National Multi-sectoral Non-Communicable Disease Strategy and Plan of Action for The Bahamas (2017-2022)

3. To reduce risk factors (i.e. tobacco use, harmful use of alcohol, physical inactivity, unhealthy eating, obesity) and promote healthy and active living throughout the life course;

4. To strengthen the health system (public and private sectors) at all levels, thereby improving equitable access to quality health services and financial risk protection; and

5. To improve the quality and scope of NCD and risk factor surveillance systems while strengthening operational research for planning, monitoring and evaluation of NCD- related policies and programs. The Plan through its five (5) Strategic Lines of Action will address the five modifiable behavioral risk factors that contribute to more than 80% of the global burden. The key strategic lines of action identified for tackling NCD prevention and control in The Bahamas are:

1. High level political commitment translating into actions: Attain heighten political commitment for NCD prevention and control through shared the values and responsibilities; foster inter and intra Ministerial communications; and strengthen monitoring and evaluation mechanisms for implementation of international commitments in a timely manner. Governance for NCD at the community level, including building alliances and net works, and fostering citizen empowerment: Engage and empower citizens and civil society to champion the adoption of healthy behaviors. Health in All Policies to build healthy and smart environments: Sensitize and build capacity for all Ministries to include health related issues in their national policies to create healthy and smart environments; enforce laws for health and implement effective fiscal measures to reduce risk factors National surveillance, research, monitoring and evaluation (M&E): Strengthen country capacity for surveillance and research on NCDs, risk factors, and determinants. Utilize research and M&E results to support evidence-based policy, pro- gram development (inclusive of academic programs) and implementation. Reorienting health services further towards prevention and care of chronic diseases: Improve coverage, equitable access and quality of care for the four main NCDs (i.e. cardiovascular diseases, cancer, diabetes, chronic respiratory diseases), mental health and other conditions of national priority. Emphasis will be placed on primary healthcare activities that include prevention and self-management. The Process Recognizing the burden of NCDs in the country, the Ministry of Health sought to facilitate the development of a roadmap that was multisectoral in nature and would define priority areas with realistic targets for intervention and implementation. Against this backdrop, an NCD Technical Working Group (TWG) (see Annex |) was established in May 2016. The work of this body included the data collection and analyses for framing the in-country epidemiologic profile of NCDs. In August 2016 the TWG engaged with a wide range of governmental and non-governmental stakeholders, with over forty (40) health and non-health actors representing both the public and private sectors (see Annex Il). Following a three (3) day conclave, the TWG and stakeholders arrived at five (5) strategic lines of action for The Bahamas. A draft Plan of Action was prepared and the updated document circulated to stakeholders for further input and concurrence. A Sub-Committee of the TWG continued to refine the Situation Analysis and the Plan of Action for finalization. The document was provided to senior officials and the Minister of Health for final review and approval. Introduction NCDs account for 36 million deaths globally each year; of these 9 million are among persons under 60 years. . Almost three quarters (28 million) of these are women. Among people under 60 years in low and middle income countries (LMIC), twenty-nine percent (29%) of deaths are due to NCDs compared to thirteen percent (13%) of deaths in high income countries. Most of these deaths occur after persons have experienced a period of illness, which more often than not posed a drain on family resources (Global Status Report, 2010). WHO estimates that sixty-three (63%) of global mortality in 2008 was due to cardiovascular disease, cancer and chronic respiratory diseases. It is estimated that by 2030, NCD will be the greatest killer in all LMIC (Robinson & Hort, 2012). Hospedales et al (2012) noted that in 2005 approximately 250 million people were said to be living with an NCD in the Americas. Another estimated 139 million (25%) of people 15 years or older were obese and 103 million of these were women. They also noted that by 2015 these numbers were expected to reach an estimated 289 million; 164 million of whom were projected to be women. The NCD burden falls more heavily upon those that are socioeconomically disadvantaged, whether in high or lower income countries. This leaves those who are poorer to be at greater risk for developing an NCD or related risk factor. Moreover, the subsequent loss of income and the associated healthcare costs drive them further into poverty. People in low- and middle-income countries tend to develop NCDs at younger ages, suffer lon- ger (often with preventable complications) and die sooner than those in high-income countries. Eighty-two (82%) percent of all deaths from cardiovascular disease (CVD) and over 90% of those from chronic obstructive pulmonary disease (COPD) occur in low- and middle-income countries (Global Status Report, 2010) (Figure 1). Males Females Figure 1. Global Prevalence of 12 Non Communicable Diseases among High Income Countries, Total deaths (millions) Low Income Countries, Males © and Females 6 Source: 4 Global Status Report on NCDs, 2010. 0 o U AFR AMR EMR EUR SEAR WPR low lower Upper: High- AFR AMR EMR EUR SEAR WPR low. lower Upper High- income middle middle- income income middle- middle- income income income income income Bi Injuries B Noncommunicable Communicable, maternal, perinatal diseases and nutritional conditions (Note: AFR=African Region, AMR=Region of the Americas, EMR= Eastern Mediterranean Region, EUR= European Region, SEAR=South-East Asia Region, WPR=Western Pacific Region). As individuals age, NCDs become the leading causes of morbidity, disability and mortality. A great proportion of healthcare needs and costs are concentrated in the latter years of people’s lives. An aging population and the NCD disease burden impose substantial costs on society. Address- ing chronic diseases and associated risk factors comprise a significant proportion of a country’s gross domestic product (GDP). Treatment costs, reduced income, early retirement and increased reliance on social safety-nets may be faced by the sufferer or caregiver. Employers, and society as a whole, bear the burden of absenteeism, reduced productivity and increased employee turn- over (WHO, 2012). The proportion of the Bahamian population 65 years and older is expected to be twelve (12) percent in 2030 - double that of its 2010 proportion. A myth that has been perpetuated by many is that NCDs mainly affect the rich, old people, or those living in the developed world. Unfortunately, these diseases are the cause for an increas- ing burden of disability, premature death, poverty and ill health growing globally inclusive of the developing world. The global burden and threat of non-communicable diseases constitutes a major public health challenge that undermines social and economic development throughout the world and, among other things, has the effect of increasing inequalities between countries and within populations (World Health Organization, 2013). Whether viewed through the CARICOM, or global lens, it is apparent that the non-communicable diseases (NCDs) continue to apply an exacting and in- creasing burden on individuals, families, societies, systems and economies. According to the Caribbean Community Secretariat (2011), the NCD epidemic that is currently being experienced in the Caribbean is the worst in the region of the Americas; causing much premature loss of life, loss of productivity and spiraling healthcare costs. Against this backdrop, the Pan American Health Organization’s Directing Council in 2006 urged its Member States to put in place policies and plans that will support a four pronged approach to tackling the growing number of persons affected by NCDs. This four pronged strategy involved (a) advocacy (b) surveillance (c) health promotion and disease prevention and (d) improved, in- tegrated management of chronic diseases and risk factors. Since this meeting, Member States have worked assiduously to reign in the devastating effects of NCDs. A major step in the fight is for countries to implement and operationalize a national Plan for the control and prevention of NCDs. Situation Analysis The Bahamas Socioeconomic and Demographic Profile The Bahamas is an archipelagic nation of 700 islands and 2,400 cays and rocks, with a land mass of 13,878 km? spread across 259,000 km? of ocean. It sits 760 miles off the coast of Florida; making it the closest country in the English-speaking Caribbean to the southern-most boundary of the United States of America. It is northeast off the coast of Cuba. Twenty-nine (29) of the islands are inhabited. The majority of the population (85%) reside on the main islands of New Providence, where Nassau the capital is located, and Grand Bahama. The remaining Is- lands are referred to as the Family Islands (www.bahamas.gov.bs). The Bahamas has a population of approximately 384,000; 82.7% of whom are Bahamians and 17.3% non-Bahamians. About 25% of the population is 14 years old or younger; while 42% are under the age of 25. Approximately 95% of the population is 60 years or older; 6% is 65 years or older; while the proportion of youth is expected to decline by the year 2030, the proportion of those 60 years or older is expected to increase by 16% by 2025. The proportion of individuals 65 years and older is expected to increase to 12% by 2030 (Department of Statistics, 2008). It remains one of the most stable and wealthiest countries in the Caribbean region. The per cap- ita GDP stands at $22,217 and the adult literacy rate of 95% are among the highest in the Ca- ribbean (World Bank, 2014). Education is compulsory for children between the ages of 5 and 16 years of age and free in the country’s 169 public schools. There are also 77 independent schools, a college (soon to become the University of The Bahamas), and other tertiary institutions, a Na- tional Training Agency and The Bahamas Technical and Vo-cational Institute (Vision 2040: The National Development Plan of The Bahamas). The Ministry of Social Services, the National Insur- ance Board and the Ministry of Labour oversee the country’s social protection systems. Tourism is the country’s main industry as it employs half the labour force. This industry directly and indirectly accounts for about 60% of the Gross Domestic Product (GDP). The financial ser- vices industry employs 10% of the population and generates 10-15% of GDP. In May 2015, the employment rate saw a decrease from 15.7% to 12%, while youth employment was 30%. A high percentage of the unemployed have not completed high school which makes them particularly vulnerable. In 2015, there were just under 4,000 discouraged workers who had left the job market; about 2,800 of whom had worked before (Department of Statistics, 2010). A young, diverse workforce is a valuable asset. High unemployment among youth can contribute to a reduction in social cohesion, loss of skills and a decrease in future employability. The aforementioned social determinants, among other factors, play a pivotal role in the level of health and wellness experienced by those in the nation. Healthcare in The Bahamas The country’s health sector is centralized with most of secondary and tertiary services provided on the major population centres (New Providence and Grand Bahama). Healthcare is provided by both public and private sectors. Basic healthcare is available to all people living in The Bahamas with care and services available for most illnesses and conditions. The public healthcare system is comprised of the Ministry of Health (MOH), the Department of Public Health and the Public Hospitals Authority. Ministry of Health (MOH) The Ministry of Health is headed by the Minister of Health, a Permanent Secretary, and Chief Medical Officer. The ministry provides governmental oversight; ensuring the overall development and regulation of the healthcare sector within The Bahamas. Additional functions include policy setting, regulatory and licensing functions, monitoring and evaluation of programs as well as monitoring of health conditions and services throughout the country. The MOH assumes direct responsibilities for the delivery of specific national pro-grams such as those for the prevention of HIV/AIDS and NCDs. Department of Public Health (DPH) The Department of Public Health is a government department under the Ministry of Health. It is governed by an Executive Management Committee comprising the Director of Public Health, the Administrator, Principal Nursing Officer and Medical Staff Coordinator. The committee has re- sponsibility for primary healthcare services provided via the community health clinics throughout New Providence and the Family Islands (excluding Grand Bahama). There are 106 primary care clinics (overseen by The Department of Public Health) for the provision of primary, secondary, and tertiary care. DPH also coordinates several national health programs, such as maternal and child health, oral health, school health, adolescent health, public health nutrition, the Expanded Program for Im- munization (EPI), family Planning, food handlers certification, national communicable disease surveillance and port health. Public Hospitals Authority (PHA) Established in 1999 as a quasi-government organization, the Public Hospitals Authority is gov- erned by a Board of Directors headed by a chairman. The Managing Director is the chief ex- ecutive who is assisted by a Senior Executive Committee (SEC). PHA is responsible for the management of the three government hospitals; the Princess Margaret Hospital, Rand Memorial Hospital and Sandilands Rehabilitation Centre. It also has mandated responsibility for the nation- al procurement of medical, surgical and pharmaceutical supplies; and operational management of the National Emergency Medical Services. The Princess Margaret Hospital is the primary public sector healthcare provider. It is located in the capital and is the largest health care facility in the country. It provides tertiary health care services in both inpatient and outpatient settings. There are 415 inpatient beds in addition to two private wards that have a total of 31 beds. Along with its general medical and surgical wards, the hospital also has a neonatal intensive care unit capable of holding 49 cots. The Accident and Emergency Department is classified as a level one trauma centre. In 2015, Princess Margaret Hospital (PMH), opened the new one hundred bed Critical Care Block which includes the new state-of-the-art Adult Intensive Care Unit, Neonatal Intensive Care Unit, Administrative Block, Theaters, Post-anesthesia Care Unit, Laboratory, Central Sterile Supplies Department, Medical Surgical Supplies Department and Chapel. The major primary provider of private inpatient services is Doctors Hospital (located in New Prov- idence with a bed capacity of 72 beds), which is staffed and outfitted for the provision of primary, secondary, and tertiary care. In 2011, the Bahamas recorded a total of 292 private, for-profit walk-in clinics (including the Lyford Cay Hospital). Healthcare Financing in The Bahamas Healthcare is financed by the general government health expenditure (GGHE), private health insurance (PHI) and out-of-pocket payments (OOP) at both public and private facilities. A minor role is played by the occupational health branch and National Prescription Drug Plan of National Insurance Board (NIB) and other external sources. GGHE is mainly financed through general taxation (Pinder, 2014). Table 1. Summary of Health Financing Statistics, The Bahamas (2013) ret 2013 a mts Millions $ GDP (SUS Current)" $8,367.0 General Government Expenditure’ $2,033.1 General Government Health Expenditure’* $385.4 47.6% Private Health Insurance (non-Government financed)” $205.9 25.4% Out-of-pocket expenditures’ $183.2 22.6% National Insurance Board: Occupational Health” $10.0 1.2% National Insurance Board: National Prescription Drug Pan” $9.5 1.2% National Insurance Board: Capital Health Expenditures $15.0 1.8% External Sources $1.0 0.1% Total Health Expenditure $810.0 100% Total Population (2013 estimate) 362,689 Total Health Expenditure as % of GDP 9.7% Per capita Total Health Expenditure $2,233 General Government Expenditure (Recurrent and Capital) as % GDP 24.3% General Government Health Expenditure as % General Government Expenditure 19.0% General Government Health Expenditure as % of GDP 4.6% Per capita General Government Health Expenditure $1,063 Per capita out-of-pocket health expenditures $505 Source: ‘World Bank and / or IMF, “Ministry of Finance, *Insurance Commission of The Bahamas, “Based on Department of Statistics 2013 Household Expenditure Survey, °National Insurance Board *Including public expenditures on private health insurance. **Estimate based on previous years’ expenditures. Source: Sanigest Internacional, 2014 The Government of The Bahamas has over the years steadily increased its allocation to health, with 19% of all government expenditure assigned to health; and total health expenditure contrib- uting 9.7% of the GDP; putting The Bahamas among the top five countries in the region with the highest Total Health Expenditure (THE) as percentage of their GDP (Figures 2 and 3). Figure 2. Total Health Expenditure for The Bahamas, 2001 - 2013 $900,000,000 19.0%, 20% $800,000,000 xe + 18% 16.4% 16.6% 16.1% = — - 16% 700,000,000 ~ seen “External $600,000,000 - _ (14% co NIB Health Total » 12% “OOP 500,000,000 ani “8 PHI (non-public financed) 10% $400,000,000 "=Total GGHE 8% ame THE as % of GDP $300,000,000 i : ; | a | gy “O"GGHE as % GGE $200,000,000 - 7 1 : rz - 4% $100,000,000 2% $- 7 7 + + r 7 7 : ~ 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: Sanigest Internacional, 2014 Figure 3. Comparison of Total Health Expenditure in Latin America and the Carib-bean, 2013 12 5 ; $2,500 lami THE as % GDP 10.9 THE 10 | # 9.7 1° 10.1 a | $2,000 9 ac ®9 fl | > 7.9 8,0 8.1 8.2 i | 3 s 8) 7.27.3 7S | tar 5 = 3 6.7 6.8 ; » $1,500 : 5 2 gy np ho nese St SSI Sane 5 5 6 5.25.3 54 | s a 4.8 4.9 4.9 4.9 7° = 3 oc 44 $1,000 = a4) E 2 e =z = e 2- $500 0° 2<epesegexyxugeezegeseese goes ss s2geree sss ww > gs 2s 8 s- 5 3 ZoweE R=} eLVTsS UL s 3 = ® c gE of @o 3 2 se SEE EER SESESES SESS ESRF SEES EES ES 2 S724 g° ase gees g sees af 28 8 = «a Ke © => ~ - O&O i“ = os - ood zl 2 2 § F a = a se £- < #£ < £ Source: Sanigest Internacional, 2014 Even with such allocations, life expectancy in The Bahamas is three years less by comparison with countries whose THE is less than half of that of The Bahamas. Figure 4. Per Capita Health Expenditure and Average Life Expectancy in Latin America and the Caribbean, 2013. $2,500 85 MQ THE “Life Expectancy Total Health Expenditures per Capita (Current $US) $2,000 Average Life Expectancy (At birth) $1,500 $1,000 70 - ill oO © 2 Oo . xr of Ra oe > SS 2 FP © FF F 2 FS 0 SF Pe EROAL, eee 2 See ve ee~ Lo ss eSoe SS ¢ ‘oe Hf xe SEF WE Se2 @ Ss < yw ‘ © és g>Wg 2 oe oo — ?” > ° So ¥ * SS nS s * * se Source: Sanigest Internacional, 2014 Non-Communicable Disease Profile The Bahamas is a young nation of 43 years, yet it is plagued with and in many cases, outstrips nations that are many years its senior when it comes to climbing trends and prevalence of NCDs and related risk factors. Over the past two decades, The Bahamas has emerged as an inter- national and regional forerunner in NCD related morbidity and mortality. NCDs are the leading cause of death and disease in The Bahamas. According to the Pan American Health Organiza- tion’s 2012 Country Profile for The Bahamas, 30% of deaths for those under the age of 70 years can be attributed to NCDS. When compared to 35 other countries in the Americas, The Bahamas ranked first and fifth for the percentage of NCD deaths for males and females, respectively, under the age of 70 years (WHO, 2013) (Figure 5). Figure 5. NCD Deaths under 70 years of Age as a Percentage of all Deaths | 29.8 "| wp 256 = 20.4 ‘ 0 | 18,5 14.9 15 5 + ;0° HH II li PLPUUERL ; EET ESUTE EE GSEUEE EE 9 . 9 3 Go ¥ aot - giaaugesé Gab ogagth es ag, |3 SSE ‘8 G g 6 $3 5° § ; a - t 3 E g 4 dj t < : : Source: Sanigest Internacional, 2014 The Bahamas is classified as a high-income country (HIC) by the World Bank. This is largely owing to the small pockets of wealthy Bahamians and permanent residents. The Global Status Report on Non-Communicable Diseases (using a statistical modeling approach, 2014) compared with fifty-three (53) HIC on many of the modifiable risk factors associated with NCDs. The Baha- mas ranked 4th, 12th and 36th in its prevalence of obesity, diabetes and hypertension. The sta- tistically derived prevalence was lower than the population-based study derived prevalence for the selected risk factors (Table 2). It should be noted however that population derived prevalence provides a more accurate national representation than statistically derived prevalence. Table 2. Global and Bahamas NCD Prevalence, 2014 & 2012 Prevalence From| Prevalence From NCD Global Status Bahamas STEPS Report (2014) Survey (2012) Obesity 36.2 49.2 Diabetes 12.8 23.9 Hypertension 22.1 34.3 Source: 1. NCD Global Status Report, 2014, 2. Planning Unit, MOH, The Bahamas STEPS Survey, 2012 The STEPS prevalence rates translates into 84,524 Bahamian diabetics and 121,305 Bahamian hypertensives, a significant number of whom still remain undiagnosed or, if diagnosed, not in care.! It is apparent that NCDs and related risk factors pose a great threat to healthcare services and expenditure in The Bahamas but also undermine health gains and impose grave financial and economic costs on its government and households. The Cost of Inaction The Bahamas’ response to its NCD epidemic has been at best, sluggish and disjointed. In the international arena, fiscal policies geared at investing in health have been touted as one of the best options for meeting and improving national economic objectives, recognizing that investing in health takes place both inside and outside the ‘health sector’. 1 These numbers were calculated using the Department of Statistics Population Census (2010) which was 353,658. Health is a precursor for a number of economic outcomes such as wages, earnings, the amount of hours worked, labour force participation, early retirement and the labour supply of those giv- ing care to household members who are ill. Whereas the relationship between health status and earnings has existed at least since the early 1960’s, The Commission on Macroeconomics and Health (CMH) notes that only in recent times has important advances in understanding this relationship come to light. Inarguably, the more healthy a people are, the greater their social participation; the more produc- tive they are, the more they are able to contribute to the development of the nation’s economy across generations. The degree to which The Bahamas is able to make successful in-roads in its health promotion and disease prevention strategies, will have profound implications on counter- acting the direct? , indirect? and intangible* costs of delayed action or inaction at the individual, societal and national levels. Literature supports that good health increases the probability of participating in the labour force; while on the other hand poor health negatively affects wages and earnings. Healthier individuals with a longer lifespan in front of them would have greater incentive to invest in education and training, as they can harvest the associated benefits for a longer period. However, studies ex- ploring the role of health in a specific country over one or two centuries has shown that a large share of today’s economic wealth is directly attributable to past achievements in health®. Education is also a critical component in labour force performance. Human capital theory sug- gests that individuals who are more educated are also more productive and obtain higher earn- ings. Good health in childhood enhances cognitive functions and reduces school absenteeism and early drop-out rates. Hence, children with better health can be expected to attain higher educational levels and therefore be more productive in the future. A review of the literature sup- ports the hypothesis that high education levels and lower incidence of illness are associated with higher wages and, by implication, higher labour productivity (Fukui and lwamoto, 2003). Tuft (1975) highlighted that the overall impact of poor health on earnings is large with the average sick person aged 18 - 64 years suffering thirty-seven (37%) percent reduction in yearly earnings. This loss owing to the result of poor health impinges on all the components of earnings: labour force participation, weeks worked per year, hours worked per week and earnings per hour®. Laplagne, Glover and Shomos (2007) found that ill health has a significant negative effect on workforce participation, impacting both individual labour market performance and that of house- hold members who may be forced to adjust their labour market behavior in response to another household member’s illness. Averting or successfully treating chronic illness was estimated to increase the probability that a person would be in the workforce by up to 30 percentage points (Australian Government Pro- ductivity Commission, 2010). Ill health Is of concern not only for the labour market performance of the individual directly concerned, but also for that of the household members, who have been found to adjust their labour market behavior in response to another household member’s illness. DX) Direct costs refer to costs falling on the health sector in relation to prevention, diagnosis and treatment. w Indirect costs typically measure the lost productivity potential of patients who are too ill to work or who die prematurely. There is no concise on the measurement to be applied for estimating indirect cost. wK Intangible costs capture the psychological dimensions of the illness to the individual (and their family) — particularly pain, bereavement, anxiety and suffering; and is usual hard to measure. Harold S. James. The Impact of Poor Health on Earnings. The Review of Economics & Statistics Vol.57, No.1 pp 43-57. aa Hourly wages can be used as an indicator for labour productivity. There is a significant and robust role for ill health in supporting the decision to retire from the labour force. Poor health increased the likelihood of retirement by fourteen percent (14%) to eighteen percent (18%), with those in poor health choosing to enter retirement between one (1) to three (3) years earlier than workers in good health with similar economic and demographic characteristics (Sammartino, 1987). Poverty is closely linked with NCDs. The increasing trend in NCDs then is predicted to impedes poverty reduction initiatives in The Bahamas particularly by forcing up household costs asso- ciated with healthcare, while simultaneously contributing to losses in productivity, increases in absenteeism, and an increase in Disability-adjusted life year (DALYs). The social burdens of NCDs in The Bahamas, in line with global and regional experiences, range in a number of areas such as premature deaths, prolonged disability, reduced productivity, loss of income, diminished resources within households, increased social tensions, greater demands on the health systems and loss of capital formation, among other socio-economic strains’. The aggregate cost of inaction is likely to result in economic pressures too great to sustain Uni- versal Health Coverage (UHC), compromised psycho-social economic states and a shrinking human capital pool. Box 1: The Cost of Diabetes Related Hospitalization® 926 diabetic related hospitalizations Average length of stay ranged from 6.4 days (underlying condition) to 7.9 days (primary diagnosis) Estimated hospitalization cost = $2.6 Million Estimated drug cost = $400K Estimated hemodialysis cost = $3.3 Million Projected laboratory cost = $200K 7 Symposium on NCD and Related risk factors: An Inter-sectoral Approach — The Report (2013) 8 Symposium on NCD and Related risk factors: An Inter-sectoral Approach — The Report (2013) If The Bahamas continues on this trajectory it will outstrip its fiscal space, financial capacity and social structures to bear the direct, indirect and intangible costs of NCDs. It is probable that The Bahamas’ fiscal elasticity may not be able to accommodate unfettered increases in the GGHE and THE. NCD Mortality Rates and Premature Deaths The measure of health of any nation is typically evaluated in terms of life expectancy or adult mortality. In 2011, life expectancy at birth is 6.2 years longer for females (76.8 years) than males (70.6 years). The mean life expectancy is 75 years and 83 years®, respectively for the top 10 per- forming OECD territories. Globally, sixty-three (63%) percent of all deaths in 2008 were attributed to non-communicable diseases, more than all other causes combined. Disaggregated, forty-eight (48%) percent of these deaths were cardiovascular disease specific, twenty-one (21%) percent cancer specific, twelve (12%) percent for chronic respiratory disease specific and three and a half (3.5%) percent diabetes specific (World Health Organization, 2013). Simply, NCDs are the world’s biggest killers. NCDs are the biggest killers worldwide and likewise in The Bahamas. Nationally published data supports the crucial role NCDs play in cumulative mortality in the country’®. Of the six leading causes of death in The Bahamas, NCDs account for four of them (with AIDS and external injury deaths rounding out the top six). Figure 6 paints a worrisome picture; not only are NCD diseases leading the rates, but also that these rates have increased. Figure 6. Trends in Selected Leading Causes of Death, All Ages, Both Sexes (Rate per 100,000 Population), Bahamas, 1994 - 2012 180 4 160 Heart Disease 140 ~ = & 120+ Ss Malignant Neoplasms 8 Ss 100 Ss a. NY, y . 80 + x 3 a XN External Causes e = ®~ - « « in oN nny ~ 60 N orm Te! s o? Ny ,¢ \ ee AIDS : ‘ “~~ - Cerebrovascular Disease 40 | >aCS 0 | —\/ ~ Z~ — 0 1994 | 1995 | 1996 | 1997 | 1998 | 1999 | 2000 | 2001 | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 e==te=e Heart Disease 92.7 | 102.9} 94.4 | 107.3 | 104.5 | 105.6 | 117.4 | 125.3 | 159.8} 119 | 133.1) 135 | 125.3 | 122.8 | 130.9 / 150.1 | 140.3 | 152.1 | 119.9 AIDS 88.3 | 97.1 | 100.7} 95.2 | 90.9 | 92.9 | 80.4 | 86.9 | 63.7 | 55.7 | 49.9 | 48.6 | 56.4 | 39.8 | 346 | 38 | 29 | 34.1 | 30.4 Malignant Neoplasms (Cancer) 86.8 | 85.3 | 70.1 | 86.9 | 90.6 | 80.1 | 71.5 | 92.7 | 92.6 | 98.7 | 84.8 | 89.2 | 86.8 | 93.7 | 104.9 | 106.6 | 106.7 | 109.6 | 102.6 == External Causes* 65.2 | 39.8 | 42.6 | 57.4 | 62.7 | 58.3 | 71.2 | 52.1 | 45.5 50 50.2 | 63.4 | 54.6 | 64.1 | 62.1 | 65.1 66 73.2 65 —e== Diabetes 34.8 | 36.2 | 40.1 | 30.4 | 43.2 | 28.8 | 34.4 | 34.2 | 14.4 | 34.8 | 27.1 | 29.2 | 29.7 | 28.1 | 24.2 | 36.5 | 28.7 | 24.2 | 30.4 Cerebrovascular Diseases (Stroke)| 37 | 46.6 | 29.2 | 49.5 | 46.6 | 36.5 | 26.9 | 32.2 | 13.1 | 33.8) 39 | 41.8 | 31.9 | 37.7 | 43.7 | 40.3 | 41.8 | 36.6 | 41.8 External Causes was previously termed "Accidents, Violence, and Poisonings". Source: Health Information and Research Unit, MOH, 2014 9 What does it mean for The Bahamas to become one of the top hearties countries in the world by 2030? August 2016 10 Rates sourced from Department of Statistics, The Bahamas. The death rates show gender differences. However for both genders, deaths due to heart dis- ease captures the number one spot. The mortality rate of ischemic heart disease was 28.7 per 100,000 inhabitants 2008. For strokes this rate was 59.3 per 100,000 inhabitants, (Ministry of Health, 2012). Ages 30 - 69 years are considered to be the productive years. Yet in The Bahamas, seventy-one (71%) percent of deaths in this age group were caused by NCDs with fifty-seven (57%) percent premature deaths being caused by the four leading NCDs - cardiovascular diseases, neoplasms, diabetes and respiratory diseases (PAHO, 2011), in order of descending burden (Figure 7). Figure 7. Percentage of Premature Deaths (30 -69 years from 4 major NCDs (2011) Percentage of premature deaths (30-69 years) from 4 major NCDs (2011) Females Males 17% 21% 2% 40% 7%, a 4% 33% 26% i Cardiovascular diseases i Respiratory diseases i Malignant neoplasms Others Diabetes mellitus Source: PAHO 2011 Country Profile In addition to gender differences, there are also age-specific differences in The Bahamas’ NCD profile. Those aged 5 to 24 years are more likely to die from land transport accidents, assaults and HIV (Dept of Statistics). The profile shifts for those aged 25 and older, likely reflecting lifestyle and behavioral choices. Taken together, 196.9 per 100,000 persons in the Bahamian population died of an NCD, or relat- ed complications (Figure 8). Figure 8. Death Rates Per 100,000, Persons 25 Years and Older FS AIDS Hypertensive diseases Ischemic heart diseases Malignant neoplasm of prostate Diabetes Malignant neoplasm of female Homicides Septicaemia Cerebrovascular diseases Influenza and Pneumonia breast Source: Primary Health Care Report, 2014, Prepared by Planning Unit, MOH Age-specific subtleties exist between the younger adults when compared to the middle aged and the elderly populations, bearing out that with advanced age comes the greater likelihood of demise due to a NCD and/or related complication(s). Notably, in 2012, Bahamians between ages of 25 to 44 years died at rate of 121.4 per 100,000 as a result of NCDs and/or related complica- tions (Figure 9). Figure 9. Death Rate Per Population, Persons Aged 25-44 Years. Cirrhosis and other diseases of Malignant neoplasms of Accidental drowning and Ischemic heart diseases Cerebrovascular diseases AIDS Land transport accidents Diabetes Heart failure and complications Homicides and ill-defined heart disease submersion liver female breast Source: Primary Health Care Report, 2014, Prepared by Planning Unit, MOH This is contrasted with a rate of 354.2 per 100,000 Bahamians in those 45 to 64 years who died of an NCD and / or related complications (Figure 10). Figure 10. Death Rate Per 100,000 among Persons Aged 45 - 64 Years 100.0 90.0 80.0 70.0 60.0 50.0 40,028:0 30.0 77 64.4 62.3 55.5 20.0 33.9 10.0 28.4 23.0 21.7 21.7 0.0 a wo 5 n w a s ° 7. w a 2 a a & s 4 ‘c & 3 3 2 < £8% 3 2 S$2 2 s go 9— Se6 3€ e a8 : : 8 8 5 o gs co = 3 82 3G g2 73 §3. 432 $23 28 2 £ 26 2 5 £5 < aos 2 ee 8 2 32 & ces 5 % = 52 & g = 3& g& 232 fio s S 2 e o = 2 Zg Sut 23 4a oO 3 = ge = = =a =6 EZz Source: Primary Health Care Report, 2014, Prepared by Planning Unit, MOH Even more glaring is the death rate observed in 2012 for the elderly population, those aged 65 years and older, which stood at 2,327.6 per 100,000 (Figure 11). Figure 11. Death Rate Per 100,000 Persons Aged 65 Years and Older. 600.0 500.0 400.0 300.870.5 480.4 200.0 449.3 413.7 320.3 100.0 182.4 129.0 97.9 93.4 93.4 3£ 38 g 3 go €6 ©E sg, 8 0.0 a o a o 3 o 2 € = < g 23 8c &‘o & 2 2 = & Ss s 28 . © s ag Tb TB SG a a o 2 os 8 or o ev . c Zé a < ato os > o © a Bo a Ea wo co s s “3 a“ a Bs 29 ¢ 2 3 zB ca BE 52 5 c 8= 2= 8 > & o 8wo a8 og 3S .S 2= & a 2 8 s ef < g g 2 o a eu ¢ = £ v = 3 5 =3 a a co SO € o 2 & = BE a aa = Source: Primary Health Care Report, 2014, Prepared by Planning Unit, MOH This data and narrative strongly supports the epidemiological conclusion that the quality of the health behaviors and decisions made earlier in life have downstream impact in the latter years of life. Modifiable NCD Risk Factors The WHO among other health organizations affirms that the vast majority of NCDs can be pre- vented through effective interventions that tackle the key shared risk factors, namely: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. In 2005, The Chronic Non-Communicable Disease and Risk Factor Survey Fact Sheet (The Baha- mas) reported that just under three quarters (70.6%) of the population were overweight or obese, and less than half (43.1% ) were obese. The 2012 Survey found that over three quarters (79.6%) of respondents were overweight or obese, with just under half (49.2%) of the overall population being obese. Prevalence increased in almost all risk factor dimensions from 2002 to 2012", and in many instances have doubled and tripled over the seven (7) year period (Figure 12). Figure 12. Comparison of Prevalence of NCD Risk Factors, 2005 & 2012 120 5 100 79.6 *° 70. 60 7.1 58.2 49.2 43. 40 N 3.9 2005 50 16.7 a 8 ™2012 7. : i 9. 0 jwaliy 1 1 1 1 Current Alcohol Use Obesity Insufficient Fruits & Veggies Diabetes Overweight Current Smoker Clinical Hypertension Clinical Hypercholesterolemia Meals Eaten Outside Home Sedentary Lifestyle Source: The Bahamas’ NCD Risk Factor Survey (2002) and the STEPS Factsheet (2012) 12 Data sourced from The Bahamas’ NCD Risk Factor Survey (2002) and the STEPS Factsheet (2012) These findings also showed an increasing trend towards overweight and obesity that is continu- ing to grow at a concerning rate. The implication of these findings suggests that Bahamians, by and large, are challenged to make healthier choices. The genesis of this is no doubt rooted in knowledge as well as cultural practices and the availability of healthy choices. It should be pointed out however that even in the face of adequate knowledge; the effect of other factors, specifically social determinants cannot be negated. The levels of literacy, employment, poverty, and national security along with enabling infrastruc- ture, protective policies and legislation within society, all have direct linkages to the pursuit of health. Undeniably overweight and obesity remains a biological risk factor for many NCDs that are modifiable through physical activity and a healthier diet. Five main modifiable behavioral risk factors have been identified as contributing to over 80% of the burden of NCDS in The Bahamas as well as globally. These are (a) Nutrition linked to insuffi- cient fruits and vegetables, (b) tobacco smoking, (c) harmful use of alcohol, (d) physical inactivity, and (e) cancers. Nutrition and Insufficient Fruits and Vegetables Consumption’? According to the 2012 STEPS survey, fruits are incorporated into Bahamian meals on an average of 3.9 days of the seven days of the week. Vegetables fare slightly better; being incorporated on an average 4.5 of the seven days. In both cases, the number of days fruits and vegetables were consumed increased with age, indicating perhaps that older persons, aged 45 — 64 years see the value in eating healthier; either because of a change in thinking, experience with illness or due to an appreciation of the aging signs and the desire to regain youth. On average from a gender perspective, females incorporated fruits and vegetables more into their daily diets than males. Bahamians reported having 1.1. and 1.2 servings of fruits and vegetables per day respectively; with was no significant difference between genders. However, as with the number of days con- sumed, the number of servings increased with age to 0.9 servings in the 25 — 34 age groups compared with 1.4 servings for those 55 years and older. Regardless of whether days consumed or number of servings per day is used as a measure, Bahamians fall short of even the minimum servings of fruit and vegetable intake. Experts recom- mend that each individual consumes 5 to 9 servings of fruit and vegetables per day. Net per capital food production in The Bahamas has essentially plateaued, with the agricultural sector contributing less than two (2%) percent to the national GDP, between the years 2000 —

