Belize National Plan of Action for the Prevention and Control of Non communicable Diseases 2013 - 2023

1. Introduction __________________________________________________________________ 9

2. Background __________________________________________________________________ 11 2.1 NCD Burden________________________________________________________________ 11 2.1.1 Global NCD Burden ................................................................................... 11 2.1.2 NCDs – Region of the Americas ............................................................... 14 2.1.3 NCD Burden in Belize ................................................................................ 16 2.1.4 Country capacity and response ................................................................. 22 2.2 Commitments &Guiding Frameworks ___________________________________________ 40

3. The Plan_____________________________________________________________________ 42 3.1 Goal: _____________________________________________________________________ 42 3.2 Vision_____________________________________________________________________ 42 3.3 Statement of Purpose ________________________________________________________ 42 3.4 Principles __________________________________________________________________ 43 3.5 Scope _____________________________________________________________________ 43 3.6 Organization of the Plan ______________________________________________________ 44 I. Risk factor reduction, health promotion and communications:........... 44  Obj. 1. To develop and implement policies and strategies that facilitates reduction of tobacco and alcohol use. ..................................................................... 44  Obj. 2. To stimulate inter-sectoral action that promotes the availability, accessibility and consumption of healthy foods by the Belizean public. ........... 44  Obj. 3. To develop and implement policies and strategies that promote physical activity. ......................................................................................................... 44 3.7 NCD Action Plan ____________________________________________________________ 46 3.7.1 Risk factor reduction, health promotion and communications............ 46 5

1. Operational Food & Nutrition Security policy by end 2015 ................. 48

2. Operational policies to support healthy eating and physical education in schools by end 2015 .................................................................................................... 48

3. Policies to reduce the impact on children of marketing of foods &non- alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt by end 2023 48 4. 30% relative reduction in prevalence of current tobacco smoking, by 2023 (baseline adolescents (%)total/males/females: 26.7/36.2/18.6; adults (%): 10.5/19.1/18.6)............................................................................................................ 48 5. 10% relative reduction in alcohol per capita consumption, measured in litres of pure alcohol by 2023 (baseline - 6 litres)............................................................. 48 6. 10% relative reduction in the age-standardised prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context by end 2023 (baseline adults(%) total/males/females: 7.6/13.1/2.7; adolescents tbd) 48 7. 10% relative reduction in the prevalence of insufficiently physically active adolescents, defined as less than 60 minutes of moderate to vigorous intensity activity daily b by end 2030 (baseline: tbd) .......................................................................... 48

8. Age-standardised prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit & vegetables per day(baseline total/males/females: <2/day) ................................................................................. 48

9. Age-standardised prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol Q5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration(baseline (%) total/males/females: 5.1/4.1/6.0) ....... 49 10. 10% reduction in sedentarism by end 2023 (baseline adults (%) total/males/females: 77.7/75.4/80.4) ..................................................................... 49 11. 0% increase in adult and/or overweight, obesity and Type II diabetes by end 2023 (baseline diabetes (%) total/males/females:13.1/8.3/17.6); baseline overweight/obesity (%): 66.3/59.2/80.4) ............................................................... 49 12. 25% relative reduction in the prevalence of raised blood pressure by 2023 (baseline (%) total/males/females: 28.7/28.6/24.4) ............................................. 49 Ministries: Health (inc. NDACC), Agriculture, Education, Human Development Social Transformation and Poverty Alleviation Youth & Sports, Finance, Trade, Public Service, Immigration & National Security, NGOs, Trade Unions, Universities, schools, 6 media, Bureau of Standards, Insurance Companies, International Cooperation Organizations .............................................................................................................. 50 3.7.2 Integrated Disease Management& Patient Self-management .............. 51 3.7.3 Surveillance, Monitoring and Evaluation................................................ 53 3.7.4 Programme Management, Policy and Advocacy ................................... 55 Key Partners ................................................................................................................ 56

4. Belize Framework of Action for the Prevention & Control of NCDs _______________________ 57 Obj. 1. To develop and implement strategies that facilitates reduction of tobacco and alcohol use. 57 Obj. 2. To stimulate inter-sectoral action that promotes the availability, accessibility and consumption of healthy foods by the Belizean public. ................................. 57 Obj. 3. To develop and implement strategies that promote physical activity. .. 57 Adults (‘06) T/M/F(%): 10.5/19.1/18.6) ................................................................ 65

5. Estimated Implementation Costs _________________________________________________ 68

6. Bibliography _________________________________________________________________ 73

7. Annexes _____________________________________________________________________ 75 Annex 1. List of NCD-related Medicines Available Free in Belize _____________________________ 75 Annex2. WHO Global Voluntary Targets for 2025 ________________________________________ 76 Annex 3. WHO Global NCD Indicators _________________________________________________ 77 Annex 4. WHO Best Buys ___________________________________________________________ 78 Annex 5. National Food-based Dietary Guidelines _______________________________________ 79 Annex 6. CARICOM NCD Progress Indicator Status / Capacity by Country in Implementing NCD summit Declaration - Updated September 2012 ________________________________________________ 80 7 List of Tables & Figures Figure 1. NCDs and Their Risk Factors - the 4 by 4 ....................................................................... 13 Figure 2. Premature NCD Deaths in Belize 2010 ......................................................................... 19 Table 1. Prevalence of Selected NCD Risk Factors in Belize ......................................................... 21 Table 2. Monitoring Framework for Selected WHO Global Indicators and Targets ..................... 65 8

1. Introduction The Belize National Plan of Actionfor the Prevention and Control of Non communicable Diseases (NCDs) 2013-2023(NCDs)aims to reduce the premature mortality caused by the four major NCDs (cardiovascular diseases, cancer, diabetes and lung disease) by 25% by 2023. This will be achieved through policy and advocacy; health promotion and risk factor reduction of the four common risk factors (tobacco, alcohol, unhealthy diet, physical inactivity); improving disease management and patient self-management; and strengthening surveillance, monitoring. This Plan was developed collaboratively with the Ministry of Health and relevant stakeholders involved in NCD prevention, control and management and with technical assistance from the PAHO Regional Office, Washington and the Instituto de Nutrición de Centroamérica y Panamá (INCAP). Itis aligned with the World Health Organization (WHO) NCD Global Monitoring Framework and Global Action Plan 2013-20201 and the PAHO Regional Plan of Actionfor the Prevention and Control of NCDs 2013-20192theMillennium Development Goals (MDG) Post 2015 Development Agenda3and aims to meet the global and regional goals of a 25% reduction in premature mortality due to NCDs. It is also harmonious with the Horizon 2030 Development Framework4 which places healthy productive citizens (throughout the life cycle) at the core of long term development and espouses the refocusing of the public health system to emphasise healthy lifestyles with a life cycle approach as a critical aspect to preventative care.Itbuilds onthe draft National Strategic Plan for NCDs 2013-2023, the development ofwhich was guided 1 WHO NCD Global Monitoring Framework and Global Action Plan 2013-2020. Available at http://www.who.int/nmh/events/2012/discussion_paper2_20120322.pdf. 2 Pan American Health Organization.RegionalPlan of Action for the Prevention and Control of NCDs 2013- 2019 available at http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=21346&Itemid= 3 Taken from WHO Discussion Paper October 2012.Positioning Health in the Post-2015 Development Agenda. Available at http://www.who.int/topics/millennium_development_goals/post2015/WHOdiscussionpaper_October 2012.pdf 4Horizon 2030 Development Framework. Available at http://www.Belize.g.ov.bz/index.php/government-initiatives/horizon-2030 9 by theStrategic Plan Of Action For The Prevention And Control Of Chronic Noncommunicable Diseases (NCDs) For Countries Of The Caribbean Community 2011-20155 and the WHO 2008- 2013Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases6and on consultation with NCD Commission members and other relevant entities across several government sectors (Health, Education, Agriculture, Economic Development), Non-governmental Organizations (NGOs) and the private sector individually as well as at a final stakeholder session that brought these entities together to further shape the plan and enrich the document which was drafted to be consistent with the WHO and CARICOM directions/frameworks but also to reflect the unique Belizean context. The draft strategy incorporates a situational analysis which was informed by epidemiological evidence, stakeholder feedback and a review of relevant policies, procedures and programmes and defines a strategic approach for Belize, providing a roadmap for the prevention, management and control of NCDs in the Belizean context. This plan of action builds on that work and applies the samevision, purpose, four lines of action,eight strategic objectives and time period of implementationbased on the established context (modified and updatedwhere applicable) going as far as the operationalisation through proposed actions, indicators (33 in total) and key partners.It will support the implementation of strategies to reduce the NCD burden and improve quality of life ensuring that services for the prioritised NCDs are sustained and equitably distributed to the population and therefore, ultimatelythe achievement of the National Health Goals which seek to make quality health care services available to all Belizeans. 5Strategic Plan Of Action For The Prevention And Control Of Chronic Noncommunicable Diseases (NCDs) For Countries Of The Caribbean Community 2011- 2015http://www.caricom.org/jsp/community_organs/health/chronic_non_communicable_diseases/nc ds_plan_of_action_2011_2015.pdf 6 WHO 2008-2013Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. available at: http://www.who.int/nmh/publications/9789241597418/en/ 10

