National Strategic Plan for the Prevention and Control of Non-Communicable Diseases – 2020-2025

HEALTH AND WELLNESS BARBADOS NATIONAL STRATEGIC PLAN FOR THE PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES 2020-2025 Government of Barbados Ministry of Health and Wellness Contents Foreword by the Prime Minister of Barbados.......................................................................................................................4 Preface by the Minister of Health and Wellness....................................................................................................................5 Message from the Chair, National Task Force on Wellness....................................................................................................6 Message from the Chair, National NCD Commission..........................................................................................................7 Acknowledgements............................................................................................................................................................8 Acronyms and abbreviations................................................................................................................................................9 Executive summary...........................................................................................................................................................11 1. Introduction.........................................................................................................................................................19 2. Background.........................................................................................................................................................22 3. Methodology.......................................................................................................................................................26 3.1 Conceptual framework..................................................................................................................................26 3.2 Process.........................................................................................................................................................27 3.3 Stakeholder engagement principles................................................................................................................27 3.4 Limitations....................................................................................................................................................28 4. Situation analysis..................................................................................................................................................28 4.1 General........................................................................................................................................................28 4.2 Epidemiological summary...............................................................................................................................30 4.3 Spending on NCDs.......................................................................................................................................35 4.4 National responses........................................................................................................................................36 4.5 Progress toward selected international targets and indicators..........................................................................46 4.6 Successes/Achievements................................................................................................................................47 4.7 Challenges/Gaps...........................................................................................................................................48 4.8 Lessons learned............................................................................................................................................48 4.9 SWOT analysis of the NCD programme.......................................................................................................49 5. Priority focus areas...............................................................................................................................................51 6. Strategic approaches............................................................................................................................................52 Vision...................................................................................................................................................................53 Mission................................................................................................................................................................53 Values/guiding principles.......................................................................................................................................53 7. Strategic agenda – the core of the strategic plan....................................................................................................53 7.1 Goal, purpose/overall outcome, specific outcomes, and outputs/expected results...........................................53 7.2 Outputs/expected results, main activities, inputs/estimated resources, indicative timelines, and proposed partners........................................................................................................................................................68 8. Implementation strategies ....................................................................................................................................85 9. Risk analysis and risk mitigation strategies..............................................................................................................86 10. Monitoring, evaluation and accountability framework............................................................................................88 Annex 1: Bibliography........................................................................................................................................................89 Annex 2: WHO Best Buys and Other Recommended Interventions for NCD Prevention and Control, including non-financial considerations..................................................................................................................................................................91 Annex 3: Survey instrument/interview guide for key stakeholder input..............................................................................98 Annex 4: List of key stakeholder agencies/entities/organisations that provided input..........................................................103 Annex 5: Possible roles of key stakeholders.....................................................................................................................104 Annex 6: MHW Organisational Chart..............................................................................................................................106 Annex 7: Progress towards WHO Best Buys and Effective and Other Recommended Interventions..................................107 Annex 8: Progress towards the Global Monitoring Framework targets and indicators........................................................115 Annex 9: NSP-NCD 20-25, Estimated Budget by Output................................................................................................120 4 Foreword by the Prime Minister of Barbados In 2018 the Barbados Labour Party presented its “People’s Manifesto: Building the Best Barbados Together”, which placed all who are Barbadian—by birth, marriage, descent, or choice—at the centre of our country’s national sustainable development. We committed to “Healthy Bajans”, through actions taken during both the initial Mission Critical phase of our governance and the longer-term Transformational Agenda. With our election and strong evidence of the confidence that the people of Barbados placed in us, the Government of Barbados continues to work toward fulfilling the commitments made for greater emphasis on the health and wellbeing of our people. Non-communicable diseases (NCDs) like heart disease, stroke, high blood pressure, diabetes, and cancer consume 70% of the budgets of the Queen Elizabeth Hospital and the Barbados Drug Service. We cannot keep putting most of our limited resources towards fighting sickness; we cannot keep waiting until we get sick to take action; and we cannot afford the high price of these diseases, neither in lives nor in public expenditure. Our parents’ and grandparents’ advice that “prevention is better than cure” is more applicable than ever in these times. We must continue on the road to making sure that all of us are educated about our health and have access to the food, facilities, and services we need to stay healthy. In advancing our national development in a sustainable way, we need all hands on deck; we need healthy, productive people at all levels to stay the course, contribute, and get our society and our economy back on track—we all contribute, and we all benefit. The development of the National Strategic Plan for the Prevention and Control of NCDs 2020-2025 was led by the Ministry of Health and Wellness, and its implementation and monitoring will also be led by that Ministry. However, let there be no doubt that it is a national plan, and all sectors of government and all of society have to be involved for its successful execution. We have full confidence that the Ministry of Health and Wellness has mechanisms in place for such involvement, and the Government of Barbados, through the Cabinet Sub-committee on NCDs, will take more than a passing interest in progress made to tackle NCDs and reduce their burden. Together, we can achieve our national health goals and contribute to the achievement of regional and global goals for sustainable development. Our goals are lofty and aspirational, but this is Barbados—we can do it! The Right Honourable Mia Amor Mottley Prime Minister of Barbados 5 Preface by the Minister of Health and Wellness In 2018 the change in name from the “Ministry of Health” to the “Ministry of Health and Wellness” was not a change made for cosmetic purposes. It represented the commitment of the then newly-elected Government of Barbados to the health and wellbeing of every person living in Barbados, through efforts led and coordinated by the Ministry of Health and Wellness. That commitment remains as strong as ever, and the remit of the Government of Barbados and the Ministry of Health and Wellness is to focus on health promotion, disease prevention, and maintaining health through the life course. An important part of that remit is the enhancement of our health systems to provide quality treatment and management,especially at the first level of care, for those persons who do become ill and who are at risk of premature death. Over the years we have put in place policies, plans, and structures to improve the prevention and control of non-communicable diseases, and have long recognised the need for all sectors to be involved—this is not something that the health sector can do alone. As examples, we need the education sector to help improve health literacy and health education; the agriculture sector to help with food and nutrition security and reducing the double burden of malnutrition; the environment sector to include health in climate change adaptation measures; the trade, industry, and commerce sectors to help keep healthy food and other commodities for health available and affordable; civil society to help with community mobilisation and outreach, and contribute to policy development; and the private sector to facilitate theproduction, provision, and distribution of health-supporting, rather than health-damaging, goods and services. The multi-sectoral Barbados National NCD Commission was created in 2007 in the wake of the Port of Spain Declaration on NCDs made by the Heads of State and Government of the Caribbean Community in that same year, and is recognised as one of premier NCD Commissions in the Caribbean region. In 2018, I established a National Task Force on Wellness to complement the Commission, enhance our multi-sectoral, whole-of-government, whole-of-society approaches to priority health issues, and foster wellness, including through NCD prevention and control. This National Strategic Plan for NCD Prevention and Control 2020-2025 will guide our actions to emphasise promotive and preventive interventions for the major NCDs, such as heart disease, high blood pressure, stroke, diabetes, cancer, and chronic respiratory diseases. We look forward to working with other Ministries, civil society organisations, and the private sector to achieve the objectives of the Plan, as we advance Barbados’ sustainable national development. Lieutenant Colonel the Honourable Jeffrey Bostic Minister of Health and Wellness Barbados 6 Message from the Chair, National Task Force on Wellness The National Task Force on Wellness (NTFW) has great pleasure in recognising the National Strategic Plan for NCD Prevention and Control 2020-2025 as a significant contribution to the health and wellness of the people of Barbados. Inintroducing the National Wellness Initiative for Barbados in 2018, the Government of Barbados and the Ministry of Health and Wellness recognised several dimensions of wellness: social, occupational, spiritual, financial, intellectual, emotional, physical, and environmental.The multi-sectoral NTFW was established in that same year to develop and implement strategies to advance wellness, with a vision of wellness activities asintegral to the daily experiences of all Barbadians, and a goal of accentuating preventive measures and reducing the need for curative responses. Multi-sectoral and inter-ministerial approaches are essential in advancing toward wellness, and, especially in light of the onerous burden of NCDs in Barbados, NCD prevention and control are critical components of wellness. The NTFW is delighted to note the emphasis given to multi-sectoral, whole-of-government, whole-of-society approaches in this NCD Strategic Plan, knowing that their successful implementation will go a long way to achieving Barbados’ wellness vision and goal. The National Task Force on Wellness looks forward to contributing to the implementation of the National Strategic Plan for NCD Prevention and Control 2020-2025, building strong partnerships with key stakeholders, including public and private sector agencies; working at community level;promoting ‘wellness champions’; recognising individual achievements; and contributing to social marketing campaigns and other interventions to enable both institutional and individual behaviour change toward wellness. Lieutenant Colonel Carlos Lovell Chairperson National Task Force on Wellness 7 Message from the Chair, National NCD Commission The Barbados National NCD Commission welcomes the National Strategic Plan for NCD Prevention and Control 2020-2025 as the guiding framework to continue multi-sectoral work in reducing these diseases and improving the health, wellness, and productivity of the people of Barbados. Continued strengthening of interventions for NCD prevention and control are closely linked with the country’s advances to universal health, where comprehensive, quality health services—including health promotion and disease prevention, diagnosis, treatment, rehabilitation, and palliation—are available to all at the time of need without risk of financial hardship. We have made considerable strides in implementing the primary health care approach in Barbados, with a strong polyclinic system and access to medicines through the Barbados Drug Service. Further enhancement of the first level of care, with efforts to reduce risk factors and improve the detection and management of NCDs, and efficient mechanisms for referral to other levels where needed, will be of great benefit in our drive to NCD prevention and control. However, we must also strengthen our “joined up” work across sectors, recognising and addressing important contributing factors such as food systems and the food environment, and underlying issues such as climate change and its effect on agriculture and food and nutrition security. Our civil society sector is growing and becoming stronger, increasingly advocating, communicating, and having a voice in “upstream” interventions for NCD reduction, such as policy development, to support and complement government’s actions. Civil society is also an important advocate for recognition and management of conflict of interest, and for protection of the policy space from interests that do not have health as their primary focus. The National NCD Commission is committed to continuing its close partnership with the Ministry of Health and Wellness, other government ministries, the National Task Force on Wellness, civil society, the health-supporting private sector, regional and international development agencies, and other key stakeholders to work towards the utopian vision of Barbados as an “NCD-free zone”. Sir Trevor Hassell Chairperson Barbados National NCD Commission 8 Acknowledgements The Government of Barbados and the Ministry of Health and Wellness acknowledge, with gratitude, the contributions of: • current and former members of the Barbados National Non-communicable Diseases Commission, particularly Sir Trevor Hassell, the Chair of the Commission, and Mr. Hewitt “Dru” Symmonds, Deputy Chair; • representatives of government ministries, statutory bodies, and agencies; • representatives of civil society, including non-governmental organisations, faith-based organisations, trade unions, academia, and persons living with NCDs; • representatives of the health-supporting private sector; • the Pan American Health Organization, Regional Office for the Americas of the World Health Organization; and • last, but not least, the team at the Ministry of Health and Wellness, particularly the former Permanent Secretary, Ms. June Chandler;the Permanent Secretary, Ms. Janet Phillips; the Chief Medical Officer, Dr. Kenneth George; the Senior Medical Officer of Health for NCDs, Dr. Arthur Phillips; the former Senior Health Promotion Officer, Ms. Denise Carter-Taylor; and the Health Promotion Officer (Acting), Ms. Donna Barker. 9 Acronyms and abbreviations AAB Asthma Association of Barbados AMI Acute Myocardial Infarction ASIR Age-Standardised Incidence Rate BAPC Barbados Association for Palliative Care BBs Best Buys BCC Barbados Community College BCHOPP Barbados Childhood Obesity Prevention Programme BCNF Breastfeeding and Child Nutrition Foundation BCS Barbados Cancer Society BDF Barbados Diabetes Foundation BDS Barbados Drug Service BNR Barbados National Registry CARICOM Caribbean Community CARPHA Caribbean Public Health Agency CDB Caribbean Development Bank CDC Centers for Disease Prevention and Control CoI Conflict of Interest COP Childhood Obesity Prevention COPD Chronic Obstructive Pulmonary Disease CMO Chief Medical Officer CROSQ Caribbean Regional Organisation for Standards and Quality CSO Civil Society Organisation CSS Cancer Support Services CVD Cardiovascular Diseases CWD Caribbean Wellness Day EIs Effective Interventions FAO Food and Agriculture Organization FBO Faith-Based Organisation FCTC Framework Convention on Tobacco Control FoPWL Front-of-Package Warning Labelling GA-CDRC George Alleyne Chronic Disease Research Centre GAP Global Action Plan GDP Gross Domestic Product GMF Global Monitoring Framework GoB Government of Barbados GSHS Global School-Based Student Health Survey GYTS Global Youth Tobacco Survey HCC Healthy Caribbean Coalition HiAP Health in All Policies HLM High-Level Meeting HoSG Heads of State and Government HoTNS Health of the Nation Survey HPU Health Promotion Unit HPV Human Papillomavirus HSFB Heart and Stroke Foundation of Barbados IDB Inter-American Development Bank IHD Ischaemic Heart Disease MAFS Ministry of Agriculture and Food Security MCCS Ministry of Creative Economy, Culture and Sports M&E Monitoring and Evaluation METVT Ministry of Education, Technological and Vocational Training MEWR Ministry of Energy and Water Resources MFEI Ministry of Finance, Economic Affairs and Investment MHW Ministry of Health and Wellness MOH Ministry of Health MIBP Ministry of Information, Broadcasting and Public Affairs MLSP Ministry of Labour and Social Partnership Relations MSBEC Ministry of Small Business, Entrepreneurship and Commerce MTWM Ministry of Transport, Works and Maintenance MYCE Ministry of Youth and Community Empowerment NCDs Non-Communicable Diseases NNC National Nutrition Centre NNCDC National Non-Communicable Diseases Commission NSP National Strategic Plan NTFW National Task Force on Wellness OCM Outcome OOP Out-of-Pocket OPT Output ORIs Other Recommended Interventions PAHO Pan American Health Organization PHC Primary Health Care PHE Public Health Expenditure PLWNCDs Persons Living With NCDs PMO Prime Minister’s Office POSD Port of Spain Declaration PS Private Sector PSE Private Sector Entity RBM Results-Based Management ROI Return on Investment QEH Queen Elizabeth Hospital SBS Special Benefit Service SCD Sudden Cardiac Death SDG Sustainable Development Goal SIDS Small Island Developing States SMOH Senior Medical Officer of Health SP Strategic Plan SSB Sugar-Sweetened Beverage STEPS STEPwise Approach To NCD Surveillance THE Total Health Expenditure 10 UN United Nations UNDG United Nations Development Group UNDP United Nations Development Programme UNIATF United Nations Interagency Task Force on the Prevention and Control of NCDs UNICEF United Nations Children’s Fund UWI University of the West Indies WoG Whole-of-Government WoS Whole-of-Society WHO World Health Organization WTO World Trade Organization 11 Executive Summary NCD prevention and control is a priority for Barbados In keeping with its commitment to the health and wellness of the people of Barbados, the development of human capital, the progressive realisation of the right to health, and national sustainable development, the Government of Barbados (GoB), through the Ministry of Health and Wellness (MHW), has developed the Barbados National Strategic Plan for the Prevention and Control of Non-communicable Diseases 2020-2025 (NSP-NCD 20-25). The NSP-NCD 20-25 was developed through a participatory and iterative process that sought input and feedback from key stakeholders in government, civil society, and the private sector. It provides a blueprint for action by these stakeholders in contributing to the multi-sectoral, whole-of-government, whole-of-society, health-in-all-policies approaches that are essential to address NCD and their risk factors, as well as their social, economic, environmental, commercial, and other determinants. Mirroring the global and regional situation, NCDs are the top causes of death and illness in Barbados, and the NSP-NCD 20 25 focuses on the four major NCDs—cardiovascular diseases (CVD), diabetes, cancer, and chronic respiratory diseases—and the four main risk factors: tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. For the period 2010-2012, the leading causes of death in Barbados included ischaemic heart disease (IHD), including acute myocardial infarction (AMI, “heart attack”); cerebrovascular disease (stroke); diabetes; hypertensive heart disease (heart disease due to high blood pressure), breast and prostate cancer; and respiratory infections.Prostate cancer accounted for the highest proportion of deaths in men in 2010 and 2011, but was secondto CVD in 2012. Together, over the period 2010-2012, diabetes mellitus, IHD, hypertensiveheart disease, and cerebrovascular diseaseaccounted for approximately one quarter (25%) of deaths among men, and one-third (33%) of deaths among women. The World Health Organization (WHO) estimated that in 2016, NCDs accounted for 83% of all deaths in Barbados, with 29% of deaths due to CVD, 23% to cancer, 9% to diabetes, 4% to chronic respiratory diseases, and 18% to other NCDs; the total risk of premature mortality from NCDs was 16% (20% for men, 13% for women). The age-standardised incidence rate (ASIR) for cancer in Barbados increased from 214.6/100,000 population in 2008 to 219.6/100,000 in 2013 and 237.0/100,000 in 2014, and, consistent with the global situation, the cancer ASIR was higher for men (265.7/100,000) than for women (218.5 per 100,000). The top cancer sites were prostate and breast, followed by colon, uterine cervix, and uterine body. The prostate cancer ASIR was 111.5 per 100,000,placing it in the top five prostate cancer rates globally, and breast cancer was the most common cancer among women, with an ASIR of 74.5 per 100,000. Barbados had one of the lowest rates of lung cancer globally (7.4 per 100,000), likely due to the country’s relatively low prevalence of tobacco smoking. If maternal and child health visits are excluded, 80% of all visits to polyclinics in Barbados are for a chronic disease; between 2010 and 2012, diabetes, hypertension, and lipid disorders were the main causes for visits to the polyclinics. In 2014, there were 584 stroke events, and 481 were admitted to the Queen Elizabeth Hospital (QEH), the sole public tertiary level health facility in the country. Of these patients, 90% had at least one NCD risk factor, and 68% had at least two risk factors; 89% had hypertension, 72% had diabetes, and 67% had high cholesterol, and 39% were obese. There were 411 AMI and sudden cardiac death (SCD)events in 407 patients, and 256 were hospitalised at the QEH. Of these patients, 86% had hypertension, 86% were obese, 80% had diabetes, and 76% had high cholesterol. In 2012, asthma was the leading disease-specific discharge diagnosis from the QEH, occurring mainly in children and adolescents. After asthma, diabetes, IHD, stroke,chronic pulmonary disease—including bronchitis,influenza, and pneumonia—and heart failure were among the leading discharge diagnoses. The most frequent cancer diagnoses were breast, colo-rectal, prostate, and cervical cancer, in order of occurrence. In 2017, of NCD discharge diagnoses at the QEH, asthma accounted for 27.7%; IHD 13.7%; colon/recto-sigmoid cancer 11.4%; stroke 10.5%; breast cancer 7.0%; bronchitis, emphysema and otherchronic obstructive pulmonary disease (COPD) 6.2%; prostate cancer 5.0%; hypertension 4.3%; and cervical cancer 1.2%. 