2009. On the other hand, between 1995 and 2012, the food import bill escalated by almost sixty percent (60%) from US$232.37 million to US$570 million. Recent estimates suggest that the country’s import bill is approaching US$ 1 billion’? . Greater than 95% of its food comes from external markets; with most of the imported food components being calorie-dense refined car- bohydrates (pastry, flour), and foods high in fats, sweeteners and sodium. Fruits and vegetables account for only 19% of total food imports. Such a high food import bill poses both a risk and a barrier to The Bahamas’ journey to wellness. 12 Inadequate serving of fruit and vegetables is defined as less than five (5) servings per day. And, meals eaten outside the home is qualified as five or more per week eaten out of the home. 13 IFAO STATS, 2015 The ease of availability and relative affordability of these calorie dense, high sugar, high salt and nutrient poor diets have contributed significantly to the burgeoning of obesity, diabetes, hyper- tension, stroke, heart diseases and cancer and related risk factors. As a signatory to the Port of Spain Declaration (2006), The Bahamas does not levy taxes/tariffs on imported fruits and vegetables. However, there is a growing concern that this lack of taxation largely benefits grocers and wholesalers, with little to no cost savings being handed down to or felt by the consumers” . At a three day NCD Symposium held in New Providence in 2013, with over one hundred multi-sector stakeholders in attendance, the lack of price control was cited as a very plausible barrier to the transfer. Additionally, the implementation of a 7.5% Value Added Tax (VAT) by The Bahamas Government, at point of purchase is also suspected of contributing to increasing prices and food availability. Moreover, the ‘Bread Basket’ introduced by The Bahamas Government in 1975, includes price controls for approximately twenty (20) items which are very high in fat, salt, starch and refined sugar. These include products such as butter, mayonnaise, margarine flour, grits, rice, sugar, tomato paste, broth and soups and canned milk, and highly processed canned meat and fish. Currently there are no mechanisms for the price control of food items that have substantively greater nutritive value. This is viewed as a major gap, and preliminary collaborations with internal partners are underway to advocate for revisions of the current Bread Basket to items of greater nutritive value. Tobacco Smoking In 2012, seventeen (16.7%) percent of Bahamians smoked tobacco products which is more than double the 2002 prevalence. With passing generations, the influence of globalization and the ease of connectivity with the global village, becomes more apparent within the confines of our aquatic boarders. Undisputedly Bahamians are increasing their level of exposure to western and eastern philosophies, societal norms, cultures and practices, via direct travel or through the power of the internet. These ex- posures are not without inherent vulnerabilities, such as greater visibility of tobacco products advertisements/images, along with the marketing of fast foods and sugary beverages. In The Bahamas, men reported greater use of tobacco products than their female counterparts. In fact, men outnumber women 4 to 1 as non-daily smokers and 4 to 1 as daily smokers. For those men who smoke, smoking practices were greatest in the 25 — 34 age range (38.5%) and the 45 — 54 age range (83.3%); perhaps attributed in part to greater susceptible to pressure and the perception of maleness during the earlier years; and, perhaps in the latter years because of mid-life. Females smoked more around age 45 — 54 years, which coincides with the entrance into mid-life and menopause. Further men begin smoking sooner than women; and smoke for a longer period of time. A mean smoking history of 20.6 years is significant however; and likely speaks to the addictive nature of tobacco products. Smoking practices peak for males earlier, between 25-34 years. On the other hand, females smoking practices peak among the 45-54 age grouping. Overall, smoking practices decrease with age. 14 Report from NCD Symposium (2013). Harmful Use of Alcohol The harmful use of alcohol is a known risk factor for non-communicable diseases, particularly cancers, heart disease and strokes. Over sixty-five (65.6%) percent of Bahamians consume al- cohol, with the remaining thirty-four (34.4%) percent having never consumed alcohol. There are varying levels of alcohol consumption; category |'®, category II'® and category Ill'”. Categories Il and Ill are associated with harmful use of alcohol. Amongst current alcohol drinkers, 70% of Bahamians fall within these categories and thirty eight (38%) percent consumed alcohol on 4 or more days. Alcohol consumption is an increasing trend with age in both sexes. Noteworthy is the fact that females far exceed males in the harmful use of alcohol. Almost three (2.5%) percent and five (5.2%) percent of females were category II and category Ill drinkers, respectively as compared to males at 1.3 and 1.8 percent. Moreover, more females reported consuming alcohol with meals than males - sixty-three (63.1%) percent and fifty-three (63.2%) percent, respectively. Taken to- gether, one third of all current drinkers consumed alcohol with meals; this practice was seen to increase with age. Of all the risk factors, current alcohol use is the only one that has seen a decline between 2002 and 2012 by almost thirty (28.5%) percent. While this is encouraging from a national picture, vulnerabilities peculiar to our Family Island communities may be obscured in this generalized national picture. Initial data from a national Health Inequities Study suggests that rate of drug and alcohol dependences among many of the Family Islands exceed that of New Providence. Local reports completed by Sanigest indicate that 5.5% of the Bahamian population over the age of 15 years has received an alcohol related diagnosis (ICD F10 and F10.2). Furthermore, in the same year, 2.8% of those in the same age range were diagnosed with alcohol dependence. The average rate with a twelve month prevalence for the top 10 OECD countries was 1.4%'8. Physical Inactivity Sedentary lifestyle as an NCD risk factor is of growing concern. A growing body of research shows that long periods of physical inactivity raise the risk of developing heart disease, diabe- tes, cancer, and obesity. In January 2010, British scientists linked prolonged periods of sitting to a greater likelihood of disease. In fact, people with sedentary lifestyles have the highest rate of heart attacks; have a 14% increased risk of developing Type 2 Diabetes; and are more prone to strokes and cognitive decline along with breast and colon cancer’?. Dunstan et al (2010) noted participants who watched at least 4 or more hours of TV per day daily had an 80% increased risk for cardiovascular disease-related death and a 46% higher risk of death from all causes when compared with those who watched less than 2 hours a day. Each hour an individual spends watching TV, there is an 18% increased risk of cardiovascular disease— related death and an 11% increase of death from all causes. Overall levels of physical inactivity in The Bahamas remain high and continue to grow. In 2012 it stood at seventy-three (72.6%) percent, an increase of fourteen (13.9%) percent over 2005. When categorized as low, moderate and high/vigorous physical activity, the gender differences in the level of physical inactivity anong Bahamians paint a worrisome picture. Over sixty (63.2%) 15 Category | is defined as drinking <40g of pure alcohol on average per day for men and <20 for women. 16 Category Il is defined as drinking 40-59.9g of pure alcohol on average per day for men and 20-39.9g for women. 17 Category Ill is defined as drinking =60g of pure alcohol on average per day for men and =40 g for women. percent of females compared to thirty-seven (36.7%) percent of males are physically inactivity. Furthermore, females spend significantly less time (55.8% less) per day engaging in physical ac- tivity than males, who on average spend 164.3 minutes engaged in physical activity. As age and immobility set in, the average of daily physical activity for both sexes is almost halved from 129.2 minutes per day for those 25 — 34 years to 62.4 minutes for those 55 — 64 years. When analyzed based on the degree to which work, transportation and recreational activity con- tribute to total physical activity, it was found that activity related to the work environment con- tributed the most — for males fifty-eight (58.3%) percent and females thirty-four (34.1%) percent. Risk Factors Among Our Youth In all of the risk factor domains, our school-aged population and youth tell a similarly disturbing story as demonstrated in Figure 13. The Global School Health Survey (GSHS) completed in 2013 with a study population of 1357 school-aged children (age range 13 to 15 years) in New Provi- dence and selected Family Islands. Figure 13. Findings of the GSHS, 2013 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Overweight 45% Obese 21% Go hungry 7% Active for 60mins everyday | 16% Drank 21 carbonated drinks per day 69% Consume salty foods > 2X per day | 42% 1st alcoholic drink before age 14 86% Tried cigarettes before age 14 86% Ever used drugs 15% Made a suicide plan 16% Attempted suicide 14% Ever had sex 33% Source: Planning Unit, MOH 18 Sanigest Internacional, 2016. What It Means for The Bahamas To Become One of The Top Ten Healthiest Countries in The World By 2030? 19 http://www.nchpad.org/403/2216/Sedentary ~Lifestyle~is~Dangerous~to~ Your~Health Most notable are the findings around the youth overweight and obesity in The Bahamas with 44.7% of respondents overweight2° and 21% of respondents being obese?'. Obesity and being overweight are most commonly associated with the risk factors of unhealthy diets and limited physical activity. Results of the survey indicated that a high percentage of youth eat too little fruit and vegetables, drink too many sodas and eat fast food on a regular basis. Many students do not walk or ride a bicycle to or from school and many spend at least three or more hours per day sitting, outside of school and when engaged in homework. In The Bahamas 28.6% of adolescents between the ages of 13 and 15 years old had at least one drink containing alcohol on one or more of the past 30 days. Among students that have ever had a drink of alcohol, 85.9% had their first drink before the age of 14 years old. A correlation was found between alcohol consumption in the past 30 days and selected mental health questions. There are concerning outcomes regarding mental health. Nineteen percent (19.3%) of the stu- dents reported having seriously considered attempting suicide in the past 12 months of the study, sixteen percent (16.3%) made a Plan about how they would attempt suicide during the past 12 months of the study; and fourteen percent (13.6%) actually attempted suicide one or more times during the past 12 months of the study. Underlying this, a correlation is found be- tween those students that sat or engaged in sitting activities and have a higher instance of re- porting worrying that prevented sleep, suicide contemplation, suicide planning, and even suicide attempts (GHHS, 2013). Cancers Cancer is among the ten leading causes of death in The Bahamas. Cancer of the breast was the leading cause of death in women 45-64 years of age in 2011 and cancer of the prostate was the third leading causes of death in men 65 years of age and older in 2011 (Figure, 13 ). The Bahamas has been documented as having the highest prevalence of the BRCA-1/BRCA-2 gene mutation in women with breast cancer worldwide at approximately 27%. This mutation has been linked to increased incidence of breast cancer. Figure 14. Ten Top Cancers in The Bahamas, 2010 - 2014. 140 4 80 60 40 20 - 0 ld abisnnse Ski in Doh te Uterus, Ovary, Vag ina Blood Disorder Breast Cervix Gastric Prostate Colorectal Head & Neck Lung Source: PMH Cancer Registry. Prepared by Planning Unit, MOH ™2010 ™2011 2012 ™2013 2014 20 >+1SD from median for BMI by age and sex 21 >+2SD from median for BMI by age and sex Non-Communicable Disease Morbidity Primary Care Visits A review of country data suggests that when compared to the level of care being sought, the vast majority of visits to health centres were of individuals seeking primary care services. In 2012 sev- enty-seven percent (77%) of all visits (including visits to community and outpatient clinics) ex- cluding hospital admissions, were made to primary care. Between 2013 and 2016, eighty (80%) to eighty-five (85%) of all visits to public health institutions were made at the primary care level?2. This reality, is not mirrored in the budgetary allocations for primary care. Over the last decade, funding for public sector primary care through the Department of Public Health has been dis- proportionately low and declining when compared to the public sector healthcare allocation for tertiary care in The Bahamas. Between the fiscal years 2011 to present, the Department, which is responsible for the vast majority of primary care, has received no more than fourteen (14%) percent of the total recurrent health budget. During this same fiscal interval, PHA has received no less than 79% of the total recurrent health budget for these three institutions (Figure, 15). Despite the fact that PHA performs minimal primary healthcare, through its Agape Clinic and Grand Ba- hama Community Health Services, its core function is as a tertiary institution with responsibility for national emergency medical services and procurement of medical . Figure 15. Comparison of Government Allocations of Recurrent Expenditure 2011-2017 N uw o Millions 199 200 201 201 a0e 200 ~ 179 186 150 = DPH PHA 100 ~ MOH 53 50 ~ 31 32 35 33 34 34 3 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 Figure Source: www.bahamas.gov.bs. Prepared by Planning Unit, MOH 22 Ministry of Health 2015/2016 Mid-term Budget Contribution, Dr. M. Perry Gomez (March, 2016) Based on the Health Information and Research Unit (HIRU) categorization of health visits, the highest average visit volumes are seen for Other clinic visits (60%), child health (18%) and school health (12%) respectively. These are followed by domicillary visits (10%), antenatal (7%) and postnatal (3%). “Other” visits account for fifty (50) percent of all visits to the community health centres. These “Other” visits encompass an array of clinical conditions as well as unspecified symptoms. In total, thirty (83) conditions/symptoms are named in this category. The number of visits to the community health clinics fluctuated between 449,693 in 2002 and 516,490 in 2012. In 2013 however the number of visits began to decline and continued to do so up until the time that the 2014 data was released. New Providence and Grand Bahama together account for eighty-five (85%) percent of the pop- ulation of The Bahamas; however the distribution of visits do not follow this population pattern, with Family Island visits accounting for forty-two percent (42%) of all outpatient/community visits. In-depth analysis indicates that although overall clinic visit volumes remain high, some clinic visit types have seen negative growth. Domiciliary and “other” clinic visits showed forty — six percent (46%) and fourteen percent (14%) positive growth respectively (Figure 16). Figure 16. Percentage of Clinic Visits by Type, 2002 -2014. 80% 30% 46% 14% -20% o = = = 86 =© =© 8© = oO < @ o c 3 = g x = 3 £ 2 c so S ° -70% 9 a =Oo < =S = 9 ~ -8% “i -33% -120% -34% -175% -170% -220% Source: HIRU Primary Healthcare Report. Further analysis of the data reveals that forty-four (44.3%) percent of all “Other” Clinic visits in 2014 were for NCD related concerns. Additionally, for the same year, nearly 31 (30.7%) percent of all domiciliary visits; fifteen (15%) percent of all School Health visits; and nearly twenty-eight (27.7%) percent Child Health visits were specific to an NCD. Although NCDs accounted for one-third of the community clinic load/volume in 2014 (which is an 8.5% increase over the previous year), when juxtaposed with the actual prevalence of NCDs and related risk factors and the best practice clinical guidelines for diabetes, hypertension and hypercholesterolemia, it becomes immediately clear that thirty-three (83%) percent visit volume for NCDs is under-represented. With this understanding, and extrapolating the current burden of NCD-related visits to commu- nity health centres (Figure 17); the assumption can be made that the primary reason for at least thirty-three (33.2%) of all visits are due to NCDs, their risk factors and complications. Figure 17. Total clinic Visits Attributed to NCDs, 2002 - 2003 30.0 25.0 24.4 24.2 25.8 25.8 25-50 2942024. 