2. Background 2.1 NCD Burden 2.1.1 Global NCD Burden Noncommunicable diseases (NCDs) account for 60% of deaths worldwide and are the largest contributor to morbidity as well as mortality.7According to the WHO, 80% of NCD related deaths occur in low and middle-income countries.1 NCDs are a therefore also a developmental issue, representing an increasing economic burden globally that impacts all levels of society. This is due to increasing health care costs and economic loss due to premature deaths. For example, a 10% rise in NCD cases is projected to cause a 0.5% decrease in the rate of annual growth.8 Moreover; poverty exposes individuals to NCD-related risk factors, while the cost of care for an NCD patient can lead families into catastrophic expenditures and worsening poverty. 7World Health Organization.Global Status Report on NCDs 2010. 8Stuckler D. Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations. Milbank Quarterly, 2008, 86:273–326. 11 9 Figure 1.Poverty Contributes to NCDs and NCDs Contribute to Poverty 9 Taken from WHO Global Status Report on NCDs 2010 12 Four diseases primarily drive the global burden of NCDs and constitute the majority of the NCD burden: cardiovascular disease, chronic respiratory disease, diabetes and cancers. In addition, these four diseases are linked by four common risk factors: tobacco consumption, alcohol consumption, physical inactivity and unhealthy diets (Figure 2). Notably, a significant percentage of NCD related deaths could be avoided with cost-effective interventions that aim to prevent and control these lifestyle-related risk factors. Figure 2. NCDs and Their Risk Factors - the 4 by 4 13 2.1.2 NCDs – Region of the Americas At the regional level, the Caribbean epidemic of chronic NCDs is the worst in the region of the Americas.10 In the Latin America and Caribbean region, in 2005, 31% of all deaths were attributed to cardiovascular disease; cancer accounted for 20% of NCD mortality; and an estimated 35 million people in the region were affected by diabetes. In terms of the risk factors, the region is characterised by a low consumption of fruits, vegetables and whole grains; low physical activity – an estimated 30-60% of the population does not achieve the minimum recommended level of physical activity; tobacco consumption is the leading cause of avoidable deaths. For deaths attributable to various risk factors, by disease type high blood pressure is the single most important cause, followed by overweight, alcohol and smoking. Alcohol, a known risk factor for cancers, CVD, liver disease and neuro-psychiatric conditions was implicated in 20-50% of road traffic fatalities in the region. With regards to economic impact, the cost of treating diabetes and hypertension has been shown to be as high as 5 to 8% of GDP in selected countries in the region.11 Regional NCD response The profile of NCDs has been raised by several regional declarations including the following: include the Caribbean Community’s Port-of-Spain declaration on NCDs (2007); the declaration from the Regional High-level Consultation of the Americas on Noncommunicable Diseases and Obesity (2011); the NCD Declaration from the Council of Ministers of Health of Central America and Dominican Republic (2011); the Union of South American Nations resolution to strengthen inter-sectoral policies on NCDs (2011); the Andean ministers of health resolution on NCDs prevention and control (2010); and the 10PAHO Health Situation in the Americas. Basic Indicators 2008 11 Taken from Strategic Plan Of Action For The Prevention And Control Of Chronic Noncommunicable Diseases (NCDs) For Countries Of The Caribbean Community 2011-2015with data provided by Dr. O. AbdullahiAbdulkadri, University of the West Indies 14 Southern Cone Common Market intergovernmental commission for NCD prevention and control (2011). Additionally, momentum has been building in the fight against NCDs as evidence by the development of action plans by several countries and the implementation of a number of population-based interventionssuch as the ratification and full implementation of the Framework Convention on Tobacco Control; restrictions on availability of retailed alcohol, with comprehensive restrictions and bans on alcohol advertising and promotion endorsed through adoption of the Global Strategy to Reduce the Harmful Use of Alcohol and a regional plan of action; replacement of trans fats with polyunsaturated fats, mass media campaigns on salt intake reduction and reduced salt and interventions to increase awareness of healthier choices and create environments that promote such choicessuch as food labelling specifications and regulations and policies on foods and drinks permitted in schools and public institutions 12. On the other hand, regional assessments point to highly fragmented health care services with inadequacies in access to high-quality, effective preventive services, early diagnosis, and timely treatment of NCD that are very often associated with socioeconomic factors and the need to emphasise improving accessibility, affordability, and quality in the broader health system.13 Challenges are also evident for allocation of resources for NCDs as indicated by less than a third of countries reportedly having a budget allocated for NCD and risk factor surveillance and less than half reportedly using their NCD data for evidence-based policy-making and planning. Additionally, the PAHO regional plan of action points to the need for health information systems to better integrate the collection of the relevant data from multiple sources and to and strengthen competences for analysis and use of the information and the adequate funding required to achieve this. 12 Point 18 of the PAHO regional Plan of Action for the Prevention and Control of NCDs 13 Point 20 of the PAHO regional Plan of Action for the Prevention and Control of NCDs 15 2.1.3 NCD Burden in Belize NCD morbidity and mortality Belize continues to undergo an epidemiological transition in which NCDs have become increasingly prominent in the disease profile and have been increasing in their share of the disease burden for well over a decade. Cardiovascular diseases (CVDs), cancers, diabetes and chronic respiratory diseases are responsible for around 40% of deaths annually- 681 out of a total of 1555 (44%) of deaths in 2011. This is compared with 28% for injuries and external causes; and 20% for communicable diseases including HIV and acute respiratory tract infections and “other” causes combined in that same year. Moreover, 320 (47%) of the 681 of the deaths due to NCDs (roughly 21% of the 1555 total deaths in 2011) were premature deaths in persons less 70 years of age of which (169) 24.8% were males less than 70 and 151 (22.2%) were females less than 70. Almost 43% of these 320 premature deaths were attributable to cardiovascular disease; 29% to cancer; 24% to diabetes and 4% to chronic respiratory diseases. 16 Chronic Respiratory Diseases 5% Cancers 23% 320 Cardiovascular premature deaths Diseases (<70 years) 50% Diabetes 22% Figure 3. Premature NCD Deaths in Belize 2011 In 2011 the overall age-standardised mortality for the four NCDs - cardiovascular diseases (CVDs), cancers, diabetes and chronic respiratory disease was approximately 338 deaths per 100,000 and 159 per 100,000 for persons less than 70 years. The highest mortality rates were for cardiovascular diseases and the lowest for chronic pulmonary diseases and generally higher in males than females except in the case of diabetes and in cancers in persons less than 70 years where the rates were higher for females. In terms of potential years of life lost (PYLL)14 2011 country data showed that the four NCDs were responsible for almost 2400 PYLL per 100,000 population with CVD accounting for roughly 41% of PYLL due to NCDs, cancers 34%, diabetes 21% and chronic respiratory diseases 4%. 14 Based on 2011 country life expectancies of 72.2, 77.1 and 74.6 years for males, females and total population respectively 17 Cardiovascular diseases For the CVDs the burden is largely attributable to ischemic heart disease (IHD), cerebrovascular disease and hypertensive disease which together account for more than 75% of deaths due to CVDs. Belize has seen an increase in the proportion of CVD deaths due to IHD and cerebrovascular disease between 2001 and 2011 going from 23.2% to 33.4% in the case of IHD and 19.8% to 27.8% of CVD deaths in the case of CVD. Cancers In the case of cancer, more than 10% of deaths annually are attributable to cancer and this proportion has not changed significantly between 2001 and 2011. Almost 40% of the 1780 cancer deaths for that period were due to cancer of the cervix (12.5%), digestive tract (colon and stomach -11.6%), lung (10.7%) and female breast (5.2%) combined.The age-standardised 18 2012 incidence rate for cervical cancer was found to be 36.9 per 100,000 population15 and is comparable to the high risk regions of Eastern and Western Africa with rates over 30 per 100,000 16 . This finding is consistent with previous assessments in which the estimated incidence rates for Belize were among the highest for the Caribbean region17. Additionally, uptake of screening according to national guidelines is suboptimal – the last reported based on a household survey conducted in 2004/2005 was 62%.18 Diabetes The proportional mortality due to diabetes has increased from 5.6% in 2001 to 9.6% of total deaths in 2011. Age-standardised mortality rates are comparable with regional estimates with females having higher rates than males both overall (87.6/10 5 and 65.2/105 respectively) and for persons <70 years (41.5/105 and 38.7/105 respectively). Hospitalization due to diabetes is also showing an increasing trend. With regards to prevalence, the 2006 the Central American Diabetes Initiative (CAMDI) survey revealed a prevalence of diabetes mellitus among persons 20 and older to be 13.1% overall (5.6% newly diagnosed and known cases7.7%) and with females having double the prevalence of males (17.6% and 8.3% respectively).19 Chronic respiratory diseases Chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD) and asthma, carry the smallest proportion of the NCD-related mortality burden, and account for approximately 2% of deaths and 5% of premature NCD deaths <70 annually. Males are affected 15 National Epidemiology Unit 2012 16 International Agency for Cancer Research.Globocan Report 2008. Available at http://globocan.iarc.fr/factsheets/cancers/cervix.asp 17 GLOBOCAN 2000: Cancer Incidence, Mortality and Prevalence Worldwide, Version 1.0. IARC CancerBase No.5. Lyon, IARC Press, 2001. 18 Taken from PAHO 2012Situation Analysis Cervical Cancer Prevention And Controlwhich was submitted by Maternal & Child Health Technical Advisor 19 TheCentral America Diabetes Initiative (CAMDI) Survey of Diabetes, Hypertension and Chronic Disease Risk Factors Belize 2009. 19 more than females with 1.5 to 4 times the number of deaths annually and approximately 1.5 times the PYLL/105 in 2011 (almost 7 times the number of PYLL/105 in 2009) as compared to females. COPD accounts for around 70% of total deaths caused by chronic respiratory diseases. With regards to morbidity, chronic respiratory diseases are responsible for between 1 to 3% of hospitalizations annually and 3 to 4% of hospitalizations in males. For the paediatric age group, asthma accounts for around 5% of emergency visits and 10-12% of admissions for the 1-4 and 5-9 age-groups. Risk factors – behavioural & metabolic The Central American Diabetes Initiative (CAMDI)20 survey also revealed a high prevalence of known NCD risk factors: overweight, obesity21 and high cholesterol were 33.2%, 32.5%, and 5.1% respectively and sedentarism22 was almost 78%. Mean number of daily servings of fruit and/or vegetables was 1.5 per day. Current tobacco use was around 10% and much higher in males (19.1%) than females (1.7%). Nonetheless, the adult prevalence of tobacco is lower than regional and global estimates and Belize is considered a relatively low smoking country. On the other hand, the prevalence of current tobacco smoking may be higher in adolescents as implied by the findings of the GYTS whereoverall prevalence was 26.7%, and the prevalence in males and females was 36.2% and 18.6% respectively. With regards to alcohol, the CAMDI finding on alcohol binge drinking was 7.6% overall and much higher in males (13.1%) than females (2.7%). Per capita consumption of alcohol is estimated at around 6 litres23 but data linking the effects of the harmful use of alcohol are lacking. However, reports from the National Drug Abuse Council indicate that over 54% of clientele seeking services for addiction are for alcohol.24 This is compared with remaining 46% 20 2006 Central American Diabetes Initiative Survey available at http://health.gov.bz/www/publications/epidemiology-publications 21 Combined overweight and obesity i.e BMI >25 kg/m 266.3% overall and 59.2 & 73.6% respectively for males and females 22 assessed as getting less than 60 minutes of exercise per week 23WHO 2011. Global Status Report on Alcohol & Health 24National Drug Abuse and Control Council (NDACC) 2012 Annual Report. 20 for other substances including marijuana, cocaine, tobacco, and heroine combined. Additionally, anecdotal evidence has linked alcohol use to homicides and road traffic fatalities in the country. Prevalence (%) of: Total Males Females Current adult tobacco smokers 10.5 19.1 1.7 Adolescent tobacco smokers (ages 13-15)25 26.7 36.2 18.6 Binge drinking among adults 7.6 13.1 2.7 Low physical activity in adults 77.7 75.4 80.4 Overweight-obesity (BMI >25 kg/m2) 66.3 59.2 73.6 Adults with diabetes 13.1 8.3 17.6 Adults with raised blood pressure 28.7 28.6 24.4 High cholesterol (>200 mg/dl) 5.1 4.1 6.0 Mean number of servings of fruits and/or <1.5 <1.5 <1.5 vegetables per day (adults) Table 1. Prevalence of Selected NCD Risk Factors in Belize 25 From the Global Youth Tobacco Survey (GYTS) 2008 conducted among persons ages 13 to 15 years 21 Economic impact of NCDs in Belize Evidence of the economic impact of NCDs in Belize is also limited. This notwithstanding, the National Health Accounts assessment exercise conducted in 2010 revealed that 1.6% of health expenditure was for dialysis.26 This is in the context that the number persons receiving dialysis is less than 0.015% of the entire population of Belize. This single cost is indicative of the high price of tertiary care for end stage disease. 2.1.4 Country capacity and response27 2.1.4.1 Public Health Infrastructure, Partnerships and Multisectoral Collaboration for NCDs The NCD Commission & Cross Sector Working The country has a multi-sectoral NCD commission chaired by the Director of Health Services of the Ministry of Health (MOH). However, a national system to facilitate international or regional inter-sectoral collaborations for NCD control is not in place. The Commission was established by MOH in 2010 in response to the Declaration of Port of Spain. The Commission’s stated goal was to strive to foster a multi-sectoral approach to addressing the epidemic of NCDs, to advocate and ensure appropriate policies and guidelines are put in place for NCD prevention and control, and to advise the Minister of Health on NCD policies and legislations. Although the commission’s membership includes stakeholders from health, private sector and representatives from national NGOs and international organizations including the following: organizations: Ministries of Health and Agriculture, National Health Insurance, Kidney Association of Belize, Belize Diabetes Association, Cancer Society, Belize Medical and Dental 26National Health Accounts, Ministry of Health Belize 2010 27Summarized based on the following surveys/assessments: WHO 2013. Country Profile of Capacity & Response to NCDs; PAHO 2012 Country Capacity Survey in Preparation for Carmen Meeting; INCAP Benchmarking Survey of National response to UN HLM on NCDs; PAHO 2012 Situation Analysis Cervical Cancer Prevention And Control and on stakeholder consultations 22 Association, PAHO, it has become apparent that certain strategic partners may also need to be included. The Ministry of Education for example does not have representation. To ensure the plan’s success, the membership should be reviewed to ensure the inclusion of essential partners. Additionally due consideration needs to be given to the terms of reference and mandate. The NCD Commission should have primarily an advocacy, monitoring and oversight role rather than an implementation role; appropriate coordination mechanisms need to be established. It needs to maintain NCDs as a priority continuously lobbying Cabinet to keep NCDs on the front burner. It is anticipated the commission will use this plan to guide and monitor its implementation. Resources for NCDs Dedicated NCD-specific resources e.g. by way of a budget line have not been allocated and an NCD programme per say does not exist with the MOH so that resources specifically for NCD prevention and control would be difficult to track. Resources for NCDs are currently subsumed under the other activities and programmes of the ministry e.g. primary prevention and health promotion, early detection/screening, health care and treatment and rehabilitation services within the scope of services offered by the ministry and integrated within the healthcare system; disease surveillance which includes communicable and noncommunicable diseases and the generation of mortality statistics by cause of death on routine basis; the free provision of NCD medicines through their inclusion on the essential drug list of the country. Political Will It is clear that the economic, social and disease burden of NCDs in Belize is high. As a group, NCDs currently represent one of the greatest threats to health, wellness and economic development in Belize; therefore this plan’s success requires raising the priority and profile of the public health threat of NCDs to provoke action. The government of Belize is the main healthcare provider, therefore a clear, strong and sustained political and policy commitment 23 from government is required. The challenge of NCDs is one that requires sustained, high level action commensurate with the scale of the problem. 