12 The Barbados Health of the Nation Survey (HoTNS) was conducted among persons 25 years and older, and core findings reported in 2015 confirmed that Barbadian adults are at high risk of NCDs due high prevalence of biological and behavioural risk factors. The HoTNS showed that: • 1 in 10 adults had an NCD, and 1 in 3 was being managed for at least one NCD • 1 in 3 had hypertension, 1 in 5 had diabetes, and of those with known hypertension or diabetes, at least 1 in 3 of those receiving treatment had sub-optimal control • 8 in 10 men, and 9 in 10 women, had at least one risk factor • 2 of every 3 adults were overweight or obese; about 1 in 10 women, and almost 1 in 20 men, had “gross” obesity (body mass index [BMI] ≥ 35 kg/m2) • 1 in 10 men, and 1 in 50 women, reported daily tobacco use • 1 in 10 men, and 1 in 50 women, reported excessive weekly alcohol consumption, with 1 in 3 men aged 25-44 years reporting binge drinking in the past 30 days • 9 in 10 adults reported low fruit and vegetable consumption • 5 in 10 adults reported low levels of physical activity • A combination of three or more risk factors (current daily tobacco smoking, inadequate fruit and vegetable consumption, physical inactivity, being overweight or obese, and having hypertension) was more common in women than men, and in older adults Risk factors in children are also cause for concern, demonstrated in the 2011 Global School-based Student Health Survey (GSHS) and the 2013 Global Youth Tobacco Survey (GYTS), both conducted among 13-15 yearold students. The findings justify childhood obesity prevention (COP) interventions in the school setting, including banson sugar-sweetened beverages (SSBs) and enhanced physical activity, as well as strengthened enforcement of restrictions on the sale of health-harming products to minors. • The GSHS showed that 46.9% of the students drank at least one drink containing alcohol on one or more of the past 30 days (48.0% boys, 45.8% girls); 31.9% were overweight (32.1% boys, 31.8% girls); 14.2% were obese (13.9% boys, 14.6% girls); 73.3% usually drank carbonated soft drinks one or more times per day during the past 30 days (74.0% boys, 71.5% girls); only 29.1% were physically active for a total of at least 60 minutes per day on 5 or more days during the past 7 days (34.5% boys, 23.3% girls); only 33.3% went to physical education class on 3 or more days each week during the school year (35.4% boys, 31.2% girls); and 64.9% spent 3 or more hours per day during a typical or usual day doing sitting activities (60.4% boys, 69.6% girls). • The GYTS showed that 14.5% of students currently used any tobacco products (17.4% boys, 11.4% girls); 12.6% currently smoked tobacco (15.7% boys, 9.3% girls); and 7.0% currently smoked cigarettes (8.8% boys, 5.0% girls). Those exposed to tobacco smoke at home constituted 19.1% of respondents; among current smokers, 22.6% obtained cigarettes by buying them from a store, shop, street vendor, or kiosk, and among current smokers who bought cigarettes, 64.6% were not prevented from buying them because of their age. There are, as yet, no data from Barbados on the use of e-cigarettes (“vaping”) and other products marketed as “cessation aids”, cleaner alternatives to conventional cigarettes, or “reduced risk” products, but their increasing use globally, especially among youth, demands that a close eye be kept on this development and relevant local evidence collected. Barbados has a long history of national efforts to combat NCDs, and of contributing to international and regional efforts, the latter including the 2001 Nassau Declaration and the 2007 Port of Spain Declaration, both made by Caribbean Community (CARICOM)Heads of State and Government (HoSG). The country appointed a Special Envoy on NCDs to strengthen its contribution to the first United Nations (UN) High-Level Meeting (HLM) on NCD Prevention and Control in 2011, and the Special Envoy has been a prominent advocate and participant in subsequent UN and WHO high-level meetings on NCDs. 13 The Prime Minister and Minister of Health and Wellness have also been prominent champions for NCD prevention and control in national, regional, and international settings, and in 2018, the UN Interagency Task Force on the Prevention and Control of NCDs (UNIATF) recognised Barbados’ efforts with an award for outstanding contributionto NCD prevention and control. As a complement to the 2020 “We Gatherin’” initiative, which encourages the Barbadian diaspora to visit the country and become involved in its transformation, the GoB and MHW intend to intensify NCD prevention and control efforts during that year, and create momentum for further action. National multi-sectoral structures have been put in place to guide and contribute to the NCD response, including the Barbados National NCD Commission (NNCDC), which was established in 2007, and the National Task Force on Wellness (NTFW) and the Cabinet Sub-committee on NCDs, bothestablished in 2018. Among the country’s successes are the development of strategic plans for NCD prevention and control;enactment of legislation for tobacco control; formulation of guidelines for nutrition and physical activity; and development of protocols for NCD management. In 2015, the GoB introduced a 10% tax on SSBs as a measure to reduce consumption, combat obesity and NCDs, and realise revenue that could be applied to support health. Efforts by the GoB—led by the MHW—to reduce NCDs are complemented and supported by CARICOM regional institutions such as the Caribbean Public Health Agency (CARPHA); international development agencies such WHO, the Pan American Health Organization (PAHO)1 and other UN agencies; regional financing institutions such as the Caribbean Development Bank (CDB) and the Inter-American Development Bank (IDB); and a strong, vibrant, and vocal civil society sector. The last mentioned includes civil society organisations (CSOs) and non-governmental organisations (NGOs) that focus on the four major NCDs;2 a coalition of NGOs that addresses COP;3 a regional umbrella organisation for CSOs working in NCD prevention and control, based in Barbados,4 which has produced strategic plans to guide civil society action in NCD prevention and control, and COP; and, most recently, a group comprising persons living with NCDs (PLWNCDs) and caregivers.5 Other CSOs contributing to NCD reduction include faith-based organisations (FBOs), trade unions, and academia; health-promoting private sector entities, such as insurance companies and sports organisations, also sponsor, promote, and participate in relevant initiatives. There is much more to be done Despite progress and successes, the cost of the increasing burden of NCDs in Barbados, in terms of their toll on people’s individual and collective health, wellbeing, and productivity, and their negative financial and economic impact, demands intensified action to reduce NCD risk factors and complications. A 2015 investment case for NCD prevention and control in Barbados showed that for CVD and diabetes alone, estimated current spending was 64 million Barbados dollars (Bds$) per year, with losses to the economy of Bds$ 145 million per year due to missed work days, poor productivity, reduced workforce participation, and the costs to business of replacing workers. These costs represented approximately 2.6% of projected gross domestic product (GDP) in 2015.Further estimates showed that NCD-relatedout-of-pocket (OOP) spending, prevention and treatment expenditures, and decreased productivity are costing Barbados not less than Bds$ 375 million per year, and could be costing as much as Bds$ 825 million per year. NCDs consume 65% of the budget allocated to the QEH, and 60% of the budget of the Barbados Drug Service (BDS) is allocated to pharmaceuticals used in the management of chronic diseases. In fiscal year 2017-2018, the BDS Special Benefit Service (SBS), which provides formulary medicines free of cost to children under 16 years of age, persons over age 65, and persons diagnosed with diabetes, cancer, hypertension, glaucoma, asthma, and/or epilepsy, spent 49.8% of its total expenditure on prescriptions for hypertension; 32.4% on diabetes; 8.6% on glaucoma; 7.4% on asthma; and 1.9% on cancer. These human and economic costs are not sustainable, especially in light of the inherent social, economic, and environmental 1PAHO is the Regional Office for the Americas of WHO. 2Including the Diabetes Association of Barbados, the Barbados Diabetes Foundation, the Heart and Stroke Foundation of Barbados, the Barbados Cancer Society, and the Asthma Association of Barbados. 3The Barbados Coalition for Childhood Obesity Prevention. 4The Healthy Caribbean Coalition (HCC). 5Our Views, Our Voices Barbados. 14 vulnerabilities—including to factors such as climate change—associated with the country’s status as a small island developing state (SIDS), and the implementation, in 2018, of the Barbados Economic Recovery and Transformation Plan (BERT). The UN Secretary General’s 2017 Report on Progress in the Prevention and Control of NCDs indicated that, globally, despite the myriad mandates, agreements, frameworks, and guidelines, progress towards the agreed global NCD targets has been unsatisfactory.In general, countries have not implemented the WHO ‘Best Buys’—cost-effective interventions for risk factor reduction and NCD management outlined in Appendix 3 of the WHO Global Action Plan for the Prevention and Control of NCDs, and updated in 2017—to the desired extent. Recommendations from the Secretary General’s report included health systems strengthening and development of national publicly-financed benefit packages providing universal health coverage that include the WHO Best Buys, Effective Interventions, and Other Recommended Interventions, and increased financing of national NCD responses, including fiscal measures that can generate revenue, such as taxation of tobacco products, alcohol, and SSBs. The health system in Barbados has traditionally focused more on communicable diseases rather than on NCDs, and on treatment and cure, rather than on promotion and prevention. The NSP-NCD 20-25 deliberately focuses on health promotion, risk factor reduction, and prevention of disease and disease complications, aiming to strengthen the primary health care (PHC) approach, take advantage ofBarbados’ network of polyclinics, enhance their functioning, and advance to universal health. This approach is in keeping with the shared vision of the draft Barbados National Strategic Plan for Health 2018-2022: “Healthy productive people and communities through excellent care for everyone, everywhere, every time”, which encapsulates the commitment of the MHW and the GoB to universal health. The NSP-NCD 20-25 builds on the successes of the Barbados Strategic Plan for the Prevention and Control of Non communicable Diseases (NCDs) 2015-2019 (SP 15-19) and addresses gaps. It takes advantage of recommended, evidence based, cost-effective interventions for NCD prevention and control, and aligns with relevant global and regional frameworks, including from WHO, PAHO, and CARICOM. As a reflection of commitments in the 2018 Manifesto of the GoB and the addition of “Wellness” to the name of the Ministry of Health in that year, the NSP-NCD 20-25 emphasises the promotion and maintenance of health, and the prevention of disease. The Plan includes interventions that are critical for advancing universal health, reducing inequities, and fulfilling the promise of the UN 2030 Agenda for Sustainable Development and its Sustainable Development Goals (SDGs) to “leave no one behind”, especially in achieving SDG 3, the goal most directly related to health: “Ensure healthy lives and promote well being for all at all ages”. The NSP-NCD 20-25 places great importance on multi-sectoral approaches to deal with determinants of health that are outside the purview of the MHW, and on civil society and private sector involvement in creating enabling, supportive environments for effective NCD prevention and control. NSP-NCD 20-25 focus areas Over the period 2020-2025, the GoB will focus on the following eight (8) priority areas for NCD prevention and control, led and coordinated by the MHW: 1. Risk factor reduction, with strengthening of the implementation of the WHO Framework Convention on Tobacco Control (FCTC); reduction in the harmful use of alcohol; promotion of healthy nutrition through improvements in health and nutrition literacy, the use of policy, legislation, regulations, and fiscal measures, introduction of front-of-package warning labelling (FoPWL) on pre-packaged foods, and elimination of trans fat; and promotion of regular physical activity through community, school, and workplace wellness interventions. Wellness grants can play a role in promoting healthy nutrition. 2. Improved management of NCDs, strengthening health systems and enhancing the application of the chronic care model and the primary health care approach, with the development, dissemination, and use of protocols and guidelines for standard management of common conditions at the first level of care, taking multi-morbidity into consideration and conducting related human resources for health (HRH) capacity-building, within a supportive policy, legislative, and regulatory environment. 15 3. Childhood obesity prevention, highlighting SSB taxation, SSBbans in and around schools,restrictions on the sale andmarketing of unhealthy products to children, and promotion of physical activity, with the involvement of key stakeholders across sectors, as well as the children themselves—as age-appropriate—their parents, guardians, and teachers. 4. Multi-sectoral work and partnerships, with high-level advocacy; strengthening the remit and functioning of multi-sectoral bodies; involving civil society and the health-promoting private sector; and demonstrating linksamong NCDs, agriculture, and climate change, among NCDs, SIDS, and trade, and between MHW and other ministries. 5. Resource allocationand mobilisation, undertaking evidence-based advocacy for greater allocation to Health of resources from the national budget; identifying and taking advantage of financial, technical, and other resources available through international development agencies and foundations; sharing experiences with other countries in and outside of the Caribbean region; and identifying co-benefits with other priorities such as climate change adaptation. 6. Communicating for health, with wide promotion of the NSP-NCD 20-25;mass media and social media campaigns in collaboration with civil society and other partners to reduce risk factors and inform of progress in implementing the NSP; and advocacy regarding effective policy options for NCD prevention and control, including to policymakers, through interventions that encompass creation of a mass movement that involves youth and PLWNCDs. 7. NCD surveillance and research,including development of a framework to identify key actors and resources, and guide systematic implementation of surveys/studies to provide updated,quality NCD-related information,including on multi morbidity, disaggregated by at least age, sex, ethnicity, geographic location, and socio-economic status to identify gender, geographic, economic, and other inequities related to the social determinants of health. These studies will inform strategic planning that includes clear goals and objectives to achieve the country’s vision for health with equity. 8. Management, monitoring, and evaluation of the NCD programme and the implementation of the NSP-NCD 20 25, including strengthened capacity for governance and leadership, development of amonitoring and evaluation (M&E) and accountability framework and plan, and enhancement of mechanisms for oversight. NSP-NCD 20-25 strategic approaches, high-level objectives, and indicative budget The NSP-NCD 20-25 carries forward the vision, mission, and values/guiding principles of the previous strategic plan, and explicitly recognises the importance of identifying and managing conflict of interest (CoI) in establishing and strengthening partnerships, especially with the private sector. The high-level objectives(goal, purpose/overall outcome, and specific outcomes) are summarised below, along with lower level objectives (outputs/expected results). The objectives are presented in detail in the Planin a Logical Framework Matrix that includes targets, indicators, means of verification, and assumptions for each objective. There is also a matrix that outlines the main activities for each output/expected result, with the inputs/estimated resources for each activity, indicative timelines, proposed partners, and an estimated budget. Vision The vision of the NSP-NCD 20-25 is to improve the health and wellbeing, and enhance the productive potential, of all Barbadians. Mission The mission of the NSP-NCD 20-25 is to empower Barbadian society, individuals, and organisations to enhance their quality of life throughout the life course through a whole-of government, whole-of-society response to NCDs, their risk factors, and the social determinants of risk, with emphasis on promotion, prevention, and the first level of care, so as to erase the avoidable burden of NCDs. Values/guiding principles • Health is a fundamental right of all Barbadians. • Development of a patient-centred, equitable, efficient, and accessible health care system of high quality is a priority, to contribute to Barbadians’ achievement of optimum physical, mental, and social well-being. • Recognising that most of the causes and solutions to NCD risk factors lie outside of the health sector, the national response must be inclusive of all sectors and persons, respecting the views of all, while holding them accountable for their actions in a transparent and collaborative manner. 16 • There needs to be empowerment of people and communities to participate in their own health, within a life-course approach to wellness, prevention, and control, using evidence-based strategies, supported by national action and international cooperation and solidarity. • Creation of an enabling environment—including policy, legislation, regulations and wellness grants—that facilitates, encourages, and supports healthy choices, while discouraging unhealthy behaviours, is an overarching principle for effective NCD prevention and control. • In all interactions with civil society and the private sector, across all government ministries and statutory bodies involved in NCD prevention and control, conflict of interest issues must be identified, disclosed, and appropriately managed according to government policies and guidelines on transparency and good governance. Goal Mortality, morbidity, and disability due to NCDs reduced. Purpose/Overall outcome Cost-effective and recommended policy options and interventions implemented to reduce the main NCD risk factors and strengthen management of the major NCDs. Specific outcomes(OCMs) and related outputs/expected results (OPTs/ERs) OCM 1: Tobacco use reduced among adolescents and adults. OPT/ER1.1 Implementation of the WHOFCTC accelerated. OCM 2: Unhealthy diet and overweight/obesity reduced. OPT/ER2.1: Strategies and mechanisms for healthy nutrition enhanced. OPT/ER2.2: Implementation of strategies and interventions for COP enhanced. OCM3: Physical inactivity reduced. OPT/ER3.1: Strategies and mechanisms implemented for increased physical activity. OCM4: Harmful use of alcohol reduced. OPT/ER 4.1: Strategies and mechanisms implemented to reduce the harmful use of alcohol. OCM 5: High blood pressure reduced, and screening for, and management of, diabetes, CVD, chronic respiratory diseases, and cancer improved. OPT/ER5.1: Interventions implemented to reduce high blood pressure and improve screening for, and integrated management of, CVD, diabetes, chronic respiratory diseases, and cancer at the first level of care, taking multi-morbidity into consideration. OCM 6: Multi-sectoral, whole-of-government, whole-of-society, and health-in-all policies approaches to NCD prevention and control strengthened. OPT/ER6.1: Strategies and mechanisms implemented to promote and strengthen multi-sectoral work and partnerships for NCD prevention and control. OCM 7: Adequate resources allocated and mobilized for enhanced functioning of the national NCD programme. OPT/ER7.1: Strategies and mechanisms implemented to improve resource allocation and mobilization (financial and human resources) to strengthen the NCD programme and facilitate execution of the NSP-NCD 20-25.Systems development linking human resources and technologies to provide continuous communication and health promotion support. Human resources will be need specific and specialized to complete tasks. Mental health support including human resource acquisition to strength this sector of NCD care. OCM 8: Increased awareness and understanding among key stakeholders of the major NCDs, their main risk factors, their impact, and responses. OPT/ER8.1:Communication strategies developed and implemented to promote the NSP-NCD 20-25 and enable NCD risk factor reduction and improved management of NCDs. 17 OCM 9: Information systems related to NCDs strengthened. OPT/ER9.1: Strategies and mechanisms implemented to strengthen NCD surveillance and research, including assessment of multi-morbidity. OCM 10: National leadership and governance of NCD prevention and control enhanced. OPT/ER10.1: Strategies and mechanisms strengthened for the efficient and effective management, monitoring, and evaluation of the NCD programme and the NSP-NCD 20-25. The total of the inputs andestimatedresources for the activities for achievement of the outputs/expected results providesan estimated budget for the NSP-NCD 20-25, which is Bds$ 2,792,000 (approximately 1,396,000 United States Dollars, US$), excluding staff, infrastructure, procurement, and other ‘in-kind’ costs. Strategies for implementation of the Plan In implementing the NSP-NCD 20-25, strategies will include: • Taking advantage of high-level multi-sectoral structures such as the Cabinet Sub-committee on NCDs and the Social Partnership, to drive whole-of-government and whole-of-society approaches and facilitate resource allocation and mobilisation. • Convening key government sectors to facilitate and enable networking, joint action, and identification of co-benefits; increase awareness of the impact on health of actions in other sectors; and demonstrate the importance of health as both a contributor to, and a marker of, sustainable development. • Strengthening engagement with public and private health care providers. • Using key global and regional declarations, agreements, and mandates to frame national responses to NCDs. • Strengthening communication, taking advantage of advances in information and communication technology to improve health literacy and promote the NSP-NCD 20-25. • Ensuring greater use of the settings approach, particularly schools and workplaces. • Enhancing involvement of, and collaboration with, civil society, including youth and PLWNCDs. • Fostering involvement of, and collaboration with, the private sector, focusing on the health-promoting private sector, and identifying and managing CoI. • Strengthening information systems for health, including the disaggregation of data to identify groups in conditions of vulnerability. • Enhancing resource mobilisation, both financial and human. • Improving human resources capacity and functioning. • Ensuring monitoring, evaluation, and accountability for outputs/expected results and outcomes, and for resources allocated and mobilised. Risks must be identified and mitigated Among the risks to the successful execution on the NSP-NCD 20-25 are: • “Policy inertia” and interference by Industry in efforts to reduce consumption of health-harming products. These risks demand high-level, evidence-based advocacy to policymakers, and involvement of youth, PLWNCDs, and other key stakeholders to make the case for, and demand, action. • Reduction of political will, due to emerging issues, crises, emergencies, and disasters. Counter measures include sensitisation across all sectors, sustained functioning of supportive mechanisms for NCD prevention and control, and evidence-based planning, implementation, monitoring and evaluation, with communication of results to policymakers. • Limited financial and human resources, where mitigation includes results-based management; capacity strengthening; resource mobilisation based on evidence-based plans and implementation of international mandates and agreements, as applicable to the national situation; and increased collaboration with CSOs, NGOs, and international development agencies. 18 • Limited intersectoral work, with perceptions of NCDs as being a health issue only. These perceptions need to be countered by increased dialogue with sectors other than health, provision of evidence on the impact of NCDs on sustainable development, identification of common objectives across sectors, demonstration of co-benefits in multi sectoral interventions for NCD reduction, and promotion of health impact assessments. Monitoring, evaluation, and accountability are critical Critical aspects of managing for results, the overarching principle of the NSP-NCD 20-25, are monitoring, evaluation, and accountability. The principals in the M&E and accountability process include the Senior Medical Officer of Health, NCDs, who coordinates the MHW NCD Unit; the Chief Medical Officer; the NNCDC; the Minister of Health and Wellness; the Cabinet Sub-committee on NCDs; and, ultimately, the Prime Minister of Barbados. The components of the strategic agenda delineated in the Plan provide the basis for the development of M&E and accountability plans, production and dissemination of periodic progress reports, and a final evaluation report, all of which will address both programmatic and financial execution of the NSP-NCD 20-25. In the M&E and accountability process, the identification of successes/achievements, challenges/gaps, and lessons learned will enable appropriate adjustments to be made over the course of the NSP-NCS 20-25. The process will also set the stage for greater efficiency and effectiveness of evidence-based, multisectoral, whole-of-government, whole-of-society interventions for NCD prevention and control in Barbadosin the next strategic planning cycle. 