24.7 20.0 213 22.2 22.7 15.0 10.0 5.0 0.0 2002 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: HIRU Primary Healthcare Report. NCD In-patient Morbidity and ALOS Statistics related to in-patient morbidity is another means by which the health and well- being of a population can be determined. Hypertensive diseases, diabetes and cancers remain the most prominent causes for inpatient morbidity. In 20072, these three conditions ranked among the leading causes for in-patient morbidity and accounted for nearly eight (7.6%) percent of total admissions to the PMH and RMH. More impor- tantly though is the increasing trend in admissions due to NCD related conditions. CAREC CNCD Report (2010)?4, which reflected data from three of the four tertiary healthcare institutions in The Bahamas (PMH, RMH and DHHS), noted that myocardial infarction, strokes, COPD and diabetes together accounted for eight (8.1%) percent of total hospital discharges (Table 3). Table 3. Percentages of Total Discharge from PMH, RMH and DHHS, 2010 Percent Total Discharges ALOS (days) All Hospitals, 2010 | All Hospitals, 2010 ———————————————————————————————————————————— Myocardial Infarction 0.9 4.3 Strokes 2.2 9.8 COPD 0.6 5.2 Diabetes 4.4 9.8 Source 1: HIRU. Source 2: PHA. Source 3: Doctor’s Hospital In the same Report, men over the age of 25 years disproportionately contribute to these statistics (Figure 18). Possibly suggesting that males have poor health-seeking behaviours, and only seek care at either very late stages of the disease process or when very severe symptoms manifest. Figure 18. Percentage of Total Discharges for Selected Diseases by Gender 7.0 6.0 6.4 5.0 4.0 Males 25 to 64 3.0 Females 25 to 64 2.7 2.8 2.0 1.0 1.4 0.9 0.3 07 0.3 0.0 MI Strokes COPD DM 23 2007 is the latest year for which complete coding has been done for the PMH 24 Report published in 2010, using 2007 data Inpatient Morbidity Through the Lens of Renal Health and Lower Extremity Complications NCDs are not without complications, from strokes to speech, physical and visual impairment to failing kidneys and extremity amputations to sexual dysfunction, to name a few. Renal Health According to the Chronic Kidney Disease (CKD) classification system, CKD stage 3 is equated to moderate kidney damage and CKD stage 4 more advanced stage. Stage 4 warrants discussions between the healthcare provider and patient advising of the possibility of and educating on the initiation of either hemodialysis, peritoneal dialysis or a kidney transplant. At CKD stage 5 a pa- tient requires kidney replacement therapy. CKD 3, 4 or 5 is more prevalent in females compared to males in The Bahamas (67% vs 33%; 62% vs. 38%; 55% vs. 45%, respectively). This was consistent for 2014-2016. In regards to age, public sector outpatient clinic referrals for CKD 3-5 in the 50-70 age group was most prevalent. What is striking, however, was the increasing number of younger patients with the diagnosis of advanced CKD (stage 4 and 5) in the 20-49 age group. In 2014, 25% of patients who presented to the outpatient specialty clinic with stage 5 CKD, 27% in 2015, and 16% in 2016 were all under the age of 50. The relatively low number of visits related to CKD-3 and CKD-4 likely supports the assertion that patients either present late with advanced stages of the disease process and/or the delayed/late referrals of CKD patients from primary care and other physicians to a Nephrologist. Patient visits for CKD-5 are triple those for the other two disease classifications. The three major culprits of end-stage renal disease (ESRD) in The Bahamas are diabetes, hy- pertension and aging. A Bahamian consultant nephrologist attributes diabetes and hypertension related ESRD to “poor diet and poor compliance with medication”. There are six (6) dialysis centres in the country, one (1) in Grand Bahama, one (1) in Marsh Har- bour, Abaco and four (4) in New Providence, one public and the others private. The centres at Princess Margaret Hospital and Grand Bahama carrying the greatest load. In 2013, there were 1,883 patients receiving dialysis at the PMH Dialysis Unit. In July 2016 two hundred and eighty one (281) patients were seen at the private dialysis centres. Leading Nephrologists in The Bahamas posit that renal transplantation is the preferred treatment for chronic renal failure. Compared to dialysis, transplantation is significantly cheaper with better quality of life and longer patient survival. The first kidney transplant was performed in The Baha- mas in 1996. In 2006 a renal transplant service was established in The Bahamas at a private sector facility, the Doctors Hospital, with the intent to provide renal transplantation from living related donors. In the intervening seven (7) years since its establishment, more than seventy (70) renal dialysis dependent patients have been identified in The Bahamas. However, due primarily to affordabil- ity gap, donor ineligibility and limited donor matches, only twenty-three (23) Bahamians have received kidney transplants in the public sector (8.7%), private sector (13%) and in the U.S.A through referrals from local dialysis centres (78.3%). Transplants were funded through patients’ private insurance Plans. Some factors/ problems encountered in CKD patient population * Denial of their kidney disease and having risk factors for kidney disease * Fear of dialysis is a major hurdle. Patients think going on dialysis is a death sentence * Poor dietary habits * Poor medication compliance * Lack of knowledge about their disease ° Late referrals of CKD patients to a Nephrologists from Primary Care Physicians Lower Extremity Amputations and NCD-related Lower Limb Vascular Com-plications Lower extremity complications including debilitating peripheral neuropathy, ulcers and amputa- tions, remain the most common reason for hospital admissions and also contribute to increased length of stay at Princess Margaret Hospital (Mitchell, 2010). It has been estimated that at any given time more than one third of all surgical beds are occupied by diabetics with lower extremity complications. According to hospital discharge data from Princess Margaret Hospital for the period 2002 - 2006 there was an average of 100 lower extremity amputations per year (Mitchell 2010)25. Between 2008-2010, there was a total of 553 discharges to the Princess Margaret Hospital with a primary diagnosis of diabetes and a secondary diagnosis of at least one concomitant lower extremity complication including Peripheral Arterial Disease (Critical Limb Ischemia, Gangrene, Rest Pain, Claudication); lower extremity ulcer or wound; Diabetic Foot; Diabetic Peripheral Neu- ropathy; Charcot Neuroarthropathy; Abscess; Infected; or Septic wound/foot, Cellulitis, and Os- teomyelitis. The mean age was 58.6 years and the gender distribution was 54% (296) female and 46% (256) males. Average length of stay for persons admitted for diabetes and a concomitant lower ex- tremity diagnosis was 10.37 days. Within this two-year period, 137 lower extremity surgical procedures were performed, represent- ing (24.8%) of the persons admitted having had a surgical procedure during their admission. Below Knee Amputations were the most commonly performed procedure (35%) followed by toe (digital) amputation (21%), wound debridement (15%) and trans-metatarsal (foot) amputations (14%). Incision and drainage and above knee amputations were less likely to be performed at 9% and 6%, respectively. Mental Health Mental disorders are independently associated with excessive mortality. Despite the suggestion that global mortality data are under-estimated, a report completed by WHO (2005) attributes about 1.2 million deaths per year to mental, neurological and substance abuse disorders (mostly caused by Dementia, Parkinson’s disease and Epilepsy). Approximately 40,000 of these deaths associated with mental disorders (mainly unipolar and bipolar depression, schizophrenia and post-traumatic stress disorder); and 182,000 to use of drugs and alcohol (Prince et al, 2007). 25 Diabetes Related Lower Extremity Complications in The Bahamas (2008-2010), Dr. Monique K. Mitchell Mental disorders also exact a significant economic impact. In 2010, globally the estimated cost of mental illnesses was around $2.5T (two-thirds in indirect costs), with an anticipated increase to over $6T by 2030 (Bloom et al, 2011). Notwithstanding the global disease burden, mental disorders continue to be the most ignored and under-funded health concern. WHO estimates that approximately 75% of persons living with mental health problems in low income countries have no access to suitable health services (WHO, 2008b). Moreover, the ratio of mental health providers in low and middle income countries is alarmingly low. Adequate numbers of psychiatrists and psychiatric nurses are critical not only for the delivery of specialist services, but even more importantly for quality assurance and super- vision of primary care providers; inter-sectoral cooperation with the education, social welfare and criminal justice systems; and for training, service development and leadership. The WHO recommends scaling up the management and treatment of mental illnesses into pri- mary healthcare settings in countries with limited resources. The medical literature provides strong rationale for integrating mental health services into primary care. This amalgamation will above all improve health outcomes and ensure that greater numbers of persons gain faster and easier access to mental health services. Further, it will improve prevention and early detection of mental disorders; reduce mental health stigma and discrimination; improve social integration; and enhance human resource capacity to deliver mental health services (WHO, 2007). While there is limited empirical evidence to delineate the true burden of mental health disorders in the Bahamas, the considerable increase in health services utilization provides strong justifi- cation that mental illnesses are a growing public health concern. Between 2002 (2,267 annual visits) and 2011(3,215 annual visits), there is a 42% increase in the number of visits due to mental disorders at the Primary Health Clinics. The community psychiatric centre recorded a five year average annual visits around 19,000 and 1,165 new client visits (mostly females) between 2009 and 2013. During the same period, Sandilands Rehabilitation Centre (psychiatry) consistently re- ported occupancy rates above 88%. Schizophrenia was the leading cause of inpatient morbidity at SRC during 2010 -— 2015, followed by Mood [Affective] Disorders and Mental & Behavioral disorders due to substance abuse; these conditions accounted for 5,189 discharges over the noted period. The Bahamas, like its global counterparts, is challenged by considerable deficits in its mental health workforce. Additionally, as a result of our geographic make-up, we are also stretched to provide equitable access to mental health services. Presently, the national ratio of mental health physician (serving in the public sector) stands at 5.97 per 100,000 population, which is 2.6 times less than the benchmark (15.6 per 100,000 population) established for OECD nations. Further, these mental health professionals provide services on the more populated islands (New Provi- dence and Grand Bahama) of the country. A scarce mental health workforce poses a substantial barrier to the improvement. of mental health services or agenda for scaling up mental health services. This barrier requires a strategic approach to human resource development, retention and deployment. Mental Health GAP Action Programme (mhGAP) Pilot In 2013, the Mental Health Gap Action Programme (mhGAP) was piloted to improve care by pro- viding an avenue for early detection and treatment of mental health. At the conclusion of the pi- lot, a total of 32 clients (with 43 encounters) met the pilot inclusion criteria. The study population was primarily female (61%). The mean age was 33 years, ranging from 17 to 78 years old. The overwhelming majority (81%) of clients were unemployed. As expected, New Providence clinics provided care to half of the study population, Grand Bahama (13%) and Family Island clinics (Abaco + Andros) (88%). Clinicians provided a pri-mary diagnosis of 53% or seventeen (17) of the total clientele (82) seen during the study period. Of those clients with a diagnosis, fifty-three percent (53%) of clients received a diagnosis of schizoaffective disorder, twelve percent (12%) alcohol misuse, and twelve percent (12%) anxiety disorder (Figure 19). Figure 19. MhGap Pilot Primary Diagnosis Related to a Mental Health Disorder. Depression with suicidal Suicidal intent 9, thoughts 6% Anxiety Disorder 6% 11% psychosis 6% bipolar disorder Alcohoh misuse 6% 12% Schizoaffective disorder 53% Suicide Suicidal intent and Depression with Suicidal Thoughts represented twelve percent (12%) of pri- mary diagnoses in the mhGAP pilot, this is cause for national concern. The Government has responded to the increase in the number of reported suicides by appointing a National Suicide Task Force to study and design a national strategy to address this social epidemic. For the period 1994 -— 2009, the number of suicides and suicidal related events in The Bahamas has remained fairly constant over time. However, the rate of inpatient and outpatient mental centre discharges at the public hospitals indicates a rising trend. Between 2010 — 2012 forty-two (42) inpatient discharges with a suicide associated diagnosis (this includes attempted suicides, inten- tional self-harm and suicide ideation) were reported at Rand Memorial Hospital. Princess Margaret Hospital reported twenty-four (24) suicide attempts between 2011 and 2012. At Sandilands Rehabilitation Centre, an average of 278 inpatient discharges with a suicide as- sociated diagnosis was recorded annually for the same period. Community Counselling and As- sessment Centre data indicates that new patients seen with suicide associated diagnoses have increased between 1996 and 2006 (the greatest increase was observed in 2004 with a 172% increase). When considering gender differences, it was noted that a greater proportion of males attempted suicide than their female counterparts. Additionally, females were more likely to present at Com- munity Counseling and Assessment Centre for suicidal associated diagnosis than males. This presents an opportunity for addressing how the healthcare system can encourage more men to access the mental health services available at this and other health facilities. Although the mhGAP pilot is not fully representative of the entire population, if taken as a snap- shot of the state of the country’s mental health, the results suggest that the strengthening and expansion of mental health services is in dire need of focused attention. Addressing known risk factors inclusive of alcohol and drug abuse through sustainable programmes and initiatives at the primary care level is a positive first step towards improved mental health outcomes. These and other socio-economic risk factors such as poverty, unemployment and other ineq- uities in health, discussed in greater detail in relevant sections of this NCD Plan all impact the mental health and well-being of the individual. The identification of existing health system gaps that may impede access to mental healthcare should assist in the development of programs to address systemic mental health challenges. The design and implementation of effective intervention programs based on risk and protective factors; review of institutional policies for provision of psychiatric care; greater collaborative ef- forts toward full integration of mental health services into primary care settings; strengthening of hospital-based information systems to identify all suicide related events; and aggressive an- ti-stigma Campaigns are but a few system-wide initiatives for improving the level of mental health services available to this vulnerable population. The Bahamian Response National Health Services The Ministry of Health (MOH) is mandated with public health services financing; health policy development and planning; regulation and monitoring; development and implementation of na- tional public health programs; and the provision of community health services. The Minister of Health leads a myriad of government institutions and regulatory bodies associated with health in The Bahamas. The Department of Public Health (DPH) within MOH is charged with surveillance, development, implementation, and coordination of national health programs, and the delivery of primary care services (except in Grand Bahama which falls under the ambit of the PHA). The Public Hospitals Authority (PHA) is administered by a Board of Directors accountable to the Minister of Health. The PHA is charged with the responsibility of the three public hospitals, the National Emergency Medical Services, the Bahamas National Drug Agency, and the Materials Management Directorate. In 2015, Princess Margaret Hospital (PMH), opened the new one hun- dred bed Critical Care Block which includes the new state-of-the-art Adult Intensive Care Unit, Neonatal Intensive Care Unit, Administrative Block, Theaters, Post-anesthesia Care Unit, Labo- ratory, Central Sterile Supplies Department, Medical Surgical Supplies Department and Chapel. The country’s health sector is centralized with most of secondary and tertiary services provided on the major population centers (New Providence and Grand Bahama). In the public sector, the delivery of healthcare and services is carried out by a network of health facilities that includes three hospitals (Princess Margaret Hospital, Rand Memorial Hospital, and Sandilands Rehabilita- tion Centre); and 106 primary care clinics (overseen by The Department of Public Health) for the provision of primary, secondary, and tertiary care. In 2015, the total public and. private hospital bed capacity stood at 995, representing 28 hospital beds per 10,000 population. The major primary provider of private inpatient services is Doctors Hospital (located in New Prov- idence with a bed capacity of 72 beds), which is staffed and outfitted for the provision of primary, secondary, and tertiary care. In 2011, the Bahamas recorded a total of 292 private, for-profit walk-in clinics (including the Lyford Cay Hospital). Policies And Other Enabling Environments Successive Governments of The Bahamas have committed to providing healthcare and services within the public sector regardless of ability to pay. There does exist though a fee structure that is applied to registration, diagnostics, laboratory and other point-of-care services to all patients ex- cept the elderly, civil servants, those seeking antenatal care, the indigent and children. Though the fee structure exists and is applied, collection rate of such fees is low and inconsistent. The National Insurance (Chronic Diseases Prescription Drug Fund) Act, 2009 of The Bahamas establishes a Chronic Diseases Prescription Drug Plan the primary objectives of which shall be — (a) to increase access to cost effective drugs for the treatment of specific chronic diseases and specified medical conditions such as Diabetes Mellitus, High Cholesterol, Hypertension, Isch- emic Heart Disease and cancer; and (b) to reduce the financial burden of beneficiaries in respect of the purchase of prescription drugs and specified medical supplies. 4 Currently, approximately 70% of Bahamians do not have health insurance, meaning have to pay for health services out of their own pockets. With the average Bahamian paying approximately $2,300 per year out of pocket on healthcare, this something many people simply cannot afford?6. The Bahamas is currently undertaking the process of implementing National Health Insurance (NHI), as the funding mechanism for Universal Health Coverage, to completely remove such fees for care and services. The first phase of implementation will focus on the delivery of primary care. It should be noted that the implementation of NHI is accompanied by four (4) major health sys- tem reforms as outlined in the budget debate contribution by Minister of Health Dr. Perry Gomez?’. These initiatives includes: * Transformation of MOH into a stronger regulatory authority with improved stewardship for the entire health sector (public and private); * Introduction of the Single Governance Structure (SGS) for all public healthcare providers (integration of PHA and DPH into a single entity); * Implementation of national Standards of Care in both the private and public sectors; and * Enactment of WHO’s “Health-In-All Policies” to foster relations with all the other Ministries in Government:- Agriculture, Transportation, Social Services, Housing, Labour, National Security, Telecommunication, Ministry of Works, Tourism, Education and Finance to ensure that new policies take into account the impact of each new policy on the effective delivery of healthcare to the population. Against this backdrop, The National Health Insurance Bill (2016) was passed in the House of Assembly in August, 2016. The Act makes provisions to implement a National Health Insurance Plan, to establish a National Health Insurance authority, and to establish a National Health In- surance fund. Taken together, the Bill will ensure that all legal Bahamian residents — no matter your income, age, island of residence or current health status can receive healthcare free of cost at point of service. Currently, approximately 70% of Bahamians do not have health insurance, meaning they may have to pay for health services out of their own pockets. With the average Bahamian household paying approximately $2,300 per year out of pocket on healthcare, this something many people simply cannot afford. The National Health Insurance Authority (NHIA) will be established to oversee implementation of NHI Bahamas. Other Enabling Policies Specific to NCDs: | ¢ The Health Services Act, 1914 ¢ Agriculture and Fisheries Act, 1963 ¢ National Insurance Act, 1972 (Amendment 2010) ¢ Health Services (Tobacco Advertising and Sales) Rules, 1976 ¢ National Insurance (Chronic Diseases Prescription Drug Fund) Act, 2009 Box 2: © The Trade Marks Rule/Act, 2015 Legislation with NCD * Tobacco Control Bill, Drafted 2014 components ¢ The Excise Act, 2103 (Amendment 2016) Enabling Policies ¢ The Healthy Bahamas Coalition, 2016 26 http://www.nhibahamas. gov.bs/understanding-nhi-bahamas/ 27 Budget Debate Contribution 2015/16 by Dr. Gomez. Accessed from http://myplp.org/2015/06/12/ ~ gomez-universal-healthcare-will-come-to-our-bahamaland/ on January 15, 2016 eS Multisectoral Plan of Action (2017-2022) Goal/Outcome The ultimate goal is to achieve a 10% relative reduction in preventable premature deaths due to NCDs in the Bahamas by 2022. Objectives

