil society, NGOs, Faith-based Organization, academic institute, private sector and media etc. A series of consultations and stakeholder meetings were conducted to identify progress made, challenges, existing gaps and opportunities for “Whole-of-Government” and “Whole-of Society’ approaches to tackle NCDs epidemic in Antigua and Barbuda. Preparation of the documents involved review of existing policies and strategies, international key resolutions, strategic plans of various programmes and general literature review to identify cost-effective interventions. Various drafts of the policy documents were developed based on input/contributions made by all concerned stakeholders, reviewed, discussed, revised and finally validated at stakeholder consensus meeting. GOVERNANCE AND LEADERSHIP The Ministry of Health and Environment shall: · Take the leadership role and responsibility for policy formation, resource mobilization and allocation within the health sector, and monitoring and evaluation of the overall health sector performance; · Set national goals and targets for the prevention and control of NCDs; · Strengthen an intersectoral approach to the development of programmes and services for the prevention and control of NCDs, including national guidelines and protocols to standardize care provided; 17 · Foster partnerships with other government agencies, international agencies, NGOs, academic institutes, private sector, Faith-Based Organizations and media to promote healthy lifestyles and a create sustainable healthy environment; · Establish mechanisms for the effective implementation, monitoring and evaluation of the NCD Policy and Multisectoral Action Planfor the Prevention and Control of NCDs. KEY STRATEGIES Considering challenges and gaps identified in the area of NCD prevention and control in Antigua and Barbuda, the following strategic areas are selected and prioritized for achieving the policy objectives: · Strategic Area 1: Strengthening coordination and management of NCD prevention and control · Strategic Area 2: Healthy and active community through multisectoral policies and partnership · Strategic Area 3: NCD risk factors and protective factors · Strategic Area 4: Health system strengthening to NCDs and risk factors at all levels and all sectors · Strategic Area 5: Surveillance, research, information and education IMPLEMENTATION, MONITORING AND EVALUATION FRAMEWORK The policy implementation will be monitored and evaluated through the Monitoring and Evaluation Framework, which will cover all aspects of the policy. An action plan is developed to operationalize this policy. The management and oversight of policy implementation, monitoring and evaluation will be effected through a National NCD and Wellness Committee. A mid-term and end-of the term report will be developed and widely disseminated for further policy development. 18 MULTISECTORAL ACTION PLAN (2015-2019) GOAL The ultimate goal is to achieve a 20% relative reduction in preventable premature deaths due to NCDs in Antigua and Barbuda by 2019. OBJECTIVES · To strengthen coordination and management of NCD prevention and control; · To promote integration of NCD prevention policies, frameworks and actions through multisectoral approaches; · To reduce risk factors (tobacco use, harmful use of alcohol, physical inactivity, obesity) and promote healthy and active living for health and well-being; · To strengthen the health system at all levels in public and private sectors which improves access to quality health services and financial risk protection; and · To improve the quality and breadth of NCD and risk factor surveillance system and strengthen operational research for planning, monitoring, and evaluation of NCD- related policies and programs. STRATEGIES In consideration of challenges and gaps identified in the area of NCD prevention and control in Antigua and Barbuda, the broad strategies were discussed and agreed upon in line with the PAHO Regional Plan of Action for the Prevention and Control of NCDs. The key strategies identified for tackling NCD prevention and control in Antigua and Barbuda are: Strategic Area 1: Strengthening coordination and management of NCD prevention and control Strategic Area 2: Healthy and active community through multisectoral policies and partnership Strategic Area 3: NCD risk factors and protective factors Strategic Area 4: Health system strengthening to NCDs and risk factors at all levels and all sectors Strategic Area 5: Surveillance, research, information and education 19 RESULTS FRAMEWORK Level Objectives Indicators/Target Means of Verification Critical Assumption To achieve a 20% relative A 20% relative reduction · National Health MoH will conduct national reduction in the mortality of premature mortality Surveys (Mini STEPS periodic health surveys from cardiovascular due to NCDs by 2019 Survey, GSHS etc.) Goal diseases, cancer, diabetes, · Surveillance in health or chronic respiratory centers diseases (NCDs) by 2019 Strategy 1: Coordination and · National NCD Focal · Formal appointment National NCD and Expected Results management of NCD Point appointed and and approval Wellness Commission prevention and control program for NCD approved and strengthened prevention and · Budget allocated for operationalized control established NCD program (Budgetary report by · National NCD and the Ministry of Wellness Commission Finance & Health ) established and operationalized · Activity Report Strategy 2: Multisectoral policies and · National multisectoral · National NCD and National NCD and Expected Results partnerships developed policies, frameworks, Wellness Commission Wellness Commission and implemented actions in at least 3 with clear Terms of sectors outside the · Annual Report Reference including rule of health sector at the procedure prepared and government level and · PAHO/WHO Country finalized partnership with a NCD Capacity Report wide range of (Biannual) stakeholders developed and implemented · 20 Strategy 3: NCD risk factors reduced · Tobacco Control Act · National Health MoH secures appropriate Expected Results and protective factors enacted Surveys (PanAM budget for national, sub- strengthened STEPS Survey, Mini- national survey (PanAm · GSHS conducted for STEPS, Mini-STEPS, GSHS STEPS, GSHS etc.) baseline and 2% etc.), implement, collect relative reduction of data and prepare report(s) · harmful use of alcohol by 2019 (15+) Antigua and Barbuda has a mechanism to respond to · Policies/cost-effective risks in real time interventions to reduce the impact on Regional institutional children of marketing infrastructural (CARICOM, of foods and non- CHOSOD, PAHO, CARPHA) alcohol beverages high support and multisectoral in saturated fats, policies in place trans-fatty acid, sugars and salt implemented MoH and MoE conduct national awareness · Baseline survey campaigns on healthy conducted for mean diets and increasing salt intake (sodium physical activity. chloride) in grams per day in persons aged 18 MoH(HID) oversight and + implement national survey · A 5% relative reduction of salt intake from baseline by 2019 · # of national campaigns, 21 sensitizations, public education on salt reduction conducted · Baseline survey (population-based survey) conducted to identify prevalence of insufficient adult physical activity · A 20% relative reduction in prevalence of insufficient physical activity among adolescents by 2019 Strategy 4: Health system response to · A model of integrated Annual report of MoH established a Expected Results NCDs and risk factors management for NCDs prevalence of National NCD prevention strengthened at all levels implemented (e.g. overweight/obesity and control programme of health services and CCM, WHO PEN) prepared accessibility and quality Commitment from MoF for improved · List of available Annual report of # of appropriate budget for essential medicines women received screening NCD prevention and for NCDs from MBS for cervical and breast control programme and OECS/PPS cancer prepared secured updated and available MoH implement an · At least 75% of integrated management of patients with NCD prevention and hypertension and Control programe diabetes controlled Stakeholders (NGOs, FBOs, · A 15% relative private sectors) support reduction in age- and “buy-in” to the standardized National NCD programme 22 prevalence of raised blood pressure A mechanism for data collection at PHC and · A 15% relative reporting established reduction in age- standardized MoH developed National prevalence of raised Guidelines and Protocol blood for cancer screening and glucose/diabetes management of risk factors for NCDs · A 5% relative reduction of age- standardized prevalence of overweight/obesity in persons aged 18+ by 2019 · A 5% relative reduction in age- standardized prevalence of overweight/obesity in school-aged children and adolescents by 2019 · A 80% of women (aged 30-49) received cervical cancer screening · A 80% of women (aged 50-69) received breast cancer screening 23 · At least 75% of eligible people received drug therapy and counselling to prevent heart attacks and strokes Strategy 5: Sustainable NCD · A 20 % relative Annual report of NCD MoH (HID) will establish Expected Results surveillance system reduction in minimum data set systematic data collection established and collected premature mortality prepared and submitted to mechanism (surveillance, data utilized for effective from the 4 leading PAHO and CARPHA survey) on mortality and policy and program NCDs by 2019 morbidity due to NCDs. development · High-quality mortality Appropriate human and data for the 4 main financial resource will be NCDs collected allocated for surveillance. · Quality cancer incidence data, by type of cancer per 100,000 population collected · At least one nationally representative population survey by 2019 conducted · Regular reports with analysis on NCDs and risk factors produced and disseminated · Research