19 1. Introduction The Barbados National Strategic Plan for the Prevention and Control of Non-communicable Diseases 2020-2025 demonstrates the continuing efforts of the Government of Barbados to address the burden of non-communicable diseases, which are the main causes of death and illness globally, in the Region of the Americas, in the Caribbean region, and in Barbados. The NSP-NCD 20-25 succeeds the Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019,6 builds on achievements and lessons learned during the previous strategic planning period, and addresses gaps and new developments. In its 2014 report on NCDs,7 the World Health Organization noted that NCDs were responsible for 68% of the world’s 56 million deaths in 2012, more than 40% of which were premature deaths, occurring in persons under age 70 years. Almost three-quarters of all NCDdeaths and the majority of premature deaths (82%) occurred in low- and middle-income countries, and WHO estimated cumulative economic losses due to NCDs under a “business asusual” scenario in these countries at a totalof US$ 7 trillion for the period 2011–2025,significantly more than the annual US$ 11.2 billion cost of implementing a set of high-impact interventions to reduce the NCD burden. In Barbados, NCDs result in massive socio economic costs as they undermine the health and wellbeing of individuals, families, and society through death, illness, and out-of-pocket and other spending costs. They account for the greatest proportion of government spending on health, and significantly contribute to reduced national productivity due to absenteeism, presenteeism, and costs to business. NCD-related costs, estimated at between Bds$ 375 million and Bds$ 825 million per year, pose a threat to sustainable national development that must be addressed,8,9 and the NSP-NCD-20-25 is therefore a critical framework for national health action. The four leading causes of NCD deaths are cardiovascular diseases, cancers, chronic respiratory diseases (including asthma and chronic obstructive pulmonary disease), and diabetes, which have four common risk factors—tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Since at least 2004, Barbados has developed specific policies for prevention and control of the four major NCDs and their four common risk factors, and has supported and aligned with global and regional frameworks for action in developing its NCD-related policy interventions.10 In recognition of the importance of addressing the social, environmental, economic, commercial, and other determinants of health in the fight against NCDs, and the need for multi-sectoral, whole-of-government (WoG), whole-of-society (WoS), health-in-all-policies (HiAP) approaches, the Barbados National NCD Commission11was created in 2007. The multi-sectoral Commission has functioned continuously since then, despite changes in government, to fulfill its mandate to advise, assist, recommend, and monitor NCD reduction efforts, collaborating closely with the Ministry of Health and Wellness and reporting to the Minister. At its January 2019 meeting, the NNCDC noted the imminent end of the period covered by the NCD Strategic Plan 2015 2019 (SP 15-19) and proposed to the MHW the development of a new strategic plan to guide actions in NCD prevention and control. The NSP-NCD 20-25 should align with the emphasis placed on health and wellness by the newly-elected GoB; 12 encompass commitments made in the GoB’s election manifesto;be consistent with the draft National Strategic Plan for Health (NSPH) 2018-2022;13 and integrate not only existing national and sub-national entities and structures, but also newly 6Ministry of Health (MOH). Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019. Bridgetown, Barbados: MOH; 2014.https://bit.ly/2K1psTC. 7World Health Organisation (WHO). Global status report on NCDs 2014. Geneva: WHO; 2014. https://bit.ly/2K2n5A8. 8WHO, UNDP, and MOH. The Investment Case for Non-communicable Disease Prevention and Control in Barbados. WHO, UNIATF, UNDP; 2015. https://bit. ly/2Q2RGBs. 9Theodore K. Real cost of NCDs and health system sustainability (presentation). BNR 10th Anniversary Seminar: Multidisciplinary stakeholder engagement in the management of NCDs. Bridgetown, Barbados, April 2019. 10Unwin N, Samuels TA, Hassell T, et al. The development of public policies to address non-communicable diseases in the Caribbean Country of Barbados: the importance of problem framing and policy entrepreneurs. Int J Health Policy Manag 2017; (6(2): 71-82. https://bit.ly/37NHcMJ. 11https://www.healthycaribbean.org/barbados-national-commission-for-cncds/. 12There was a change in government after general elections held in Barbados in May 2018. 13MHW, GoB. Barbados National Strategic Plan for Health 2018-2022: Working Together for a Healthier Nation (Draft). Bridgetown: MHW; 2017. 20 established ones, such as the National Task Force on Wellness (NTFW) and the Cabinet Sub-committee on NCDs, the latter beinga ministerial-level platform designed to facilitate policy coherence and greater,effective intersectoral collaboration for NCD prevention and control. Barbados is signatory to many international frameworks and agreements for health, including the International Covenant on Economic, Social and Cultural Rights (ICESCR),14 which the country ratified in 1973,and the Convention on the Rights of the Child (CRC),15 which was ratified in 1990. Article 12 of the ICESCR recognises the right of everyone to the enjoyment of thehighest attainable standard of physical and mental health, and Article 24 of the CRC recognises the right of the child to the highest attainable standard of health and to “facilities for the treatment of illness and rehabilitation of health”. The country has made significant advances in the progressive realisation of these rights, and is also committed to the 2030 Sustainable Development Agenda16 and its Sustainable Development Goals, approved by the UN General Assembly in 2015. The SDGs include SDG 3, the goal most directly related to health: “Ensure healthy lives and promote well-being for all at all ages”, and targets 3.417 and 3.8,18 which address, respectively, reducing premature mortality from NCDs, and achieving universal health. The Pan American Health Organization uses the term “universal health” (UH) to include universal access to health and universal health coverage (UHC). UH implies that “all people and communities have access, without any kind of discrimination, to comprehensive, appropriate, timely, quality health services determined at the national level according to needs, as well as access to safe, effective, and affordable quality medicines, while ensuring that the use of such services does not expose users to financial difficulties, especially groups in conditions of vulnerability”.19 The primary health care approach is a core component of UH, and is defined by WHO as an approach to health and well being centred on the needs and preferences of individuals, families, and communities, providing whole-person care for health needs throughout the lifespan, not just for a set of specific diseases.20 PHC ensures that people receive comprehensive care, ranging from promotion and prevention to treatment, rehabilitation, and palliative care, as close as feasible to their everyday environment. The PHC approach and UH both work to reduce inequities in health and promote social inclusion and justice. WHO further notes that the approaches needed to contain the escalating costsof health care and provide sophisticated medicalservices for NCDs and their complications includemore investment in prevention and primary care,as well as reduction of the costs of treating the major NCDs and complications that require hospitalisation, such as heart attacks, strokes, and amputations; blindness due to diabetic or hypertensive retinopathy; and end-stage kidney disease requiring dialysis. The selection and implementation of essential evidence-based interventions can reduce costs, but despite the existing knowledge, services at the first level of care, especially inresource-constrained settings, are often limited, inappropriate, and not evidence based. The situation is compounded by low per capita health expenditure in many countries, inadequate for the integration of NCD interventions into primary care in a comprehensive manner. In response to this situation, WHO prioritiseda core set of interventions to guide its Member States, reflected in the WHO Package of Essential NCD Interventions for PHC in Low resource Settings21 and the WHO Best Buys.22 14https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx. 15https://www.ohchr.org/EN/professionalinterest/pages/crc.aspx. 16https://www.un.org/ga/search/view doc.asp?symbol=A/RES/70/1&Lang=E. 17https://unstats.un.org/sdgs/metadata?Text=&Goal=3&Target=3.4. 18https://unstats.un.org/sdgs/metadata/?Text=&Goal=3&Target=3.8. 19PAHO. Strategy for universal access to health and universal health coverage. Document CD53/5, rev.2. Washington, D.C.: PAHO; 2014. https://www.paho.org/hq/ dmdocuments/2014/CD53-5-e.pdf. 20WHO. Primary health care: key facts. Geneva: WHO; 2019. https://bit.ly/32xSmB6. 21WHO. Package of Essential NCD Interventions (PEN) for Primary Health Care in Low-resource Settings. Geneva: WHO; 2010. https://www.who.int/nmh/publications/ essential ncd interventions lr settings.pdf. 22WHO. Tackling NCDs: Best Buys and Other Recommended Interventions for the Prevention and Control of NCDs. Geneva: WHO; 2017. https://bit.ly/2Q2iXDK. 21 Barbados can be justly proud of its progress in these areas. The public health system provides services free at the point of delivery to citizens and residents of the country,and there is a strong polyclinic and district hospital network that provides access to essential services.The NSP-NCD 20-25 aims to strengthen the PHC approach even further, enhancing the first level of care and the network of promotive, preventive, and treatment services to reduce the main NCD risk factors and complications of the major NCDs. Successes in these areas will propel the country further towards universal health, reduction of inequities, progressive realisation of the right to health, and attainment of the SDGsby 2030. 22 The UN Third UN HLM on NCD Prevention and Controlheld in September 2018 added mental health disorders and air pollution to, respectively, the four major NCDs and the four main risk factors to establish “5x5” priorities for action in NCD reduction. However, the NSP-NCD 20-25 will not focus on these added conditions, since Barbados has a Mental Health Commission that addresses mental health disorders, and though the MHW addresses issues related to indoor air quality in the workplace setting, reduction of air pollution is the remit of another government sector. However, the MHW and the NNCDC will cooperate and collaborate with these entities as needed in reducing the NCD burden and fostering the health and wellbeing of the people of Barbados. The NSP-NCD 20-25 presents the background to its development; the methodology; a summary situation analysis, priority areas to be addressed; strategic approaches; goals, overall and specific outcomes, outputs, indicators, and targetsthat are congruent with the national situation and with regional and global targets for NCD prevention and control; activities and related inputs and resources, indicative timelines, and proposed partners. It also includes an estimated budget, a monitoring and evaluation framework, implementation strategies, risks to successful execution, and risk management strategies. With its focus on wellness and prevention, and taking into consideration the social, economic, environmental, commercial, and other determinants of health, the NSP-NCD 20-25 provides a blueprint for not only the MHW, but also for all government ministries, CSOs, and private sector entities (PSEs). It will enable these key stakeholdersto play their roles and assume their responsibilities to contribute to NCD prevention and control, the health and productivity of the people of Barbados, and the country’s sustainable social and economic development. 2. Background Global attention to NCDs has been building since the First UN HLM on NCD Prevention and Control in 201123 and its Political Declaration,24 which recognised “the primary role and responsibility of Governments in respondingto the challenge of non-communicable diseases and the essential need for the effortsand engagement of all sectors of society to generate effective responses for theprevention and control of non-communicable diseases.”Subsequent to the HLM, WHO and PAHO developed, respectively,global and regional guidance for their Member States to take action according to the national situation, including, but not limited to, the frameworks listed in the bibliography in Annex 1. Notable among the WHO frameworks are the Global Monitoring Framework (GMF) with nine voluntary targets to be achieved by 2025—including a 25% reduction in premature mortality from the four major NCDs—and 25 indicators,25 and the Global Action Plan (GAP) 2013-2020.26 The GAP contains Appendix 3, a menu of policy options and cost-effective interventions that address risk factor reduction and disease management, including14 ‘Best Buys’, interventions thatare especially cost-effective and affordable for all countries. The ‘Best Buys’ were updated in 2017 to a total of 16 interventions, in addition to Effective and Other Recommended Interventions for NCD prevention and control.27 The WHO Best Buys (BBs), Effective Interventions (EIs), and Other Recommended Interventions (ORIs) arelisted in Annex 2, and include a wide range of options that address the provision of supportive environments;promotion, education, prevention, and screening; taxation, legislation, enforcement, and trade; packaging, labelling, portion size, and reformulation of food; advertising, promotion, and sponsorship; and counselling, referral, treatment, drug therapy, care, rehabilitation, and palliation. 23https://www.un.org/en/ga/ncdmeeting2011/. 24https://www.who.int/nmh/events/un ncd summit2011/political declaration en.pdf. 25WHO. Global Monitoring Framework. Geneva: WHO; 2011. https://bit.ly/32pEsBa. 26WHO. Global Action Plan for the Prevention and Control of NCDs 2013-2020. Geneva: WHO; 2013. https://bit.ly/2pVmN79. 27WHO. Tackling NCDs: Best Buys and Other Recommended Interventions for the Prevention and Control of NCDs. Geneva. 23 Not withstanding these recommendations, the Report on progress in the prevention and control of NCDs – Report of the UN Secretary-General, December 201728 showed unsatisfactory progress toward the agreed global targets, with health system interventions not being scaled-up in the majority of developing countries, and limited translation of political commitments into action. Economic and trade promotion interests were identified as impeding the implementation of some of the BBs, EIs, and ORIs, and funding for national programmes from domestic resources and international finance was said to be still “grossly insufficient” in developing countries. Recommendations from the 2017 UN Secretary General’s report included: • Prioritisation of implementation of the BBs; • Health systems strengthening and development of national publicly-financed benefit packages providing UHC that include the BBs, EIs, and ORIs; • Increased financing for national responses to NCDs, with creation of fiscal space for interventions that have the capacity to generate revenue, such as the taxation of tobacco products, alcohol, and sugar-sweetened beverages; • Reinforcement of the role of non-State Actors, including civil society and the private sector; • Development of health-promoting strategies,including media campaigns,to encourage healthier behaviours; and • Promotion of accountability, including leveraging SDG review processes to incorporate NCD reporting; conducting periodic NCD risk factor surveys based on WHO survey methodology; and establishing or strengthening population based cancer registries, cause-specific mortality reporting, and assessments of health systems performance. The Political Declaration29 from theThird UN HLM on NCDs held in September 201830 contained commitments by the participating Heads of State and Government, including to: • Promote and implement policy, legislative, and regulatory measures, including fiscal measures, to reduce the main NCD risk factors; • Accelerate the implementation of the WHO Framework Convention on Tobacco Control;31 • Implement interventions to halt the rise of overweight and obesity, in particular childhood obesity; • Develop a national investment case on NCD prevention and control to raise awareness of their public health burden and impact on equity, poverty, and socioeconomic development; • Establish or strengthen national multi-stakeholder dialogue mechanisms; • Scale up efforts to use information and communication technologies and innovations in NCD prevention and control; • Strengthen health systems and reorient them towards the achievement of UHC and improved health outcomes; • Promote meaningful civil society engagement to develop multi-sectoral responses to NCDs, forge multi-stakeholder partnerships and alliances, and amplify the voices of PLWNCDs; • Engage with the private sector, giving due regard to managing conflict of interest; • Establish or strengthen transparent national accountability mechanisms for NCD prevention and control; and • Commit to mobilise and allocate adequate and sustained resources for national NCD responses through domestic, bilateral, and multilateral channels, and continue exploring voluntary innovative financing mechanisms and partnerships, including with the private sector, to advance action at all levels. 28 https://www.who.int/ncds/governance/high-level-commission/A 72 662.pdf. 29https://www.un.org/en/ga/search/view doc.asp?symbol=A/RES/73/2. 30https://www.who.int/ncds/governance/third-un-meeting/en/. 31https://bit.ly/2p1Fwxn. 24 The role of fiscal measuresas effective interventions for NCD prevention and control has gained traction globally, including taxation on unhealthy commodities such as tobacco, alcohol, and SSBs. In its 2019 report, the Task Force on Fiscal Policy for Health stated that: “large excise taxes on tobacco, alcohol, and sugary beverages are essential to reaching the targets set by the Sustainable Development Goals related to ensuring healthy lives, ending poverty, and promoting full and productive employment. Such taxes can also contribute to domestic revenue mobilization, as highlighted for the case of tobacco taxes”.32 The Task Force noted that “if all countries increased their excise taxes to raise prices on tobacco, alcohol, and sugary beverages by 50%, over 50 million premature deaths could be averted worldwide over the next 50 years, while raising over US$20 trillion of additional revenues in present discounted value” and characterised excise tax policy as an “underutilised yet highly effective policy measure to reduce tobacco, alcohol, and sugary beverage consumption and reap huge health benefits”. Childhood obesity prevention has also received global attention, with WHO’s publication of an overview of COP interventions33 and a set of tools for Member States34 in 2012, and the Report of the WHO Commission on Ending Childhood Obesity (ECHO)35 in 2016. The ECHO report considered interventions to address the obesogenic environment36 and identified three critical periods in the life-course: preconception and pregnancy, infancy and early childhood, and older childhood and adolescence. In 2019, in observance of the 30th anniversary of the CRC, the UN Children’s Fund (UNICEF) focused on the nutritional status of the world’s children37 and the use of the rights-based approach to create and safeguard food environments that enable healthy diets for children.38 The double burden of malnutrition, defined as the co-existence of overnutrition (overweight and obesity) alongside undernutrition (stunting and wasting), has received renewed attention, and healthy diets and supportive food systems that provide people with healthy, safe, affordable, and sustainable diets are of critical importance.39 The Global Syndemic of undernutrition, overnutrition, and climate change has been described, with major systems of food and agriculture, transportation, urban design, and land use driving the syndemic.40 These factors further emphasise the need for multi sectoral interventions that address the issues concurrently—double-and triple-duty actions—and ensure synergy in reducing unhealthy diets and NCDs. Double-duty actions aim to tackle undernutrition, overnutrition, and diet-related NCDs with the same intervention, programme, or policy, and address early-life nutrition, diet quality, food environments, and socio economic factors. They are delivered through health services; social safety nets; educational settings; and agriculture, food systems, and food environments.41 32The Task Force on Fiscal Policy for Health. Health taxes to save lives: employing effective excise taxes on tobacco, alcohol, and sugary beverages. April 2019. https://bit. ly/36SMI07. 33WHO. Population-based approaches to childhood obesity prevention. Geneva: WHO; 2012. https://bit.ly/2Ntl9T8. 34WHO. Prioritizing areas for action in the field of population-based prevention of childhood obesity: a set of tools for Member States to determine and identify priority areas for action. Geneva: WHO; 2012. https://bit.ly/2NTEpbA. 35WHO. Report of the Commission on Ending Childhood Obesity. Geneva: WHO; 2016. https://bit.ly/34OHXTn. 36The obesogenic environment is defined as ‘the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations.’ Lake A, Townshend T. Obesogenic environments: exploring the built and food environments. J R Soc Promot Health 2006; 126: 262-267.https://www.ncbi. nlm.nih.gov/pubmed/17152319. 37UNICEF. The State of the World’s Children 2019: Children, food and nutrition.https://bit.ly/2QL70Tu. 38UNICEF and UN Special Rapporteur on the Right to Food. Protecting children’s right to a healthy food environment. Geneva: UNICEF and UN Human Rights Council; 2019. https://bit.ly/2XJmXev. 39Branca F, Demaio A, Udomkesmalee E et al. Comment: A new nutrition manifesto for a new nutrition reality. Lancet 2019; published online December 15, 2019. https:// bit.ly/2tsWdUn. 40Swinburn BA, Kraak VI, Allender S, et al. The Global Syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393: 791 846. https://bit.ly/2LrgNLY. 41Hawkes C, Ruel H, Salm L, et al. Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms. Lancet 2019; published online December 15, 2019. https://bit.ly/36I2jhP. 25 In the Region of the Americas, PAHO developed a regional Plan of Action for COP42 to complement its Regional Strategy and Plan of Action for NCD Prevention and Control,43,44 aligned with the global frameworks, but tailored to regional specificities.In September 2019, the PAHO 57th Directing Council approved a Plan of Action that providesguidance to its Member States for the elimination of trans fats from the food supply,45 aiming to decreaseconsumption of unhealthy fats and contribute to CVD reduction. This regional Plan of Action for trans fat elimination is aligned with global nutrition and diet-related NCD targets under the commitments of the UN Decade of Action on Nutrition 2016-2025.46 In the Caribbean region, theCaribbean Community,47 the main regional political integration body—of which Barbados is a member—has long recognised NCDs as a priority for joint action. These disorders have been included in the CARICOM regional health agenda, the Caribbean Cooperation in Health (CCH)48 since its inception in 1984—its fourth iteration, CCH IV,49 covers the period 2016-2025. The 1993 Caribbean Charter for Health Promotion50 focused on health and wellness, advocating that “people’s health is a positive resource for their living”, while the 2001 Nassau Declaration on Health51 by CARICOM HoSG stated that “the health of the region is the wealth of the region” and recognised the need to reorient and restructure health services; give special attention to vulnerable groups, including youth and women; and focus on NCDs and mental health, as well as human immunodeficiency virus (HIV). Further, in a world-leading Summit on NCDs in 2007, the CARICOM HoSG developed the Port of Spain Declaration (POSD), 52 which remains the premier guiding framework for regional and national interventions for NCD prevention and control. Indicators related to the POSD and allied frameworks are monitored annually through the development of a grid that shows the status of related interventions in CARICOM countries. The 2017 POSD grid53 shows that despite successes relating to the development of NCD policies and plans, funding for NCD programmes, and celebration of Caribbean Wellness Day (CWD), 54 several countries, including Barbados, are lagging in taxation of some health-harming products, such as tobacco, alcohol, and unhealthy foods and non-alcoholic beverages, among other interventions. The Caribbean Public Health Agency,55 a CARICOM regional institution that plays a major role in NCD prevention and control, especially in surveillance and research, developed a framework for COP to guide CARICOM Member States56 and a six-point policy package for improving food environments in the region.57 The Healthy Caribbean Coalition58 (HCC), an umbrella organisation of CSOs working in NCD prevention and control in the Caribbean—the only such regional entity—has published many documents on the status of the NCD response in the region, focusing on civil society and the private sector, and has developed frameworks to guide civil society action in NCD prevention and control59 and COP.60 42PAHO. Plan of action for the prevention of obesity in children and adolescents. Washington, D.C.: PAHO; 2015. https://www.paho.org/hq/dmdocuments/2015/Obesity Plan-Of-Action-Child-Eng-2015.pdf. 43PAHO. Strategy for the prevention and control of NCDs 2012-2025. Document CSP28/9, Rev. 1. Washington, D.C.: PAHO; 2012.https://www.paho.org/hq/dmdocu ments/2012/CSP28-9-e.pdf. 44PAHO. Plan of action for the prevention and control of NCDs in the Americas 2013-2019. Washington, D.C: PAHO; 2014. https://www.paho.org/hq/dmdocuments/2015/ action-plan-prevention-control-ncds-americas.pdf. 45PAHO. Plan of action for the elimination of industrially-produced trans-fatty acids 2020-2025. Document CD57/8. Washington, D.C.: 2019; PAHO. https://bit.ly/2NST46V. 46https://www.un.org/nutrition/. 47https://www.caricom.org/. 48https://bit.ly/2PZVraE. 49http://carpha.org/downloads/CCH-IV-Version7.pdf. 50https://bit.ly/33J0xfe. 51https://bit.ly/2pK2R7j. 52https://bit.ly/36PfKxB. 53http://onecaribbeanhealth.org/wp-content/uploads/2018/03/POS-Declaration-country-grid-2017.pdf. 54Bartholomew L, Bishop L, Brown CR et al. Caribbean Wellness Day: promoting a region-wide day of action. Rev Panam Salud Publica. 2018; 42: e105. https://bit. ly/35XDq1P. 55http://carpha.org/. 56CARPHA. Plan of Action for Promoting Healthy Weights in the Caribbean: Prevention and Control of Childhood Obesity 2014-2019. http://carpha.org/Portals/0/docs/ HealthyWeights.pdf. 57https://www.paho.org/spc-crb/index.php?option=com content&view=article&id=491:paho-facilitates-agreement-between-chile-and-caricom-to-address-childhood obesity&Itemid=0&showall=1. 58https://www.healthycaribbean.org/. 59HCC. Strategic Plan 2017-2021: Enabling Caribbean civil society’s contribution to national, regional, and global action for NCD prevention and control. Bridgetown, Barbados: HCC; 2017. https://bit.ly/33XbGIW. 60HCC. Civil Society Action Plan 2017-2021: Preventing childhood obesity in the Caribbean.Bridgetown, Barbados: 26 Barbados has contributed significantly to this rich background of Caribbean leadership and advocacy, which played an important role in the convening of the 2011 HLM on NCDs61 and the GoB continues to demonstrate its commitment to NCD reduction at home and abroad, appointing a Special Envoy on NCDs,62 and collaborating with national, regional, and international entities in the fight against NCDs. The Prime Minister of Barbados is recognised as a strong advocate and champion for NCD prevention and control; in 2018 she spoke in international and regional fora of the imperative to take relevant action. 