2.1.4.2 Status of NCD-Relevant Policies, Strategies & Action Plans NCD policy An NCD policy has not been developed but an integrated national NCD strategy has been drafted for the priority NCDs diabetes mellitus, CVDs, cancer and chronic respiratory diseases and for which the following four strategic lines of work have been devised: Risk Factor Reduction, Health Promotion and Communications; Integrated Disease Management & Patient Self-Management; Surveillance, Monitoring & Evaluation; Programme Management, Policy & Advocacy. It addresses the major risk factors harmful use of alcohol, unhealthy diet, physical activity, tobacco. An NCD action plan which is aligned with this strategy is currently under development and combines early detection, treatment and care focusing on the four major NCDs: cancer, diabetes, CVD, overweight / obesity, and chronic respiratory diseases. The settings for the interventions include health care facility, school, community, workplace and households. An action for cancer is also under development. Tobacco & Alcohol With regards to tobacco policy, Belize has not had not yet achieved the highest level in any of the policy areas of implementation the tobacco policy (MPOWER) measures28,Belize has signed the WHO Framework Convention on Tobacco Control. The National Drug Abuse Control Council (NDACC) is currently championing the drafting of FCTC legislation to make Belize fully compliant although the council is not duly constituted and this is likely to pose some challenges. Notwithstanding this, legal counsel was retained to complete the review and drafting and the adoption of this legislation has cabinet support. Key to the success of the adoption is 28World Health Organization 2008.MPOWER: A Policy Package to Reverse the Tobacco Epidemic. 24 enforcement. The full adoption of this legislation will demonstrate the political commitment to addressing one of the key risk factors for NCDs. In Belize, there is currently no restriction on alcohol advertisement. As a result, a number of alcohol ads play during primetime often at news time. It is anticipated that the recently held regional meeting on National Alcohol Policy Development which was hosted in Belize will result in some tangible positive developments with regards to alcohol policy in Belize. Additionally, Belizeans are exposed to TV and radio from external sources including fast food commercials for food and food high in sugar, salt and trans fats. Trade and importations The legislative option is at times necessary; however it should be kept in mind that legislative changes are not made in a vacuum. The impact on other sectors must be considered e.g. on trade and tourism. In anticipation of potential barriers, NCD policy positions must be formulated in a systematic fashion that considers comprehensive impact assessments and means to mitigate any unwanted effects. The Government of Belize imposes a number of duties as well as exemptions on given imports29. For example gym and other exercise equipment are subject to a general sales tax of 12.5% and an environmental of 2%. On the other hand, a number of goods slated for food for humanconsumption including cooking oil, lard and salted edible meats appear on the list of duty-exempt goods. This avenue has yet to be examined to reduce the cost of goods and services that promote healthy living and conversely make access to unhealthy products more difficult. This population-based approach would include dialoguing with the relevant agencies and advocacy to bring NCD issues to the fore among key entities including pricing, content and quality of imported goods e.g. exercise equipment; foods with high trans-fat and monosodium glutamate content; 29 Belize customs & excise Information available at http://www.customs.gov.bz/customs_duties.html 25 NutritionPolicy While a national nutrition policy/plan does not exist per say, the National Food Based Dietary Guideline30 (FBDG) was developed and launched in early 2012. This was a multisectoral collaborative effort spearheaded between the Ministries of Health, Agriculture (via the Food and Nutrition Security Commission), Economic Development, Human Development, Social Transformation and Poverty Alleviation, Belize Bureau of Standards, Belize Agricultural Health Authority and University of Belize with technical support from PAHO and INCAP. This guideline is being used extensively as an educational tool that provides advice about ways to improve diets and health in a manner that is easy for the public to understand and that incorporates the concept of a health Belizean food basket (Annex 5). They were developed with the following objectives: encourage healthy food choices in respect of variety, quality and quantity; limit the intake of fat, sugar and sodium; reduce the prevalence of overweight and obesity; reduce the incidence and prevalence of CNCDs among Belizeans; promote increased consumption of fruits and vegetables; improve the food handling practices of Belizeans; reduce the incidence and prevalence of micronutrient deficiency diseases; promote increased levels of physical activity among Belizeans. The guideline targets the general health population from two years of age upwards and can be used by health care providers, policy makers, community leaders, educators and the public at large. A multisectoralFood and Nutrition Security Commission involving several of the same actors and chaired by the Ministry of Agriculture is in the process of revising the Food and Nutrition Security Policy. This presents another opportunity to bring about positive changes that could have substantial population level impact. Emphasis should be placed on incorporating measures to reduce salt, sugar and fats – saturated and trans fats. 30 Food-Based Dietary Guidelines for Belize 2011 available at www.health.gov.bz 26 MOH has also held consultation with the Bureau of Standards regarding the labelling of cigarette packs to ensure cigarette packs carry messages on the harmful effects of smoking. There has been sensitization of the only tobacco distributor, Caribbean Tobacco Limited of this impending action. The messages given were taken on board and they have pledged to work with MOH. School feeding programme Improving the quality of school meals is vital for improving children’s health, especially in the effort to decrease levels of obesity and future risks of related diseases such as heart disease and diabetes. Furthermore, there is evidence that improvements in diet may benefit children’s academic performance. In Belize, there is no policy covering school meals and coverage by feeding programmes is variable and focused on preventing malnutrition. Therefore the menus of those schools covered by the feeding programme are not predetermined and no minimum nutritional standards have been set. Additionally, vendors sell food next to school premises and control over the nutritional content of their goods is virtually non-existent. On the other hand, the MOE receives technical support from the MOH’s nutritionist with regards to the nutritional content and quality of school meals. The MOE is also in the process of developing a school gardens programme for the production of healthy foodstuffs i.e. fruits and vegetables for consumption by the student population – primary schools in the first instance. Nutrition strategies An increasing proportion of the population purchase food from local industries or producers. Initiatives should also involve strategies to encourage voluntary reduction of salt, fat and sugar in locally produced by engaging the local food industry in dialogue food and providing local vendors with education. There is also a need to facilitate the re-interpretation of Belizean food in a healthy, affordable way. The links between the NCDs and other issues that are associated over the life course should also be borne in mind. This would include maternal and child health, breastfeeding and 27 childhood nutrition and development. The MOH continues to spearhead a number of population-based initiatives exclusive breastfeeding campaigns (for the first six months of life) and healthy complementary feeding thereafter (up to 18 to 24 months) as well as micronutrient supplementation and deworming initiatives for pregnant women, women of child-bearing age and children. In addition, the MOH is now in the process of collaborating on a rice fortification initiative along with the Belize Bureau of Standards and the Ministry of Agriculture. Physical Activity Regular physical activity can help prevent cardiovascular disease, reduce the risk of developing type II diabetes and some cancers. It can also help build and maintain healthy bones, muscles and joints reducing the risk of injury; and promotes psychological well-being.31,32 Physical Activity Guidelines National Physical Activity Guidelines for Belizeans would outline the minimum levels of physical activity required to gain health benefits and outline everyday ways to incorporate physical activity. Since the requirements vary with age, these guidelines should look at different stages of life, children, adolescents, adults and the elderly. The focus must remain on low cost, practical options for people and should be heavily promoted to encourage take up. This guidance should involve expertise from MOH, MOE, Ministry of Sports and other relevant partners to develop a national physical activity guide. Of particular concern is physical education (PE) in schools. Currently the requirement is a single session weekly and in the sessions teachers are not required to participate with students. The national guidance needs to place a renewed emphasis on PE in schools, elevating its importance to that of other subjects since being physically active is essential for growth in children and 31Global Recommendations on Physical Activity for Health World Health Organization 2010 32Parfitt G and Eston RG.The relationship between children's habitual activity level and psychological well-being.ActaPaediatr. 2005 Dec;94(12):1791-7. 28 adolescents. Due consideration also has to be given to the issue of adequate spaces in which to conduct PE. Adult guidelines should also include succinct guidance for work-based programs. While a few Belizean businesses have started wellness initiatives, it is still the exception rather than the rule. Making Physical Activity Safer and Easier Safety concerns are a barrier to outdoor (low cost) physical activity particularly in urban areas. There is therefore a need for safe spaces where people can safely undertake activities such as walking, cycling, jogging and games. The Belize District including Belize City, which is the commercial centre of the country, is the most populous part of the country where almost 30% and 20% of the population respectively reside33Belize City is undergoing major renovations to many of its streets and some parks. This improved infrastructure while primarily aimed at improving conditions for vehicular traffic may also present the opportunity to undertake mass population physical activity such as seen in other countries of the region with the potential to reach a considerable proportion of the population and that could be replicated elsewhere in the country. 2.1.4.3 Health Information Systems, Surveillance & Surveys for NCDs NCD surveillance Surveillance, monitoring and evaluation perform a vital function across the intervention pathway for NCD management. In resource constrained settings such as Belize, it is essential that there is an evidence-based case for instituting policy and interventions to reduce NCD burden. Epidemiological data on both risk factors and chronic disease conditions provide critical information on where to base priority as well as the selection of interventions for particular target groups. NCD surveillance is subsumed under the national surveillance system which is 33Derived from Statistical Institute of Belize 2010 Population Census results. 29 managed by the National Epidemiology Unit. Reporting includes cause-specific mortality (utilizing ICD-10 codes to assign the underlying cause of death) and hospital-based morbidity. These statistics have been mainly limited to counts of reported cases, hospitalizations and deaths aggregated by age group, sex and geographic distribution. Although data dissemination mechanisms are in place and include quarterly and annual reporting and access via the MOH webpage, room for improvement exists for more systematic and timely reporting as well as in the use of the information for policy and planning. Currently much of the basic morbidity and mortality data are being reported from the Belize Health Information System (BHIS). Belize Health Information System (BHIS)34 The BHIS is the main data capture tool of the MOH and is a web-based system that came on stream in 2008. It is currently distributed in all major public health facilities & labs countrywide and provides a comprehensive and integrated infrastructure to capture clinical, laboratory, pharmacy data in electronic health records (EHR) and supply chain management data in “real time”, thereby allowing for the capture of population-based, health services and record-based data incorporating the use of standardised data lists for improved data capture and integrity. The full potential of the system to provide information has yet to be realised. This has powerful potential to improve individual health outcomes and public health performance, and optimise resource utilization. Chronic diseases registries are special databases containing information about people diagnosed with a specific type of disease and are now widely recognised for their potential to improve quality of care. Electronic medical record systems can be used to facilitate the development of such registries and their increasing use in this manner represents the transition that is occurring from traditional surveillance systems into the realm of health and clinical informatics. The BHIS with its EMR component can facilitate the development of disease registries. 34 Description of the BHIS available at www.health.gov.bz 30 This system therefore holds incredible opportunities to reap the benefits of disease registries thereby improving patient outcomes. Its potential has yet to be fully realised and limited human capacity in these areas is in large part to blame. There is need to better exploit the potential of the BHIS maximally. Additionally, for the BHIS to be fully utilised in NCD management, it must be linked to patient care management systems. Ideally, the BHIS would also be able to flexibly accommodate an NCD registration system or easily link to or integrate with other systems. 31 NCD risk factor surveillance and minimum dataset reporting Belize has made considerable strides in NCD surveillance. A significant milestone was achieved in the execution of the CAMDI survey in 2006. The following risk factor surveys have also been conducted: the 2008 Global Youth Tobacco Survey (GYTS) and the Global School Health Survey (GSHS). The areas covered are as follows: harmful alcohol use, raised total cholesterol, low fruit and vegetable consumption, raised blood pressure/hypertension physical inactivity, overweight and obesity, tobacco use, raised blood glucose/diabetes. For this information to remain current, these surveys must be repeated on a periodic basis, ideally every 3 to 5 years. Another major milestone was in the establishment of the Caribbean Minimum Dataset (CMDS) which was developed by the Caribbean Public Health Agency (CARPHA). Belize was one of the countries that piloted the dataset in 2008 and has since been submitting reports annually to CARPHA since 2009. The report is divided into minimum, optimum and optional data elaborated as 44 core, 19 expanded and 12 optional indicators related to morbidity, mortality, risk factors and preventive service provision for cardiovascular disease, cancer, diabetes, asthma and COPD, violence and injuries. This dataset allows the captures information on mortality from/with selected NCDs including age-standardised mortality rates <70 years and PYLL (based on national life expectancies); prevalence/incidence of selected conditions; risk factors for chronic diseases (Adults & Youth); health system performance Indicators including access to services, screening for NCDs and complications from NCDs and socioeconomic and context indicators. To date Belize has reported on 31 of the 44 core, none of the 19 expanded (mainly health systems performance indicators) and all of the 12 optional indicators. 32 Gaps in NCD surveillance However, national targets for reduction in risky health behaviours have yet to be set.With regards to disease registries, efforts have been made in the area of establishing a cancer registry but much work remains to be done. Additionally, there is a need to ensure collation of critical information for use in policy/planning/implementation, which may go beyond the NCD dataset currently used. These need to include but may not be limited to:

1. Inpatient and outpatient (including clinic return) hospital morbidity and mortality data including those in the private sector

2. National registries for selected diseases (Cancer, Diabetes)

3. Data on standard indicators of the major risk factors and their determinants

4. Data on process, output and outcome indicators for monitoring and evaluation of all programs related to prevention and control of major NCDs

5. Data for monitoring standards of care (audits)

6. Data generated from research and special studies on NCDs

7. The systematic publication of findings, including graphs and summaries, on the MOH webpage Additionally, known gaps in information include the following: a comprehensive epidemiological picture of NCDs and disaggregated by ethnicity region, age, gender, vulnerable groups etc.; information of the health effects and impact of alcohol use; data on the economic costs of NCDs; impact assessments of interventions 33 2.1.4.4 Capacity for NCD Prevention, Early Detection, Treatment & Care within the Health System The following NCD-related components are integrated to various degrees within the healthcare system: primary prevention and health promotion; support for self -help and self-care; risk factor detection; support for home-based care; risk factor and disease management. Primary prevention & health promotion Primary prevention &risk factor detection With regards to primary prevention and early detection, the mechanism and services are in place to a large extent for parameters related to overweight and obesity, cardiovascular diseases and diabetes, except for the availability of Haemoglobin A1C testing in the public sector and the application of individual risk management with a validated CV risk score for CVDs assessments. Cervical cancer screening is widely available through pap smear services as is faecal occult blood testing for colorectal cancer. Visual inspection with acetic acid (VIA) (and followed by cryotherapy in a single visit), HPV DNA testing are and HPV vaccination have not been implemented as part of a national protocol. Mammography for breast cancer screening is not widely available in the public sector and has limited availability in the private sector. Health promotion MOH - The Health Education and Community Participation Bureau (HECOPAB) HECOPAB is the health promotion unit of MOH. The unit undertakes a number of different activities including the following:  Maintains a health information resource centre  Produces health information materials (leaflets, fliers, posters, booklets)  Provides health educators for school and community health education sessions, discussion and demonstrations  Designs health education messages for public information (radio & TV)  Provides training in community organization and development 34  Provides training in the design of health education materials and visual aids  Coordinates and facilitates the training of the Community Health Workers  Facilitate training in public health areas  Plans and organises health fairs  Provides technical support in programme planning and implementation with allied health personnel, other government ministries/departments, non-governmental organizations, other health and social agencies and UN agencies HECOPAB has NCDs on its priority list of activities and health promotion is crucial to NCD prevention. However, the unit is vastly under-resourced to deal with this challenge. There certainly is a need to ensure that the wider population has access to comprehensive information about the health risks of alcohol and tobacco. To effectively engage with the public so that their messages resonate with people, HECOPAB must innovate and take a marketing approach, with Wellness as its product. A comprehensive national communication strategy is urgently required with mass media campaigns targeting NCD risk factors. It is urgent that HECOPAB receives the human and financial resources to achieve its tasks. Health Education Health and Family Life Education (HFLE) is a comprehensive, life-skills based programme that focuses on the development of the whole, resilient person. It educates children, adolescents, and adults through guided experiences to become contributing and productive citizens; provides a full understanding of healthy living that incorporates psychological and spiritual wellbeing, healthy eating, and physical fitness, establishes life-skills that emphasise effective interpersonal and informed sexual and reproductive choices; and, fosters the development of skills, attitudes, and knowledge that result in healthy social and family values and lifestyles. The current HFLE curriculum is only available at the primary school level. Although some high schools do attempt to offer some degree of health and nutrition education and life skills training, these curricula are not standardised as with the HFLE. As a result there has been a push towards the adoption of HFLE for secondary schools. 35 Advocacy Caribbean Wellness Day was started in 2008 in order to mobilise CARICOM citizens to engage in activities that promote and sustain healthy lifestyles. This was an initiative that emanated from the declaration of Port of Spain meeting and has since been expanded to Caribbean Wellness Week. This week is an ideal time to endorse health promotion. It can also be used as a launch pad for new Wellness initiatives. MOH has been involved in a number of activities promoting Caribbean Wellness Week. These activities can be coordinated to reflect the priorities of this strategic plan. Currently activities are focused on nutrition and physical activity. However, the scope can indeed be widened and the opportunity seized to continue those initiatives that are deemed successful. Risk factor & disease management A holistic wellness approach that puts the patient at the centre of management rather than the disease is essential for successful integrated care. Each interaction with health services should be an opportunity to ensure the wellness of the individual rather than the management of a single aspect of disease. In addition, the required human resources and clinical support services must also be in place and also entails the most cost efficient use of these scarce resources. This speaks to a reorientation of services so that NCDs can be managed and their course positively influenced. Primary health care services in Belize The national public health system, through which approximately 75% of the population accesses health care, delivers services through a network of institutions at the primary, secondary, and tertiary levels. Approximately one third of primary care services are delivered by Primary Care Providers (PCPs) from whom the National Health Insurance (NHI) arm of the Social Security Board, contracts an explicit package of primary care services which includes screening for NCD risk factors as well as breast cancer screening; management of NCDs and 36 prenatal care. Currently this scheme is limited to the Southside of Belize City and the two southern districts. NHI has adopted in contracts with the PCPs a set of Key Performance Indicators (KPIs) , implemented in an incremental manner as building blocks, that outline its targets. PCPs that achieve the required standards are rewarded financially. On the other hand, Belize has a number of challenges in the provision of clinical support services. The demand for laboratory services has increased significantly; however lab services have failed to keep pace and face a number of issues in the areas of human resource, infrastructure and maintenance of supplies and equipment. Crucial to the delivery of quality evidence-based care is the availability of the necessary services such as laboratory and pharmacy. For this to be comprehensive, they should be integrated as a package of services with minimum standards covering all essential needs. To date, the NHI model provides the only experience in country along that line. This should be objectively assessed in terms of its strengths and weaknesses with the aim of expanding the successes to the national level in a sustainable manner. A cost effective clinical package will need to cover interventions, care such as urinalysis, and measurement of blood pressure, blood sugar, body weight and height as well as screening for NCDs. NCDs often affect people in many ways resulting in complex psychological & physical challenges. Patients may be vulnerable and require support services beyond health clinic visits. There is a substantial need for services to include community outreach for those at high risk including psychosocial support. Patient self-management It is well known that people living with Diabetes can be taught to actively control their blood sugar levels by using self-monitoring devices. We must help people with NCDs to manage their condition in a better way, providing them with tools for self-management and care. Empowering individuals with NCDs to take responsibility for their condition can significantly reduce disease burdens. In Belize, some clinics are increasing efforts to improve patient 37 education and self-management including diabetic foot care. Moreover, collaborations on initiatives with supporting organizations such as the Belize Diabetes Association (BDA) have occurred. Current Belize, through the efforts of the BDA and in collaboration with the MOH, has embarked on a six-country initiative called the Bridges Project which involves the implementation of a culturally sensitive lay diabetes education program for adults with type 2 diabetes.However, these collaborations have generally been fragmented and non-systematic rather than an integral part of primary care. Furthermore, such initiatives have been carried to an even lesser extent for the other NCDS. Therefore, there is the need to not only establish patient self-management as a priority but also ensure that the mechanisms that support patient self-management are in place. These mechanisms may include offering different formats and venues for patient education and self-management services, and using educational processes and materials that are culturally relevant and language appropriate. It should also emphasise each clinic visit as opportunities to describe/reinforce the patient’s role in their self- management and the healthcare professional’s role in supporting them. Protocols/clinical managementguidelines Although there are some protocols are in place, e.g. covering diabetes and hypertension, these protocols do not cover all priority NCDs and their risk factors and they have had limited roll out nationally. With the exception of NHI clinics, the impact and uptake of these protocols is not clear. Especially lacking are screening guidelines for many NCDs, in particular cancers, and as a result there is wide variation in screening practices in different settings (NHI/non-NHI, public/private, urban/rural). Work on protocol development must continue, particularly screening protocol and this must be supported by national roll out and training to use these protocols. Furthermore, other dimensions such as secondary and tertiary level interventions encompassing comprehensive cancer management, pain relief, palliative care and treatment, although not the focus of this document, have also been found to be cost effective and should be included in a cancer control action plan and programme. 38 Accountability NHI covers about 40 % of the population, which includes the south side of Belize City and the southern region of the country (Stann Creek and Toledo districts). Financial incentives are linked to performance and contracted health clinics must fulfil monthly and annual performance indicators to earn their incentive payments.35Compliance with Medical Protocols implementation is included in these Key Performance Indicators (KPIs). This two-tier system where some clinics are accountable and some are not fosters inequalities in delivery of care. Greater accountability supported by annual audits should be a part of every primary care facility to enable effective implementation of the NCD plan. This can be done in stages; key parts will include: standardizing medical records; establishing audit criteria; initial and refresher training of protocols. Human Resources Development The training and up-skilling of Belize’s primary care work force is fundamental for the provision of services by health care professionals who have right skills and competencies to deliver first- rate care to manage NCDs and improve the overall wellness of the nation. Furthermore, a truly integrated approach to care means that they cannot function in silos managing conditions in isolation, particularly in Belize’s resource-constrained setting. For example, a national referral system is in place with a protocol that defines its operation. However, particularly the counter- referral component (information sent back to the doctor who referred the patient in the first instance) has functioned sub optimally. This affects the continuity of care and may have significant implications for patient outcome. 35 Vanzie M, Hsi N, Beith A, and Eichler R: 201.Using Supply-side Pay for Performance to Strengthen Health Prevention Activities and Improve Efficiency: The Case of Belize. Bethesda, Maryland: Health Systems 20/20, Abt Associates Inc. 39 The professional public health workforce includes 30% of physicians and 10% of nurses from other countries in addition to an increasing attrition rate of nurses (from 7.7% in 2001 to 9.6% in 2006).36A significant challenge that must be anticipated is the high turnover of foreign healthcare personnel. While they play a crucial role in healthcare delivery in Belize, they are often not permanent staff and are assigned to healthcare facilities for varying periods of time. This poses a significant training/orientation issue that must be overcome to ensure that all staff is providing the required standard of care. This applies to any new staff should this training/orientation not be provided in a timely manner. Availability of NCD-related medicines & technologies NCD medicines are generally available (Annex 1) with the exception of nicotine replacement therapies. The main gaps in treatment are for specialised NCD care such as chemo and radiotherapy, cardiac bypass and angioplasty and retinal photocoagulation. 2.2 Commitments &Guiding Frameworks Belize’s is a party several regional and subregional declarations and resolutions including Caribbean Community’s Port-of-Spain declaration on NCDs (2007); the declaration from the Regional High-level Consultation of the Americas on NCDs and Obesity (2011) and the NCD Declaration from the Council of Ministers of Health of Central America and Dominican Republic (2011) as well as the global WHO Framework Convention on Tobacco Control (FCTC). This action plan has also benefited from the development of the World Health Organization (WHO) NCD Global Monitoring Framework and Global Action Plan 2013-2020 and the PAHO Regional Plan of Actionfor the Prevention and Control of NCDs 2013-2019 and is very closely aligned with these frameworks. It targets the same four NCDs and risk factors and operates 36PAHO/WHO & USAID (2009). Health Systems Profile Belize: Monitoring and Analyzing Health Systems Change/Reform. 40 along four very similar lines of action. It has a total of 33 indicators. It adopts and adapts seven (7) of the nine (9) WHO voluntary global targets (Annex 1),18 of the 25 global WHO indicators (Annex 2), 8 of the 10 additional PAHO regional indictors; the remaining 7 are country-specific. The 8 PAHO and 7 country-specific indicators are more process oriented as opposed to the outcome indicators of the WHO Global Monitoring Framework. This plan is a continuation of the work that was begun with the draft National Strategic Plan for NCDsin late 2011, thedevelopment of which was guided by the Strategic Plan Of Action For The Prevention And Control Of Chronic Noncommunicable Diseases (NCDs) For Countries Of The Caribbean Community 2011-2016 and the WHO 2008-2013Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, and is essentially the operationalization of that strategy so that the goal, vision, purpose, four lines of action, eight strategic objective remain the same. The time period of implementation reflects that of the revised the National Health Sector Strategic Plan 2013-2023. 41