agendas that include operational research studies on NCDs and risk factors for strengthening 24 evidence-based policies, program development set 25 Activity Plan Strategic Line of Action 1: Strengthening coordination and management of NCD prevention and control (Impact: Coordination mechanism strengthened) Time (indicated starting Strategies Activities Performance Responsible time, a total amount Cost of implementation Indicators period needs to be identified) 1.1.1 Establish a National NCD program Approved Cabinet Implementation coordinated by Medical Officer Health paper Agency: MoH (MOH) Executing Agency : 2nd quarter, $ 2,500 MoH, Cabinet of the 2015 Government of Antigua and 1.1 Strengthen Barbuda Multisectoral 1.1.2 Establish a NCD and Wellness A responsible Implementation coordination and Commission with clear Terms of person appointed Agency: MoH leadership for 2nd quarter, Reference to coordinate response to by the Ministry of $ 5,000 NCD prevention Executing Agency : 2015 NCDs Health and control MoH 1.1.3 Establish a Multisectoral Task A responsible Implementation Force to coordinate response person appointed Agency: MoH by Chairman of 3rd quarter, Executing Agency : $2,500 National NCD and 2015 Wellness MoH Commission 1.2.1 Conduct public education Policy and Plan of Implementation campaign and advocacy on prevention Action approved Agency: MoH 2nd quarter, 1.2 Advocacy $ 40,000 and control of NCDs and risk factors and disseminated 2015 Executing Agency : MoH, Govt 26 Information Services (GIS) 1.2.2 Conduct dialogue with other Policy and Plan of Implementation sectors and NGOs in understanding Action widely Agency: MoH 2nd quarter, policy and action plan and developing disseminated $ 10,000 Executing Agency : 2015 (3months) joint programmes for implementation MoH 1.3.1 Establish an earmarked tax for Approved Cabinet Implementation prevention and control of NCD paper Agency: MoH programmes Executing Agency : MoH, Cabinet of the 4th quarter, $ 25,000 Government of 2015 Antigua and Barbuda, National Economic and Social 1.3 Strengthen Council resource 1.3.2 Establish diversion of existing Approved Cabinet Implementation mobilization taxes (sales tax from tobacco, snacks paper Agency: MoH high in salt, trans fat, sugar etc.) Executing Agency : Cabinet of the 4th quarter, $ 20,000 Government of 2015 Antigua and Barbuda, National Economic and Social Council (Currency in Eastern Caribbean Dollars) 27 Strategic Line of Action 2: Healthy and active community through multisectoral policies and partnerships (Impact: Multisectoral policies developed and implemented through wide range of partnerships) Time (indicated starting time, Strategies Activities Performance Responsible a total amount of Cost Indicators implementation period needs to be identified) 2.1.1 Secure budgetary Cabinet, NGOs, Implementation allocations for prevention and FBOs, private Agency: MoH control of NCDs to be sectors allocated Executing Agency : 2nd quarter, 2015 $ 2,000 implemented via multisectoral budget (including approaches in-kind MoH, MoF contributions) 2.1.2 Develop and implement National Implementation National multisectoral policy and multisectoral policy Agency: MoH plan for the prevention and and plan approved 2nd quarter, 2015 $ 50,000 control of NCDs and implemented Executing Agency : MoH 2.1 Strengthen Multisectoral 2.1.3 Assess national capacity for National Capacity Implementation policies and prevention and control of NCDs for NCDs assessed Agency: MoH partnerships 2nd quarter, 2015 $ 20,000 Executing Agency : MoH 2.1.4 Conduct effective resource Resources allocated Implementation mobilization via partnerships for NCD prevention Agency: MoH with various sectors including and control 4th quarter, 2015 $ 5,000 civil society, NGOs, media programmes Executing Agency : MoH 2.1. 5 Establish an “Alliance” for Alliance established Implementation health promotion, prevention partnership with Agency: MoH 4th quarter, 2015 $ 5,000 and control for NCDs MSJMC, Med Ben, Insane Boot Camp, Executing Agency 28 Diabetes MoH Association and Rotary Club 2.1.6 Develop structure year-long Programmes Implementation community-based prevention established in Agency: MoH programme and implement via collaboration with 2nd quarter, 2015 $ 60,000 partnerships NGOs, FBO, private Executing Agency : sector NGOs, civil society 2.2.1 National campaigns to raise Cabinet Committee Implementation public and political awareness on engaged Agency: MoH 2.2 Advocacy NCD prevention and control 2nd quarter, 2015 $ 20,000 conducted Public supported to Executing Agency : combat NCDs as MoH national priority (Currency in Eastern Caribbean Dollars) 29 Strategic Line of Action 3: NCD risk factors and protective factors (Impact: Policies in place and implemented to reduce prevalence of risk factors and strengthen protective factors) Time (indicated starting time, Strategies Activities Performance Responsible a total amount of Cost Indicators implementation