63,64Shortly after his appointment in 2018, the Minister of Health and Wellness presented the National Wellness Initiative for Barbados, noting the dimensions of wellness—social, occupational, spiritual, financial, intellectual, emotional, physical, and environmental—and highlighting the vision of “significantly reducing the impact of NCDs on the population by promoting and providing an enabling environment where wellness activities become part of the daily experiences of all Barbadians”. In 2018, the Barbados MHW received an award from the UNIATF65 for outstanding contribution to NCD prevention and control,66 and in June 2018 and July 2019, respectively, Barbados’ Permanent Mission to the Organisation of American States successfully sponsored resolutions for multi-sectoral actions to address NCDs and for inclusion of school-based interventions for COP in the Inter-American Education Agenda, in collaboration with PAHO.67 Barbados is the current Chair of the Regional Technical Subcommittee established in May 2018 to facilitate efforts by the Caribbean Regional Organisation for Standards and Quality (CROSQ) to revise the Caribbean Regional Standard (CRS) 5—Specification for labelling of pre-packaged foods to include FoPWL that provides information on foods high in salt, sugar, and fats. In November 2019, the Minister of Health and Wellness identified 2020 as a year of intensified action to reduce NCDs in Barbados68 concurrent with the “We Gatherin’ Barbados 2020”69 initiative that encourages the Barbadian diaspora to visit the country during that year and help to catalyse national transformation. 3. Methodology 3.1 Conceptual framework The main conceptual framework for the development of the NSP-NCD 20-25 is results-based management (RBM), whichthe UN Development Group (UNDG) defines as “a management strategy by which all actors, contributing directly or indirectly to achieving a set of results, ensure that their processes, products, and services contribute to the achievement of desired results (outputs, outcomes, and higher level goals or impact). The actors, in turn, use the information and evidence on actual results to inform decision-making on the design, resourcing, and delivery of programmes and activities, as well as for accountability and reporting.”70 RBM, as applied to the development of the NSP-NCD 20-25, utilises the Theory of Change, defined as “a method that explains how a given intervention, or set of interventions, is expected to lead to specific development change, drawing on a causal analysis based on available evidence.”71 It provides the “big picture” to guide analysis of the possibilities, and is 61Chattu VK, Knight AW. Port of Spain Summit Declaration as a successful outcome of global health diplomacy in the Caribbean region: a systematic review. Health Promot Perspect 2019; 9(3): 174-180. https://bit.ly/2NTFiAW. 62https://www.who.int/global-coordination-mechanism/sir trevor hassell/en/. 63https://www.barbadosadvocate.com/news/urgent-action-needed-tackle-ncds-says-pm-mottley. 64https://bit.ly/2DpSuZx. 65https://www.who.int/ncds/un-task-force/en/. 66https://www.who.int/ncds/un-task-force/events/2018-awards/en/. 67Healthy Caribbean Coalition. Weekly News Roundup, 16 July 2019. https://bit.ly/2qBkM01. 68http://www.loopnewsbarbados.com/content/health-minister-2020-year-win-ncd-battle. 69https://www.wegatherinbarbados.com/. 70UNDG. Results-based Management Handbook: Harmonizing RBM concepts and approaches for improved development at country level. UNDG, October 2011.https:// bit.ly/34QmHN7. 71UNDG. Theory of change. UNDAF companion guidance.https://bit.ly/2NYHRBC. 27 complemented by the Logical Framework Approach (LogFrame, LFA),72 which analyses the particular strategy and pathway that the project or programme will use. The LFA leads tothe development of the LogFrame Matrix (LFM) which summarises what the project or programme intends to do, and how; what the key assumptions are; and how the outputs, outcomes, and goal in the hierarchy of objectives will be monitored and evaluated. The SP 15-19 for NCD prevention and controlalso used the LFA and LFM format, and was included in a PAHO qualitative analysis of NCD multi-sectoral action plans in the Caribbean,73 which identified success factors, strengths, gaps, and lessons learned, and made recommendations for improvement of the plans. The development of the NSP-NCD 20-25 takes advantage of the lessons learned and the recommendations, including clarity of means-end relationships in achieving the desired results. The core components of the NSP-NCD 20-25 are presented in an LFM in Section 7 of this document. 3.2 Process A consultant was selected through a competitive process to assist the MHW with the development of the NSP-NCD 20-25, and was required to develop an inception report (IR) for the consultancy, including major milestones and indicative timelines. The MHW reviewed and approved the IR, and subsequent activities included: • Meetings with MHW staff and the NNCDC. • Desk review of key documents related to NCD prevention and control, including those listed in Annex 1. • Development and dissemination of a survey instrument/interview guide to obtain input from key stakeholders related to the implementation of the NCD SP 15-19; their work in NCD prevention and control; strengths, weaknesses, opportunities, and threats (SWOT); and priorities for inclusion in the NSP-NCD 20-25.The survey instrument/interview guide is in Annex 3. • In engaging stakeholders in the process of developing the NSP-NCD 20-25, the MHW solicited the participation of, and input from, MHW entities; other government ministries; CSOs and NGOs, including disease-specific NGOs, academia, FBOs, trade unions, and PLWNCDs; and the private sector. This was done either directly or through the representation of these entities in the NNCDC or HCC. Alist of key stakeholder entitiesthat provided input, including those at the stakeholder meeting mentioned below, is in Annex 4. • Analysis of survey and interview responses,and development of a summary report. • Development of a “pre-draft 1” document for review by key MHW personnel and the NNCDC, to facilitate the production of draft 1 of the NSP-NCD 20-25. • Development of draft 1 of the NSP-NCD 20-25, dissemination of the draft, and convening of a meeting with key stakeholders to obtain feedback on the draft. • Incorporation of feedback received to produce a penultimate version, its dissemination to the MHW and NNCDC for comments, and production of the final NSP-NCD 20-25. 3.3 Stakeholder Engagement Principles Stakeholders may be defined as any individuals, groups of people, institutions, or organisations that may have a significant interest in the success or failure of a project around the issue of concern, and that may be affected either positively or negatively by the project.When identifying stakeholders, consideration must be given to groups in potential conditions of vulnerability, such as women, older persons, youth, persons with disabilities, and persons living in poverty, so that they are represented 72UN Public Administration Network (UNPAN). Module 3. Online training course on Results-based Monitoring and Evaluation (RMBE) for MDG implementation: Logical Framework Approach and RMBE. The Logical Framework Approach—Background, concepts, tools, and practices (Presentation).https://bit.ly/2qBPzts. 73PAHO. In-depth qualitative assessment of noncommunicable diseases multi-sectoral action plans in the Caribbean. Washington, D.C.: PAHO; 2018. https://bit.ly/2E7ovqR. 28 in the process, especially if the issue will affect their lives. It is also important to understand the stakeholders and their varying levels of interest and power to influence the project, as well as the motivation and capacity—resources, knowledge, and skills—that they bring to the issue.74 This is especially applicable to civil society and the private sector. The WHO tool for the development of multi-sectoral action plans (MAP) for NCD prevention and control,75identifies stakeholder subgroups that may be engaged. They include, but are not limited to: • Public sector: Ministers and advisors (executive); civil servants and departments (administrative and technical); elected representatives (legislative); courts (judicial); political parties; local government councils; the military; commissions; and international and development bodies, such as the UN and the World Bank. • Private sector: Corporations and businesses; business associations; professional bodies; individual business leaders; and financial institutions. • Civil society: Media; FBOs; schools and universities; social movements and advocacy groups; trade unions; national NGOs; and international NGOs. The WHO MAP tool also notes possible roles of key stakeholders, as outlined in Annex 5, and highlights the importance of networks, since each stakeholder may be part of several NCD prevention and control-related networks or non-NCD programmes that enable integrated approaches and realisation of co-benefits. Networks contribute to strengthening the participant- and resource-base; help to build the knowledge, skills, and competencies of their members; and offer both individuals and organisations more opportunities to access resources and expertise, including through international agencies that can facilitate network development. Enhanced and effective functioning and networking of the multi-sectoral bodies already established in Barbados can play a significant role in marshalling the strengths and actions of key stakeholders for equitable NCD reduction. 3.4 Limitations Limitations in the methodology included: • Absence of reports on the monitoring or evaluation of the SP 15-19; this gap was addressed rapidly and qualitatively through the key stakeholder survey and interviews. • The small number of persons responding to the key stakeholder survey and interviews, and participating in the stakeholder consultation. • Incomplete knowledge of the SP 15-19 and NCD interventions by respondents both within and outside of the health sector, notwithstanding that the stakeholders who responded provided valuable input, as did the well-kept minutes of NNCDC meetings for the period January 2015-July 2019. • Limited responses to requests for feedback on the drafts of the NSP-NCD 20-25. 4. Situation analysis 4.1 General Barbados is an independent, English-speaking island located in the Lesser Antilles, and is the easternmost of the Caribbean islands, with an area of 166 square miles (430 square km). It is a member of the Commonwealth of Nations,76with a constitutional 74Community Sustainability Engagement Evaluation Toolbox: Stakeholder analysis. https://bit.ly/2OUVWSs. 75WHO. NCD MAP Tool: Stakeholder engagement and multisectoral governance mechanisms. http://apps.who.int/ncd-multisectoral-plantool/home.html. 76https://thecommonwealth.org/. 29 monarchy in which the titular Head of State is the Queen of England, represented by the Governor General. Legislative power is vested in Parliament, which comprises an elected House of Assembly, a nominated Senate, and the Governor General. The 2010 censuspopulation estimate was 277,821,7747.9% male and 52.1% female; ethnicity 92.4% Black, 3.1% Mixed, 2.7% White, and 1.3% South Asian, with East Asians and Middle Easterners included in the remaining 0.5%. The main religion is Christianity, with Anglicans comprising the largest group (23.9%), followed by Pentecostals (19.5%), Seventh Day Adventists (5.9%), Methodists (4.2%), Roman Catholics (3.8%), and smaller percentages of other groups. Non-Christian religious groups in the country include Rastafarians, Muslims, Hindus, Jews, Baha, and Buddhists.78 Barbadosis one of the most densely populated countries in the world, with 1,627 inhabitants per square mile (639 per square km). In 2015, the life expectancy at birth was 75.1 years79 (73.1 years in men, and 77.9 years in women) and the total fertility rate was 1.3 children per woman; the dependency ratio is increasing and is expected to continue to rise.80 During the period 2010-2012, infants (children under 1 year old) represented approximately 1.1% of the estimated totalpopulation; children ages 1-4 years 5.1%; children ages 5-9 years 6.8%; adolescents 10-19 years old 14.0%; and the proportion of elderly persons (over 65 years old) 13.7%81—this last is expected to rise to 18% by 2025.82 Barbados is known for its centenarians: as at 5 May 2016, there were 114 centenarians (103 females and 11 males) living in the country83 and in October 2019, the GoB, in collaboration with the Barbados Museum and Historical Society, launched an official website of Barbadian centenarians.84 Persons with disabilities account for 4% of the population,85 primary and secondary level education are mandatory and free to Barbadian students, andthe literacy rate is 97%; since 2018, tertiary level education is again being provided free of cost to students. Telecommunications systems are good, with 79.5% of the individuals using the Internet in 2017.86 In 2015, the per capita gross domestic product was US$ 15,600; Barbados is classified as a ‘developing economy’ by the UN Department of Economic and Social Affairs (UN/DESA),87 and as ‘high-income’ by the World Bank.88 Its economy is service based, with tourism, international business, and retail trade being the main drivers of economic activity. Vulnerability to external shocks in the financial markets, as occurred in 2008-2009, resulted in declining output and an increase in unemployment. Unemployment rateswere 10.7% in 2010, 11.3% in 2011, and 11.6% in 2012;8912.3% in 2014, 11.3% in 2015, 9.7% in 2016, 10.0% in 2017 and an estimated 9.2% in 2018.90 Most unemployed persons (47.7%) were in the 15-19 year age group, indicating a challenge with youth employment, and the Country Assessment of Living Conditions conducted in 2010 found that 15% of households lived below the poverty line of US$ 3,930 per year, with 62% of poor households headed by women and an unemployment rate among poor households of slightly more than 25%.91 Since 2018, the Barbados Economic Recovery and Transformation Plan (BERT) has been in effect.92 77Barbados Statistical Service (BSS). 2010 Population and Housing Census, Volume I. Bridgetown: BSS; 2013. https://bit.ly/34LhxSe. Note: The 2014 mid-year population estimate was 286,100. 78https://www.gov.bb/Visit-Barbados/demographics. 79In 2017 and 2018, life expectancy at birth was, respectively 75.5 and 75.6 years. MHW Planning and Research Unit. The Barbados Health Report: ‘Healthy productive people and communities’ (Draft). Bridgetown: MHW; 2019. 80PAHO. Health in the Americas+. Washington, D.C.: PAHO; 2017.https://bit.ly/2Q2PSsa. 81Government of Barbados, MOH. Chief Medical Officer’s (CMO’s) report 2010–2012. Bridgetown: MOH; 2016. https://bit.ly/2Ctw1Ky. 82Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019. 83The Nation Newspaper (Barbados), 26 May 2016. Barbados home to over 100 centenarians. https://bit.ly/2X04TfO. 84https://centenariansofbarbados.com/. 85PAHO. Health in the Americas+. Washington, D.C.: PAHO; 2017. 86International Telecommunications Union (ITU). The state of broadband 2018: broadband catalyzing sustainable development. Geneva: ITU; 2018.https://bit.ly/2NQel0Y. 87UN/DESA. World Economic Situation and Prospects 2014: Statistical annex—Country classification. New York: UN; 2014. https://bit.ly/2pV98Nr. 88https://data.worldbank.org/country/barbados. 89CMO’s report 2010–2012. 90Caribbean Development Bank (CDB). Barbados Economic Brief 2018.https://bit.ly/2WYRxQF. 91PAHO. Health in the Americas+. Washington, D.C.: PAHO; 2017. 92Central Bank of Barbados. Barbados’ economic recovery: adjustment, adaptation, and the way forward. November 2018. https://bit.ly/2CrGkin. 30 The country’s Human Development Index (HDI)93 for 2017 was 0.800, which putsit in the ‘very high’ human development category and positions it at 58 out of 189 countries and territories. However, when the value is discounted for inequality, the HDI falls to 0.669, a loss of 16.4% due to inequality in the distribution of the HDI dimension indices.94 Barbados is one of the SIDS, a group of countries facing specific social, economic, and environmental vulnerabilities, including limited opportunities to create economies of scale due their small size, natural hazards, global climate change, and sea-level rise.95 Climate change mitigation and adaptation are critical, especially in light of the country’s status as a water-scarce country and the impact of further reduction in water availability on agriculture, food and nutrition security, and health. 4.2 Epidemiological Summary Mortality The average number of deaths per year for the period 2010-2012 was 2,342, and crude death rates for 2010, 2011, and 2012, respectively, were 8.2, 8.8 and 8.4 per 1,000 population, adjusted to 5.8, 6.3, and 5.9 per 1,000 population, respectively, after standardisation to the world standard population.In the younger age groups (less than 44 years), men consistently accounted for higher proportion of deaths, but the ratio of male to female deaths was more evenly distributed in the older age groups. There was no significant change in Barbados’ crude death rate for the period 2002-2012.96 NCDs, namely IHD, including AMI (“heart attack”); cerebrovascular disease (stroke); diabetes; hypertensive heart disease; breast and prostate cancer; and respiratory infections,were among the leading causes of death for the period 2010-2012, as shown in Table 1 below. Table 1. Top ten causes of death in Barbados and rank, 2010-2012 Final deliverable – 31 Dec 2019 Page 38 of 134 The country’s Human Development Index (HDI)93 for 2017 was 0.800, which putsit in the ‘very high’human development category and positions it at 58 out of 189 countries and territories.However, when the value is discounted for inequality, the HDI falls to 0.669, a loss of 16.4% due to inequality in the distribution of the HDI dimension indices.94Barbados is one of the SIDS, a group of countries facing specific social, economic, and environmental vulnerabilities, including limited opportunities to create economies of scale due their small size, natural hazards, global climate change, and sea-level rise.95 4.2Epidemiological summary Climate change mitigation and adaptation are critical, especially in light of the country’s status as a water-scarce country and the impact of further reduction in water availability on agriculture, food and nutrition security, and health. Mortality The average number of deaths per year for the period 2010-2012 was 2,342, and crude death rates for 2010, 2011, and 2012, respectively, were 8.2, 8.8 and 8.4 per 1,000 population, adjusted to 5.8, 6.3, and 5.9 per 1,000 population, respectively, after standardisation to the world standard population.In the youngerage groups (less than 44 years), men consistently accountedfor higher proportion of deaths, but the ratio of male to female deaths was more evenly distributed in the older age groups. There was no significant change in Barbados’ crude death rate for the period 2002-2012.96 Cause of death NCDs, namely IHD, including AMI (“heart attack”); cerebrovascular disease (stroke); diabetes; hypertensive heart disease; breast and prostate cancer; and respiratory infections,were among the leading causes of death for the period 2010-2012, as shown in Table 1 below. Table 1. Top ten causes of death in Barbados and rank, 2010-2012 Rank 2010 2011 2012 Stroke, not specified as haemorrhage or infarction 1 1 1 Unspecified diabetes mellitus without complications 2 2 2 Malignant neoplasm of prostate (prostate cancer) 3 3 4 Acute myocardial infarction, unspecified 4 4 3 Unspecified acute lower respiratory infection 5 - 7 Breast, unspecified 6 5 8 93 The HDI is a summary measure that combines life expectancy, mean years of schooling among the adult population, expected years of schooling for children of school-entry age, and gross national income per capita. 94 UN Development Programme. Human development indices and indicators: 2018 statistical update—Barbados. New York: UNDP; 2018. http://hdr.undp.org/sites/all/themes/hdr theme/country-notes/BRB.pdf. 95https://en.wikipedia.org/wiki/Small Island Developing States. 96CMO’s Report 2010-2012. Final deliverable – 31 Dec 2019 Page 39 of 134 Cause of death Rank 2010 2011 2012 Septicaemia, unspecified 7 6 5 Colon unspecified 8 8 Unspecified dementia 9 10 10 Urinary tract infection, site not specified 10 - Pneumonia, unspecified - 7 6 Unspecified acute lower respiratory infection - 9 Essential (primary) hypertension - - 9 Source: MOH, Barbados. CMO’s Report 2010-2012 Prostate cancer accounted for the highest proportion of deaths in men in 2010 and 2011, but was secondto CVD in 2012. Together, over the period 2010‒2012, d iabetes mellitus, IHD, hypertensiveheart disease, and cerebrovascular diseaseaccounted for approximately one quarter of deaths among men, and one-third of deaths among women. WHO estimated that in 2016, NCDs accounted for 83% of all deaths in Barbados, with 29% of deaths due to CVD, 23% to cancer, 9% to diabetes, 4% to chronic respiratory diseases, and 18% to other NCDs; the total risk of premature mortality from NCDs was 16% (20% for men, 13% for women).97 In 2014, the age-standardised incidence rate for cancer in Barbados was 237.0/100,000 population, compared with 219.6/100,000 in 2013 and 214.6/100,000 in 2008. Consistent with the global situation, the ASIR for men (265.7/100,000) was higher than that for women (218.5 per 100,000) and the top cancer sites were prostate and breast, followed by colon, uterine cervix, and uterine body. The prostate cancer ASIR was 111.5 per 100,000,placing it in the top five prostate cancer rates seen globally, and breast cancer was the most common cancer among women, with an ASIR of 74.5 per 100,000. The ASIR of colon cancer was 28.4/100,000 in men and 28.0/100,000 in women; cervical cancer 25.4/100,000; and cancer of the uterine body 18.2/100,000. Barbados had one of the lowest rates of lung cancer globally (7.4 per 100,000), likely due to the low prevalence of tobacco smoking. Morbidity 98 If maternal and child health visits are excluded, 80% of all visits to polyclinics in Barbados are for a chronic disease; between 2010 and 2012, diabetes, hypertension, and lipid disorders were the main causes for visits to the then eight polyclinics. 99 97 WHO. Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018. In 2014,there were 584 stroke events, of which 81% were classified as ischaemic and 16% as haemorrhagic—481 were admitted to the sole public tertiary level health facility in the country, the Queen Elizabeth Hospital. There were 411 AMI and SCDevents in 407 patients, of which 84.2% had a definite diagnosis of AMI, and https://bit.ly/2Nx6R3T. 98 Barbados National Registry (BNR). Cancer in Barbados 2014. Bridgetown: George Alleyne Chronic Disease Research Centre (GA-CDRC), UWI; 2014. 99 Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019. Note: Theninth polyclinic was opened in 2015. 93The HDI is a summary measure that combines life expectancy, mean years of schooling among the adult population, expected years of schooling for children of school entry age, and gross national income per capita. 94UN Development Programme. Human development indices and indicators: 2018 statistical update—Barbados. New York: UNDP; 2018. http://hdr.undp.org/sites/all/ themes/hdr theme/country-notes/BRB.pdf. 95https://en.wikipedia.org/wiki/Small Island Developing States. 96CMO’s Report 2010-2012. 31 Prostate cancer accounted for the highest proportion of deaths in men in 2010 and 2011, but was secondto CVD in 2012. Together, over the period 2010-2012, diabetes mellitus, IHD, hypertensive heart disease, and cerebrovascular disease accounted for approximately one-quarter of deaths among men, and one-third of deaths among women. WHO estimated that in 2016, NCDs accounted for 83% of all deaths in Barbados, with 29% of deaths due to CVD, 23% to cancer, 9% to diabetes, 4% to chronic respiratory diseases, and 18% to other NCDs; the total risk of premature mortality from NCDs was 16% (20% for men, 13% for women).97 Morbidity In 2014, the age-standardised incidence rate for cancer in Barbados was 237.0/100,000 population, compared with 219.6/100,000 in 2013 and 214.6/100,000 in 2008. Consistent with the global situation, the ASIR for men (265.7/100,000) was higher than that for women (218.5 per 100,000) and the top cancer sites were prostate and breast, followed by colon, uterine cervix, and uterine body. The prostate cancer ASIR was 111.5 per 100,000,placing it in the top five prostate cancer rates seen globally, and breast cancer was the most common cancer among women, with an ASIR of 74.5 per 100,000. The ASIR of colon cancer was 28.4/100,000 in men and 28.0/100,000 in women; cervical cancer 25.4/100,000; and cancer of the uterine body 18.2/100,000. Barbados had one of the lowest rates of lung cancer globally (7.4 per 100,000), likely due to the low prevalence of tobacco smoking.98 If maternal and child health visits are excluded, 80% of all visits to polyclinics in Barbados are for a chronic disease; between 2010 and 2012, diabetes, hypertension, and lipid disorders were the main causes for visits to the then eight polyclinics.99 In 2014,there were 584 stroke events, of which 81% were classified as ischaemic and 16% as haemorrhagic—481 were admitted to the sole public tertiary level health facility in the country, the Queen Elizabeth Hospital. There were 411 AMI and SCD events in 407 patients, of which 84.2% had a definite diagnosis of AMI, and 256 were hospitalised at the QEH.100 Table 2 below presents a comparison of these events in 2014 and in 2016,101 including identified risk factors. Table 2. Summary of CVD events and risk factors in QEH patients, 2014 and 2016 Final deliverable – 31 Dec 2019 Page 40 of 134 256 were hospitalised at the QEH.100Table 2 below presents a comparison of these events in 2014 and in 2016,101 CVD events and risk factors including identified risk factors. Table 2. Summary of CVD events and risk factors in QEH patients, 2014 and 2016 2014 (risk factor %) 2016 (risk factor %) Number of stroke events 584 (481 abstracted) 723 (476 abstracted) At least one risk factor 90 86 At least two risk factors 68 61 Hypertension 89 72 Diabetes 72 46 Obesity 39 28 High cholesterol 67 63 Smokers 12 7 Prior stroke or ischaemic attack 47 26 Number of AMI or SCD events 411 (234 abstracted) 439 (217 abstracted) Hypertension 86 84 Diabetes 80 65 Obesity 86 61 Hyperlipidaemia 76 73 Smokers 19 16 Alcohol use 23 21 Prior IHD/AMI/stroke 71/35/25 78/29/11 Source: Barbados National Registry (BNR) Annual Reports 2014 and 2016 In 2012, asthma was the leading disease-specific discharge diagnosis from the QEH, occurring mainly in children and adolescents.After asthma, diabetes, IHD, stroke,chronic pulmonary disease—including bronchitis,influenza, and pneumonia—and heart failure were among the leading discharge diagnoses. The most frequent cancer diagnoses were breast, colo-rectal, prostate, and cervical cancer, in order of occurrence, and were highest in those 55 years of age and older, reaching a peak in those 75 years and older. In 2017, of NCD discharge diagnoses at the QEH, asthma was again the leading condition, accounting for 27.7%; IHD 13.7%; colon/recto-sigmoid cancer 11.4%; stroke 10.5%; breast cancer 7.0%; bronchitis, emphysema, and otherCOPD 6.2%; prostate cancer 5.0%; hypertension 4.3%; and cervical cancer 1.2%.102In 2011, there were 118 admissions to the Geriatric Hospital; the leading cause for referral and admission was dementia.103 100 Barbados National Registry (BNR). Annual Report 2014. Bridgetown:GA-CDRC, UWI; 2014. https://bit.ly/2K4xHhA. 101 BNR. Annual Report 2016. Bridgetown: BNR; 2016.https://bit.ly/2NSVlPv. 