3. The Plan The Belize National Plan of Actionfor the Prevention and Control of Non communicable Diseases(NCDs)was developed collaboratively with the Ministry of Health and relevant stakeholders involved in NCD prevention, control and management including NDACC, NHI, Belize Cancer Society, Belize Diabetes Association, Ministry of Education, Belize and with technical assistance from the PAHO Regional Office, Washington. The development of the plan was also informed by previouscollaborative work on the NCD Strategy with NCD Commission members and other relevant entities across several government sectors (Health, Education, Agriculture, and Economic Development), Non-governmental Organizations (NGOs) and the private sector. 3.1 Goal: To reduce premature mortality from NCDs the chronic disease burden by 25% by 2023. This will be achieved by combining integrated action on NCD risk factors and their underlying determinants and strengthen health systems so as to reduce NCD morbidity & mortality 3.2 Vision Improve the wellness of Belizeans by prevention and control of noncommunicable diseases and their risk factors. 3.3 Statement of Purpose The purpose of this national plan is to promote the establishment of policies and implementation of actions geared towards the meaningful reduction of NCDs in Belize.It is intended to act as a blueprint for the organization of efforts across sectors to produce a holistic response to the impact of NCDs and their risk factors. This plan should then result in a reduction in NCD disease burden; improve life expectancy and well-being. 42 3.4 Principles The following principles guided the construction of the plan: • An integrated holistic view of health • Emphasis on risk factor reduction and health promotion • Complementarity with Belize’s national health plan in its aim to promote cost-effective interventions and address key health priorities • Multi-sectoral and multi-stakeholder involvement along with a cross-government approach • Balanced population-wide and individual-based approaches • Focus on reducing inequities in health • Gender based approach 3.5 Scope As per the global and regional action plans and national strategy, this plan focuses on targeting the four (4) major chronic diseases -cardiovascular disease, diabetes mellitus, chronic respiratory diseases, cancer and their four main risk factors: unhealthy diet, lack of physical activity, harmful use of alcohol, and tobacco use. The focus of this plan is primarily on health promotion and disease prevention initiatives, primary health care services, and policy development/implementation. While established disease management is crucial, the acute care model has not been effective in the prevention and management of NCDs. Furthermore, this approach is consistent with Belize’s Health Sector Reform, which strives to reorient services to deliver quality, cost-effective services. 43 3.6 Organization of the Plan As per the national NCD strategy, the plan consists of four lines of action and eight corresponding strategic objectives: I. Risk factor reduction, health promotion and communications:  Obj. 1. To develop and implement policies and strategies that facilitates reduction of tobacco and alcohol use.  Obj. 2. To stimulate inter-sectoral action that promotes the availability, accessibility and consumption of healthy foods by the Belizean public.  Obj. 3. To develop and implement policies and strategies that promote physical activity.  Obj. 4. To develop and implement a comprehensive health communication strategy II. Integrated Disease Management& Patient Self-management:  Obj. 5. To facilitate and support the strengthening of the capacity and competencies of the health system based on a primary care approach, for the integrated management of NCDs and their risk factors. III. Surveillance, Monitoring and Evaluation:  Ob.j 6. To encourage and support the development and strengthening of the capacity for surveillance of chronic diseases, their risk factors, determinants and consequences, as well as monitoring and evaluation of the impact of public health interventions. 44 IV. Programme Management, Policy and Advocacy:  Objective 7: To ensure the effective leadership and implementation of the National Strategic Plan for NCDs  Objective 8: To engage all sectors of society and foster international cooperation. For each line of action and objectives there are proposed activities and indicators (33 in total). It has a total of 33 indicators. It adopts and adapts seven (7) of the nine (9) WHO voluntary global targets (Annex 1), 18 of the 25 global WHO indicators (Annex 2), 8 of the 10 additional PAHO regional indictors; the remaining 7 are country-specific. The 8 PAHO and 7 country- specific indicators are more process oriented as opposed to the outcome indicators of the WHO Global Monitoring Framework. Targets and baselines (where available) will be explicitly stated for this latter group of indicators. 45 3.7 NCD Action Plan 3.7.1 Risk factor reduction, health promotion and communications 3.7.1.1 Proposed Activities

1. Finalise draft alcohol policy ensuring that key areas such as point of sale restrictions, advertising and taxation are addressed

2. Submit to cabinet the alcohol policyfor approval

3. Ensure the enforcement of the existing and proposed new policies & regulations for tobacco and alcohol (ensuring that key areas such as to address the four main articles of the WHO FCTC, namely taxation, smoke free policies, advertising bans, and warning labels in the case of tobacco and point of sale restrictions, advertising and taxation in the case of alcohol are addressed)

4. Ensure comprehensive inclusion of risk factor education in the HFLE programme; develop a similar approach at secondary school level

5. Review Food & Nutrition Security policy ensuring the inclusion of salt reduction, saturated fats, trans fats & sugar

6. Continue the efforts with the Bureau of Standards in food labelling

7. Develop/revise school physical education and nutrition policies

8. Implement and monitor policies related to alcohol, tobacco, physical education, nutrition and healthy eating

9. Devise and implement a comprehensive health communication strategy

10. Vendor education, industry dialogue and support for the voluntary reduction of salt, fat and sugar in locally produced food

11. Support population-based,community and work-based initiatives for physical activity and health living

12. Maintain social mobilization activities such as Wellness Week, Caribbean Nutrition Day to engage more people in healthier living 46

13. Engage media in the promotion of NCD agenda e.g.increasing public awareness on diet and physical activity; voluntary regulation of alcohol advertising and promotion, especially ads aimed at young people, particularly during primetime 47 3.7.1.2 Indicators/targets/baselines Process