period needs to be identified) 3.1.1 Revise and implement Public Health Act Implementation Public Health Act enacted Agency: MoH 1st quarter,2016 $ 200,000 Executing Agency : Legal Affairs 3.1.2 1Revise and strengthen Liquor Licensing Implementation enforcement of Liquor Licensing Act amended and Agency: MoH Act enforced 2nd quarter, 2015 $ 200,000 Executing Agency : Legal Affairs 3.1 Strengthen 3.1.3 Assess, revise, develop and School Health Implementation implement a National School Policy approved Agency: MoE, MoH legislative Health Policy and implemented 3rd quarter, 2015 $ 100,000 framework and Executing Agency : support MoE, MoH 3.1.4 Implement WHO FCTC Tobacco Control Implementation (Tobacco Control Act.) Act enacted and Agency: MoH enforced 2nd quarter, 2015 $ 400,000 Executing Agency : MoH 3.1.5 Develop Legislation on Legislation Implementation increased tax on foods in high fat, developed, Agency: MoH salt and sugar and utilize tax enacted 4th quarter, 2015 $ 400,000 revenue for strengthening school Executing Agency : health promotion (healthy diets, Legal Affairs 30 PA) 3.2.1 Conduct sensitization and Political Implementation public awareness for alcohol- commitment and Agency: MoH attributable burden and reduce leadership 2nd quarter, 2015 $ 20,000 the harmful use of alcohol and engaged and Executing Agency : tobacco use public supported MST&HRD 3.2.2 Conduct national campaign # of educational Implementation for prevention and control of campaigns Agency: MoE, MoH, obesity (particularly focused on conducted and MoS 1st quarter, 2016 $ 100,000 3.2 Advocacy childhood obesity) assessed Executing Agency : MoE, MoH, MoS 3.2.3 Conduct national campaign, # of educational Implementation sensitization and education on campaigns Agency: MoE, MoH, healthy diets and physical activity conducted and MoS, MoA assessed 2nd quarter, 2015 $ 20,000 Executing Agency : MoE, MoH, MoS, MoA 3.3.1 Analyze available data on Report prepared Implementation breast feeding, identify the gaps and at least 70% of Agency: MoH and develop action plan for mothers exclusive 3rd quarter, 2015 $ 5,000 strengthening exclusive breast breast feeding Executing Agency : 3.3 Reduce risk feeding MoH factors and 3.3.2 Incorporate Monitoring and Implementation strengthen recommendations for evaluation Agency: MoE, MoA protective factors via strengthening school feeding conducted on 2nd quarter, 2015 $ 10,000 cost-effective programs for prevention and school feeding Executing Agency : interventions control of diet-related diseases programs MoE, MoA 3.3.3 Implement Child Friendly At least 70% of Implementation School Initiative to prevent and schools joined and Agency: MoH 2nd quarter, 2015 $ 400,000 reduce obesity to protect children implemented the from marketing of foods and non- initiative Executing Agency : 31 alcoholic beverages high in MoH, MoE, MoA saturated fats, trans fatty acids, free sugars 3.3.4 Develop and implement # of public and Implementation cost-effective interventions on school education Agency: MoH, MoE salt reduction at population level and training by using WHO Tool Kit for salt conducted on Executing Agency : reduction understanding MoH, MoE, MoA food labeling and FBDG National salt targets for each food category identified Use of salt, saturated fat and 1st quarter, 2016 $ 400,000 sugars reduced # of School Cafeteria Meals reviewed and reformed for reduction of salt intake A 5 % relative reduction of salt consumption in population by 2019 32 3.3.5 Scale up open spaces for Sporting facilities Implementation physical activity at school and scaled up Agency: MoS, MoH community 4th quarter, 2015 $ 150,000 Executing Agency : MoS, MoE (Currency in Eastern Caribbean Dollars) 33 Strategic Line of Action 4: Health system strengthening to NCDs and risk factors at all levels (Impact: Accessibility to quality of care and affordability for essential medications and technologies improved) Time (indicated starting Strategies Activities Performance Responsible time, a total amount of Cost Indicators implementation period needs to be identified) 4.1.1 Implement and scale up a Chronic Illness Implementation model of integrated Care Assessment Agency: MoH management for NCDs (e.g. CCM, conducted WHO PEN) Executing Agency: In-country audit 2nd quarter 2015 $ 100,000 conducted for MoH, CMO, MOH,PNO, quality of care SPHN, Quality and patients’ Department-MSJMC satisfaction 4.1.2 Develop tracking system Unique patient ID Implementation 4.1 Strengthen for patients established and Agency: MoH health system used in all levels 2nd quarter, 2015 $ 400,000 response to of health services Executing Agency : NCDs and risk MBS, MSJMC, HID factors at all levels 4.1.3 Develop a mechanism for Guidelines and Implementation effective referral, discharge, protocols for Agency: MoH follow-up and feed-back and referral, implement discharge, feed- Executing Agency : 2nd quarter, 2015 $100,000 back and follow- MOH, MSJMC, Private up developed and