102 The Barbados Health Report: ‘Healthy productive people and communities’ (Draft). 2019 103 PAHO. Health in the Americas+. Washington, D.C.: PAHO; 2017. 97WHO. Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018. https://bit.ly/2Nx6R3T. 98Barbados National Registry (BNR). Cancer in Barbados 2014. Bridgetown: George Alleyne Chronic Disease Research Centre (GA-CDRC), UWI; 2014. 99Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019. Note: Theninth polyclinic was opened in 2015. 100Barbados National Registry (BNR). Annual Report 2014. Bridgetown:GA-CDRC, UWI; 2014.https://bit.ly/2K4xHhA. 101BNR. Annual Report 2016. Bridgetown: BNR; 2016.https://bit.ly/2NSVlPv. 32 In 2012, asthma was the leading disease-specific discharge diagnosis from the QEH, occurring mainly in children and adolescents.After asthma, diabetes, IHD, stroke,chronic pulmonary disease—including bronchitis, influenza, and pneumonia—and heart failure were among the leading discharge diagnoses. The most frequent cancer diagnoses were breast, colo-rectal, prostate, and cervical cancer, in order of occurrence, and were highest in those 55 years of age and older, reaching a peak in those 75 years and older. In 2017, of NCD discharge diagnoses at the QEH, asthma was again the leading condition, accounting for 27.7%; IHD 13.7%; colon/recto-sigmoid cancer 11.4%; stroke 10.5%; breast cancer 7.0%; bronchitis, emphysema, and other COPD 6.2%; prostate cancer 5.0%; hypertension 4.3%; and cervical cancer 1.2%. 102In 2011, there were 118 admissions to the Geriatric Hospital; the leading cause for referral and admission was dementia.103 Risk factors The Barbados Health of the Nation Study: Core Findings 2015, 104showed that Barbadian adults (persons aged 25 years and older) are at high risk from NCDs due to high prevalence of biological and behavioural risk factors. In addition, the occurrence of multiple risk factors occurring together greatly increases the risk of NCD development, compared with risk factors occurring in isolation. The HoTNS showed that: • 1 in 10 adults had an NCD, and 1 in 3 was being managed for at least one NCD • 1 in 3 had hypertension, 1 in 5 had diabetes, and of those with known hypertension or diabetes, at least 1 in 3 of those receiving treatment had sub-optimal control • 8 in 10 men, and 9 in 10 women, had at least one risk factor • 2 of every 3 adults was overweight or obese; about 1 in 10 women, and almost 1 in 20 men, had “gross” obesity (body mass index [BMI] ≥ 35 kg/m2) • 1 in 10 men, and 1 in 50 women, reported daily tobacco use • 1 in 10 men, and 1 in 50 women, reported excessive weekly alcohol consumption, with 1 in 3 men aged 25-44 years reporting binge drinking in the past 30 days • 9 in 10 adults reported low fruit and vegetable consumption • 5 in 10 adults reported low levels of physical activity • A combination of three or more risk factors (current daily tobacco smoking, inadequate fruit and vegetable consumption, physical inactivity, being overweight or obese, and having hypertension) was more common in women than men, and in older adults 102The Barbados Health Report: ‘Healthy productive people and communities’ (Draft). 2019 103PAHO. Health in the Americas+. Washington, D.C.: PAHO; 2017. 104http://www.archive.healthycaribbean.org/newsletters/aug-2015/CDRC HealthOfTheNationSurvey.pdf. 33 A summary of selected findings from the HoTNS and comparison with findings from the 2007 Barbados Risk Factor Survey (BRFS), 105both of which were based on the WHO STEPS106 methodology, are in Table 3 below. Table 3. Selected data from the HoTNS core findings 2015 and the 2007 BRFS The results of risk factor studies in children108 in Barbados are also cause for concern: selected findings from the 2011WHO Global School-based Student Health Survey109 conducted among 13-15 year old students, and from the 2013 Global Youth Tobacco Survey,110 conducted among the same school-based population, are in Tables 4 and 5, respectively. Final deliverable – 31 Dec 2019 Page 41 of 134 Risk factors TheBarbados Health of the Nation Study: Core Findings 2015,104 • 1 in 10 adults had an NCD, and 1 in 3 was being managed for at least one NCD showed thatBarbadian adults (persons aged 25 years and older) are at high risk from NCDs due to high prevalence of biological and behavioural risk factors.In addition, the occurrence of multiple risk factors occurring together greatly increases the risk of NCD development, compared with risk factors occurring in isolation. The HoTNS showed that: • 1 in 3 had hypertension, 1 in 5 had diabetes, and of those with known hypertension or diabetes, at least 1 in 3 of those receiving treatment had sub-optimal control • 8 in 10 men, and 9 in 10 women, had at least one risk factor • 2 of every 3 adults was overweight or obese; about 1 in 10 women, and almost 1 in 20 men, had “gross” obesity (body mass index [BMI] ≥ 35 kg/m2) • 1 in 10 men, and 1 in 50 women, reported daily tobacco use • 1 in 10 men, and 1 in 50 women, reported excessive weekly alcohol consumption, with 1 in 3 men aged 25-44 years reporting binge drinking in the past 30 days • 9 in 10 adults reported low fruit and vegetable consumption • 5 in 10 adults reported low levels of physical activity • A combination of three or more risk factors (current daily tobacco smoking, inadequate fruit and vegetable consumption, physical inactivity, being overweight or obese, and having hypertension)was more common in women than men, and in older adults A summary of selected findings from the HoTNS and comparison with findings from the 2007Barbados Risk Factor Survey (BRFS),105 STEPSboth of which were based on the WHO 106 Risk factor and conditions methodology, are in Table 3 below. Table 3. Selected data from the HoTNS core findings 2015 and the 2007 BRFS 2015 2007 Total Men Women Total Men Women Currently smoke tobacco (%) 9.2 15.5 3.7 8.4 15.3 2.2 Currently smoke tobacco daily (%) 6.4 11.0 2.3 6.1 11.3 1.4 Drank alcohol in last 30 days (%) 42.4 56.8 29.9 28.7 42.1 16.9 Heavy episodic alcohol consumption (binge drinking) (%) 14.5 25.4 5.4 - 21.9 9.7 Percentage who drank alcohol on 4 or more days in the last week 5.5 9.3 2.4 13.8 17.8 4.4 Percentage who ate less than 5 combined servings of fruit and vegetables per day 90.0 91.9 88.5 95.4 96.6 94.3 Salt added at the table (%, Yes/Sometimes) 5.1/7.2 8.3/8.8 2.3/5.8 - - 104http://www.archive.healthycaribbean.org/newsletters/aug-2015/CDRC HealthOfTheNationSurvey.pdf. 105https://www.who.int/ncds/surveillance/steps/Barbados 2007 STEPS FactSheet.pdf. 106https://www.who.int/ncds/surveillance/steps/en/. Final deliverable – 31 Dec 2019 Page 42 of 134 Risk factor and conditions 2015 2007 Total Men Women Total Men Women Salt added during cooking (%, Yes) 73.4 55.4 65.1 - - Prevalence of physical inactivity 49.9 30.0 67.2 51.3 42.5 59.0 Percentage who are overweight or obese (BMI ≥25 kg/m2) 66.2 57.5 74.2 65.2 54.6 74.3 Percentage who are obese (BMI ≥30 kg/m2) 33.8 23.4 43.4 28.5 20.3 35.5 Percentage with raised blood pressure (BP) (systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg) OR currently on medication 40.7 36.9 44.0 20.5 25.9 15.3 Percentage with raised blood glucose (fasting glucose ≥ 7 mmol/dl) OR self reported diabetes 18.7 15.9 21.0 14.9 12.7 16.7 Percentage with raised total cholesterol (≥ 5 mmol/l)107 21.2 19.3 22.9 35.0 38.6 32.1 Percentage with three or more of the following risk factors occurring together: current daily tobacco smoking, inadequate fruit and vegetable consumption, physical inactivity, being overweight or obese, and having hypertension 48.6 37.0 58.6 44.0 34.5 52.2 The results of risk factor studies in children108 Global School-based Student Health Survey in Barbados are also cause for concern: selected findings from the 2011WHO 109 Global Youth Tobacco Survey conducted among 13‒15 year old students,and from the 2013 ,110 Variables conducted among the same school-based population, are in Tables 4 and 5, respectively. Table 4. Selected findings from the 2011 Barbados GSHS: 13‒15 year old students Total Boys Girls Alcohol use % who drank at least one drink containing alcohol on one or more of the past 30 days 46.9 48.0 45.8 Among those who ever had a drink of alcohol (other than a few sips), % who had their first drink before age 14 88.7 88.7 88.6 % who drank so much alcohol that they were really drunk one or more times in their life 24.1 29.0 19.0 Dietary behaviour % who were overweight 31.9 32.1 31.8 % who were obese 14.2 13.9 14.6 107 In the 2007 BRFS, the cut-off point was (≥ 5.2 mmol/l). 108 For the purposes of this Strategic Plan, a child is defined as a person less than 18 years of age, aligned with the definition on the Convention on the Rights of the Child. 109https://www.who.int/ncds/surveillance/gshs/2011 Barbados GSHS FS.pdf. 110https://www.paho.org/hq/dmdocuments/2017/Tobacco-Barbados-GYTS-2013-Factsheet-(Ages-13-15)-FINAL 508tagged.pdf. 105https://www.who.int/ncds/surveillance/steps/Barbados 2007 STEPS FactSheet.pdf. 106https://www.who.int/ncds/surveillance/steps/en/. 107In the 2007 BRFS, the cut-off point was (≥ 5.2 mmol/l). 108For the purposes of this Strategic Plan, a child is defined as a person less than 18 years of age, aligned with the definition on the Convention on the Rights of the Child. 109https://www.who.int/ncds/surveillance/gshs/2011 Barbados GSHS FS.pdf. 110https://www.paho.org/hq/dmdocuments/2017/Tobacco-Barbados-GYTS-2013-Factsheet-(Ages-13-15)-FINAL-508tagged.pdf. 34 Table 4. Selected findings from the 2011 Barbados GSHS: 13-15 year old students Table 5. Selected findings from the 2013 Barbados GYTS: 13-15 year old students Final deliverable – 31 Dec 2019 Page 42 of 134 Risk factor and conditions 2015 2007 Total Men Women Total Men Women Salt added during cooking (%, Yes) 73.4 55.4 65.1 - - Prevalence of physical inactivity 49.9 30.0 67.2 51.3 42.5 59.0 Percentage who are overweight or obese (BMI ≥25 kg/m2) 66.2 57.5 74.2 65.2 54.6 74.3 Percentage who are obese (BMI ≥30 kg/m2) 33.8 23.4 43.4 28.5 20.3 35.5 Percentage with raised blood pressure (BP) (systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg) OR currently on medication 40.7 36.9 44.0 20.5 25.9 15.3 Percentage with raised blood glucose (fasting glucose ≥ 7 mmol/dl) OR self reported diabetes 18.7 15.9 21.0 14.9 12.7 16.7 Percentage with raised total cholesterol (≥ 5 mmol/l)107 21.2 19.3 22.9 35.0 38.6 32.1 Percentage with three or more of the following risk factors occurring together: current daily tobacco smoking, inadequate fruit and vegetable consumption, physical inactivity, being overweight or obese, and having hypertension 48.6 37.0 58.6 44.0 34.5 52.2 The results of risk factor studies in children108 Global School-based Student Health Survey in Barbados are also cause for concern: selected findings from the 2011WHO 109 Global Youth Tobacco Survey conducted among 13‒15 year old students,and from the 2013 ,110 Variables conducted among the same school-based population, are in Tables 4 and 5, respectively. Table 4. Selected findings from the 2011 Barbados GSHS: 13‒15 year old students Total Boys Girls Alcohol use % who drank at least one drink containing alcohol on one or more of the past 30 days 46.9 48.0 45.8 Among those who ever had a drink of alcohol (other than a few sips), % who had their first drink before age 14 88.7 88.7 88.6 % who drank so much alcohol that they were really drunk one or more times in their life 24.1 29.0 19.0 Dietary behaviour % who were overweight 31.9 32.1 31.8 % who were obese 14.2 13.9 14.6 107 In the 2007 BRFS, the cut-off point was (≥ 5.2 mmol/l). 108 For the purposes of this Strategic Plan, a child is defined as a person less than 18 years of age, aligned with the definition on the Convention on the Rights of the Child. 109https://www.who.int/ncds/surveillance/gshs/2011 Barbados GSHS FS.pdf. 110https://www.paho.org/hq/dmdocuments/2017/Tobacco-Barbados-GYTS-2013-Factsheet-(Ages-13-15)-FINAL 508tagged.pdf. Final deliverable – 31 Dec 2019 Page 43 of 134 Variables Total Boys Girls % who usually drank carbonated soft drinks one or more times per day during the past 30 days 73.3 74.0 71.5 Physical activity % who were physically active for a total of at least 60 minutes/day on 5 or more days during the past 7days 29.1 34.5 23.3 % who went to physical education class on 3 or more days each week during the school year 33.3 35.4 31.2 % who spent 3 or more hours/day during a typical or usual day doing sitting activities 64.9 60.4 69.6 Tobacco use % who smoked cigarettes on one or more days during the past 30 days 9.7 12.7 6.6 Among those students who ever smoked cigarettes, % who first tried a cigarette before age 14 years 85.9 88.2 82.2 % of students who reported that people smoked in their presence on one or more days during the past 7 days 57.1 58.5 55.6 Table 5. Selected findings from the 2013 Barbados GYTS: 13-15 year old students Variables (%) Total Boys Girls Currently used any tobacco products 14.5 17.4 11.4 Currently smoked tobacco 12.6 15.7 9.3 Currently smoked cigarettes 7.0 8.8 5.0 Currently used smokeless tobacco 2.9 2.9 3.0 Exposed to tobacco smoke at home 19.1 - Exposed to tobacco smoke inside enclosed public spaces 22.6 - Current smokers who obtained cigarettes by buying them from a store, shop, street vendor or kiosk 22.6 - Among current smokers who bought cigarettes, those who were not prevented from buying them because of their age 64.6 - Though there are, as yet, no data from Barbados on the use of e-cigarettes and other products marketed as “cessation aids”, cleaner alternatives to conventional cigarettes, or “reduced risk” products, their increasing use globally, especially among youth, demands that a close eye be kept on this development and relevant evidence collected. Most of these products simulate the act of smoking while typically delivering nicotine; they include heated tobacco products (HTPs), and electronic nicotine delivery systems (ENDS), the latter commonly referred to as e-cigarettes or “vaping” products.111 Centers Research is ongoing, but recent reports from the United States 111 WHO. Report on the global tobacco epidemic, 2019: Offer help to quit tobacco use. Geneva: WHO; 2019. https://bit.ly/2XgJsHq. Final deliverable – 31 Dec 2019 Page 43 of 134 Variables Total Boys Girls % who usually drank carbonated soft drinks one or more times per day during the past 30 days 73.3 74.0 71.5 Physical activity % who were physically active for a total of at least 60 minutes/day on 5 or more days during the past 7days 29.1 34.5 23.3 % who went to physical education class on 3 or more days each week during the school year 33.3 35.4 31.2 % who spent 3 or more hours/day during a typical or usual day doing sitting activities 64.9 60.4 69.6 Tobacco use % who smoked cigarettes on one or more days during the past 30 days 9.7 12.7 6.6 Among those students who ever smoked cigarettes, % who first tried a cigarette before age 14 years 85.9 88.2 82.2 % of students who reported that people smoked in their presence on one or more days during the past 7 days 57.1 58.5 55.6 Table 5. Selected findings from the 2013 Barbados GYTS: 13-15 year old students Variables (%) Total Boys Girls Currently used any tobacco products 14.5 17.4 11.4 Currently smoked tobacco 12.6 15.7 9.3 Currently smoked cigarettes 7.0 8.8 5.0 Currently used smokeless tobacco 2.9 2.9 3.0 Exposed to tobacco smoke at home 19.1 - Exposed to tobacco smoke inside enclosed public spaces 22.6 - Current smokers who obtained cigarettes by buying them from a store, shop, street vendor or kiosk 22.6 - Among current smokers who bought cigarettes, those who were not prevented from buying them because of their age 64.6 - Though there are, as yet, no data from Barbados on the use of e-cigarettes and other products marketed as “cessation aids”, cleaner alternatives to conventional cigarettes, or “reduced risk” products, their increasing use globally, especially among youth, demands that a close eye be kept on this development and relevant evidence collected. Most of these products simulate the act of smoking while typically delivering nicotine; they include heated tobacco products (HTPs), and electronic nicotine delivery systems (ENDS), the latter commonly referred to as e-cigarettes or “vaping” products.111 Centers Research is ongoing, but recent reports from the United States 111 WHO. Report on the global tobacco epidemic, 2019: Offer help to quit tobacco use. Geneva: WHO; 2019. https://bit.ly/2XgJsHq. 35 Though there are, as yet, no data from Barbados on the use of e-cigarettes and other products marketed as “cessation aids”, cleaner alternatives to conventional cigarettes, or “reduced risk” products, their increasing use globally, especially among youth, demands that a close eye be kept on this development and relevant evidence collected. Most of these products simulate the act of smoking while typically delivering nicotine; they include heated tobacco products (HTPs), and electronic nicotine delivery systems (ENDS), the latter commonly referred to as e-cigarettes or “vaping” products.111 Research is ongoing, but recent reports from the United States Centers for Disease Prevention and Control112 (CDC) have implicated the use of these devices in lung injury, which has resulted in several deaths, including among young people.113 With regard to dietary issues, the country has experienced a shift away from consumption of traditional and locally sourced foods to ‘fast foods’ prepared outside the home, which are frequently high in fat, salt, and sugar. This shift is due to several concurring developments, including globalization, increased income, ashift from agriculture to tourism as a primary industry, and a perceived “lack of time” to prepare foods at home, especially during the week. In addition, fresh and healthy foods suchas fruit and vegetables are often more expensive than unhealthy options, and are not as easily available. 114These findings strongly justify the focus of the NSP-NCD 20-25 on NCD risk factor reduction—especially healthy nutrition to address the double burden of malnutrition, with a particular focus on children—and prevention of NCD complications, and highlight the need for strengthened multi-sectoral interventions and action at the first level of care. 4.3 Spending on NCDs An investment case for NCD prevention and control in Barbados was developed in 2015, through collaboration among WHO, the UN Development Programme (UNDP), UNIATF, and the MHW. The findings showed:115 • Current spending estimates of Bds$ 64 million, or approximately Bds$ 220 per capita, per year, on CVD and diabetes. • Losses to the economy of Bds$ 145 million per year due to missed work days (absenteeism), poor productivity (presenteeism), reduced workforce participation, and the costs to business of replacing workers from CVD and diabetes alone. These costs represent around 2.6% of projected GDP in 2015. • Estimated financial resources of Bds$ 56 million to implement the prevention and primary care activities in the Barbados NCD Strategic Plan 2015-2019 in 2015, increasing to Bds$ 97 million in 2019. These figures were dominated by the drugs and supply costs required for diabetes treatment and pharmaceutical prevention of CVD.Over the course of the 5-year scale up of treatment coverage, the implementation of the SP 15-19 would have a minimum return on investment (ROI) of 1.9. The report also noted that by scaling up actions to prevent hypertension, diabetes, IHD, and stroke, Barbados would increase workforce participation, productivity, and GDP.Avoided mortality would be the greatest contributor to GDP gains, which would reach Bds$ 17 million in 2019, and Bds$ 414 million in 2030, due to the selected set of interventions. Over the 15 year SDG period (2015-2030), scaling up prevention interventions, combined with diagnostic and treatment coverage over the next 5 years, and then holding coverage constant, would give a ROI of 4.1 (6.3 with health returns included), or a total of Bds$580 million in increased productivity, representing around 1% of annual GDP. For preventive interventions, the ROI would continue to grow beyond the duration of the SP 15-19, due to the long-term nature of the health outcomes.A major conclusion was that a move towards increased preventive actions would yield a greater ROI based on the relatively low cost of population-wide strategies, and recommendations included a WoG approach, with Health developing operational partnerships involving particularly Education, Labour/Social Affairs, Commerce, Town Planning, Youth and Sports, and Agriculture. 111WHO. Report on the global tobacco epidemic, 2019: Offer help to quit tobacco use. Geneva: WHO; 2019. https://bit.ly/2XgJsHq. 112https://www.cdc.gov/. 113CDC. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Updated 20 December 2019. https://www.cdc.gov/tobacco/basic information/ e-cigarettes/severe-lung-disease.html. 114UNIATF Joint Mission, Barbados, 13–17 April 2015. Geneva: WHO;2017. 115WHO, UNDP, and MOH. The Investment Case for Non-communicable Disease Prevention and Control in Barbados. WHO, UNIATF, UNDP; 2015.https://bit. ly/2Q2RGBs. 36 These findings were further emphasised and expanded in an April 2019 lecture by Professor Karl Theodore of the Health Economics Unit, University of the West Indies (UWI), St. Augustine, Trinidad and Tobago. He noted that the two main types of costs associated with NCDs were personal—comprising OOP, pain and disability, and loss of family and community time—and social, including loss in national savings due to increased expenditure for prevention and treatment, and loss of productivity due to illness and death. NCD-related OOP spending, prevention and treatment expenditures, and decreased productivity cost Barbados not less than Bds$ 375 million, and could be costing as much as Bds$ 825 million, per year, a situation that is not sustainable, especially given the burgeoning NCD epidemic. 116Data from Barbados related to these four variables are summarised in Table 6 below, and Professor Theodore identified key interventions for sustainability as: • Stopping the NCD epidemic through PHC and UH, focusing on prevention and early diagnosis; • Proper coverage of everyone to access health care; and • Building efficiency in the health system through adequate allocation of resources, mainly to primary care and public health, and effective cost control mechanisms, including incorporation of agreed standards of care and a modern health information system. Table 6. Summary of NCD cost estimates, Barbados 4.4 National Responses Selected responses to advance NCD prevention and control in Barbados are noted below, under the headings of the WHO health system ‘building blocks’.117 Leadership and Governance The MHW is the executing agency for the delivery and financing of health care in the publicsector, with a mission to promote health, provide comprehensive health care, and ensure that environmental concerns are considered in all aspects of national development.118 The MHW is headed by a Minister whose authority is vested in the Health Services Act 1969 Cap. 44119 Final deliverable – 31 Dec 2019 Page 45 of 134 SDG period (2015-2030), scaling up prevention interventions, combined with diagnostic and treatment coverage over the next 5 years, and then holding coverage constant, would give a ROI of 4.1 (6.3 with health returns included), or a total of Bds$580 million in increased productivity, representing around 1% of annual GDP. For preventive interventions, the ROI would continue to grow beyond the duration of the SP 15-19, due to the long-term nature of the health outcomes.A major conclusion was that a move towards increased preventive actions would yield a greater ROI based on the relatively low cost of population-wide strategies, and recommendations included a WoG approach, with Health developing operational partnerships involving particularly Education, Labour/Social Affairs, Commerce, Town Planning, Youth and Sports, and Agriculture. These findings were further emphasised and expanded in an April 2019 lecture by Professor Karl Theodore of the Health Economics Unit, University of the West Indies (UWI), St. Augustine, Trinidad and Tobago. He noted that the two main types of costs associated with NCDs were personal—comprising OOP, pain and disability, and loss of family and community time—and social, including loss in national savings due to increased expenditure for prevention and treatment, and loss of productivity due to illness and death. NCD-related OOP spending, prevention and treatment expenditures, and decreased productivity cost Barbados not less than Bds$ 375 million, and could be costing as much as Bds$ 825 million, per year, a situation that is not sustainable, especially given the burgeoning NCD epidemic.116 • Stopping the NCD epidemic through PHC and UH, focusing on prevention and early diagnosis; Data from Barbados related to these four variables are summarised in Table 6 below, and Professor Theodore identified key interventions for sustainability as: • Proper coverage of everyone to access health care; and • Building efficiency in the health system through adequate allocation of resources, mainly to primary care and public health, and effective cost control mechanisms, including incorporation of agreed standards of care and a modern health information system. Table 6. Summary of NCD cost estimates, Barbados Costs Data sources Estimates Comments OOP United States Agency for International Development (USAID) 2008 43% of health expenditure Bds$ 280 million Prevention expenditure Barbados National Health Accounts 0.7% of health expenditure Bds$ 5 million Treatment expenditure Barbados NCD Investment Case Study 30% public health expenditure Total expenditure estimated at twice this Bds$ 220 million 116 Theodore K. Real cost of NCDs and health system sustainability (presentation). BNR 10th Anniversary Seminar: Multidisciplinary stakeholder engagement in the management of NCDs. Bridgetown, Barbados, April 2019. Final deliverable – 31 Dec 2019 Page 46 of 134 Costs Data sources Estimates Comments Productivity costs Economic studies 2003 2017 3%-12% GDP Bds$ 150-600 million Source: Theodore K. Real cost of NCDs and health system sustainability (presentation). Barbados, April 2019 4.4National responses Selected responses to advance NCD prevention and control in Barbados are noted below, under the headings of the WHO health system ‘building blocks’.117 The MHW is the executing agency for the delivery and financing of health care in the publicsector, with a mission to promote health, provide comprehensive health care, and ensure that environmentalconcerns are considered in all aspects of national development. Leadership and governance 118 Health Services Act 1969 Cap. 44 The MHW is headed by a Minister whose authority is vested in the 119 of the Laws of Barbados. The Minister has overall responsibility for formulatinghealth policies, setting strategic directions, developing norms and standards, enforcing regulations, and providing political leadership for the sector. Decision-making is centralised andthere are no local health authorities.The Permanent Secretary is the administrative head of the Ministry, functioning as the chiefexecutive and accounting officer, with responsibility for the effective functioning of all sectionsof the Ministry, while the Chief Medical Officer (CMO)is responsible for all technical and professionalfunctions of the health sector.120 The GoB and MHW have been forward-looking in the recognition of NCD prevention and control as a priority for action—a Health Promotion Unit (HPU) and the posts of Senior Health Promotion Officer and Senior Medical Officer of Health for NCDs (SMOH-NCDs)were established in 2006, to coordinate the respective programmes. An organisational chart of the MHW is in Annex 6. 