1. Operational Food & Nutrition Security policy by end 2015

2. Operational policies to support healthy eating and physical education in schools by end 2015

3. Policies to reduce the impact on children of marketing of foods &non-alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt by end 2023 Outcome 4. 30% relative reduction in prevalence of current tobacco smoking, by 2023 (baseline adolescents (%)total/males/females: 26.7/36.2/18.6; adults (%): 10.5/19.1/18.6) 5. 10% relative reduction in alcohol per capita consumption, measured in litres of pure alcohol by 2023 (baseline - 6 litres37) 6. 10% relative reduction in the age-standardised prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context by end 2023 (baseline adults(%) total/males/females: 7.6/13.1/2.7; adolescents tbd38) 7. 10% relative reduction in the prevalence of insufficiently physically active adolescents, defined as less than 60 minutes of moderate to vigorous intensity activity daily b by end 2030 (baseline: tbd)

8. Age-standardised prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit & vegetables per day(baseline total/males/females: <2/day) 37WHO 2011. Global Status Report on Alcohol & Health 38To be determined… 48

9. Age-standardised prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol Q5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration(baseline (%) total/males/females: 5.1/4.1/6.0) 10. 10% reduction in sedentarism by end 2023 (baseline adults (%) total/males/females: 77.7/75.4/80.4) 11. 0% increase in adult and/or overweight, obesity and Type II diabetes by end 2023 (baseline diabetes (%) total/males/females:13.1/8.3/17.6); baseline overweight/obesity (%): 66.3/59.2/80.4) 12. 25% relative reduction in the prevalence of raised blood pressure by 2023 (baseline (%) total/males/females: 28.7/28.6/24.4) 49 3.7.1.3 Key Partners: Ministries: Health (inc. NDACC), Agriculture, Education, Human Development Social Transformation and Poverty Alleviation Youth & Sports, Finance, Trade, Public Service, Immigration & National Security, NGOs, Trade Unions, Universities, schools, media, Bureau of Standards, Insurance Companies, International Cooperation Organizations 50 3.7.2 Integrated Disease Management& Patient Self-management Proposed Activities

1. Revise Human Resources for Health Plan

2. Determine minimum standards and minimum package of services covering essential drugs, laboratory services, basic equipment and maintenance checks at community (including the community health worker (CHW) network), primary and secondary levels.

3. Implement model of integrated management for NCDs (e.g. Chronic Care Model (evidence-based guidelines, clinical information system, self-care, community support)

4. Utilise the PAHO Strategic Fund and Revolving Fund and/or other cost-saving mechanisms to procure essential medicines and health technologies relevant to prevention, control and palliation for the four leading NCDs e.g., chemotherapy drugs, palliation medications, insulin, dialysis and haemodialysis, and hepatitis B and human papilloma virus (HPV) vaccines.

5. Continuing medical and professional education in relevant areas including NCDs for delivery of quality evidence-based care

6. Improve/strengthen referral mechanisms and secure healthcare professional compliance

7. Functional official commission that selects, according to the best available evidence, and operating without conflicts of interest, NCD prevention, treatment and palliative care medicines and technologies for inclusion in/exclusion from public sector services

8. Strengthen national laboratory services (including BAHA & CML)

9. Develop/Revise/Update comprehensive evidence-based cost-effective care protocols and guidelines (including screening) that cover multiple levels of staff and multiple levels of care (including palliative care) 51

10. Develop or improve mechanisms that support patient self-management introducing guidelines that include and psychological support behaviour and educational programmes which enable patients to take responsibility and manage their condition

11. Conduct feasibility study and implementation protocol for the introduction of the HPV vaccine Indicators Process

1. Model of integrated management for NCDs (e.g. Chronic Care Model (evidence-based guidelines, clinical information system, self-care, community support) implemented a by end 2015

2. Minimum package of services covering essential drugs, laboratory services, basic equipment and maintenance checks developed by end 2014

3. PAHO Strategic Fund and Revolving Fund and/or other cost-saving mechanisms utilised to procure essential medicines and health technologies relevant to prevention, control and palliation for the four leading NCDs by end 2014

4. Functional official commission that selects, according to the best available evidence, and operating without conflicts of interest, NCD prevention, treatment and palliative care medicines and technologies for inclusion in/exclusion from public sector services by end 2014

5. Availability, as appropriate, of cost-effective & affordable, of vaccines against HPV according to national programmes & policies

6. Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants: target 100% (baseline:tbd)

7. Proportion of women screened and treated for cervical cancer according to national guidelines – target 80% (baseline: 62%)

8. Proportion of women screened for breast cancer according to national guidelines – baseline and target tbd

9. Report from HPV vaccination feasibility study by end 2014 52 Outcome 10. 80% availability of affordable of quality, safe & efficacious essential NCD medicines, including generics& basic technologies in both public & private facilities by end 2018 (baseline: >80%)  Incidences of cervical & breast cancer39 (baselines cervical and breast respectively: 36.9 & 30.9) Key Partners Ministry of Health, Karl Heusner Memorial Hospital Authority, NHI, Disease-specific NGOs, Private medical practitioners, BMDA, Belize Medical Council, Nurses Association of Belize, University of Belize 3.7.3 Surveillance, Monitoring and Evaluation Proposed Activities

1. Monitor at national level the selected targets and indicators in the global monitoring framework and regional NCD action (MOH as lead)

2. Setting of a research agenda for NCDs including cost benefit and analytical studies such as for the implementation of new vaccines (HPV) and technologies e.g. VIA, CVD risk score, NHI impact evaluation and roll out feasibility assessment…

3. Improve the completeness and quality of data including improved reporting in NCD minimum dataset, data/evidence gap and trend analyses

4. Development of chronic disease registries utilizing BHIS and other relevant data sources

5. Ensure the execution of risk factor surveys for the four risk factors 39 To be incorporated in the indicator “cancer incidence by type /100,000) 53 Indicators Process

1. Periodic Reviews of NCD Operational Plans annually

2. At least one repeated nationally representative population survey of NCD risk factors, in adults and youth by end 2018 and another by end 2023

3. Functional population-based disease registries for cancer and diabetes by 2015

4. Mid-term & Final Evaluations of NCD Plan (2018 & 2023) Outcome 5. 25% reduction in the unconditional probability of dying between the ages of 30 and 70 from NCDs by end 2023 (baselines tbd)

6. Cancer incidence by type/100,000 population (baselines cervical and breast respectively: 36.9 & 30.9) Key Partners Ministry of Health (Epidemiology unit, PCPs), NHI, Belize Cancer Society, Belize Diabetes Association, Belize Centre for Visual Impairment, Belize Cancer Center of Dangriga 54 3.7.4 Programme Management, Policy and Advocacy Proposed Activities

1. Present multi-sectoral NCD plan to cabinet for approval and endorsement

2. Develop an NCD program in the MoH , with clear leadership and governance over a multi-sector committee on NCDs, and with corresponding budget

3. Establish asecretariatto deal with NCDs- structure and operations (terms and mandate of reference)

4. Assign clear responsibility and accountability for the NCD portfolio across the various sectors

5. Expand social protection policies to provide universal health coverage and more equitable access to services, essential medicines, and technologies for NCD diagnosis, treatment, rehabilitation, and palliative care 55 Indicators

1. Endorsed NCD Plan by end 2013

2. Functional NCD Secretariat by end 2014

3. Social protection policy developed that includes NCDsby end 2018

4. NCD prevention policies in at least 3 sectors outside the health sector (e.g. agriculture, trade, education, labour, development, finance, urban planning, environment and transportation and other sectors) by end 2018 Key Partners: Ministries: Health, Education, Economic Development, Human Development Social Transformation and Poverty Alleviation, Finance, Trade, Labour & Local Government, Attorney General’s Ministry; NGOs, Trade Unions, Universities, schools, Food manufacturers, media, food vendors, private companies 56

4. Belize Framework of Action for the Prevention & Control of NCDs Line of Action Strategic Objectives Activities Indicators (&Targets) Key Partners Risk factor 1. Finalise draft alcohol 1. Operational Food & Ministries: Health (inc. reduction, health Obj. 1. To develop and policy ensuring that key Nutrition Security NDACC), promotion and implement strategies that areas such as point of policy by end 2015 Agriculture,Education, communications facilitates reduction of Food & Nutrition Security sale restrictions, tobacco and alcohol use. 2. Operational policies to Committee,Human advertising and taxation are addressed support healthy eating Development Social Obj. 2. To stimulate inter- 2. Submit to cabinet the and physical Transformation and sectoral action that alcohol policy for education in schools Poverty AlleviationYouth& promotes the availability, approval by end 2015 Sports, Finance, Trade, accessibility and 3. Ensure the enforcement 3. Policies to reduce the Public Service, consumption of healthy of the existing and impact on children of Immigration & National foods by the Belizean proposed new policies & marketing of foods & Security NGOs, Trade public. regulations for tobacco non-alcoholic Unions, Universities, and alcoholensuring beverages high in schools, media, Bureau saturated fats, trans of Standards, Insurance Obj. 3.To develop and that key areas such as fatty acids, free Companies implement strategies that to address the four sugars, or saltbby end promote physical main articles of the 2023 activity. WHO FCTC, namely 4. 30% relative reduction taxation, smoke free in the prevalence of Obj. 4. To develop and policies, advertising current tobacco use implement a among adolescents by bans, and warning comprehensive health end 2023 labels in the case of communication strategy 5. 30% relative reduction tobacco and point of sale restrictions, in the age- standardised advertising and prevalence of current taxation in the case of tobacco use among alcohol are addressed persons aged 18+

4. Ensure comprehensive yearsb by end 2023 inclusion of risk factor 6. 10% relative reduction 57 education in the HFLE in alcohol per capita programme; develop a consumption, similar approach at measured in litres of secondary school level pure alcohol by 2023b

5. Review Food & Nutrition 7. 10% relative reduction Security policy ensuring in the age- the inclusion of salt standardised reduction, saturated fats, prevalence of heavy trans fats & sugar episodic drinking

6. Continue the efforts with among adolescents the Bureau of Standards and adults, as in food labelling appropriate, within

7. Develop/revise school the national context b physical education and by end 2023 nutrition policies 8. 10% relative reduction

8. Implement and monitor in the prevalence of policies related to insufficiently alcohol, tobacco, physical physically active education, nutrition and adolescents, defined healthy eating as less than 60

9. Devise and implement a minutes of moderate comprehensive health to vigorous intensity communication strategy activity daily b by end

10. Vendor education, 2030 industry dialogue and 9. Age-standardised support for the voluntary prevalence of persons reduction of salt, fat and (aged 18+ years) sugar in locally produced consuming less than food five total servings (400

11. Support population- grams) of fruit & based, community and vegetables per day b work-based initiatives for 10. Age-standardised physical activity and prevalence of raised health living total cholesterol 58

12. Maintain social among persons aged mobilization activities 18+ years (defined as such as Wellness Week, total cholesterol Q5.0 Caribbean Nutrition Day mmol/l or 190 mg/dl); to engage more people in and mean total healthier livingand cholesterol ensure that all concentration b communities 11. 10% reduction in throughout the country sedentarism by end 2023b are provided with 12. 0% increase in the educational messages, prevalence of community fairs to overweight and learn about healthy obesity in adolescents ways of life by end 2023 b