1. To strengthen coordination and management of NCD prevention and control;

2. To promote integration of NCD prevention policies, frameworks and actions through multisectoral approaches;

3. To reduce risk factors (tobacco use, harmful use of alcohol, physical inactivity, unhealthy eating, obesity) and promote healthy and active living for health and well-being through life course approach;

4. 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

5. 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. Strategic Lines of Action In consideration of challenges and gaps identified in the area of NCD prevention and control in the Bahamas, the broad strategies were discussed and agreed upon in line with the PAHO Re- gional Plan of Action for the Prevention and Control of NCDs. The key strategic lines of action identified for tackling NCD prevention and control in the Bahamas are:

1. High level political commitment translating into actions: Attain heighten political commitment for NCD prevention and control through shared values and responsibilities; foster inter and intra Ministerial communications; and strengthened monitoring and evaluation mechanisms for implementation of international commitments in a timely manner.

2. Governance for NCD at the community level, including building alliances and networks, and fostering citizen empowerment: Engage and empower citizens and civil society to tackle national health crisis

3. Health in All Policies to build healthy and smart environment: Sensitize and build capacity for all Ministries to include health related issues in their national policies to create healthy and smart environment; enforce laws for health and/or, implement effective fiscal measures to reduce risk factors

4. National surveillance, monitoring and evaluation, and research: Strengthen country capacity for surveillance and research on NCDs, related risk factors, and their determinants, and utilize the results of research to support evidence-based policy, academic programs, and program development and implementation (improving health system, educating citizens)

5. Reorienting health services further towards prevention and care of chronic diseases: Improve coverage, equitable access, and quality of care for the four main NCDs (cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases), mental health and others of national priority, with emphasis on primary health care that includes prevention and strengthened self-management support. RESULTS FRAMEWORK Level Objectives Indicators/Target Means of Verification Critical Assumption (What to achieve) (Measuring change) (Where & How to get (Be aware of) information) Outcome Achieve a 10% relative | A 10% relative reduction | * Registrar General Resource mobilization is reduction in the mor- of premature mortality Office a shared value tality from major NCDs_ | due to NCDs by 2022 * CMO Report (cardiovascular diseas- PAHO/CARPHA NCD Commitments are made es, cancer, diabetes, Minimum data set for the strengthening of and chronic respiratory Report enabling environments diseases) by 2022 MOH will All sectors recognize their role in addressing NCDs Conduct national peri- odic health surveys Line of Action 1 e = Agreed Interna- # of International Universal Health ¢ Cabinet will en- High level political tional Commit- signed Declarations, Coverage Laws en- dorse legislations commitment translat- ment(s) shared and Treaties, and Reso- forced ing into actions and Parliament implemented with- lutions etc. imple- Tobacco Control Act will enact the bills in a specific time mented (e.g. FCTC, framework GMF, Post 2020 enacted ¢ NCDs are elevat- Agenda for SDG, Convention Secretar- ed on the na- CCH IV, Political iat FCTC Report tional priority Declaration for (Global Status Report NCDs, POS Declara- agenda for Tobacco Control) tion etc.) ¢ Advocacy for NCD WHO Global Status Current baseline prevention and Report for NCDs total health ex- control stems penditure for health from the political promotion and dis- domain ease prevention de- termined * Capacity exists to At least 30% in- ensure estima- crease above base- tions for NCD line of total health prevention and expenditure allocat- control expendi- ed for health pro- Level Objectives Indicators/Target Means of Verification Critical Assumption (What to achieve) (Measuring change) (Where & How to get (Be aware of) information) motion and disease tures prevention and con- trol programmes and initiatives Line of Action 2 Citizens engaged Needs assessment HBC Annual Report Appropriate Governance for NCD at and civil society conducted and cri- # of LOA and/or budget allocated the community level MOU exchanged empowered to teria and TORs de- and empowerment of with civil and coop- for specific com- tackle national veloped for com- civil society erate society munity-based civ- health crisis (NCDs munity leaders and risk factors) il society activi- Guidelines and ties Standards for com- munity-based pro- Government grams developed agreement for and operationalized subventions to supported by HBC such programs At least 1 active NGO and corpo- champion per com- munity trained and rate Bahamas fi- in place nancially sup- ports such com- Number of costed munity based community-based programs programs Number of activities conducted related to NCD prevention and control in each community Level Objectives Indicators/Target Means of Verification Critical Assumption (What to achieve) (Measuring change) (Where & How to get (Be aware of) information) Line of Action 3 ¢ Healthy and smart At least 3 sectors Enacted national leg- ¢ Key Ministries Health in All Policies to environment avail- outside of health islations, policies, and civil society build healthy and able for all citizen sector collaborate in regulations smart environment work together to in the Bahamas the development Annual report of HBC develop Health in and implementation of the multisectoral All Policies policies ¢ Civil society will Shared-budget for support devel- implementation of opment and im- multispectral poli- plementation of cies provided from HiAP to create various sectors healthy and A mechanism for smart environ- regular reporting ment from non-state sec- tors to the Ministry ¢ HiAP workshop is of Health estab- supported and lished attended by vari- At least one HiAP ous ministries workshop conduct- and agencies ed before 2022 Line of Action 4 Sustainable and quality High-quality, na- Annual report of PA- MOH will establish sys- National surveillance, assured surveillance tional mortality data HO/CARPHA NCD tematic data collection monitoring and evalu- system developed and for the 4 main NCDs Minimum Data Set mechanism (surveil- Level Objectives Indicators/Target Means of Verification Critical Assumption (What to achieve) (Measuring change) (Where & How to get (Be aware of) information) ation, and research research for timely and collected lance, survey) on mor- effective policy and ¢ STEPS Survey tality and morbidity due programme develop- Annual reports with to NCDs. ment conducted analysis on NCDs ¢ DOS Annual Report and risk factors pro- The existence of an duced and dissemi- ¢ Compilation and dis- agreement to Data Shar- nated semination of CMOs ing Policy for NCDs be- Report to relevant tween the MOH and the At least one nation- stakeholders private health sector ally representative population survey ¢ Implementation of Adequate human and by 2022 conducted national cancer regis- financial resource will try be allocated for national Information system surveillance. to report on dietary patterns, and over- National Health Re- weight and obesity search Council becomes of a nationally rep- operational and speci- resentative sample fies NCDs as an area of of pregnant women research interest/focus and school-aged children and adoles- cents, every 2-3 years established Research agendas that include opera- tional research stud- ies on NCDs and risk factors for strength- Level Objectives Indicators/Target Means of Verification Critical Assumption (What to achieve) (Measuring change) (Where & How to get (Be aware of) information) ening evidence- based policies, pro- gram development set Line of Action 5 Sustainable health National adoption ¢ Assessment of National NCDs pro- Reorienting health system response to model of integrated Chronic Illness (ACIC) tocols reviewed, services further to- management for Report updated, aligned prevent and con- wards prevention and NCDs scaled up (e.g. with NHI guidelines trol NCDs across all care of chronic diseas- Chronic Care Model) ¢ ~=Arevised edition of and ratified. es age groups essential medication List of cost-effective list An integrated man- essential medicines agement of NCD for NCDs updated ¢ Annual report of #0 prevention and Con- and available screenings for can- trol in place, de- cers prepared fined by a Plan and At least 52% of pa- solidified by agree- tients with hyper- ments from relevant ¢ Protocols for periodic tension and diabe- agencies health check-ups, tes controlled timely detection of Commitment from 75% of NCDs clients risks and threats, and Cabinet for appro- the treatment of managed according priate budget for to the integrated health problems NCD prevention and model control secured ¢ Report of clinical da- A 10% relative re- ta addressing older Stakeholders duction in age- persons (NGOs, FBOs, pri- standardized preva- vate sectors) sup- lence of raised ¢ Research conducted ported and “Buy-in” blood pressure on service delivery interventions for and perception of NCD prevention and Level Objectives Indicators/Target Means of Verification Critical Assumption (What to achieve) (Measuring change) (Where & How to get (Be aware of) information) A5 % relative re- care in older popula- control duction in age- tion standardized preva- A mechanism for lence of raised data collection at blood glu- PHC and hospitals cose/diabetes and reporting estab- lished A 80% of women (aged 30-49) re- MOH developed ceived cervical can- National Guidelines cer screening in the and Protocol for last 3 years cancer screening At least 80% of and management of women (aged 40- risk factors for 69) received breast NCDs, which are ac- cancer screening cepted and ratified At least 50% of NHI by private sector providers having partners primary health care services incorporat- ing family-oriented obesity prevention activities including healthy eating and physical activity A national hospital certified (accredit- ed) BFHI by 2022 Strategy to optimize services for older adults in PHC devel- oped Prevention and con- trol of chronic dis- eases and other health problems of older persons im- proved Activity Plan Strategic Line of Action 1: High level political commitment translating into actions Strategies Activities Performance Indicators Sensitization and lobby for NCD pre- Policy and Multisectoral Action Plan approved and budget allocated vention and control to remain a na- tional priority to the Cabinet Mem- Passage of UHC and FCTC legislations Advocacy Bets Sensitization for civil society about # of sensitization, national campaigns, awareness conducted important role and responsibilities of civil society to support political commitment translating into actions Strengthen capacity of technical Specific roles, responsibilities and tasks for implementation of Multi- staff to implement the Multisectoral sectoral Action Plan and International Commitments identified, defined Build capacity for Action Plan for NCD Prevention and and ratified. technical units in- Control and International Commit- ter-intra Ministries ments (e.g. FCTC, GMF, SDG etc.) # of training conducted Assess national capacity, progress WHO Assessment Report of National Capacity for NCDs by every 2 made and challenges for prevention years Routine monitoring and control of NCDs and report to and evaluation the Cabinet Members and socie- Progress report (M&E) for implementation of agreed International ty/citizens Commitments disseminated to Cabinet and wider stakeholder group Strategic Line of Action 2: Governance for NCD, including building alliances and networks, and fostering citizen empowerment Strategies Activities Performance Indicators Conduct Stakeholder meetings with various sec- Assessment of stakeholders conducted tors for “buy-in”, engagement and partnership for implementation of the programme # of signed MOU/LOA exchanged between the MOH and different partners Develop guidelines and standards for community- guidelines and standards developed by the HBC Engagement & based programs and operationalize Networking Conduct dialogue with other Ministries, private Policy and Plan of Action widely disseminated and dis- sectors, NGOs, FBOs in understanding policies/ cussed action Plan, and developing joint programmes for implementation Conduct capacity building for communities # of capacity training conducted (NGOs, FBOs etc.) At least 1 active champion per community trained and in place # of community programs or workshops done Empowerment Revitalize the Healthy Bahamas Coalition with # of capacity training provided for the HBC Members clear understanding of Terms of Reference to co- ordinate response to NCDs via multisectoral ap- Terms of Reference reviewed and revised based on needs proach assessment Strategic Line of Action 3: Health in All Policies to build healthy and smart environment Strategies Activities Performance Indicators Sensitize the Government and civil society for # of sensitization, awareness, public education con- share the values of “Health-in-All Policies” and its ducted implementation via “Whole-of-Government” and “Whole-of-Society” Collaborate with at least 3 sectors outside of health approaches sector in development and implementation of the multisectoral policies Conduct sensitization and public awareness for Budget allocated for alcohol reduction awareness ac- alcohol-attributable burden and reduce the harm- tivities ful use of alcohol and tobacco use particularly youth and adolescents # of sensitization, public awareness and education conducted Advocacy Lobbying for increasing taxes on alcohol, tobacco, Taxes increased and tax revenue utilized for subsidy SSB, EDNPP and increase subsidy for fresh fruits for locally grown organic produce and vegetables Conduct national campaign, awareness and public # of educational campaigns conducted and assessed education for prevention and control of obesity (particularly focused on childhood obesity) includ- ing healthy diets and physical activity Conduct sensitization and public education for salt # of sensitization, educational campaigns conducted reduction and assessed Conduct community-based but nation-wide # of partners beyond health sector engaged Awareness Week for Healthy Living (Caribbean Wellness Day, Health & Wellness Week etc.) # of community-based activities and impact assessed Develop effective Communication Strategies for Communication Strategies, packages, slogans, mes- specific target groups to effectively address reduc- sages developed tion of risk factors Make a “Brand” of such communications via social marketing approaches Implement WHO FCTC (particularly protect people Tobacco Control Legislation enacted, implemented from tobacco smoke, health and danger warning and enforced on package, banning tobacco advertisement and fiscal measures) Analyze the existing legisla- Various legislations/policies/regulations reviewed and tions/policies/regulations and adapt, adopt and amended (such as alcohol legislation) amend as necessary to improve protective envi- Strengthen legisla- ronment from risk factors exposure Enforcement of such legislations, regulations tive framework strengthened and support Develop and implement a National School Health National School Health Policy adopted Policy and Action Plan in line with WHO Health Promoting School via multisectoral approaches # of schools joined WHO Health Promoting Schools Adapt CROSQ CARICOM Standard on food labelling The Bahamas adapted CARICOM Standard and develop front-of-package labelling system to assure quality of foods Strategies Activities Performance Indicators Disseminate approved National Food Nutrition Se- National Food Nutrition Security Policy enacted ad im- curity Policy (draft) and FBDG widely for improving plemented healthy diets and healthy choices #of educational training conducted using FBDG Analyze available data on breast feeding, identify Report prepared and at least 50 % of mothers exclu- the gaps and develop action Plan for strengthen- sive breast feeding ing exclusive breast feeding Incorporate recommendations for strengthening Monitoring and evaluation conducted on school feed- school feeding programs for prevention and con- ing programs trol of diet-related diseases Implement Child Friendly School Initiative to pre- ¢ At least 50% of schools joined and implemented vent and reduce obesity to protect children from the initiative Reduce risk factors marketing of foods and non- alcoholic beverages and strengthen high in saturated fats, trans fatty acids, free sugars protective factors Develop and implement cost-effective interven- Cost-effective interventions at school implemented, via cost-effective tions on salt reduction (at population level) by us- monitored and evaluated interventions ing WHO Tool Kit for salt reduction # of public and school education and training conduct- ed on understanding food labeling and best utilization of FBDG National salt targets for selected food categories iden- tified Use of salt, saturated fat and sugar reduced # of School Cafeteria Meals reviewed and reformed for reduction of salt intake Conduct baseline study for intake (consumption) Baseline data on intake of salt collected of salt Household Consumption Survey on salt conducted A 5% relative reduction of salt consumption in popula- tion by 2022 Report on KAP Changes in targeted populations Implement Healthy Workplaces At least 50% of increase in the # of workplaces with healthy food choices, wellness programmes including risk factor assessment for NCDs Implement school programmes that include at At least 70% of schools have implemented least 30 minutes a day of moderate to intense physical activity. Create a mechanism for safe public transportation, # of groups established for safe road walk pedestrian groups, and scale up open spaces (safe # of recreational spaces scaled up recreational spaces) for physical activity in the community Analyze available data on breast feeding, identify Report prepared and at least 50 % of mothers exclu- the gaps and develop action Plan for strengthen- sive breast feeding ing exclusive breast feeding Incorporate recommendations for strengthening Monitoring and evaluation conducted on school feed- school feeding programs for prevention and con- ing programs trol of diet-related diseases Strategic Line of Action 4: National surveillance, monitoring and evaluation, and research: Strategies Activities Performance Indicators Conduct assessment for capacity of surveillance for Assessment report produced health system and maintain an efficient surveil- lance system in NCD components Provide training for health professionals to collect # of training sessions conducted and report quality data routinely. Conduct training and implement National Popula- # of training sessions conducted, resources secured and tion-Based Survey (PAHO STEPS, Mini-STEPS etc.) survey implemented Secure appropriate budget allocation for estab- Budget allocated for surveillance on NCDs and risk fac- lishment of sustainable surveillance system for tors through resource mobilization Strengthen sus- NCDs and monitoring risk factors tainable NCDs sur- Conduct assessment for capacity of surveillance for Assessment report produced veillance system health system and maintain an efficient surveil- lance system in NCD components Provide training for health professionals to collect # of training sessions conducted and report quality data routinely. Implement National Population-Based Survey (PA- # of surveys implemented HO STEPS, Mini-STEPS etc.) Secure appropriate budget allocation for estab- Budget allocated for surveillance on NCDs and risk fac- lishment of sustainable surveillance system for tors through resource mobilization NCDs and monitoring risk factors Produce and disseminate regular reports with anal- Annual report produced Best utilization of ysis on NCDs and risk factors collected data for Planning, monitor- Policy dialogues with relevant stakeholders based Support from various sectors such as academia to ing and evaluation on patterns in data strengthen surveillance system secured and develop pol- of NCD-related pol- icy brief icies and programs Develop and implement operational research for Research agenda published on relevant govern- effective policy development ment/committee websites, with noted priority areas to include NCDs Monitor trends and evaluate program implementa- M&E Report tion to measure the performance Conduct national sensitization, public education ¢ Policy briefs developed using data produced and policy brief for development of effective poli- cies, programme and improving health systems for ¢ Communication strategy developed NCD prevention and control ¢ #of national sensitization, advocacy, public educa- Advocacy tion conducted Strategic Line of Action 5: Reorienting health services further towards prevention and care of chronic diseases: Strategies Activities Performance Indicators Conduct an overall assessment of PHC services to Assessment report by using PCAT or similar tools identify gaps, needs and opportunities for integrat- ed management of NCDs Scale up health system to improve quality of care Chronic Care Model adapted and implemented for people living with chronic diseases at all levels of health services Chronic Illness Care Assessment Conducted In-country audit conducted for quality of care and patients’ satisfaction Implement prevention programme for over- At least 5 government or civil society agencies with Strengthen health weight/obesity including children and adolescents family-oriented, whole-of-society obesity preven- system response to through healthy diets, physical activity and exclu- tion activities NCDs and risk fac- sive breast feeding tors at all levels Improve accessibility and availability of the opti- Accessibility and availability of the services for older mize services which meet older people’s needs persons improved (chronic diseases and other health problems of older persons Adapt and implement available Clinical Guide- Compliance of following Guidelines assessed lines/Protocols (Caribbean Guidelines) on NCDs Guidelines and protocols for referral, discharge, feed- back and follow-up developed and in use Risk Assessment for Cardiovascular Diseases con- ducted at all PHC Provide health education and promotion for all and # of workshops for PAHO/Stanford Chronic Disease counselling for patients with NCDs and their family Self-Management Programme conducted with healthy lifestyle education increasing self- efficacy and self-management skills Pre and Post (comparison study) KAPB Study con- ducted Empower Commu- nity Promote timely and specific medical interventions At least 75% of patients with CVDs and DM received (patients and providers) for management and care effective drug therapy and counselling for NCDs Improve patients adherence to medications, fol- CCP being utilized and patient record updated low-up care through health education Provide continued training for health professionals # of health professionals received training to effectively deal with NCD prevention and control Prepare a Plan for Accreditation of the BFHI and A Plan for Accreditation of the BFHI developed Scale up health provide capacity training for health professionals professionals skills # of training conducted for health professionals and motivation Provide incentives and motivational packages for Packages developed and approved in conjunction health care providers with NHIA Limitations and Constraints The following limitations and constraints were noted and experienced during the devel- opmen- tal stages of this Plan and throughout meetings with multi-sectoral stakeholders;