121 117 WHO. Everybody’s business: Strengthening health systems to improve health outcomes – WHO’s framework for action. Geneva: WHO; 2007. The need for multi-sectoral action was recognised and relevant entities were created, including theNNCDC (2007),for which the HPU provides technical and administrative support, and whichis funded through a line item in the HPU budget; a Task Force on Physical Activity and Exercise (2009); an Inter-Ministerial Committee (2014), now replaced by the Cabinet Sub-committee on NCDs (2018); and a National Wellness Task Force (2018). Other key leadership and governance responses include, but are not limited to: https://www.who.int/healthsystems/strategy/everybodys business.pdf. 118 Barbados Estimates 2018-2019.https://bit.ly/2K4nOAx. 119http://extwprlegs1.fao.org/docs/pdf/bar20130.pdf. 120 CMO’s report 2010-2012. 121Guell C, Samuels TA, Hassell TA, Unwin N. Chronic disease policy in Barbados : analysis and evaluation of policy initiatives. September 2013. https://bit.ly/2sWnCLM 116Theodore K. Real cost of NCDs and health system sustainability (presentation). BNR 10th Anniversary Seminar: Multidisciplinary stakeholder engagement in the management of NCDs. Bridgetown, Barbados, April 2019. 117WHO. Everybody’s business: Strengthening health systems to improve health outcomes – WHO’s framework for action. Geneva: WHO; 2007. https://www.who.int/ healthsystems/strategy/everybodys business.pdf. 118Barbados Estimates 2018-2019.https://bit.ly/2K4nOAx. 119http://extwprlegs1.fao.org/docs/pdf/bar20130.pdf. 37 of the Laws of Barbados. The Minister has overall responsibility for formulating health policies, setting strategic directions, developing norms and standards, enforcing regulations, and providing political leadership for the sector. Decision-making is centralised and there are no local health authorities. The Permanent Secretary is the administrative head of the Ministry, functioning as the chief executive and accounting officer, with responsibility for the effective functioning of all sections of the Ministry, while the Chief Medical Officer (CMO) is responsible for all technical and professional functions of the health sector. 120An organisational chart of the MHW is in Annex 6. The GoB and MHW have been forward-looking in the recognition of NCD prevention and control as a priority for action—a Health Promotion Unit (HPU) and the posts of Senior Health Promotion Officer and Senior Medical Officer of Health for NCDs (SMOH-NCDs)were established in 2006, to coordinate the respective programmes.121The need for multi-sectoral action was recognised and relevant entities were created, including the NNCDC (2007),for which the HPU provides technical and administrative support, and whichis funded through a line item in the HPU budget; a Task Force on Physical Activity and Exercise (2009); an Inter-Ministerial Committee (2014), now replaced by the Cabinet Sub-committee on NCDs (2018); and a National Wellness Task Force (2018). Other key leadership and governance responses include, but are not limited to: • Commitment of the Social Partnership,122 a unique tripartite body that comprises representation from government, trade unions, and private sector employers, to “support and commit, both individually within their respective spheres of influence and collectively at the national level, to take action to slow the pandemic of chronic diseases”.123 • Appointment of a Special Envoy on NCDs and high-level advocacyby ‘policy entrepreneurs’—highly-respected local champions, including senior medical personnel, public health professionals, and researchers—with the credibility to gain access to senior government members. These persons have played a key role in putting and keeping NCDs on the political agenda.124 • Advances in the implementation of the WHO FCTC, with an increase in excise duty on tobacco products and the enactment of tobacco control legislation125 in 2010 that banned smoking in public places and sale of tobacco products to minors, and regulated health warnings on tobacco products. In 2017 the legislation was amended to include electronic smoking devices and require picture-based warnings on tobacco packaging. • Development of various frameworks and guidelines, including the NCD Strategic Plans 2002-2012 and 2015-2019; National Nutrition Improvement and Salt Reduction Initiative (2009); Food and Nutrition Security Policy (2013) and Plan of Action 2014-2018;126 Food-based Dietary Guidelines (revised 2017);127 guidelines for healthy foods in schools (2015);128 physical activity guidelines; and the Barbados Childhood Obesity Prevention Programme (BCHOPP) National Plan of Action for Childhood Obesity Prevention and Control 2015-2018.129 • Collaboration and cooperation between the MHW and NGOs, with development of a draft policy for relations with NGOs in June 2010, and the piloting of a Health NGO Desk in June 2012 as an experiment to strengthen therelationship between the MHW and the NGO sector. • Collaboration with regional and international entitiesin strategic programme planning, implementation, monitoring, and evaluation, including the HCC; UWI Cave Hill Campus; CARICOM Secretariat; CARPHA; international technical cooperation and development agencies, such as PAHO/WHO, UNICEF, UNDP, and other UN agencies; international financing institutions, such as CDB and the IDB; and selected health-promoting PSEs. 120CMO’s report 2010-2012. 121Guell C, Samuels TA, Hassell TA, Unwin N. Chronic disease policy in Barbados : analysis and evaluation of policy initiatives. September 2013. https://bit.ly/2sWnCLM 122https://labour.gov.bb/social-partnership/. 123Protocol 6 of the Social Partnership. https://labour.gov.bb/pdf/social-partnership-protocols/Protocol%206.pdf. 124Unwin N, Samuels TA, Hassell T, Brownson RC, Guell C. The development of public policies to address NCDs in the Caribbean country of Barbados: the importance of problem framing and policy entrepreneurs. Int Journal Health Policy Manag. 2017; 6(2):71-82. https://bit.ly/34OLuRD. 125https://www.tobaccocontrollaws.org/legislation/country/barbados/laws. 126http://extwprlegs1.fao.org/docs/pdf/bar171434.pdf. 127http://www.fao.org/3/I9680EN/i9680en.pdf. 128National Nutrition Centre, MOH, Barbados. Nutritious and healthy foods in schools: nutritional and practical guidelines for Barbados. Bridgetown: National Nutrition Centre; 2015. https://bit.ly/2K3qFdh. 129https://bit.ly/2m000F7. 38 In 2015, a UNIATF Joint Mission visited Barbados in support of the UN Country Team and the GoB, and made several recommendations for strengthening the NCD response. The recommendations included: strengthening intersectoral action to tackle risk factors; obesity reduction, particularly COP; school-based promotion of healthy nutrition and physical activity; acceleration of the implementation of the WHO FCTC, including an FCTC needs assessment to identify gaps in tobacco control; building an investment case for NCDs; and improving health care, particularly at the first level of care.130 Health Services The centrepieces of Barbados’ healthcare system have been the PHC delivery framework established on the principles of the 1978 Declaration of Alma Ata,131and a secondary and tertiary care system established in collaboration with the UWI Faculty of Medical Sciences.132Services comprise a public-private mix where approximately 65% of health care is public and 35% private, with up to 80% of private health care paid for out-of-pocket.133 The public health services in Barbados are organised into the following programmeareas:134 • The first level of care, which is delivered from nine polyclinics and three satellite clinics that arestrategically located along the major road networks within each catchment area, making them readily accessible. The polyclinicmodel is based on the PHC approach and the Chronic Care Model,135,136and provides a wide range ofpreventive and curative services, including maternal and child care, immunisation,family planning, dental care, general practice, nutrition counselling, andenvironmental health. In July 2019, in further efforts to strengthen the health system, improve access, and advance towards universal health, the MHW implemented 24-hour service in one polyclinic as part of a phased rollout of extended opening hours at several such facilities. • Acute, secondary, tertiary and emergency care, provided at the QEH,137with support through the Medical Aid Scheme for services that are not available at that institution. The QEH is the country’s leading acute care medical facility, with a capacity of 600 beds, which comprise 94% of all hospital beds in Barbados. It provides services to Barbadians and permanent residents at no charge to the users, is accredited as a teaching hospital affiliated with the UWI Faculty of Medical Sciences, and serves as a referral centre for patients from other eastern Caribbean states. The QEH has laboratory, baby-friendly, and HACCP138accreditation and also has gold accreditation status with Accreditation Canada International.139It receives an operating budget as approved by Parliament, disbursed from the treasury through the Ministry of Finance, Economic Affairs and Investment (MFEI) and the MHW.140 • Mental health services, which are provided at the Psychiatric Hospital, with the Roseville Halfway House andEverton House serving as community centres for the rehabilitation of people with psychiatricdisorders who have been discharged from hospital. In 2003, the MHW entered into apartnership with the Substance Abuse Foundation141and Teen Challenge142 to treatpersons who are medically recommended for substance abuse treatment services. • Care of the Elderly, provided through the Geriatric Hospital and three District Hospitals thatprovide in-patient, long-term care for the senior citizens. This programme includes the Alternative Care of the Elderly Programme, which is a partnership arrangement between the MHW andprivate sector providers of long-term care for senior citizens. The Geriatric Hospital also housesan adult day care programme. 130WHO. Joint mission of the UNIATF on the Prevention and Control of NCDs, April 2015. Geneva: WHO; 2017. https://bit.ly/34MWqyS. 131https://www.who.int/publications/almaata declaration en.pdf. 132MOH Barbados, Planning and Research Unit. Discussion paper on health financing reform in Barbados. Bridgetown: MOH; January 2015.https://bit.ly/2qBSRgi. 133Labonté R, Runnels S, Crooks V, et al. What does the development of medical tourism in Barbados hold for health equity? An exploratory qualitative case study. Glob Health Res Policy 2017; 2:5. https://bit.ly/2PHBfsj. 134CMO’s Report 2010-2012. 135Institute for Healthcare Improvement (IHI). Chronic care management. https://bit.ly/34HL2EC. 136CARICOM. Chronic care policy and model of care for the Caribbean Community. Georgetown, Guyana: CARICOM Secretariat; 2014.https://bit.ly/2NUcisT. 137http://www.qehconnect.com/. 138Hazard Analysis and Critical Control Point.http://www.fao.org/3/y1579e/y1579e03.htm. 139https://accreditation.ca/intl-en/accreditation/qmentum/. 140Business View Caribbean. The Queen Elizabeth Hospital: a new prescription. Oct. 2019. https://bit.ly/36PkinF. 141http://thesafinc.com/. 142https://www.chnet.com/9664/teen-challenge-barbados.html. 39 • Care of Persons with Disabilities, which provides assessment and rehabilitation services forchildren and young adults with disabilities at the Albert Cecil Graham Development Centre (formerly the Children’s Development Centre). In-patient, long-term care for people with physical and mental disabilities is provided at the Elayne Scantlebury Centre. • Pharmaceutical Services, provided by the Barbados Drug Service,143which is responsible for the annual production of the Barbados National Drug Formulary, and for the procurement and distribution of the drugs listed in the formulary. • Inspection and Licensing Programmes, which include: o The Medical, Nursing, Pharmacy, Dental, and Paramedical Professional Councils, each responsible forsetting the standards for professional conduct, and for registration of, respectively, physicians, nurses, pharmacists, dentists,and allied health professionals. o The Drug Inspectorate, which maintains the inspection and licensing programme for public and private pharmacies, and pharmaceutical manufacturing plants. o Environmental Health Officers, who maintain the inspection and licensing programme for restaurants, bakeries, supermarkets, and other service providers and retail establishments. o The Advisory and Inspection Committee, which is responsible for the inspection, licensing, and periodic monitoring of the operations of nursing homes and senior citizens’ homes. o The Senior Laboratory Technologist, who heads a team responsible for licensing and providing oversight of the operations of private and public medical laboratories. In 2012, the QEH Department of Medicine had a bed occupancy rate of 122.3%; the institution is often obligated to admit patients affected by chronic conditions that may have stabilised, or who are at an incurable stage in the disease process, contributing to the high occupancy rate. In addition, elderly persons who can no longer live on their own, or those whose relatives can no longer cope with the challenges of care, are in many instances “abandoned” at the QEH. These issues prompted analysis of the appropriateness of care and the cost-effectiveness of undertaking certain types of care inan in-patient tertiary level setting versus utilizing other modalities such as day-case, hospice, nursing home, or community care settings.144 Recent estimates indicate that NCDs consume 65% of the QEH budget145and in 2012 an Institutional Assessment and Expenditure Review of the Health Sector found that though the delivery of health care was satisfactory with regard to comprehensiveness, coverage, and accessibility, challenges included continuity and coordination of care across the network of services; insufficient community-based services; outdated operational policies and procedures; and inadequate regulation of health institutions in the private and public sectors.146The review also showed that the performance of the Ministry and the QEH continued to be constrained by several factors, including inadequate health information systems, insufficient funding, absence of cost accounting systems, weak quality improvement schemes, and inadequate income generation in the health sector. It was suggested that overall efficiency of the sector could be improved if clinical services at the QEH and the polyclinics were re-designed, the approach to the management of patients with NCDs made systematic, and procurement processes reformed. The number of people who seek treatment overseas, especially for services not available in Barbados, is not easily estimated, as data from the private sector are not currently captured. Access to overseas medical services is made possible through the Medical Aid Scheme at a cost of Bds$4.0 million annually, but the range and number of persons sent overseas for treatment have diminished, due to the establishment of a variety of medical specialties in Barbados during the past two decades.147Statistics from the Medical Aid Scheme showed that for 2010, 2011, and 2012, respectively, 29, 26, and 30 persons accessed treatment overseas, partly as a result of the chronic disease burden,148while the period 2016-2018 saw 57 referrals for medical treatment abroad, from various specialities.149Contributory developments to the decline have been the capacity of the private health sector to offer services that the QEH has been unable to establish or maintain; establishment of new public 143http://drugservice.gov.bb/. 144CMO’s Report 2010-2012. 145Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019. 146PAHO Health in the Americas+ 2017. 147MOH Planning and Research Unit. Discussion paper on health financing reform. January 2015. 148CMO’s Report 2010-2012. 149The Barbados Health Report: ‘Healthy productive people and communities’ (Draft) 2019. 40 private partnerships with outsourcing of certain services, especially in the diagnostics sector; and inter-governmental exchanges of resourced medical teams that have brought new skills and expertise. Public health laboratory servicesare provided by the Best-Dos Santos Public Health Laboratory (BDSPHL), which was officially opened in January 2018. The facility is an amalgamation of the Public Health Laboratory, the Leptospira Laboratory, and the Ladymeade Reference Unit Laboratory, and serves as the major public health laboratory in the country, providing routine testing services to all of the polyclinics and some private clinics. It has bio-safety level three capacity, improved laboratory safety, and the capability for an enhanced range and quality of tests, and offers reference laboratory services to private laboratories, as well as services for other regional laboratories, clinics, and programmes. The BDSPHL collaborates with several regional and international organisations, including CARPHA, Caribbean Med Labs Foundation,150PAHO/WHO, and the CDC. The QEH Laboratory provides clinical testing services for the hospital and other public health facilities.151,152 The MHW provides subventions to national CSOs to enhance service delivery, including the Barbados Cancer Society153and the Diabetes Association of Barbados,154and has entered into contractual arrangements with the Barbados Diabetes Foundation155 (BDF); the Barbados National Registry156(BNR); the Heart and Stroke Foundation of Barbados157(HSFB); Diagnostic Radiology Services158(DRS); and SILS Dialysis Barbados159to provide services on behalf of the Ministry.160 • The BDF, a specialist centre of excellence, provides a six-month comprehensive assessment and treatment programme for people living with diabetes in the initial stages of developing complications who are referred to the facility. The programme includes medical, nursing, nutrition, and counselling support, with an emphasis on self-management. • The BNR is a population-based, national surveillance system operated by the UWI George Alleyne Chronic Disease Research Centre (GA-CDRC)161on behalf of the MHW, comprising three registries: BNR-Stroke, BNR-Heart, and BNR Cancer. • The HSFB provides CVD risk reduction and cardiac rehabilitation services. • DRS provides radiology services to institutions in the public sector, including magnetic resonance imaging, computerized tomography, ultrasound, mammography, and other specialised imaging. • SILS collaborates with the QEH for the provision of dialysis services. The network of private health services in Barbados includes general practitioners, specialists, laboratories, pharmacists, dentists, and rehabilitation therapists on a fee-for-service basis. The private sector includes a 24-bed hospital, diagnostic imaging, a renal dialysis provider, a halfway house providing mental health services, two substance abuse treatment providers, and 45 nursing and senior citizens’ homes that offer long-term care for older persons.162 Health Workforce The effective recruitment, distribution, and management of quality human resources for health (HRH) are essential for advancing to universal health. Barbados has, overall, become self-sufficient in meeting its demand for HRH through the training of doctors, primarily at the UWI Cave Hill Campus, and training of nurses and other health care professionals at the 150http://cmedlabsfoundation.net/. 151The Barbados Health Report: ‘Healthy productive people and communities’ (Draft) 2019. 152Barbados National Strategic Plan for Health, 2018-2022. 153https://www.barbadoscancersociety.com/. 154https://www.diabetes.bb/. 155http://www.thebarbadosdiabetesfoundation.org/. 156http://www.bnr.org.bb/cms/. 157https://www.hsfbarbados.org/. 158http://diagnosticradiologyservices.org/. 159https://www.silsdialysis.com/. 160The Barbados Health Report: ‘Healthy productive people and communities’ (Draft) 2019. 161http://www.uwi.edu/cdrc/cdrc-home. 162Barbados National Strategic Plan for Health 2018-2022. 41 Barbados Community College163(BCC). All medical personnel must be registered with the Barbados Medical Council, which has statutory responsibility for the regulation of all medical practitioners; the Nursing, Dental, Pharmacy, and Paramedical Professionals Councils hold similar responsibility for the respective professions.164 In 2007, the PAHO Sanitary Conference adopted resolution CSP27.R7,165which addressed strategies for strengthening HRH in the Region of the Americas, and a Regional Task Force developed a set of HRH goals for theperiod 2007 to 2015.166In 2012, Barbados had 21 doctors and 44 nurses per 10,000 populationin the public sector (1 doctor per 516 persons and 1 nurse per 227 persons). This equates to 2.3 nurses per doctor, which met the regional HRH benchmark (goal 4) of at least a 1:1 ratio of qualified nurses to physicians. Barbados also exceeded the regional standard of 25 health professionals per 10,000 population (goal 1), with an average of 49 health professionals per 10,000 population over the period 2010-2012; this achievement has been maintained despite the fact that, more recently, the country has experienced nursing shortages due in part to migration, and has sought to fill gaps by recruiting nurses from other countries, including Ghana.167 Currently, the MHW, with PAHO/WHO’s technical cooperation, is developing a strategy and action plan to improve HRH management, including an analysis of the state of HRH in the country. 163http://www.bcc.edu.bb/. 164The Barbados Health Report: ‘Healthy productive people and communities’ (Draft) 2019. 165http://www1.paho.org/english/gov/csp/csp27.r7-e.pdf?ua=1. 166PAHO. Regional Goals for Human Resources for Health 2007-2015. Document CSP27/10. Washington, D.C.: PAHO; 2007. http://www1.paho.org/english/gov/csp/ csp27-10-e.pdf?ua=1. 167https://barbadostoday.bb/2019/07/02/govt-team-to-recruit-ghanaian-nurses-minister/. 168CMO’s Report 2010-2012. 169The Barbados Health Report: ‘Healthy productive people and communities’ (Draft) 2019. 42 Table 7: Human resources for health per 10,000 population, Barbados, 2010-2012 and 2017 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 5 4 of 1 34 Ta bl e 7: H um an re so ur ce s f or h ea lth p er 1 0, 00 0 po pu la tio n, B ar ba do s, 2 01 0 20 12 a nd 2 01 7 20 10 20 11 20 12 20 17 Ca te go rie s # W or ke rs De ns ity # W or ke rs De ns ity # W or ke rs De ns ity # W or ke rs De ns ity Do ct or s 56 4 20 .3 47 7 17 .2 58 2 21 .1 64 2 23 .4 De nt ist s 77 2. 8 65 2. 3 69 2. 5 79 2. 9 Ho sp ita l A dm in ist ra to rs 10 0. 4 10 0. 4 10 0. 4 10 0. 4 Ve te rin ar ia ns 34 1. 2 25 0. 9 27 1. 0 41 1. 5 So ci al W or ke rs 11 0. 4 11 0. 4 11 0. 4 16 0. 6 N ut rit io ni st s/ Di et iti an s 8 0. 3 6 0. 2 9 0. 3 * * N ur se s 1, 32 2 47 .6 1, 14 9 41 .4 1, 21 4 44 .0 * * N ur sin g As sis ta nt s 39 4 14 .2 35 2 12 .7 35 5 12 .9 39 5 14 .4 Ra di og ra ph er s ( Di ag no st ic ) 33 1. 2 19 0. 7 29 1. 0 34 1. 2 La bo ra to ry T ec hn ol og ist s/ Te ch ni ci an s 79 2. 8 68 2. 4 28 1. 0 31 1. 1 Ph ar m ac ist s/ Di sp en se rs 27 4 9. 9 23 2 8. 4 26 1 9. 4 N I N I Ph ys io th er ap ist s 48 1. 7 42 1. 5 46 1. 7 N I N I O cc up at io na l T he ra pi st s 14 0. 5 13 0. 5 12 0. 4 11 0. 4 De nt al A ux ili ar ie s 9 0. 3 9 0. 3 9 0. 3 6 0. 2 En vi ro nm en ta l H ea lth O ffi ce rs 11 3 4. 1 11 7 4. 2 11 7 4. 2 99 3. 6 En vi ro nm en ta l H ea lth A ss ist an ts 92 3. 3 92 3. 3 92 3. 3 75 2. 7 St at ist ic s a nd M ed ic al 74 2. 7 74 2. 7 74 2. 7 N I N I * Re gi st er ed n ur se s 1, 17 8 42 .9 *M id w iv es 13 4 4. 9 *P sy ch ia tr ic n ur se s 25 5 9. 3 *N ur sin g au xi lia rie s 61 3 22 .3 *D ie tit ia ns 11 0. 40 *N ut rit io ni st s 6 0. 22 + De nt al te ch ni ci an 9 0. 33 + Em er ge nc y m ed ic al d isp at ch er 6 0. 22 + Em er ge nc y m ed ic al te ch ni ci an 80 2. 9 So ur ce s: C M O ’s Re po rt 2 01 0 20 12 a nd B ar ba do s H ea lth R ep or t ( Dr af t) 20 19 N I = n o in fo rm at io n pr ov id ed in 2 01 9 re po rt * = ca te go rie s s ep ar at ed in 2 01 9 re po rt + = N ew c at eg or ie s i n 20 19 re po rt 43 Health Financing The healthcare system in Barbados is supported by a health financing model based on tax revenues approved by Parliament and allocated to the MHW through the MFEI to pay for the delivery of services to the population.170During the 2010-11 to 2012-13 fiscal years, the MHW expenditure (Public Health Expenditure, PHE, or government health spending) rose from Bds$355.3 million to Bds$415.0 million. In 2012-13, PHE accounted for approximately 11% of total government expenditure and was estimated at 4.7% of Barbados’ GDP; PHE per capita was estimated at Bds$1,495.50. Total health expenditure (THE) 2012-13 was estimated at Bds$ 732.7 million, 8% of GDP;171THE in 2017 and 2018, respectively, was 13.1% and 7.5% of total government expenditure.172 During 2010-11 and 2012-13, PHE facilitated eight programme areas: Direction and Policy Formulation, Primary Health Care, Hospital Services, Care of the Disabled, Pharmaceutical Programmes, Care of the Elderly, HIV/AIDS Prevention and Control, and Environmental Health Services. Despite the intended focus on health and wellness, following the trend of previous years, the Hospital Services programme areas was allocated the largest share of PHE: 51.8% in 2010-11 and 61.0% in 2012-13, while PHC was allocated 7.9% and 7.2% for the respective periods.173The NCD programme itself is funded through line items under the HPU budget and Procurement of Services, the latter to cover contractual arrangements for outsourced services. The first Barbados Health Accounts Report, 2012-2013,was published in 2014,174and in 2018, a study on health spending for 2016-2017175was conducted to update the 2014 findings. Table 8 below provides a comparison of key indicators in the studies, which demonstrate a reduction in THE and PHE over the intervening period, with an increase in OOP spending. Table 8. Key health financing indicators 2012-13 and 2016-17 Final deliverable – 31 Dec 2019 Page 55 of 134 Health financing The healthcare system in Barbados is supported by a health financing model based on tax revenues approved by Parliament and allocated to the MHWthrough the MFEI to pay for the delivery of services to the population.170During the 2010-11 to 2012-13 fiscal years, the MHW expenditure (Public HealthExpenditure, PHE, or government health spending) rose from Bds$355.3 million to Bds$415.0 million. In 2012-13, PHE accounted for approximately 11%of total government expenditure and was estimated at 4.7% of Barbados’ GDP; PHE per capita was estimated at Bds$1,495.50. Total health expenditure (THE) 2012-13 was estimated at Bds$ 732.7 million, 8% of GDP;171 THE in 2017 and 2018, respectively, was 13.1% and 7.5% of total government expenditure.172 During 2010-11 and 2012-13, PHEfacilitated eight programme areas: Direction and Policy Formulation, Primary Health Care, Hospital Services, Care of the Disabled, Pharmaceutical Programmes, Care of the Elderly, HIV/AIDS Prevention and Control, and Environmental Health Services. Despite the intended focus on health and wellness, following the trend of previous years, the Hospital Services programme areas was allocated the largestshare of PHE: 51.8% in 2010-11 and 61.0% in 2012-13, while PHC was allocated 7.9% and 7.2% for the respective periods. 