13. Engage media in the 13. 0% increase in the promotion of NCD age-standardised agenda e.g.increasing prevalence of public awareness on diet overweight and and physical activity; obesity in persons voluntary regulation of aged 18+ years alcohol advertising and (defined as body mass promotion, especially ads index Q 25 kg/m² for aimed at young people, overweight and body particularly during mass index Q 30 primetime kg/m² for obesity) by end 2023 b 14. 25% relative reduction in the prevalence of raised blood pressure by 2023b Integrated Disease Obj. 5 To facilitate and 1. Revise Human Resources 1. Model of integrated Ministry of Health, Karl Management&Pat support the strengthening for Health Plan management for NCDs Heusner Memorial Hospital 59 ient Self- of the capacity and 2. Determine minimum (e.g. Chronic Care Authority, NHI, Disease- management competencies of the standards and minimum Model (evidence- specific NGOs, Private health system for the package of services based guidelines, medical practitioners, integrated management of covering essential drugs, clinical information BMDA, Belize Medical NCDs and their risk laboratory services, basic system, self-care, Council, Nurses Association factors. equipment and community support) of Belize, University of maintenance checks at implemented a by end Belize community (including the 2015 community health worker 2. Minimum package of (CHW) network), primary services covering and secondary levels. essential drugs,

3. Implement model of laboratory services, integrated management basic equipment and for NCDs (e.g. Chronic maintenance checks Care Model (evidence- developedby end based guidelines, clinical 2014 information system, self- 3. PAHO Strategic Fund care, community support) and Revolving Fund

4. Utilise the PAHO Strategic and/or other cost- Fund and Revolving Fund saving mechanisms and/or other cost-saving utilised to procure mechanisms to procure essential medicines essential medicines and and health health technologies technologies relevant relevant to prevention, to prevention, control control and palliation for and palliation for the the four leading NCDs four leading NCDsa by e.g., chemotherapy drugs, end 2014 palliation medications, 4. Functional official insulin, dialysis and commission that haemodialysis, and selects, according to hepatitis B and human the best available papilloma virus (HPV) evidence, and vaccines. operating without 60

5. Continuing medical and conflicts of interest, professional education in NCD prevention, relevant areas including treatment and NCDs for delivery of palliative care quality evidence-based medicines and care technologies for

6. Improve/strengthen inclusion in/exclusion referral mechanisms and from public sector secure healthcare servicesa by end 2014 professional compliance 5. 80% availability of

7. Functional official affordable of quality, commission that selects, safe & efficacious according to the best essential NCD available evidence, and medicines, including operating without generics, & basic conflicts of interest, NCD technologies in both prevention, treatment public & private and palliative care facilitiesb by end 2018 medicines and 6. Availability, as technologies for inclusion appropriate, if cost- in/exclusion from public effective & affordable, sector services of vaccines against

8. Strengthen national HPV according to laboratory services national programmes (including BAHA & CML) & policies b

9. Develop/Revise/Update 7. Vaccination coverage comprehensive evidence- against hepatitis B based cost-effective care virus monitored by protocols and guidelines number of third doses (including screening) that of Hep-B vaccine cover multiple levels of (HepB3) administered staff and multiple levels to infants b of care (including 8. Proportion of women palliative care) screened and treated 61

10. Develop or improve for cervical cancer mechanisms that support according to national patient self-management guidelinesb introducing guidelines 9. Proportion of that include and womenscreened for psychological support breast cancer behaviour and according to national educational programmes guidelinesa which enable patients to 10. Report from HPV take responsibility and vaccination feasibility manage their condition study by end 2014

11. Conduct feasibility study and implementation protocol for the introduction of the HPV vaccine Surveillance, Obj. 6. To encourage and 1. Monitor at national level the 1. 25% reduction in the Ministry of Health Monitoring and support the development selected targets and unconditional (Epidemiology unit, PCPs), Evaluation and strengthening of the indicators in the global probability of dying NHI, Belize Cancer Society, capacity for surveillance of monitoring framework and between the ages of Belize Diabetes chronic diseases, their risk regional NCD action 30 and 70 from NCDs Association, Belize Centre factors, determinants and 2. Setting of a research agenda by end 2023b for Visual Impairment consequences, as well as for NCDs including cost 2. Cancer incidence by monitoring and evaluation benefit and analytical studies type/100,000 of the impact of public such as for the population b health interventions. implementation of new 3. Mid-term & Final vaccines (HPV) and Evaluations of NCD technologies e.g. VIA, NHI roll Plan (2018 & 2023) out feasibility 4. Periodic Reviews of

3. Improve the completeness NCD Operational Plans and quality of data including annually improved reporting in NCD 5. At least one repeated minimum dataset, nationally data/evidence gap and trend representative 62 analysesa population survey of

4. Development of chronic NCD risk factors, in disease registries utilizing adults and youth by BHIS and other relevant data end 2018 and another sources by end 2023

5. Ensure the execution of risk 6. Functional population- factor surveys for the four based disease risk factors registries for cancer and diabetes by 2015 Programme Objective 7: To ensure the 1. Present multi-sectoral 1. Endorsed NCD Plan by end Ministries: Health, Management, effective implementation NCD plan to cabinet for 2013a Attorney General’s Policy and of the National Strategic approval and Ministry, Advocacy Plan for NCDs endorsement 2. Functional NCD Ministries: Health, 2. create an NCD program Secretariat by end 2014 Education, Economic Objective 8: To develop in the MoH , with clear Development, Human public policy and action leadership and 3. Social protection policy Development Social plans, defining policy governance over a multi- developed that includes Transformation and a priorities, engaging all sector committee on NCDs by end 2018 Poverty Alleviation, sectors of society and NCDs, and with Finance, Trade, Labour & fostering international corresponding budget 4. NCD prevention policies in Local Government; NGOs, cooperation. 3. Formalise and Strengthen at least 3 sectors outside Trade Unions, Universities, the NCD Commission - the health sector (e.g. schools, Food structure and operations agriculture, trade, manufacturers, media, (terms and mandate of education, labour, food vendors, private reference) development, finance, companies,

4. Assign clear responsibility urban planning, and accountability for the environment and NCD portfolio across the transportation) a by end various sectors 2018

5. Expand social protection policies to provide universal health coverage and more equitable access to services, 63 essential medicines, and technologies for NCD diagnosis, treatment, rehabilitation, and palliative care a Adapted from PAHO regional action plan to country level b Adapted from WHO global monitoring framework to country level 64 Table 2. Monitoring Framework for Selected WHO Global Indicators and Targets Framework Element Target Indicator Baselines Morbidity & Mortality Premature Morbidity (1) A 25% relative reduction in the (1) Unconditional probability of tbd overall dying between ages of 30 and 70 from NCDs mortality from cardiovascular from cardiovascular diseases, cancer, diseases, cancer, diabetes or chronic respiratory diabetes, or chronic respiratory diseases diseases (local target set to Additional indicator by 2023) (2) Cancer incidence, by type of cervical and breast cancer, per 100 000 population respectively: 36.9 & 30.9 (‘12) Risk Factors Behavioural risk factors Harmful use of (2) At least 10% relative reduction (3) Total (recorded and unrecorded) 6 litres (‘11) in the alcohol per capita (aged 15+ years alcohol1 harmful use of alcohol,2as old) consumption within a calendar appropriate, within year in litres of pure alcohol, as the national context (local target appropriate, within the national set to 2017) context (4)Age-standardised prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national Physical inactivity context (3) A 10% relative reduction in prevalence of (6) Prevalence of insufficiently insufficient physical activity physically active Tbd adolescents, defined as less than 60 minutes of moderate to vigorous intensity activity daily (7) Age-standardised prevalence of T/M/F: 77.7/75.4/80.4) Tobacco use insufficiently physically active persons aged 18+ years (defined as less than 150 (5) A 30% relative reduction in minutes of moderate-intensity prevalence of activity per week, or equivalent) current tobacco use in persons Biological risk factors aged 15+ years ((local target set to 2023) Adolescents (‘08) (%) T/M/F: Raised blood (9) Prevalence of current tobacco use among adolescents 26.7/36.2/18.6 pressure (10) Age-standardised prevalence of current tobacco use among persons Adults (‘06) T/M/F(%): aged 18+ years 10.5/19.1/18.6) (6) A 25% relative reduction in the prevalence (11) Age-standardised prevalence of of raised blood pressure or contain raised blood Diabetes and obesity4 the pressure among persons aged 18+ prevalence of raised blood years (defined as systolic blood pressure, according pressure Q140 mmHg and/or to national circumstances (local diastolic blood pressure Q90 mmHg) T/M/F (%): 28.7/28.6/24.4 target by end 2023) and mean systolic blood pressure (12) Age-standardised prevalence of (7) Halt the rise in diabetes and raised blood obesity – local target: 0% increase glucose/diabetes among persons 65 in adult and/or overweight, obesity aged 18+ years (defined as fasting and Type II diabetes by end 2023 plasma glucose concentration Q 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose) T/M/F (’06) (%):13.1/8.3/17.6 (13) Prevalence of overweight and obesity in adolescents Tbd (14) Age-standardised prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index Q 25 kg/m² for overweight and body mass index Q T/M/F (’06) (%): 30 kg/m² for obesity) 66.3/59.2/80.4 Additional indicators 16) Age-standardised prevalence of persons (aged 18+ years) Total/Males/Females (’06) consuming less than five total (%): <1.5/day (all groups) servings (400 grams) of fruit & vegetables per day (17) Age-standardised prevalence of raised total cholesterol among Total/Males/Females(’06) persons aged 18+ years (defined (%): 5.1/4.1/6.0 as total cholesterol Q5.0 mmol/l or 190 mg/dl); an National systems response Essential NCD (9) An 80% availability of the (19)Availability % affordability of >80% (’13) affordable basic technologies and quality, safe & efficacious essential medicines & basic essential noncommunicable disease technologies to treat medicines, including generics, medicines, including generics, & major NCDs required to treat major NCDs in basic technologies in both public & both public private facilities d mean total and private facilities cholesterol concentration Additional Indicators (22) Availability, as appropriate, if Tbd cost-effective and affordable, of vaccines against HPV, according to national programmes and policies (23) Policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt (24) Vaccination coverage against Tbd hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants (25) Proportion of women between 62% (’04/’05) the ages of 30–49 screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies (target 80%) 1 Countries will select indicator(s) of harmful use as appropriate to national context and in line with WHO’s global reduce the harmful use of alcohol and that may include prevalence of heavy episodic drinking, total alcohol per capita alcohol-related morbidity and mortality, among others. 66 2 In WHO’s global strategy to reduce the harmful use of alcohol the concept of the harmful use of alcohol encompasses that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, patterns of drinking that are associated with increased risk of adverse health outcomes. 4 Countries will select indicator(s) appropriate to national context. 67

5. Estimated Implementation Costs40 The costs outlined below are the crucial additional investment required to make a real reduction in the NCD burden in Belize. Reference costs were largely unavailable; therefore these conservative estimates were based on several sources with indicative costs. These include:

1. National Health Accounts Health Accounts, MOH 2010

2. NHI audit and training cost information

3. Previous survey costs

4. MOH meeting costs Although all costs included below are critical, some require special attention: i. Prevention- As previously discussed health promotion forms the cornerstone of NCD prevention, so HECOPAB has a central role in realising the goals of this plan and are in need of urgent funding. ii. Integrated care- Current spending on laboratory services amounts to 1.3% of expenditure (BZD$2,046,273). These services urgently need to be scaled up in order to meet current demand. iii. Surveillance- Capacity building in data management systems, including chronic disease registries and for the necessary period repetition of risk factor surveys is an essential component of this plan. The former has potential far reaching benefits for strengthening of the health system that go well beyond the NCD agenda. iv. Programme management- This NCD strategy must have a dedicated coordinator for oversight, monitoring and auctioning of this plan. Currently stakeholders’ resources are stretched and a 40Taken with minor adaptations from its original estimation and description in the Draft National NCD Strategy 2012-2016 68 significant threat to this plan is that it does not take root not due to lack of will of partners, but rather due to lack of organization and facilitation. 69 Table 3.EstimatedBudget of NCD Action Plan Implementation Area Major Outputs/Activities Year 1 Years 2-10 Total Cost (over 10 year period of implementation) Risk factor reduction, health Support the work of HECOPAB 200,000 1,800,000 2,000,000 promotion and communications Development of major plans & communications strategy e.g. Nutrition, Phys. Activity, HFLE for Primary and High schools 500,000 500,000 Integrated Disease Management & Strengthen 1° care services 500,000 3,000,000 3,500,000 Patient Self-Management (Including development of minimum service package, reorientation of services & staff training) Strengthen & support laboratory services 500,000 4,500,000 5,000,000 Development of major protocols & plans e.g. screening guidelines, cancer, update of NCD management protocols 150,000 150,000 Development and national roll out of auditing mechanism for 1° care services 250,000 250,000 Capacity building for monitoring and 100,000 180,000 180,000 evaluation Surveillance, Monitoring and Strengthen surveillance including capacity 70 Evaluation building for data management and establishment of chronic disease registries 150,000 450000 600000 Mid-term & Final Evaluations of NCD Plan 100,000 100, 000 Annual reviews of NCD Action Plan 5,000 45,000 50,000 Risk Factor Surveys (CAMDI, GYTS, GSHS)  with biomarkers (x1) 200,000 200,000  without biomarkers (x2) 200,000 200,000 Programme Management, Policy Reproduction & Socialization of NCD plan 30,000 30,000 and Advocacy Subvention for NCD secretariat 300,000 2,700,000 3000,000 Post of a National NCD Coordinator 50,000 500,000 550,000 established and filled Advocacy activities (incl. Caribbean Wellness 100,000 1,500,000 1,600,000 Week & media campaigns) Total 2835000 15,175,000 17,810,000 Contingency (10%) 283500 1517500 1781000 Total BZD$ 3,118,500 16,692,500 19,591,000 71 The costs of implementing a nation-wide NCD plan are a tiny fraction of the total health expenditure compared to the burden of disease that NCDs cause. Estimated costs for the first year amount to less than 3% of the recurrent health expenditure for 2011/2012 and the costs for the subsequent years are even less. This is compared to the 6.84% of the 2008/2009 National Health Budget that was spent on HIV & AIDS41 and 1.6% on dialysis in 2010. This must be viewed as an investment and one that is quite small relative to the formidable costs of NCDs. With the integration of services and commitment of all partners, this strategic plan can make a difference in real terms. 41 Abstract of Statistics, Ministry of Finance Belize 2008. 72

6. Bibliography  Belize Health Information System Booklet – Available at health.gov.bz  Food-Based Dietary Guidelines for Belize 2011 available at www.health.gov.bz  Global Recommendations on Physical Activity for Health World Health Organization 2010  Henry F. 2007. Combating Obesity and NCDs in the Caribbean: The Policy Perspective. Pan American Health Organization.  Horizon 2030 Development Framework.  Available at http://www.Belize.g.ov.bz/index.php/government-initiatives/horizon-2030  http://www.paho.org/hq/index.php?gid=16710&option=com_docman&task=doc_view  http://www.who.int/nmh/events/2012/discussion_paper2_20120322.pdf.  National Drug Abuse and Control Council (NDACC) 2012 Annual Report.  National Epidemiology Unit, Ministry of Health Belize 2010  PAHO/WHO & USAID (2009). Health Systems Profile Belize: Monitoring and Analyzing Health Systems Change/Reform  Pan American Health Organization 2010. The Central America Diabetes Initiative (CAMDI)Survey of Diabetes, Hypertension and Chronic Disease Risk Factors -Belize, San José, San Salvador (Santa Tecla),Guatemala City (Villa Nueva), Managua and Tegucigalpa. Available at  Pan American Health Organization.Regional Plan of Action for the Prevention and Control of NCDs 2013-2019  Parfitt G and Eston RG. The relationship between children's habitual activity level and psychological well-being.ActaPaediatr. 2005 Dec;94(12):1791-7.  Strategic Plan Of Action For The Prevention And Control Of Chronic Non communicable Diseases (NCDs) For Countries Of The Caribbean Community (Caricom) 2011 – 2015. Available at http://www.caricom.org/jsp/community_organs/health/chronic_non_communicable_di seases/ncds_plan_of_action_2011_2015.pdf  The Belize draft National Strategic Plan for NCDs 2013-2023 73  The Central America Diabetes Initiative (CAMDI) Survey of Diabetes,Hypertension and Chronic Disease Risk Factors Belize 2009.  Vanzie M, Hsi N, Beith A, and Eichler R: 201.Using Supply-side Pay for Performance to Strengthen Health Prevention Activities and Improve Efficiency: The Case of Belize. Bethesda, Maryland: Health Systems 20/20, Abt Associates Inc.  WHO Discussion Paper October 2012. Positioning Health in the Post-2015 Development Agenda. Available at http://www.who.int/topics/millennium_development_goals/post2015/WHOdiscussion paper_October2012.pdf  World Health Organization. A comprehensive global monitoring framework including indicators and a set of voluntary global targets for the prevention and control of noncommunicable diseases [Internet]. Geneva (Switzerland): WHO; 2012 (Second WHO Discussion Paper, version dated 22 March 2012) [cited 2013 Mar 1].  World Health Organization. Global Status Report on NCDs 2010  World Health Organization 2008. MPOWER a Policy Package to Reverse the Tobacco Epidemic  World Health Organization.NCD Global Monitoring Framework and Global Action Plan 2013-2020  World Health Organization 2011. From Burden to “Best Buys”: Reducing the Economic Impact of Non communicable Diseases in Low- and Middle-Income Countries 74

7. Annexes

Annex 1. List of NCD-related Medicines Available Free in Belize42  Insulin  Aspirin (100mg)  Metformin  Thiazide Diuretics  ACE Inhibitors  Calcium Channel Blockers  Statins  Oral Morphine  Steroid Inhaler  Bronchodilator 42As per the WHO Country Profile of Capacity & Response to NCDs 2013 Survey 75 Annex2. WHO Global Voluntary Targets for 2025 76

Annex 3. WHO Global NCD Indicators 77

Annex 4. WHO Best Buys 43 Risk Factor/Disease Interventions Tobacco use •Tax increases •Smoke-free indoor workplaces and public places •Health information and warnings •Bans on tobacco advertising, promotion & sponsorship Harmful alcohol use •Tax increases •Restricted access to retailed alcohol •Bans on alcohol advertising Unhealthy diet & physical inactivity •Reduced salt intake in food •Replacement of trans fat with polyunsaturated fat •Public awareness through mass media on diet and physical activity Cardiovascular disease (CVD) and diabetes •Counselling and multi-drug therapy for people with a high risk of developing heart attacks and strokes (including those with established CVD) •Treatment of heart attacks with aspirin Cancer •Hepatitis B immunisation to prevent liver cancer (already scaled up) •Screening and treatment of pre-cancerous lesions to prevent cervical cancer 43 “Best Buy” interventions are cost-effective, feasible and appropriate interventions to implement within the constraints of the local LMIC health systems description available at http://www.who.int/nmh/publications/best_buys_summary.pdf 78

Annex 5. National Food-based Dietary Guidelines 79

Annex 6. CARICOM NCD Progress Indicator Status / Capacity by Country in Implementing NCD summit Declaration - Updated September 2012 POS NCD Progress A A B B B B B C D G G H J M S S S S T T Indicator V NCD N N A A E E V A O R U A A O K T G U R C # G T H R L R I Y M E Y I M N N L R T I COMMITMENT 1,14 NCD Plan X X ± √ ± √ √ √ √ √ √ X √ √ √ ± ± √ X 4 NCD budget X ± X √ X X X √ ± X ± X X X √ X X √ X 2 NCD Summit convened X √ X √ X √ √ X √ ± √ X √ X √ X √ √ X 2 Multi-sectoral NCD X X X √ ± √ √ X ± √ √ X ± X √ X ± √ X Commission appointed and functional 12 NCD Communications X X ± ± X √ X √ ± ± √ X ± X ± X ± √ X plan TOBACCO 3 FCTC ratified * √ √ √ √ * * √ √ √ √ X √ * √ √ √ √ √ * 3 Tobacco taxes >50% X X X √ X X ± X √ X √ ± X X √ X X sale price 3 Smoke Free indoor X √ X √ ± √ √ √ ± √ √ X ± X √ X ± √ X public places 3 Advertising, promotion X X X √ X √ √ √ X X ± X √ X X X ± √ X & sponsorship bans NUTRITION 7 Multi-sector Food & √ √ √ √ ± X √ X √ √ √ X √ √ √ X √ X ± ± Nutrition plan implemented 7 Trans fat free food X X X ± X X X X X supply 7 Policy & standards √ √ ± √ X ± ± ± √ ± X X X ± X promoting healthy eating in schools implemented 80 8 Trade agreements X X ± X X X X √ X utilised to meet national food security & health goals 9 Mandatory labelling of X X ± ± ± ± X X X ± X X packaged foods for nutrition content PHYSICAL ACTIVITY 6 Mandatory PA in all √ √ ± ± √ √ ± ± X X X √ √ grades in schools 10 Mandatory provision for √ √ X X X X X X X X X PA in new housing developments 10 Ongoing, mass X √ √ √ √ √ X √ √ √ √ √ √ √ √ √ √ X Physical Activity or New public PA spaces EDUCATION / PROMOTION 15 CWD multi-sectoral, √ √ √ √ √ √ √ √ √ √ √ X √ √ √ √ √ √ √ √ multi-focal celebrations 10 ≥50% of public and X X X X X ± ± X X ± X private institutions with physical activity and healthy eating programmes 12 ≥30 days media √ √ X √ X ± ± √ √ √ ± X X √ X broadcasts on NCD control/yr (risk factors and treatment) SURVEILLANCE 11, Surveillance: - STEPS X X √√ √ √ ± √ ± √ √ ± X √ √ ± X ± √ ± 13, or equivalent survey √ 14 - Minimum Data Set X X √ √ √ √ √ √ √ ± ± X √ X √ √ √ √ √ X reporting - Global Youth Tobacco X √ √ √ √ X √ ± √ √ √ √ √ ± √ √ √ √ X Survey - Global School Health √ √ √ ± √ √ ± √ √ √ X √ ± √ √ √ √ X Survey 81 TREATMENT 5 Chronic Care Model / X √ √ ± ± ± ± ± X ± ± X √ X √ X X √ X NCD treatment protocols in ≥ 50% PHC facilities 5 QOC CVD or diabetes ± √ √ ± ± ± √ X √ √ ± √ ± √ X √ √ X demonstration project A A B B B B B C D G G H J M S S S S T T V N N A A E E V A O R U A A O K T G U R C G T H R L R I Y M E Y I M N N L R T I 82