Healthcare Facilities in use 4.1.4 Standardize and implement Screening for Implementation screening for NCDs (cancer, NCDs Agency: MoH 2nd quarter, 2015 $ 400,000 cardiovascular diseases, kidney implemented diseases/failure etc.) and its Executing Agency : MOH, NGOs 34 reporting format (Partnership Donors) 4.1.5 Restructure and re-define Restructured Implementation existing primary health services organizational Agency: MoH in Antigua and Barbuda for chart with terms 1st quarter, 2016 $ 5,000 integrated approach for NCD of reference Executing Agency : prevention and control MoH/MOH 4.2.1 Provide health education # of health Implementation and promotion for all and education Agency: MoH counselling for patients with provided NCDs and their family with Executing Agency : healthy lifestyle education (diet, MoH/HID 2nd quarter, 2015 $ 50,000 PA, maintain healthy weights, quit smoking etc.) 4.2 Continue empowering 4.2.2 Promote timely and At least 75% of Implementation patients and specific medical interventions patients with Agency: MoH strengthen (patients and providers) for CVDs and DM community management and care for NCDs received effective Executing Agency : 2nd quarter, 2015 $ 100,000 linkage drug therapy and SPHN, CMO, Private counselling Healthcare Facilities, DPS 4.2.3 Improve patients CCP being utilized Implementation adherence to medications, and patient Agency: MoH follow-up care through health record updated 2nd quarter, 2015 $ 500,000 education Executing Agency : MoH/CMO, SPHN 4.3.1 Provide continued training # of training Implementation 4.3 Scale up health for health professionals to provided Agency: MoH 2nd quarter, 2015 $ 500,000 professionals effectively deal with NCD skills and prevention and control Executing Agency : MOH, (Partnership 35 motivation Donors) 4.3.2 Provide incentives and Packages Implementation motivational packages for health developed and Agency: MoH care providers approved 1st quarter, 2016 $ 10,000 Executing Agency : MOH, MOT (Currency in Eastern Caribbean Dollars) 36 Strategic Line of Action 5: Surveillance, research, information and education (Impact: High quality mortality data due to major NCDs collected and a 20% relative reduction in premature mortality from the 4 leading NCDs achieved by 2019) Time (indicated starting time, Strategies Activities Performance Responsible a total amount of Cost Indicators implementation period needs to be identified) 5.1.1 Conduct assessment for Assessment report Implementation capacity of health professionals produced Agency: MoH and quality of existing data 2nd quarter, 2015 $ 5,000 Executing Agency : MOH ,HID 5.1.2 Provide training for health # of training Implementation 5.1 Strengthen professionals to collect and sessions Agency: MoH sustainable NCDs report quality data routinely. conducted 4th quarter, 2015 $ 15,000 surveillance Executing Agency : system MOH, HID 5.1.3 Conduct training and # of training Implementation implement National Population- sessions Agency: MoH Based Survey (PanAM STEPS, conducted, Executing Agency : 4th quarter, 2015 $ 1,000,000 Mini-STEPS etc.) resources secured and survey MoH, PAHO, implemented CARPHA 5.2 Secure 5.2.1. Secure appropriate budget Budget allocated Implementation appropriate allocation for establishment of for surveillance on Agency: MoH budget allocated sustainable surveillance system NCDs and risk 2nd quarter, 2015 $ 400,000 for sustainable for NCDs and monitoring risk factors Executing Agency : surveillance factors MoH, MOH 37 system 5.2.2 Obtain support from Implementation various sectors such as academia Support obtained Agency: MoH to strengthen surveillance system (including in-kind 1st quarter, 2016 $ 400,000 contributions) Executing Agency : MoH, MOH 5.2.3 Secure appropriate Budget allocated Implementation resources for development of for establishment Agency: MoH Chronic Diseases Registries of cancer registry (Cancer Registry) Executing Agency : 2nd quarter,2016 $ 600,000 Cancer Registry MoH, MOH established and in operation 5.3.1 Develop communication # of national Implementation strategy for sensitization of sensitization, Agency: MoH surveillance on NCDs and risk advocacy, public 2nd quarter, 2015 $ 50,000 factors education Executing Agency : conducted MoH, MOH 5.3.2 Conduct national # of national Implementation sensitization for surveillance and sensitizations Agency: MoH national survey on NCDs and risk conducted 4th quarter, 2015 $ 100,000 5 Advocacy factors Executing Agency : MoH, MOH 5.3.3 Utilize the media (audio, # of media being Implementation visual) to reach out entire utilized Agency: MoH population Executing Agency : 3rd quarter, 2015 $ 15,000 MoH, Communication Specialist (Currency in Eastern Caribbean Dollars) 38 Implementation Role of Ministry of Health and Environment The Ministry of Health and Environment is the lead agency for intersectoral collaboration for the implementation of the multisectoral policies and plans on NCD prevention and control.