173 The first Barbados Health Accounts Report,2012-2013,was published in 2014, The NCD programme itself is funded through line items under the HPU budget and Procurement of Services, the latter to cover contractual arrangements for outsourced services. 174and in 2018, a study on health spending for 2016-2017175 Indicator was conducted to update the 2014 findings.Table 8below provides a comparison of key indicators in the studies, which demonstrate a reduction in THE and PHE over the intervening period, with an increase in OOP spending. Table 8. Key health financing indicators 2012-13 and 2016-17 2012-13 2016-17 Total health expenditure (Bds$) 732.7 million 651.6 million THE as a percentage of GDP 8.7 7.0 THE as a percentage of total government expenditure 11.0 THE per capita (Bds$) 2,582 2,232 PHE as a percentage of total government expenditure 11.0 8.0 PHE as a percentage of THE 55.0 51.0 OOP household expenditure as a percentage of THE 39.0 43.0 Private health insurance as a percentage of THE 5.0 5.8 170 MOH Planning and Research Unit. Discussion paper on health financing reform in Barbados. January 2015. 171 CMO’s Report 2010-2012.Note: Bds$ 1.00 ≈ US$ 0.50. 172The Barbados Health Report: ‘Healthy productive people and communities’ (Draft), 2019. 173 CMO’s report 2010–2012. 174 MOH. Barbados 2012-2013 Health Accounts Report. Bridgetown: 2014; MOH. https://bit.ly/2K77LlD. 175 Barbados 2016/17 Health Spending Estimation: Final Results (Presentation). https://bit.ly/2NZdpHy. 170MOH Planning and Research Unit. Discussion paper on health financing reform in Barbados. January 2015. 171CMO’s Report 2010-2012.Note: Bds$ 1.00 ≈ US$ 0.50. 172The Barbados Health Report: ‘Healthy productive people and communities’ (Draft), 2019. 173CMO’s report 2010–2012. 174MOH. Barbados 2012-2013 Health Accounts Report. Bridgetown: 2014; MOH. https://bit.ly/2K77LlD. 175Barbados 2016/17 Health Spending Estimation: Final Results (Presentation). https://bit.ly/2NZdpHy. 44 In 2012-2013: • The THE of approximately 11% of total government expenditure representeda decline from 12.1% in 2011-2012, and was followed by a further decline to 10.6% in 2014-2015.176 • The THE per capita ofBds$ 2,582 was the third highest in the Caribbean, behind the British Virgin Islands and The Bahamas. • While the government spending of 55% of THEwas in line with the government’s commitment to the health of the people of Barbados, the household OOP spending of 39% of THE was much higher than the WHO benchmark of 20% and the regional average of 30%. This is cause for concern, since WHO estimates that at least 1% of households may be at risk of falling below the poverty line due to OOP spending on health. • Private health insurance plans provided coverage for 27% of the population—13% employer-based and 14% individual based—so thatapproximately one in four of the adult population had private health insurance cover, increasing to one in three when restricted to those currently working.177 • One-third of THE was spent at the first level of care, primarily through polyclinics and private doctors’ offices; 44% on secondary care; 6% on tertiary care; 3% on long-term care; and 9% was spent on purchasing medicines, laboratory tests, and radiological investigations in the private sector. In 2016-2017: • The fall of 14% in real health spending was driven by a fall of 21% in MHW spending. • Governments and households remained the two biggest spenders on health. • Private medical clinics, paid for by household OOP spending, dominated health spending (39.8%), with the QEH accounting for the next largest share (27.6%); 96% of spending at the QEH was from government, and the remainder was from private insurance and OOP payments. • Over 75% of health spending was on curative care, with only 2% spent on prevention. • Private doctors’ offices were the main providers for households paying OOP. • Approximately 28% and 27% of polyclinic medicines spending was for, respectively, diabetes and hypertension. These statistics, particularly the spending of 50% of THE on secondary and tertiary care, have serious policy implications, and further justify the MHW’s renewed focus on health promotion and disease prevention, with strengthening of the PHC approach. In 2015, estimates indicated that over the next five years, Bds$ 38 million (Bds$ 26 per capita per year) would be required to scale up a limited set of prevention and treatment activities for CVD, which would also have significant impact on preventing diabetes and cancer. Low coverage levels for pharmaceutical prevention of vascular events would be improved, along with the implementation of policy actions to lower tobacco use and salt intake in line with the cost-effective interventions outlined by WHO.178 The allocation to the MHW for the fiscal year 2018-2019 was Bds$ 319.3 million, representing 7.2% of GoB’s projected total expenditure for the period. As in previous years, hospital services received the major share of the allocation, 56.7%, while PHC received 12.1%; the proportional allocations for 2017-2018 were, respectively, 56.5% and 9.7%, demonstrating an increase for PHC. However, the allocations for 2019-2020 are estimated at 60.9% and 9.5%, showing an increase for hospital services and a mild decrease for PHC.179 176PAHO Health in the Americas+ 2017. 177HoTNS Core Findings 2015. 178WHO, UNDP, MOH. Investment Case for NCD Prevention and Control in Barbados. 2015 179The Barbados Health Report: ‘Healthy productive people and communities’ (Draft), 2019. 45 While there are recommendations from WHO that government spending on health should be at least 5% of GDP for adequate financial protection—one of the key components of UHC—there is no “magic number” for health spending, as health system performance is a function of several factors other than PHE.180However, it is critical for governments to allocate and mobilise adequate financial resources to improve access to, and the quality and delivery of, health services. The WHO Universal Health Coverage Global Monitoring Report 2019181calls on governments to redouble their pace of expanding coverage and immediately commit to spending at least 1% of GDP on PHC, to support advances to UHC.This call recognises, as the UHC Global Monitoring Report states, “the need to invest first and foremost in strong PHC, with an emphasis on health promotionand disease prevention. Secondary and tertiary servicesare important parts of every health system, but no country can afford to rely on curative care. By promoting health and preventing disease, countries canprevent or delay the need for more expensive services. That increases the efficiency of health spending, saveslives, and increases healthy life expectancy”. The National Insurance Scheme (NIS) has been in place for 50 years and provides benefits related to unemployment, workplace injury, maternity, disability, and old age security. The MHW has been examining methods and policy options that would lead to sustainable financing of public health services, while ensuring UHC. In October 2018 one such measure was introduced, with increases in NIS contributions from employers and employees, respectively, of 1.5% and 1.0%, a Health Services Contribution that is expected to raise Bds$ 45 million each year; the NIS will transfer these funds directly to the QEH. Recommendationsfrom extensive health financing consultations include implementation of a system of financing that guarantees a pool of funds earmarked for the health services; conduct of an actuarial study to determine the population base that can contribute to such a fund and the level of the contributions; and determination of the essential basket of services at primary, secondary, and tertiary care levels to be covered by the fund. Hospital Philanthropy was also introduced at the QEH as an innovative approach for generating capital revenue to support technology replacement.182 Access to essential medicines, vaccines, and health technologies The Barbados Drug Service is the agency responsible for maintaining, updating, and administering the Barbados National Drug Formulary, and is also responsible for the Supply and Inventory Service, which procures and distributes medicines; the Special Benefit Service; the BDS Pharmacy Service; the Drug Inspectorate; the Drug Information Centre; pharmacovigilance; and related administration and financial management. The BDS has spearheaded rational drug use policies and programmes, including the use of reputable generic preparations. Children under 16 years of age, persons over age 65 years, and individuals who have been diagnosed with diabetes, cancer, hypertension, glaucoma, asthma, and/or epilepsy can obtain formulary drugs free of charge through the SBS.Sixty percent of the BDS budget is allocated to pharmaceuticals used in the management of chronic diseases; all NCD drugs are designated ‘special benefit’ and are available free of cost to patients in the public and private sectors.183Prescriptions can be filled at either government pharmacies or private participating pharmacies (PPPs)contracted by the BDS to dispense formulary drugs,and there is no provision for patients to make a co-payment; patients who opt to fill prescriptions under the SBS at PPPsare required to pay the dispensing fee only. An assessment of prescription activity in the private sector under the SBS showed that hypertension accounted for the largest prescription volume and expenditure—42.5% and 47.5% respectively—followed by diabetes, at 18.8% and 22.9% respectively. In fiscal year 2017-2018, the SBSspent 49.8% of its total expenditure on prescriptions for hypertension; 32.4% on diabetes; 8.6% on glaucoma; 7.4% on asthma; and 1.9% on cancer.184On average, 2,700,000 prescriptions are filled by the BDS annually.185 180Jowett M, Brunal MP, Flores G, Cylus J. Spending targets for health: no magic number. Geneva: WHO; 2016 (WHO/HIS/HGF/HFWorkingPaper/16.1; Health Financing Working Paper No.1). https://bit.ly/2K6DdAp. 181https://www.who.int/healthinfo/universal health coverage/report/uhc report 2019.pdf?ua=1. 182Barbados National Strategic Plan for Health 2018-2022. 183Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019. 184The Barbados Health Report: ‘Healthy productive people and communities’ (Draft), 2019. 185MOH Planning and Research Unit. Discussion paper on health financing reform. January 2015. 46 Barbados has a strong immunisation programme, and in 2015 vaccine coverage with the commonly-used antigens, according to the recommended schedule186was estimated to be 96%. Specifically related to NCDs, the human papillomavirus vaccine (HPV) was introduced in 2014 for girls aged 11 and older—coverage is estimated at 50%—and seasonal influenza vaccines are offered to persons 65 years of age and older.187The Expanded Programme on Immunisation procures vaccines through the PAHO Revolving Fund for Vaccine Procurement.188 Information systems for health Over the years Barbados has made efforts to strengthen national information systems for health (IS4H) and improve the collection, analysis, and use of health information for decision-making, monitoring, and evaluation, including in relation to NCD prevention and control. NCD-related IS4H interventions include, but are not limited to: • Implementation of the 2007 Behaviour Risk Factor Survey, based on the WHO STEPS methodology. • Establishment in 2009 of the BNR for NCDs, which documents all cases of stroke, heart attack, and cancer. • Conduct of PAHO/WHO-recommended risk factor surveys, including the GYTS and theGSHS, which were last conducted in, respectively, 2013 and 2011; these need updating to continue to detect trends and monitor risk factor interventions. • Implementation of the 2015 HoTNS, based on the STEPS methodology. The country has also taken action to strengthen its health information system through phased implementation of an eHealth strategy, supported by PAHO’s IS4H initiative189and a World Bank project addressing HIV/AIDS. A Health Information Policy and Legislative Notes, and a Health Data Dictionary, have been developed; Barbados’ electronic medical records system, known as MedData, has been put into service in all of the nine polyclinics, with modules for electronic health records, admissions, discharge records, transfers, and appointments already in place. MedData has also been applied in the QEH Medical Records Department to facilitate admissions, discharges, coding, and census functions, and the hospital has telemedicine solutions available across the institution for laboratory investigations and imaging studies, so that diagnostic investigations can be transmitted electronically.190 Health information collected in Barbados is commonly disaggregated by age and sex; however, SDG target 17.18191 calls for “the availability of high-quality, timely, and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts” to enable the identification of inequities and groups in conditions of vulnerability. This analysis facilitates the development and implementation of interventions that “leave no-one behind” in keeping with the overarching principle of the SDGs, contributingto equitable, sustainable national development. 4.5 Progress Toward Selected International Targets and Indicators The WHO BBs, EIs, and ORIs; the WHO GMF; the PAHO Plan of Action on the Prevention and Control of NCDs; and the CARICOM POSD, among other frameworks, provide major targets and indicators related to NCD prevention and control that can guide countries’ efforts. Many of these targets and indicators were reflected in the SP15-19, and addressedNCD behavioural and biological risk factors; the national systems response, including improvement in the quality of health services for NCDs management, gender issues, multi-sectoral action, public awareness programmes, population surveys, M&E, and dissemination of information; and NCD mortality and morbidity.192 186DTP3, Polio3, Hib3, HepB3, MMR1, MMR2 187PAHO Health in the Americas+, 2017. 188https://bit.ly/2NxDuyE. 189https://www.paho.org/ish/index.php/en/stories/?id=134. 190Business View Caribbean. The Queen Elizabeth Hospital: a new prescription. 25 October 2019. 191https://unstats.un.org/sdgs/metadata/?Text=&Goal=17&Target=17.18. 192PAHO. In-depth Qualitative Assessment of Noncommunicable Diseases:Multisectoral Action Plans in the Caribbean (Annexes V, VI, and VII). Washington, D.C.: PAHO; 2018. https://bit.ly/2E7ovqR. 47 Barbados’ progress related to the WHO BBs, EIs, and ORIs, based on information from the MHW NCD Unit, is summarised in Annex 7. Of the 40 BBs, EIs, and ORIs associated with the four main risk factors, the country has fully implemented seven (17.5%), while it has implemented 18 (56.3%) of the 32193BBs, EIs, and ORIs associated with management of the four major NCDs, indicative of the greater emphasis given to disease management over risk factor reduction and prevention. In addition, the country’s progress toward the components of the POSD and related interventions is reflected in the 2017 POSD evaluation grid;194although Barbados (“BAR” in the grid) implemented relatively more strategies/indicators than other countries, several critical ones remained unimplemented, again reflecting less focus on risk factor reduction, especially the use of fiscal measures. Data related to the country’s progress towards GMF targets and indicators, with relevant sources, are summarised in Annex 8. Major successes/achievements, challenges/gaps, and lessons learned related to NCD prevention and control, including those identified by key stakeholders, are summarised below. 4.6 Successes/Achievements Major successes and achievements include: • Greater national awareness in all sectors of the challenge posed by NCDs and the need for action. This has resulted from public awareness programmes, events, dissemination of information, and community outreach by the MHW HPU, National Nutrition Centre (NNC), national NGOs dealing with specific diseases, and the HCC, especially in observance of regional and international markers such as Caribbean Wellness Day, Caribbean Alcohol Reduction Day, World Health Day, and other “world days”. A 2018 HSFB public opinion poll195showed significant public concern about obesity (83% of respondents) and childhood obesity (88% of respondents), as well as an appreciation of the importance of the government’s role in taking action to reduce obesity (78% very important, 17% somewhat important). Campaigns for reduction in salt, alcohol,and SSB consumption have been conducted, and other common activities to raise public awareness include promotion of physical activity with “mass walks”; health fairs; and emphasis on nutritious eating. The MHW and HCC often partner with PAHO/WHO in mounting events and disseminating messages. • Development of strategic plans addressing health, NCDs, childhood obesity prevention, and cancer control, among other frameworks. • Enactment of legislation related to the WHO FCTC, whichenables tobacco taxation, currently at 47.1% of the retail price of tobacco products;196smoke-free spaces; tobacco product graphic labelling; and bans on sales of tobacco products to minors. • Bans on sales of alcohol to minors. • Imposition of a 10% tax onSSBs in 2015, which resulted in a decrease in SSB sales.197 • Continuous functioning of the National NCD Commission. • Production of a National Workplace Wellness Policy (2019). • Civil society-led advocacy and interventions for COP focusing on healthy nutrition—involving mainly the HSFB and the HCC—through mass media campaigns, establishment of coalitions, involvement of youth, and work in school settings. 193There are 33 BBs, EIs, and ORIs related to management of the four priority NCDs, but the MHW deemed the ORI “Access to improved stoves and cleaner fuels to reduce indoor air pollution” inapplicable in the Barbados context, and it was omitted in this analysis. 194http://onecaribbeanhealth.org/wp-content/uploads/2018/03/POS-Declaration-country-grid-2017.pdf. 195https://www.healthycaribbean.org/wp-content/uploads/2019/03/CADRES-Infographic-FLYER.pdf. 196WHO. Report on the global tobacco epidemic, 2019: Offer help to quit tobacco use. Geneva: WHO; 2019. https://bit.ly/2XgJsHq. 197Alvarado M, Unwin N, Sharp S et al. Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: an observational study. International Journal of Behavioral Nutrition and Physical Activity. 2019; 16:13. https://doi.org/10.1186/s12966-019-0776-7. 48 4.7 Challenges/Gaps Many challenges and gaps remain, including: • Failure to move the issue of NCDs from being a health issue to being a national development issue, despite the existence of the Cabinet Sub-committee on NCDs. • Inadequate use of fiscal measures for NCD prevention and control. Tobacco taxation is not at the WHO-recommended level of at least 75% of the retail price; SSB taxation is only half of the recommended minimum of 20%; and there has been no increase in taxation on alcoholic beverages. The study that documented the decrease in SSB sales after the introduction of the SSB tax also found that consumers may also have responded by purchasing cheaper sugary drinks and substituting untaxed products, which has implications for tax design.198 • Gaps in WHO FCTC implementation, including in legislation to ban tobacco advertising, promotion, and sponsorship, and eliminate illicit trade in tobacco products. • Insufficient financial and human resources, and inadequate reallocation and realignment of available human and financial resources,for an efficient and effective response to NCDs. • Inadequate realignment of health services from a focus on treatment to emphasis on promotion and prevention, as well as fragmentation of service delivery. • Food insecurity and limited food sovereignty, with a high level of food importation that includes unhealthy commodities. • Negative impact of the food, beverage, alcohol, and tobacco industries on health interventions—Industry interference— due to their economic power and resulting political influence. • Inadequate identification and management of CoI. • Insufficient engagement and participation of the medical and nursing professions in NCD prevention and control. • Limited health and nutrition literacy among certain segments of the population. • Inadequate communication about, and coordination of, actions for NCD prevention and control, including the remit and functioning of the NNCDC, with most of the information remaining within the MHW and related institutions. • Lack of explicit focus on gender issues in NCD-related planning and interventions. • Inadequate consideration of multi-morbidity, defined by WHO as the coexistence of two or more chronic conditions in the same individual199and by the Academy of Medical Sciences as “the coexistence of two or more chronic conditions, each one of which is either a physical non-communicable disease of long duration, such as a cardiovascular disease or cancer; a mental health condition of long duration, such as a mood disorder or dementia; or an infectious disease of long duration, such as HIV or hepatitis C”.200 Multi-morbidity poses a challenge for health care systems, which are mostly organised to treat single conditions, and its burden is increasing globally, likely driven by the ageing population, overweight and obesity, urbanisation, and the growing burden of NCDs; it is more prevalent is older adults and in women.201 4.8 Lessons Learned Among the lessons learned are that: • Multi-sectoral involvement is critical—health-supporting policies do not have to emanate from the MHW; other sectors are important in developing and implementing such policies. • The link between NCDs and other national priorities such as climate change and the green economy must be demonstrated and exploited, with consideration given to the use of Geographical Information Systems202 (GIS) to present relevant information and facilitate decision-making. 198Ibid. 199WHO. Multimorbidity: Technical Series on Safer Primary Care. Geneva: WHO; 2016.https://bit.ly/350S5s9. 200The Academy of Medical Sciences. Multimorbidity: a priority for global health research. London: Academy of Medical Sciences; April 2018. https://acmedsci.ac.uk/file download/82222577. 201Editorial. Making more of multimorbidity: an emerging priority. Lancet 2018: 391; 1637. https://bit.ly/2rI9KXk. 202WHO. Maps and spatial information technologies (Geographical Information Systems) in health and environment decision-making. https://www.who.int/heli/tools/maps/ en/. 49 • A mass movement for NCD prevention and control must be created through greater public outreach, involvement of youth, and participation of PLWNCDs. • Mechanisms must be defined for constructive and effective engagement with the private sector, and for identifying and managing CoI. • Successes in NCD prevention and control should be identified, documented, promoted, and marketed to provide incentives for further action, encourage participation, and add to the national and regional evidence base. • The NSP-NCD 20-25 must be disseminated to key stakeholders (including all ministries and civil society), and communities, businesses, and partners must be involved from an early stage for greater mobilisation of human and financial resources. • Guidelines are ineffective without support from strong, enforceable policy, legislation, and regulations to enable compliance, and the availability of, and access to, essential medicines and technologies. • Greater efforts should be made to obtain exemptions from certain World Trade Organization (WTO) rules that are inimical to health, since WTO structures allow such exemptions, with justification. • Gender-related gaps must be highlighted and addressed. For example, the greater prevalence of obesity and physical inactivity in women should trigger targeted, evidence-informed interventions in that group, and in improving HRH, a sex disaggregated analysis of categories of workers in various settings may highlight areas and opportunities for more active recruitment and training of men and women, including in strengthening interdisciplinary teams and task-shifting at the first level of care.203 • More research on multi-morbidity is needed, especially in lower- and middle-income countries,204 and guidelines for the integrated management of NCDs, including at the first level of care, must take multi-morbidity into consideration. This is particularly relevant in light of the potential for interactions between medications and between diseases, which makes application of single-disease-based clinical guidelines potentially hazardous for people with multiple conditions.167 • Production and dissemination of up-to-date, quality information are critical for successful strategic planning and M&E, and the BNR and GA-CDRC play important roles that should be expanded, with relevant allocation of resources by the GoB, resource mobilisation, and support from CARPHA and other regional and international entities, as appropriate. 