1. Lack of shared values and goals related to NCDs between the health and non- health sectors;

2. Insufficient recognition of NCDs as a whole-of-society issue and not just a health issue with impact on human, economic and social development; Insufficient dedicated national financial commitment and resources (including human resources) for NCD prevention and control; Lack of a robust national priority setting, collaboration and coordination for NCD prevention and control with all sectors inclusive of Government Insufficient and imbalanced resource mobilization; and aon Lack of a formalized data transfer/sharing policy allowing for there to be a national centralized repository for NCD related data reflecting inputs from all sectors, both public and private. References Ahmedani, B. (2011). Mental health stigma: society, individuals, and the profession. Journal of Social Work Values & Ethics, 8 (2). Australian Governement Productivity Commission. (2010). The effects of education and health on wages and productivity. Melbourne: Media and Publications. Bethell, K., & Allen, D. (2013). The task force report on suicides in the Bahamas (2008- 2013). Nassau, The Bahamas: The Allen Institute for Research & Training. Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., ... Weinstein, C. (2011). The global economic burden of noncommunicable dis- eases. Geneva: World Economic Forum Caribbean Community Secretariat. (2011). Strategic Plan for the prevention and control of non-communicable diseases for countries of the caribbean community (2011- 2015). Washing- ton, D. C.: Pan American Health Organization. Dunstan, D. W., Barr, E. L. M., Healy, G. N., Salmon, J., Shaw, J. E., Balkau, B., Magliano, D. J... Owen, N. (2010, January 26). Television viewing time and mortality. Circula- tion, 121 (3). Fuki, T., & lwamoto, Y. (2003, February). Medical Spending and the Health Outcome of the Japa- nese Population. Retrieved from http: // www.esri.go.jp/jp/prj/int_prj/prj-rc/macro/macro1 4/08hi- totsubashi_t1.pd Health Information Research Uunit. (2014). STEPS 2012 factsheet. Nassau, The Bahamas: Min- istry of Health. Hosepedales, C. J., Barcelo, A., Lucaini, S., Legetic, B., Ordunez, P, & Blano, A. (2012). NCD prevention and control in Latin America and the Caribbean. Geneva: World Heart Federation. Laplagne, P., Glover, M. & Shomos, A. (2007, May). Effects of Health and Education on Labour Force Participation, Staff Working Paper, Melbourne. Productivity Com- mission. Murray, CL, & Lopez, AD. (1997). Global mortality, disability and the contribution of risk factors: global burden of disease study. Lancet, 349, 1436-42. PAHO. (2011). Advancing the NCD Agenda in the Caribbean. Washington, D.C.: PAHO. Policy and Planning Unit. (2015). mhGap pilot final evaluation report. Nassau: The Bahamas: Public Hospitals Authority (Unpublished). Policy & Planning Unit. (2013). Suicides in The Bahamas: A situational analysis. Nassau: The Bahamas: Public Hospitals Authority (Unpublished). Pinder, E. (2014). Specification and costing of services for inclusion in The Bahamas’NHI benefit package. Nassau: Sanigest Internacional. Prince, M., Patel, V Saxena, S., Maj, M., Maselko, J., Phillips, M. R. & Rahman, A., (2007). No health without mental health. Lancet, 370:859-877. Robinson, H. M. & Hort, K. (2012, April). Non communicable diseases and health sys- tems re- form in low and middle income countries. Pacific health dialog, 18 (1), 179 -90. Sammartino F. J. (1987, February). The effect on health retirement. Social Security Bulletin, 50 (2), 31-47 Samuels, T. A., Kirton, J., & Guebert, J. (2014). Monitoring compliance with high-level commit- ment in health: The case of the CARICOM summit on chronic non- communicable diseases. Bulletin World Health Organization, 92 (270-276b). doi:http://dx.doi.org/10:2471/BLT.13.126128 State of the Nation Report (2016). Vision 2040: National development Plan of the Bahamas: a summary report. Nassau, The Bahamas: Government of The Bahamas Statistics Unit. (2014). Community counselling & assessment centre workload statistics: 2009-2013. Nassau, The Bahamas: Public Hospital Authority (Unpublished). Statistics Unit (2014). SRC leading grouped causes of inpatient morbidity: 2010 —- 2015, Nassau, The Bahamas: Public Hospitals Authority (Unpublished) Tuft, H. S. (1975). The impact of poor health on earnings. The Review of Economics & Statistics, 57, 43-57. World Health Organization. (2001). Mental health: New understanding, new hope. Ge- neva: WHO World Health Organization. (2007). Integrating Mental into Primary Health Care. Gene- va: WHO World Health Organization. (2008a). The Global Burden of Disease: 2004 Update. World Health Organization. (2008b). Mental health gap action programme (mh gap): scaling up care for mental, neurological and substance use disorders. Geneva: WHO World Health Organization. (2011). Global status report on non-communicable diseases, 2010. Geneva: WHO WHO Regional Office for Europe. (2012). Action Plan for the implementation of the european strategy for the prevention and control of noncommunicable diseases (2012 - 2016). Denmark: WHO Regional Office for Europe. World Health Organization. (2013). WHO global action Plan for the prevention and control of non-communicable diseases (2013-2020). Geneva: WHO Press. Annexes Annex |: National Programmes and Selected Initiatives Related to Health Promotion Programs Description/Scope of Service/Programme Primary Care (DPH Preventative Care, Treatment, Monitoring, Evaluation Clinics and Centers) and Referral Discharge Planning Follow-up care after hospital discharge, referral for con- (Hospital Liaison) tinuity of services via Poly Clinic Adolescent Health Screen, treatment and refer for NCD’s Programme Health Information Research and data analysis along with distribution of in- Unit formation relevant to NCDs Nutrition Unit Consultation, referrals, preventative treatment, and edu- cation School Health Screening, monitoring, and educating the school-aged population and referrals of identified high risk students Maternal and Child Screening, monitoring, treatment, follow-up care and re- Health ferrals CNCD Programme Monitor, evaluate the management of NCD’s in the pub- lic health care system Healthy Lifestyle Pro- Screening, referrals and educational arm for the general gramme population including corporate entities, government agencies, civic groupings etc Dental Services Screening, assessments, treatment and educating on the importance of oral health Mental Health Gap Management, Treatment, Referral and Follow-up Men’s Health Screening, education, and referrals geared toward the male population Social Services Financial, food assistance and other assistance. Refer- rals and networking Private Physicians Render service, donate screening items Faith-based Organi- Health fairs, screening, monitoring and evaluation, cook- zations ing classes Private gyms Donate items, time and partners with public sector initia- tives Private pharmacies Discount on items Salt Reduction Cam- A televised series sponsored by MOH and PAHO paign CYCLOVIA Cyclovia by definition is the closure of major roadways to allow for the creation of safe spaces for engaging in physical activity as groups, families and communities. Cyclovia was a public health sector initiative executed twice during 2014/2015 period. Ask The Doctor Public sector initiative that is interactive with the public. The Physician answers questions from the community that were received via an electronic platform Doctor’s Hospital 30 second health tip that is aired every evening after the Health Tip national news on NB1i2 PHA Minute 30 second health tip that is aired every evening after the national news on ZNS Caribbean Wellness Annual event to encourage a more active and healthy Week lifestyle NCD Symposium Three-day multi-sectoral symposium facilitated in 2014 by MoH and PAHO. The objective was to highlight the collaborative effort required to tackle NCDs; and to de- vise approaches for the Bahamian context. PAHO has the report from this symposium. Dialysis Support Groups Six Weeks To Well- Seventh Day Adventist initiative geared towards achiev- ness ing wellness through rethinking our foods and daily activ- ities Healthy Bahamas Coalition National Prescription A financial mechanism introduced by the Government of The Drug Plan Bahamas to improve access to and remove point-of-care costs for prescription drugs and medical supplies for selected chronic diseases The number of diseases covered was expanded in March 2012, and currently includes: Arthritis, Asthma, Benign Pros- tate Hypertrophy, Breast Cancer, Diabetes, Epilepsy, Glauco- ma, High Cholesterol, Hypertension, Ischaemic Disease, Pros- tate Cancer, Psychiatric Illness, Sickle Cell Anaemia and Thy- roid Disease. Garden-Based Learn- A Ministry of Education driven pilot. The Pilot sought to inte- ing Programme Pilot grate nutrition education in all subject areas along with start- ing a garden. Done in NP, GB and Andros for a total of 9 schools. Pilot was never fully implemented. School Lunch Pro- Has two components:- gramme

1. School Vending — lunch is made available to all stu- dents within the public school setting at a fee

2. School Feeding— focuses on providing breakfast and lunch meals to children whose families qualify for Government social services assistance. There is an attempt to consolidate both to reduce wastage and remove stigmatization. Virgin Pulse Pro- Atlantic Medical sponsors this workplace wellness pro- gramme gramme Healthy School Initia- Inconsistent attempts to implement this over the years. tive Renal Health Initiative The objective of the Renal Health Initiative is to provide a standardized practice through introducing a protocol and al- gorithm for screening of adverse kidney states among the cli- ents seeking care in public community health facilities; and a mechanism for referring those meeting the set criteria to secondary and tertiary care. BahamaHealth Run- Run Dirty is an innovative private sector wellness initiative Dirty and a fun endurance event that is certain to become a main- stay in the Bahamas. The Biggest Loser A private sector sponsored reality TV series which challenged employees to healthy choices regarding food intake, daily ex- ercise and weight management.

Annex II: Regional and Global Mandates Only The Bahamas, Jamaica, Montserrat and St. Lucia have enacted legislation specifically re- ferring to obesity, diabetes and cardiovascular diseases in the English Speaking Caribbean. For example; the National Insurance (Chronic Diseases Prescription Drug Fund) Act, 2009 of the Bahamas; the National Health Fund Act 2003 — 23 of Jamaica; the Public Health Act (Chapter 14:01) of Montserrat; and the Public Hospitals (Management) Act (Chapter 11:03) of St. Lucia. Some legislation in other countries may be considered as providing the framework within which action may be taken relating to the prevention and control of obesity, diabetes and cardiovascu- lar diseases.” REGIONAL EFFORTS Organizations within the English-speaking Caribbean play a crucial role in formulating NCD pre- vention and control policies of non-communicable diseases in the various countries and ter- ritories. They are the Caribbean Public Health Agency (CARPHA), the Caribbean Agricultural Research Institute (CARDI), The Caribbean Food and Nutrition Institute (CFNI), The Caribbean Cooperation for Health Initiative (CCH), the Caribbean Health Research Council (CHRC), the Ca- ribbean Commission on Health and Development (CCHD), and the regional headquarters of the Pan American Health Organization for the Caribbean region (CCPC PAHO/WHO). CARPHA and PAHO/WHO provide a joint Secretariat with responsibility for the revision of the Regional Plan for the Prevention and Control of Non-Communicable Diseases and for the mon- itoring and evaluation of the Port-of-Spain Declaration. PAHO acting through CAREC and CAR- ICOM is coordinating a project in the area of public health and policy coordination, concerned with a Caribbean Regional Non-Communicable Diseases (NCD) Surveillance System. Beneficia- ries are Jamaica, Barbados, The Bahamas, Trinidad & Tobago, Guyana and Belize. The Project aims to achieve improvements in the counties’ capacity to deliver cost-effective health services associated with the major causes of morbidity and mortality. GLOBAL EFFORTS UN HIGH LEVEL SUMMIT ON NCD’S (September 2011): NCD ALLIANCE PLAN https://ncdalliance.org/sites/default/files/rfiles/NCD%20Alliance%20Plan_web.pdf THE GLOBAL STRATEGY TO REDUCE THE HARMFUL USE OF ALCOHOL http://www.who.int/substance_abuse/msbalcstrategy.pdf FIRST MINISTERIAL CONFERENCE ON HEALTHY LIFESTYLE AND NCDs COMMIT-MENT TO ACTION http://www.un.org/en/ga/president/65/issues/moscow_declaration_en.pdf WHO 2008-2013 ACTION PLAN FOR THE GLOBAL STRATEGY FOR THE PREVEN-TION AND CONTROL OF NON-COMMUNICABLE DISEASES A61/8, April 2008 PAHO STRATEGIC LINES OF ACTION FOR 2013-2019 ON PREVENTION AND CONTROL NON-COMMUNICABLE DISEASES http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&ltemid =270&gid=21348&lang=en REGIONAL FRAMEWORK FOR NCD PREVRNTION AND CONTROL http://www. paho.org/hq/index.php?option=com_docman&task=doc _view&ltemid=270&gid=21349&lang=en PLAN OF ACTION FOR THE PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES IN THE AMERICAS 2013-2019 http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&ltemid =270&gid=27517&lang=en