1 — Strengthen an intersectoral approach to the development of programmes and

1. Strengthen an intersectoral approach to the development of programmes and services for the prevention and control of NCDs, including national guidelines and protocols to standardize care provided;

2 — Foster partnerships with other government agencies, Regional and International

2. Foster partnerships with other government agencies, Regional and International Agencies, NGOs, academic institutes, private sector, Faith-Based Organization, media to promote healthy lifestyle and create sustainable healthy environment;

3 — Establish mechanisms for the effective implementation, monitoring and evaluation

3. Establish mechanisms for the effective implementation, monitoring and evaluation of the NCD policy; Roles of National NCD and Wellness Commission

1 — The Ministry of Health will transform existing National NCD and Wellness

1. The Ministry of Health will transform existing National NCD and Wellness Committee to the National NCD and Wellness Commission which will be approved by the Cabinet.

2 — A National NCD & Wellness Commission will be the body responsible for the

2. A National NCD & Wellness Commission will be the body responsible for the oversight of implementation, monitoring, evaluation and dissemination of the findings (report).

3 — A Chairman of the Commission will report recommendations and advise to Minister

3. A Chairman of the Commission will report recommendations and advise to Minister of Health via Chief Medical Officer. Monitoring and Evaluation

1 — The management and oversight of this plan will be effected through a National NCD

1. The management and oversight of this plan will be effected through a National NCD and Wellness Commission on NCD prevention and control. Data collection to monitor implementation of this Plan of Action will be included as part of the national monitoring system. In addition, data will be collected through PanAm STEPS Survey, mini-STEPS, GSHS, and other available data collection mechanisms on a routine basis.

2 — Output indicators and means of verifications will be collected through different data

2. Output indicators and means of verifications will be collected through different data sources.

3 — A baseline survey will be needed in order to establish several of the indicators and

3. A baseline survey will be needed in order to establish several of the indicators and to evaluate relative reduction. Accordingly, progress will be evaluated every two years. 39 Summary Budget This summary budget needs to be completed based on discussions and agreement with all concerned stakeholders. Source of Funding Unfunded Funded Total Action MoH MoE MoA NGO Others Budget Budget Budget S1: Strengthening coordination and management of NCD prevention and 105,000 control S2: Healthy and active community through multisectoral policies and 162,000 partnership S3: NCD risk factors and protective 2,405,000 factors S4: Health system strengthening to NCDs and risk factors at all levels 2,165,000 S5: Surveillance, research, information and education 2,585,000 Total Budget 7,422,000 (Currency in Eastern Caribbean Dollars) 3 Acknowledgements The Ministry of Health and Education wishes to express its appreciation for the support rendered by the various stakeholders in planning, developing and finalizing this National Policy for the Prevention and Control of NCDs and its Multisectoral Action Plan (2015- 2019). 40 Contributors list (Key members contributed for finalization of the policy and plan) Name Organization / Title Ms. Nikita Lake Statistical Officer Mr. Sean Samuel Ministry of Education Dr. Oritta Zachariah Medical Officer of Health Mrs. Coralita Joseph SPHN, Ministry of Health Mrs. Cleo Hampson DSPHN, Ministry of Health Dr. Leon Cox Physician Mrs. Almarie Coates Family Nurse Practitioner Mrs. Avis Jonas Chief Nutrition Officer, Ministry of Health Mrs. Elnora Warner Principal Nursing Officer, Ministry of Health Mrs. Ena Henry NCD Focal Point, Ministry of Health Mrs. Owolabi Elabanjo Agriculture Extension, Ministry of Agriculture Mrs. Natasha Gomes-George Sr. Trade Policy Analyst, Ministry of Trade Ms. Juanita James President-Diabetes Association Ms. Andrea Airall Ministry of Education Mr. Colin O'Keiffe Health Information Division, Ministry of Health Mr. Jason Percival Health Information Division, Ministry of Health Mr. Alfred Athill Director of Pharmecutical Services Dr. Helen Makinde Medical Officer of Health, Ministry of Health Ms. Natasha Watts Ministry of Finance Mr. Alton Forde Fiennes Institute 41 Ms. Harriet Liddie Ministry of Education Mr. Clarence Pilgrim Clarevue Psychiatric, Ministry of Health Dr. Teri-Ann Joseph Clarevue Psychiatric, Ministry of Health Mr. Lionel Michael Chief Health Inspector, Ministry of Health Dr. Rhonda Sealey-Thomas Chief Medical Officer, Ministry of Health Ms. Michele Lynch Secretary-Breast Friends Mrs. Norma Jeffrey-Dorset Substance Abuse Prevention, Ministy of Transformation Ms. Kim Martin Substance Abuse Prevention, Ministy of Transformation Ms. Samantha Moitt Dietician, MSJMC, Ministry of Health Ms. Rhea Ireland Ministry of Health Dr Tomo Kanda Advisor on NCDs, Pan American Health Organization 42

ANNEX 1: Policy links for NCD prevention and control with various sectors — Policy links for NCD prevention and control with various sectors

ANNEX 1: Policy links for NCD prevention and control with various sectors The table below connects the response to NCDs with the priorities of other sectors, making these links explicit and preparing for harmonization of policies across sectors. Sector Policy Links · Approving dedicated staff and budget for NCD’s. · Granting concessions on monitoring equipment to persons with Finance and Trade NCD’s · Endorsing Trade treaties supporting ban of trans fat · Ensuring the equity of access to prevention and care for services related to NCDs Social Policy · Reducing the disparities in burden of NCDs among people of different social class (defined by age, sex, income, occupation, education, and geographic location · Enhancing the academic performance of school children through promotion of healthy behaviours · Strengthening the work on health promoting schools and related Education activities to improve the health of students, teachers using the Food Based Dietary Guidelines · Finalizing the Draft Health and Family Life Education Policy · Ensuring food availability and security as outlined in the Food Agriculture, Lands & the and Nutrition Security Policy. (e.g. introduction of new fruits and Environment vegetables for agriculture, promotion of local products) · Promoting the messages of the Food Based Dietary Guidelines · Work with civil society and women’s groups to enhance the social norms to adopt behaviours that reduce the risk of NCDs Civil society · Empower individuals and communities to manage and cope with existing burdens of NCDs through education, self-management to enjoy improved health and wellness. · Seeking opportunities for work place health promotion extending the concept of occupational health to cover the prevention of NCDs · Seeking opportunities for consultation and cooperation where Private sector appropriate (e.g. physical activity promotion, salt reduction, food product reformulation) · Seeking opportunities for resource mobilization (financing) · Setting standards and enforcing these as and where appropriate · Developing the capacity for health policy makers and civil society to understand the policy concerns of other sectors and to engage in meaningful and lasting dialogue · Health in All Policies takes into account health implications of decisions, seeks synergies, and avoids harmful health impacts, in Health order to improve population health and health equity. It ensures that the health implications of all policies are considered in the policymaking process, regardless of the sector in which the policies are being developed. It recognizes that public policies and decisions made in policy areas other than health have a significant impact on population health and health equity. 43

ANNEX 2: Summary of Responsible Organization for the Prevention and Control of — Summary of Responsible Organization for the Prevention and Control of

ANNEX 2: Summary of Responsible Organization for the Prevention and Control of NCDs and Risk Factors Stakeholders address Harmful use of Physical Tobacco Unhealthy Diet Risk Factors alcohol inactivity Ministry of Health & ○ ○ ○ ○ Environment Ministry of Education, ○ ○ ○ ○ Science & Technology Ministry of Agriculture, Lands, Fisheries and ○ ○ Barbuda Affairs Ministry of Trade, Commerce, Industry, Sports, ○ ○ ○ ○ Culture & National Festival Ministry of Foreign Affairs & ○ ○ ○ International Trade Ministry of Information, Broadcasting, ○ ○ ○ ○ Telecommunication & Information Technology Ministry of Public Utilities, Civil Aviation & ○ ○ ○ ○ Transportation Ministry of Tourism, Economic Development, ○ ○ ○ ○ Investment & Energy Ministry of Legal Affairs, Public Safety, Immigration ○ ○ ○ ○ and Labor Ministry of Works & Housing ○ ○ ○ ○ Ministry of Social Transformation & Human ○ ○ ○ ○ Resource Development Ministry of Finance & ○ ○ ○ ○ Corporate Governance NGOs, FBOs, Civil Society, Private Sectors, Academic ○ ○ ○ ○ Institute International Organizations: PAHO/WHO, UNCEF, FAO, ○ ○ ○ ○ UN Women, WTO, UNFPA, UNDP,CARPHA, IICA, JICA 44