ANNEX III: Membership of the NCD Technical Working Work (TWG) NAME INSTITUTION ade Dr. Cherita Moxey MoH, TWG Chair Governmental Agency Mrs. Camille Nairn MoH Governmental Agency Dr. Sabriquet Pinder-Butler MOH Governmental Agency Dr. Monique Mitchell MoH Governmental Agency Dr. Delon Brennen, DCMO NHI Secretariat Governmental Agency Dr. Victoria Kelly NHI Secretariat Governmental Agency Dr. Keva Thompson PHA Governmental Agency Mrs. Astacia Brice PHA Governmental Agency Dr. Carnille Farquharson Bahamas Association of Governmental Agency Primary Healthcare Phy- sicians Mrs. Andrea Linden, Nurse DPH Governmental Agency Dr. Olive Rolle, Nurse DPH Governmental Agency Ms. Camelta Barnes Nutrition Unit Governmental Agency Mrs. Marcia Munnings HBC Secretariat Governmental Agency Dr. Yasmin Williams Robinson Walk-in Clinic Private Sector Miss. Ashley Cadman,Consultant PAHO CO NGO

ANNEX IV: Agenda for Stakeholders’ Forum Days 1 thru 3 were intense technical sessions with Dr. Tomo Kanda. L DAY FOUR AGENDA 8:30am Registration 9:00am Prayer Mrs. Andrea Linden 9:05am Welcome and Introductions Ms. Camelta Barnes 9:15am Meeting Objectives Dr. Cherita Moxey Expected Outcomes Methodologies 9:20am NCD Situation Analysis in Dr. Cherita Moxey The Bahamas 9:25am Childhood Obesity Dr. Delon Brennen 9:35am Discussion Dr. Victoria Bethel-Kelly 9:45am NCD Video 10:00am BREAK & GROUP PHOTO 10:30am WHO/PAHO Perspective on NCD Dr. Tomo Kanda Prevention & Control 10:45am Introduction of The Bahamas’ Dr. Tomo Kanda Draft Multi-Sectoral Action Plan (2017 — 2022) 11:15am Discussion Dr. Victoria Bethel-Kelly 12:00am LUNCH 1:00pm Working Group Facilitators S/H Analysis & Capacity (Annex 1 — 2) 3:00pm Plenary (Group Presentations) Dr. Tomo Kanda 4:00pm Wrap-up and Close

ANNEX V: Stakeholders Represented at the NCD Plan Five-Day Forum Name Organization Amelia Schurton Ministry of Works Andrea Linden CNCD Programme Angela Albury AG & Marine Resources Ashley Cadman PAHO Astacia Brice PHA Corporate Office Beatrice Hield Sandilands Rehabilitation Center Bibi Clare Ministry of Health Brian Beneby Water & Sewerage corporation Brickell Pinder Ministry of Agriculture & MR Calae Philippe Ministry of Health Camille Nairn Health Information & Research Unit Carnille Farquharson The Bahamas Primary Care Physicians Association Carol Johnson Min. of Works Carol Johnson Ministry of Social Services Chena Scott The Bahamas Pharmacy Council Cherita Moxey Ministry of Health Danny Davis College of The Bahamas Dermie C. Smith Sandilands Rehabilitation Center Dion Hepburn College of The Bahamas Dorcena Nixon Rolle Doctors Hospital Elechicmae Roberts Water & Sewerage Corporation Garnell Ritchie Doctors Hospital Gustavo Mery PAHO Helen Mukiri Smith Economic Development Planning Unit, Office of Prime Minister Keith Philippe BEST Commission Name Organization Amelia Schurton Ministry of Works Andrea Linden CNCD Programme Angela Albury AG & Marine Resources Ashley Cadman PAHO Astacia Brice PHA Corporate Office Beatrice Hield Sandilands Rehabilitation Center Bibi Clare Ministry of Health Brian Beneby Water & Sewerage corporation Brickell Pinder Ministry of Agriculture & MR Calae Philippe Ministry of Health Camille Nairn Health Information & Research Unit Carnille Farquharson The Bahamas Primary Care Physicians Association Carol Johnson Min. of Works Carol Johnson Ministry of Social Services Chena Scott The Bahamas Pharmacy Council Cherita Moxey Ministry of Health Danny Davis College of The Bahamas Dermie C. Smith Sandilands Rehabilitation Center Dion Hepburn College of The Bahamas Dorcena Nixon Rolle Doctors Hospital Elechicmae Roberts Water & Sewerage Corporation Garnell Ritchie Doctors Hospital Gustavo Mery PAHO Helen Mukiri Smith Economic Development Planning Unit, Office of Prime Minister Keith Philippe BEST Commission

ANNEX VI: Stakeholder Analysis: Summary of Organizations Responsible for the Pre- vention and Control of NCDs and Risk Factors Harmful . Stakeholders Unhealthy Physical In- Tobacco : Use of Al- . Diet activity cohol Civil Society & NGOs ° ° ° ° Faith-based Organizations ° ° ° ° Corporate Bahamas ° ° ° ° Unions ° ° ° ° Academic Institute oO oO oO oO Ministry of Health ° ° ° ° Public health Sector ° ° ° ° Private health sector ° ° ° ° Health Councils and Associations oO oO ° oO Ministry of Agriculture, Marine oO oO oO oO Resources and Local Government Ministry of Education, Science oO oO oO oO and Technology Ministry of Environment and . oO oO oO oO Housing Ministry of Finance ° ° ° ° Ministry of Financial Services & oO oO oO oO Investments Ministry of Foreign Affairs and oo oO oO oO oO Immigration Office of the Governor-General oO oO ° oO Ministry of Grand Bahama ° ° ° ° Ministry of Housing ° ° ° ° Ministry of Labour and National oO oO oO oO Insurance Department of Local Government ° ° ° ° Ministry of National Security oO ° oO oO Ministry of National Health Insur- oO oO oO oO ance Harmful Stakeholders Unhealth Physical In- Tobacco : Y| Use of Al- ysica Diet activity cohol Office of the Attorney General & we . ° ° ° ° Ministry of Legal Affairs Office of the Prime Minister oO oO O oO Ministry of Public Service oO oO O oO Ministry of Social Services and . oO oO oO oO Community Development Ministry of Tourism oO oO oO oO Ministry of Transport and Avia- . oO oO oO O tion Ministry of Works and Urban De- oO oO oO oO velopment Ministry of Youth, Sports and O O O ° Culture International Organizations PA- HO/WHO, UNCEF, FAO, UN Women, WTO, UNFPA, Oo Oo Oo Oo UNDP,CARICOM, CARPHA, JICA, IDB etc.

ANNEX VII: Summary of Risk Factor Policy Links with All-of-Society Diet Key Actions Key Messages Trade and Industry Include nutrition considerations when estab- Strengthening capacity for cross-sectoral co- lishing trade agreements; ordination and improving governance of pol- icy-making processes are essential to enable Support regulation and food reformulation, and motivate enhanced coherence between replacing saturated fats or trans fats by un- trade policy and nutrition action. saturated fats; The core of any strategy for policy coherence Set target levels for the amount sodium in the is to agree on common policy objectives aim- foods that contribute the most salt in the di- ing to address both trade and nutrition- et; related challenges in a coordinated and con- Implement an interpretive, front-of pack nu- sistent manner. trient labelling system Setting targets for sodium levels in food was key in 10 out of 12 countries that have so far reported a reduction in population salt in- take. Tax and Revenue Implement fiscal measures to increase con- Appropriately designed fiscal policies, when sumption of healthy foods and beverages and implemented with other policy actions, have decrease demand of unhealthy foods and considerable potential for promoting health- beverages, e.g. taxes on sugar sweetened ier diets. They will also improve weight out- beverages and subsidies on fruits and vegeta- comes and other diet-related risk factors, bles. and will ultimately contribute to the preven- tion and reduction of the health and eco- Introduce taxes to support health promotion, nomic burden of NCDs. e.g., healthy food and safe drinking water in schools, access to physical activity opportuni- Vulnerable populations, including low- ties income consumers, young people, and those at most risk of obesity, are most responsive to changes in the relative prices of foods and beverages. Sugary drinks contribute to the global rise of overweight and obesity in youth, including 41 million children aged under 5. 20% tax on sugary drinks can reduce con- sumption by 20%. Key Actions Key Messages Education Establish a school food policy at all levels to Promoting health and nutrition in schools promote healthy eating and physical activity improves attendance, cognition and educa- as part of the health promoting schools initia- tional achievement of students tive Educate children, parents and communities on diet and physical activity through the cur- riculum and outreach activities Establish nutrition standards for foods availa- ble in schools Ban marketing and advertising of foods high in sugar, fats and salt Food Safety Agency Promote nutrition-sensitive agriculture and Healthy nutrition and sustainable production the production of nutritious foods, including should be taken into account in designing ag- (Food and agriculture) indigenous foods and conservation of biodi- ricultural policies versity Promote production and access to fruits and vegetables and other fresh food products Promote community horticulture projects Set target levels for the amount sodium in the foods that contribute the most salt in the diet Set nutrition standards for foods delivered in food services Urban Planning Plan for farmers markets, allotment gardens, Appropriately designed communities that urban gardening and easy access to super- allow for green spaces, walking and cycling markets and groceries selling fresh foods for paths. home-cooking. Communications Implement a mass media campaign promot- Public awareness through mass media on ing healthy eating diet and physical activity is a ‘best buy’ inter- vention for reducing NCD burden Implement the WHO Recommendations on the Marketing of Foods and Non-alcoholic Reducing exposure and power of marketing Beverages to Children. of unhealthy foods and beverages to children requires effective government legislation and enforcement mechanisms Employment Implement healthy workplace programmes Healthy workplaces have the potential to improve the health status of workers, con- Increase availability of healthy foods and tribute to a positive and caring image, im- beverages in cafeterias or vending machines prove staff morale, reduce staff turnover and in line with nutrition standards absenteeism, enhance productivity and re- duce sick leave, health Plan costs and work- ers ‘compensation and disability payments. Increase investments in policies and interven- Investments in diet and physical activities are tions promoting healthy diets cost-effective and small compared to the costs of inaction. Advocate for the implementation of regulato- Civil society organizations can act as a pow- ry policies on making healthy foods available erful voice for change, by influencing political and accessible to protect and promote the decisions through advocacy, holding gov- health of the population ernment and private sector accountable, and galvanising public support Monitor and disseminate industry action on food reformulation, nutrition labelling and marketing of foods and non-alcoholic bever- ages to children Executives (Heads of States) Mobilize government sectors to enable an A population increasingly suffering from adequate whole-of-government and whole- NCDs means decreasing productivity and tax of-society response to address the root- base and increasing demand for health and causes of the NCD epidemic. other social expenditures, and therefore economic losses. NCDs pose a significant threat to development. Allocating more resources to healthcare will not be sufficient. Strong whole-of- government and whole-of-society action by multiple sectors is needed to effectively ad- dress the root causes of NCDs and their in- equitable distribution within the population. Legislators Draft regulatory policies and legislation to Legislators play pivotal role to push for inter- reduce the accessibility, affordability and sectoral action and to hold sectors account- marketing and promotion of foods high in able for results. sugar, salt and fat. Legislators have responsibility and authority to provide the legal and budgetary frame- works for measures to take place. Physical Activity Key Actions Key Messages Trade and Industry Develop criteria/standards for the importa- Health is everyone’s business tion of food and food products Tax and Revenue Reduce customs tariffs on sports equipment Introduce road-user charging schemes Levy taxes to pay for public transport and fund infrastructure to facilitate active transport Education Increase the number of physical education Physical activity enhances cognitive perfor- classes mance, has a positive influence on children’s psychological and social wellbeing and can Introduce walk or cycle to school programs counteract risk behaviour Invest in extracurricular opportunities for Increasing the number of physical education physical activity classes is one of the most direct policies to increase student’s physical activity. Food Safety Agency Increase production of locally grown produce, Food safety and security is another vital (Food and agriculture) poultry and meats component to national development. BAMSI can play a very significant role in this. Introduce best practice standards for the farm-to-table safety approach Enforce and monitor compliance Urban Planning National, regional and local urban Planning Large distances between destinations can should require mixed-use zoning that places limit opportunities for non-motorized, active shops, services and jobs near homes transport Require zoning policies to include active living Access to green spaces can influence physi- components to support cycling, walking and cal activity levels of residents public transit Increase public space for recreation Improve the accessibility, acceptability and safety of, and supportive infrastructure for walking and cycling Communications Implement a mass media campaign promot- Public awareness through mass media on ing participation in physical activity diet and physical activity is a ‘best buy’ in- tervention for reducing NCD burden Employment Implement healthy workplace programmes Developing a national preventive health cul- ture is already part of ILO’s Promotional Include physical activity promotion as part of Framework for Occupational Health and the national occupational health and safety Safety Convention, 2006. policy There is a need to build the capacity of those Include training in physical activity counselling in a position to promote physical activity as part of curriculum for health workers Finance Increase investment in parks, sidepaths, Well-connected, quality public transport sys- walkways and trails to enable active transport tems provide opportunities for physical ac- and other physical activity tivity to access transit stops. Increase investment in public transport Civil society Advocate for increasing time for physical ac- Health is everyone’s business tivity in schools and at work places, increasing taxes on individual motorized traffic, and reg- ulating urban Planning to encourage walking, cycling and recreational exercising. Executives Branch of Gov- Mobilize government sectors to enable an Health is everyone’s business ernment adequate whole-of-government and whole- of-society response to address the root- causes of the NCD epidemic. Legislators Draft legislation to promote physical activity Health is everyone’s business through increasing taxes on motorized traffic, and urban Planning regulations that entail walking, cycling and recreational exercising WELLNESS IN THE NATION The National Multi-sectoral Non-Communicable Disease Strategy and Plan of Action for The Bahamas (2017-2022)