ANNEX 3: Summary of Stakeholder Analysis — Summary of Stakeholder Analysis

ANNEX 3: Summary of Stakeholder Analysis collaboration to tackle NCD prevention and control Capacity (Human, Motivation to Political Possible Financial & Produce Influence Actions Technical Change resources) H: Medium High Strengthening Provide F: Medium multisectoral adequate T: High policies and resources actions for an (human, integrated financial, approach for technical); prevention and control of NCDs Provide leadership and coordination H: Medium Medium Strengthen Provide a F: Low holistic setting for T: Medium approach for supportive human environment development for children for Antigua and and network Barbuda with community H: High Medium Strengthen Provide F: Low infrastructure leadership and T: High development technical for food support for production for agricultural all development H: Low Medium Creating a Provide F: Medium culture technical T: High encompassing support for health, physical implementation activity and of the 45 healthy eating multisectoral action plan H: Medium High Strengthen Provide F: Medium compliance of implementation T: Medium the national support products and importations in line with WTO H: Medium High Increasing Provide health F: Medium awareness of information to T: High healthy various sectors lifestyle and both private prevention and and public control of NCDs H: Low High Ensuring Provide timely F: Low Antigua and technical T: Medium Barbuda legally review of comply with legislations Regional (Port related to NCDs of Spain to facilitate the Declaration) approval and process International Conventions H: Low Medium Strengthen Provide access F: Medium community to families at T: Medium linkage to risk and share address NCDs assessment and and risk factors referral mechanism to other sectors and agencies H: Medium High Executing the Provide F: Medium national budget financial T: High for cost- support for effective cost-effective impact programme on NCD prevention and control 46 H: High High To achieve Provide F: Medium ultimate UN technical T: High Goal support and guidance and resource mobilizations H: Low High Strengthening Provide F: Low multisectoral advocacy and T: Medium policies and support for actions through people living community- with NCDs based networking Provide partnerships, resource mobilization and networking H: High High Increase Provide F: High cooperate sponsorships T: High image and partnerships for NCD prevention and control programme H: High Medium Contribute to Provide F: Medium reduce technical T: High premature support for deaths due to research, NCDs and risk education and factors via publication on research NCDs prevention and control 47

ANNEX 4: REFERRENCE — REFERRENCE

ANNEX 4: REFERRENCE · Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978: http://www.who.int/publications/almaata_declaration_en.pdf · Ottawa Charter on Health Promotion 1986: http://www.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.pdf · WHO Global Strategy for Prevention and Control of NCDs (2000): 53RD WORLD HEALTH ASSEMBLY A53/14. Provisional agenda item 12.11 22 March 2000 · WHO Global Action Plan for the Prevention and Control of NCDs (2013-2020): http://www.who.int/nmh/events/ncd_action_plan/en/ · WHO Global Monitoring Framework ad Global Action Plan (2013-2020): http://www.who.int/nmh/global_monitoring_framework/en/ · WHO Framework Convention of Tobacco Control (2005): http://www.who.int/fctc/text_download/en/ · PAHO Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and Control of Chronic Diseases, 2007: http://www.paho.org/hq/index.php?option=com_content&view=article&id=5352&Itemid=400 41&lang=en · PAHO Plan of Action for the Prevention and Control of Noncommunicable Diseases in the Americas (2013-2019): Http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=2 7517&lang=en · PAHO Plan of Action for the Prevention of Obesity in Children and Adolescents, 2014: http://www.nutritotal.com.br/diretrizes/files/357--PAHO_planofaction.pdf · United Nation NCD Resolution, 2010: http://www.who.int/nmh/events/un_ncd_summit2011/resolutions/en/ · United Nation High Level Meeting: Political Declaration, 2011: http://www.who.int/nmh/events/un_ncd_summit2011/resolutions/en/ · CARICOM Port of Spain Declaration, 2007: http://www.caricom.org/jsp/pressreleases/pres212_07.jsp · Caribbean Cooperation in Health Phase III (CCH III): Regional Health Framework (2010 – 2015): http://www.caricom.org/jsp/community_organs/health/cch_iii_summary.pdf 48 49