4.9 SWOT Analysis of the NCD Programme As the MHW focal point for the coordination, implementation, monitoring, and evaluation of the NSP-NCD 20-25, the NCD programme needs to recognise and build on its strengths, address weaknesses, take advantage of opportunities, and identify and manage threats to efficient and effective functioning. Table 9 below presents a SWOT analysis of the NCD programme in Barbados, based on stakeholder input. Table 9. SWOT analysis of the national NCD programme Strengths • Existence of national frameworks and guides related to health, including national strategic plans for health, childhood obesity prevention, and cancer control. • Emergence of an increasingly strong civil society sector as a partner for action, support, and contribution to NCD reduction. • Commitment of current personnel in the NNCDC and the NCD programme. • Barbados’ position as a leader in NCD prevention and control, and a potential model of success in that arena, reflected, for example, in the low prevalence of smoking and associated lung cancer. • Existence of strong political commitment to human capital development and the increasing realisation of the negative effect of NCDs on that capital. 203PAHO. Plan of action on human resources for universal health and universal health coverage 2018-2023. Document CD56/10, Rev.1. Washington, D.C.: PAHO; 2018. https://bit.ly/2NZfFyN. 204Eyowas FA, Schneider M, Yirdaw BA, Getahun FA. Multimorbidity of chronic non-communicable diseases and its models of care in low- and middle-income countries: a scoping review protocol. BMJ Open 2019; 9:e033320. https://bit.ly/33LKz47. 50 • Establishment of the Cabinet Sub-committee on NCDs and existence of the Social Partnership, which provide vehiclesto strengthen multi-sectoral action and to insert NCD prevention and control into the national development agenda. • Establishment of the BNR, conduct of research by the UWI/GA-CDRC, and implementation of standardised NCD related surveys such as the GSHS, GYTS, and STEPS, demonstrating a commitment to gather evidence. • Establishment of an electronic medical records system (MedData). Weaknesses • Muted MHW leadership voice in the wider political sphere, beyond the MHW. • Insufficient visibility of, and action by, the Cabinet Sub-committee on NCDs. • Inadequate governance systems and guidance to identify and manage CoI when engaging with the private sector. • Delayed finalisation and persistence in draft status of several national frameworks and guides for health, limiting their publication, dissemination, and use to inform NCD reduction interventions. • Absence of a clear strategy and plan to implement and finance advances to UH, which would benefit NCD reduction. • Persisting focus on programme development and resource allocation for the prevention and control of communicable diseases, to the detriment of NCD reduction. • Greater allocation of resources to medications and treatment of NCDs than to their prevention and early detection. • Inadequate coordination of NCD-related interventions and activities across the health sector and absence of standardised protocols for NCD management at the various levels of care. • Overdependence on development of guidelines to drive behaviour change and improvement in quality of care, with limited focus on their promotion, dissemination, implementation, monitoring, and evaluation, and supporting policy, legislation, and regulations. • Limited capacity to develop and enact enabling policies and legislation. • Limited information on the financial andeconomic cost/impact of NCDs. • Limited and outdated statistics on NCD mortality and morbidity; outdated information on risk factors; insufficient data collection from the private sector; and inadequate dissemination of NCD data to sectors other than health and selected civil society organisations. • Failure to take advantage of MedData and use the available information for policy development and programme planning. • Inadequate inclusion of civil society in strategic planning and policy development processes, with limited capacity of civil society to effectively engage in those processes. Opportunities • Strong efforts of local, regional, and international CSOs and NGOs in NCD prevention and control, with global partnerships that can facilitate resource mobilisation. • Tertiary learning institutions located in Barbados, including the BCC; UWI; American University of Barbados School of Medicine;205Ross University School of Medicine;206and University of the Southern Caribbean (USC).207 • Focus on wellness in the new name and remit of the health ministry. • Exploration of involvement of the diaspora and development of new partnerships through the “We Gatherin’” initiative in 2020. • Major meeting of the UN Conference on Trade and Development208 (UNCTAD) to be held in Barbados in 2020, which can strengthen local linkages among NCDs, trade, climate change, and SIDS. • Enhanced funding from HSFB for its COP campaign, which allows the MHW to partner with the HSFB to get messages to the public and counter Industry messages. • Interest of the media in covering priority health issues that resonate with the public. 205https://www.aubmed.org/. 206https://medical.rossu.edu/student-life/barbados. 207https://www.usc.edu.tt/. 208https://unctad.org/. 51 • Overtures from the Barbados Chamber of Commerce and Industry (BCCI), which can foster positive engagement with Industry. • Interest of private sector health providers in using MedData. • GoB’s evident intent to enhance the functioning of the Cabinet Sub-committee on NCDs. • Cabinet approval of the National Workplace Wellness Policy and establishment of the National Workplace Wellness Committee, chaired by the Ministry of Labour and Social Partnership Relations (MLSP), which offer more opportunities for collaboration/partnerships among ministries, particularly on workplace- and community-related objectives. • Wide dissemination of the NSP-NCD 20-25 to CSOs, to facilitate its use as a framework and resource mobilisation instrument, and enable their more structured contribution to NCD prevention and control. • MHW’s intent to establish a mechanism in the Ministry for effective engagement and enhanced collaboration with NGOs around issues such as COP. • Availability of WHO technical packages and policy guidance for risk factor reduction and management of priority NCDs, including MPOWER209 (tobacco control); SAFER210 (alcohol reduction) and the WHO Global Strategy for Reduction of the Harmful Use of Alcohol;211REPLACE212 (trans fat elimination); SHAKE213 (salt reduction); ACTIVE214 (physical activity); PEN215(PHC interventions); and HEARTS216(CVD management in PHC). Threats • Continued reluctance of policymakers to develop and implement policy and legislation related to certain aspects of risk factor reduction, with inadequate “push” to do so from the public and key constituents (“policy inertia”). • Private sector interference. • Name and nature of NCDs, which are not fully understood by many stakeholders. • Inadequate prioritisation of, and allocation and mobilisation of financial and human resources for, NCD prevention and control. • Insufficient technical and administrative support for the NCD programme in the MHW. • Strategic plans related to health and NCDs that are not finalised, disseminated widely, and monitored, to drive multi sectoral action in achieving agreed objectives. 5. Priority Focus Areas Based on the situation analysis, national responses, progress to date, and the results of the SWOT analysis, the GoB will focus on the following eight (8) priority areas for NCD prevention and control during the period 2020-2025, led and coordinated by the MHW: 1. Risk factor reduction, with strengthening of the implementation of the WHO FCTC; reduction in the harmful use of alcohol; promotion of healthy nutrition through improvements in health and nutrition literacy, the use of policy, legislation, regulations, and fiscal measures, introduction of FoPWL on pre-packaged foods,217and elimination of trans fat; and promotion of regular physical activity through community, school, and workplace wellness interventions. 209https://www.who.int/tobacco/mpower/mpower report six policies 2008.pdf. 210https://www.who.int/substance abuse/safer/msb safer framework.pdf?ua=1. 211https://apps.who.int/iris/bitstream/handle/10665/44395/9789241599931 eng.pdf?sequence=1. 212https://www.who.int/nutrition/topics/replace-transfat. 213https://bit.ly/2WYDQ4a. 214https://apps.who.int/iris/bitstream/handle/10665/275415/9789241514804-eng.pdf?sequence=1&isAllowed=y. 215WHO. Package of Essential NCD Interventions (PEN) for Primary Health Care in Low-resource Settings. Geneva: WHO; 2010. https://www.who.int/nmh/publica tions/essential ncd interventions lr settings.pdf. 216https://www.who.int/cardiovascular diseases/hearts/en/. 217As at the time of writing, no regional consensus on FoPWL has been reached through the CROSQ process. However, Barbados endorses FoPWL and will take relevant action to put the local standard in place. 52 2. Improved management of NCDs, strengthening health systems and enhancing the application of the chronic care model and theprimary health care approach, with the development, dissemination, and use of protocols and guidelines for standard management of common conditions at the first level of care, taking multi-morbidity into consideration and conducting related HRH capacity-building, within a supportive policy, legislative, and regulatory environment. 3. Childhood obesity prevention, highlighting SSB taxation, SSB bans in and around schools, restrictions on the sale and marketing of unhealthy products to children, and promotion of physical activity, with the involvement of key stakeholders across sectors, as well as the children themselves—as age-appropriate—their parents, guardians, and teachers. 4. Multi-sectoral work and partnerships, advocating at the level of the Social Partnership and the Cabinet Sub committee on NCDs; strengthening the remit and functioning of multi-sectoral bodies such as the NNCDC and the NTFW; involving civil society and the health-promoting private sector; and demonstrating links among NCDs, agriculture, and climate change, among NCDs, SIDS, and trade, and between MHW and other ministries. 5. Resource allocation and mobilisation and allocation, undertaking evidence-based advocacy for greater allocation to Health of resources from the national budget; identifying and taking advantage of financial, technical, and other resources available through international development agencies and foundations; sharing experiences with other countries in and outside of the Caribbean region; and identifying co-benefits with other priorities such as climate change adaptation. 6. Communicating for health, with wide promotion of the NSP-NCD 20-25;mass media and social media campaigns in collaboration with civil society and other partners to reduce risk factors andinform of progress in implementing the NSP; and advocacy regarding effective policy options for NCD prevention and control, including to policymakers, through interventions that encompass creation of a mass movement that involves youth andPLWNCDs,. 7. NCD surveillance and research,including development of a framework to identify key actors and resources, and guide systematic implementation of surveys/studies to provide updated, quality NCD-related information,including on multi morbidity, disaggregated by at least age, sex, ethnicity, geographic location, and socio-economic status to identify gender, geographic, economic, and other inequities related to the social determinants of health. These surveys/studies include the GYTS, GSHS, STEPS(amended to include e-cigarettes/vaping), and follow-up to the 2015 investment case for NCD prevention and control, to inform strategic planning that includes clear goals and objectives to achieve the country’s vision for health with equity. 8. Management, monitoring, and evaluation of the NCD programme and the implementation of the NSP-NCD 20 25, including strengthened capacity for governance and leadership, development of an M&E and accountability framework and plan for the NSP-NCD 20-25, and enhancement of mechanisms foroversight by the MHW, NNCDC, NTFW, Social Partnership, and Cabinet Sub-committee on NCDs. 6. Strategic Approaches The NSP-NCD 20-25 is aligned with the draft Barbados National Strategic Plan for Health (NSPH) 2018-2022: “Working Together for a Healthier Nation”, which embraces the contributions of a wide range of national and international stakeholders, and emphasises partnerships, collaboration, and coordination. The NSPH‘s shared vision is “healthy productive people and communities through excellent care for everyone, everywhere, every time”, which encapsulates the commitment of the MHW and the GoB to universal health. Its goals are to 1) promote and protect the health of the population; 2) provide safe, client-centred services; 3) improve the performance of the health system; and 4) engage and mobilise partners in health. The NSP-NCD 20-25 mirrors these goals through its focus on promotion of health, risk factor reduction, and prevention of NCD complications; the PHC approach and strengthening the first level of care, with improved management of NCDs at that level; communication and constructive partnerships with civil society and the health-promoting private sector; and information for evidence-based decision-making, policy development, monitoring, and evaluation. The NSP-NCD 20-25 is also consistent with BCHOPP,the draft National Cancer Control Plan for Barbados 2019-2024, and other national frameworks for health, as summarised in Annex 1. The vision, mission and values/guiding principles of the SP 15-19 remain valid and inform those of the NSP-NCD 20-25. 53 Vision The vision of the NSP-NCD 20-25 is to improve the health and wellbeing, and enhance the productive potential, of all Barbadians. Mission The mission of the NSP-NCD 20-25 is to empower Barbadian society, individuals, and organisations to enhance their quality of life throughout the life course through a whole-of government, whole-of-society response toNCDs, their risk factors, and the social determinants of risk, with emphasis on promotion, prevention, and the first level of care, so as to erase the avoidable burden of NCDs. Values/Guiding Principles • Health is a fundamental right of all Barbadians. • Development of a patient-centred, equitable, efficient, and accessible health care system of high quality is a priority, to contribute to Barbadians’ achievement of optimum physical, mental, and social well-being. • Recognising that most of the causes and solutions to NCD risk factors lie outside of the health sector, the national response must be inclusive of all sectors and persons, respecting the views of all, while holding them accountable for their actions in a transparent and collaborative manner. • There needs to be empowerment of people and communities to participate in their own health, within a life-course approach to wellness, prevention, and control, using evidence-based strategies, supported by national action and international cooperation and solidarity. • Creation of an enabling environment—including policy, legislation, and regulations—that facilitates, encourages, and supports healthy choices, while discouraging unhealthy behaviours, is an overarching principle for effective NCD prevention and control. • In all interactions with civil society and the private sector, across all government ministries and statutory bodies involved in NCD prevention and control, conflict of interest issues must be identified, disclosed, and appropriately managed according to government policies and guidelines on transparencyand good governance. The strategic agenda of the NSP-NCD 20-25 is presented in Section 7 below. 7. Strategic Agenda – The Core of the Strategic Plan 7.1 Goal, purpose/overall outcome, specific outcomes, and outputs/expected results The goal of theBarbados National Strategic Plan for the Prevention and Control of NCDs 2020-2025 is to reduce mortality, morbidity, and disability due to the major NCDs, and its purpose/overall outcome—the impact—is reduction of the main NCD risk factors and strengthening of the management of the major NCDs, focusing on the first level of care. Table 10 sets out, below, in a Logical Framework Matrix, the key elements of the strategic agenda—the goal, purpose/overall outcome, specific outcomes, and outputs/expected results, including relevant targets, indicators, means of verification, and assumptions. Definitions and baselines for the targets and indicators of the goal and specific outcomes are in Annex 8, which summarises data on Barbados’ progress towards the WHO Global Monitoring Framework targets and indicators, which provide the basis for the specific outcome targets and indicators in the NSP-NCD 20-25; the targets are to be achieved by 2025. 54 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 6 9 of 1 34 7. S tra te gi c ag en da – th e co re o f t he s tra te gi c pl an 7. 1 G oa l, pu rp os e/ ov er al l o ut co m e, s pe ci fic o ut co m es , a nd o ut pu ts /e xp ec te d re su lts Th e go al o f t he Ba rb ad os N at io na l S tr at eg ic P la n fo r t he P re ve nt io n an d Co nt ro l o f N CD s 20 20 2 02 5 is to re du ce m or ta lit y, m or bi di ty , a nd d isa bi lit y du e to t he m aj or N CD s, an d its p ur po se /o ve ra ll ou tc om e— th e im pa ct — is re du ct io n of t he m ai n N CD r isk f ac to rs a nd s tr en gt he ni ng o f th e m an ag em en t o f t he m aj or N CD s, fo cu sin g on th e fir st le ve l o f c ar e. Ta bl e 10 be lo w s et s ou t, be lo w , i n a Lo gi ca l F ra m ew or k M at rix , t he k ey e le m en ts o f th e st ra te gi c ag en da — th e go al , p ur po se /o ve ra ll ou tc om e, sp ec ifi c ou tc om es , a nd o ut pu ts /e xp ec te d re su lts , i nc lu di ng r el ev an t ta rg et s, in di ca to rs , m ea ns o f ve rif ic at io n, a nd a ss um pt io ns . D ef in iti on s an d ba se lin es fo r t he ta rg et s a nd in di ca to rs o f t he g oa l a nd sp ec ifi c ou tc om es a re in A nn ex 8 , w hi ch su m m ar is es d at a on B ar ba do s’ p ro gr es s t ow ar ds th e W HO G lo ba l M on ito rin g Fr am ew or k ta rg et s a nd in di ca to rs , w hi ch p ro vi de th e ba sis fo r t he sp ec ifi c ou tc om e ta rg et s a nd in di ca to rs in th e N SP N CD 2 0 25 ; t he ta rg et s a re to b e ac hi ev ed b y 20 25 . Ta bl e 10 . L og ic al F ra m ew or k M at rix : S tr at eg ic A ge nd a fo r t he B ar ba do s N SP N CD 2 02 0 20 25 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns G oa l M or ta lit y, m or bi di ty , a nd di sa bi lit y du e to N CD s r ed uc ed . Re du ct io n in p re m at ur e m or ta lit y fr om th e fo ur m aj or N CD s b y 25 % b y 20 25 .21 8 U nc on di tio na l p ro ba bi lit y of dy in g be tw ee n ag es o f 3 0 an d 70 fr om C VD , c an ce r, di ab et es , or c hr on ic re sp ira to ry d ise as es . M HW m or ta lit y da ta Su st ai ne d ef fe ct iv e m ul ti se ct or al a ct io n, a llo ca tio n of ad eq ua te h um an a nd fin an ci al re so ur ce s f or co m pr eh en siv e N CD pr ev en tio n an d co nt ro l, an d ad va nc es to u ni ve rs al h ea lth . Re du ct io n in c er vi ca l ca nc er in ci de nc e by 2 5% b y 20 25 .21 9 M HW /B N R in ci de nc e da ta Pu rp os e/ O ve ra ll ou tc om e Co st e ffe ct iv e an d re co m m en de d po lic y op tio ns an d in te rv en tio ns im pl em en te d to re du ce th e m ai n N CD ri sk fa ct or sa nd st re ng th en m an ag em en t o f t he m aj or At le as t 4 0% im pl em en ta tio n of th e W HO B Bs , E Is , a nd O RI s f or re du ct io n of th e fo ur m ai n N CD ri sk fa ct or s— to ba cc o us e, u nh ea lth y di et , ph ys ic al in ac tiv ity , a nd Pr op or tio n of W HO B Bs , E Is, an d O RI s i m pl em en te d re la te d to N CD ri sk fa ct or re du ct io n. Ba se lin e (2 01 9) : 1 7. 5% 22 0 M HW re po rt W HO N CD C ou nt ry P ro fil e Su st ai ne d al lo ca tio n of hu m an a nd fi na nc ia l re so ur ce s a nd e ffi ci en t im pl em en ta tio n of e ffe ct iv e po lic y op tio ns a nd in te rv en tio ns fo r p rim ar y, se co nd ar y, a nd te rt ia ry 21 8 U sin g 20 10 b as el in e da ta , a s s tip ul at ed in th e GM F. S ee h tt ps :/ /w w w .w ho .in t/ nm h/ nc d to ol s/ de fin iti on t ar ge ts /e n/ . 21 9 Ib id . 22 0 S ee fi rs t p ar ag ra ph in A nn ex 7 . 55 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 0 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns N CD s. ha rm fu l u se o f a lc oh ol by 20 25 . pr ev en tio n of th e m aj or N CD s. At le as t 7 0% im pl em en ta tio n of W HO BB S, E Is , a nd O RI s f or m an ag em en t o f t he fo ur m aj or N CD s— CV D, di ab et es , c an ce r, an d ch ro ni c re sp ira to ry di se as es by 2 02 5. Pr op or tio n of W HO B Bs , E Is, an d O RI s i m pl em en te d re la te d to th e m an ag em en t o f t he fo ur m aj or N CD s. Ba se lin e (2 01 9) : 5 6. 3% .22 1 M HW re po rt W HO N CD C ou nt ry P ro fil e Sp ec ifi c ou tc om es 1. To ba cc o us e re du ce d am on g ad ol es ce nt s a nd ad ul ts . 10 % re la tiv e re du ct io n in pr ev al en ce o f c ur re nt to ba cc o us e in p er so ns ag ed ≥ 13 y ea rs . Pr ev al en ce o f c ur re nt to ba cc o us e am on g st ud en ts a ge d 13 15 y ea rs . GY TS St re ng th en ed W HO F CT C im pl em en ta tio n, in cl ud in g pr ot ec tin g he al th p ol ic ie s fr om to ba cc o in du st ry in te rf er en ce , a nd co nt in ua tio n of in te rv en tio ns to c re at e to ba cc o fr ee no rm s, st an da rd s, an d cu ltu re . Ag e st an da rd ise d pr ev al en ce o f cu rr en t t ob ac co u se a m on g pe rs on s a ge d ≥2 5 ye ar s. ST EP S/ Ho TN S 2. U nh ea lth y di et a nd ov er w ei gh t/ ob es ity re du ce d. 30 % re la tiv e re du ct io n in m ea n po pu la tio n in ta ke o f sa lt. Ag e st an da rd ise d m ea n po pu la tio n in ta ke o f sa lt/ so di um p er d ay (i n gr am s) in p er so ns a ge d ≥2 5 ye ar s. ST EP S/ Ho TN S Im pr ov em en t i n ag ric ul tu ra l pr ac tic es a nd fo od a nd nu tr iti on se cu rit y an d su pp ly sy st em s t o al lo w e as y ac ce ss to a ffo rd ab le , h ea lth y fo od an d be ve ra ge s, re du ct io n in ob es og en ic e nv iro nm en ts , an d ad ap ta tio n to c lim at e ch an ge . Ha lt th e ris e in o be sit y an d di ab et es . Ad op tio n of n at io na l p ol ic ie s th at li m it sa tu ra te d fa tt y ac id s an d vi rt ua lly e lim in at e pa rt ia lly hy dr og en at ed v eg et ab le o ils (t ra ns fa t) in th e fo od su pp ly . Co py o f p ol ic ie s a nd do cu m en ta tio n of re la te d in te rv en tio ns Ag e st an da rd ize d pr ev al en ce o f ra ise d to ta l c ho le st er ol a m on g pe rs on s a ge d ≥ 25 y ea rs . ST EP S/ Ho TN S Pr ev al en ce o f o ve rw ei gh t a nd GS HS 22 1 S ee fi rs t p ar ag ra ph in A nn ex 7 . 56 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 1 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns ob es ity a m on g st ud en ts a ge d 13 1 5 ye ar s. Ag e st an da rd ize d pr ev al en ce o f ov er w ei gh t a nd o be sit y in pe rs on s a ge d ≥2 5 ye ar s. ST EP S/ Ho TN S At le as t 1 0% d ec re as e in th e pr ev al en ce o f p er so ns ag ed ≥ 25 y ea rs c on su m in g le ss th an fi ve to ta l s er vi ng s of fr ui t a nd v eg et ab le s p er da y. Ag e st an da rd ize d pr ev al en ce o f pe rs on s a ge d ≥2 5 ye ar s co ns um in g le ss th an fi ve to ta l se rv in gs o f f ru it an d ve ge ta bl es pe r d ay . ST EP S/ Ho TN S At le as t 1 0% d ec re as e in th e pr ev al en ce o f c hi ld re n ag ed 1 3 15 y ea rs d rin ki ng ca rb on at ed so ft dr in ks (o r ot he r S SB s) d ai ly . Pr ev al en ce o f c hi ld re n ag ed 1 3 15 y ea rs d rin ki ng c ar bo na te d so ft d rin ks (o r o th er S SB s) o ne or m or e tim es p er d ay d ur in g th e pa st 3 0 da ys . GS HS At le as t 1 0% in cr ea se in th e pr ev al en ce o f e xc lu siv e br ea st fe ed in g fo r t he fi rs t six m on th s o f l ife . Pr ev al en ce o f e xc lu siv e br ea st fe ed in g. Ba se lin e( 20 12 ): 19 .7 % 22 2 M HW re po rt 3. Ph ys ic al in ac tiv ity re du ce d. 10 % re la tiv e re du ct io n in pr ev al en ce o f i ns uf fic ie nt ph ys ic al a ct iv ity . Pr ev al en ce o f i ns uf fic ie nt ly ph ys ic al ly a ct iv e st ud en ts a ge d 13 1 5 ye ar s. GS HS Cr ea tio n an d m ai nt en an ce o f sp ac es , f ac ili tie s, an d op po rt un iti es fo r r eg ul ar ph ys ic al a ct iv ity in sc ho ol , w or kp la ce , a nd c om m un ity se tt in gs . Ag e st an da rd ize d pr ev al en ce o f in su ffi ci en tly p hy sic al ly a ct iv e pe rs on s a ge d ≥2 5 ye ar s. ST EP S/ Ho TN S 4. Ha rm fu l u se o f a lc oh ol re du ce d. At le as t 1 0% re la tiv e re du ct io n in h ar m fu l u se o f al co ho l. To ta l a lc oh ol c on su m pt io n pe r ca pi ta (i n pe rs on s a ge d ≥2 5 ye ar s) w ith in a c al en da r y ea r, in li tr es o f p ur e al co ho l. M HW re po rt Co nt in ua tio n of in te rv en tio ns to c re at e no rm s, st an da rd s, an d cu ltu re th at v al ue re du ct io n of a lc oh ol r el at ed ha rm s, in cl ud in g ad op tio n of ne w le gi sla tio n/ re gu la tio ns Ag e st an da rd ize d pr ev al en ce o f ST EP S/ Ho TN S 22 2 P AH O /W HO . W or ld B re as tf ee di ng W ee k 20 18 : B re as tf ee di ng — Fo un da tio n of L ife (P re se nt at io n, S lid e 7) . ht tp s: // w w w .p ah o. or g/ hq /in de x. ph p? op tio n= co m d oc m an & vi ew =d ow nl oa d& ca te go ry s lu g= 20 18 9 95 7& al ia s= 45 71 1 pr es en ta tio n w or ld b re as tf ee di ng w ee k 20 18 71 1& Ite m id =2 70 & la ng =e n. 57 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 2 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns he av y ep iso di c dr in ki ng a m on g st ud en ts a ge d 13 1 5 ye ar s a nd ad ul ts (p er so ns a ge d ≥2 5 ye ar s) . w ith ou t a lc oh ol in du st ry in te rf er en ce . 5. Hi gh b lo od p re ss ur e re du ce d; sc re en in g fo r, an d in te gr at ed m an ag em en t o f, di ab et es , C VD , c hr on ic re sp ira to ry d ise as es , a nd ca nc er im pr ov ed . 25 % re la tiv e re du ct io n in th e pr ev al en ce o f r ai se d bl oo d pr es su re . Ag e st an da rd ize d pr ev al en ce o f ra ise d bl oo d pr es su re a m on g pe rs on s a ge d ≥2 5 ye ar s. ST EP S/ Ho TN S Re so ur ce a llo ca tio n, c ap ac ity bu ild in g, a nd P HC a pp ro ac h en ha nc ed , w ith st ro ng le ad er sh ip a nd g ov er na nc e, ad eq ua te fu nd in g, h um an re so ur ce s, so ci al p ro te ct io n, he al th in fo rm at io n, se rv ic e de liv er y, a nd a cc es s t o es se nt ia l m ed ic in es a nd te ch no lo gi es , i n ta nd em w ith ot he r m ea su re s t o ad va nc e to u ni ve rs al h ea lth . At le as t 5 0% o f e lig ib le pe op le re ce iv e dr ug th er ap y an d co un se lli ng (in cl ud in g gl yc ae m ic co nt ro l) to p re ve nt h ea rt at ta ck s a nd st ro ke s. Pr op or tio n of e lig ib le p er so ns re ce iv in g dr ug th er ap y an d co un se lli ng (i nc lu di ng gl yc ae m ic c on tr ol ) t o pr ev en t he ar t a tt ac ks a nd st ro ke s. M HW re po rt 80 % a va ila bi lit y of th e af fo rd ab le b as ic te ch no lo gi es a nd e ss en tia l m ed ic in es , i nc lu di ng ge ne ric s, re qu ire d to tr ea t th e fo ur m aj or N CD s i n bo th p ub lic a nd p riv at e fa ci lit ie s. Av ai la bi lit y an d af fo rd ab ili ty o f qu al ity , s af e an d ef fic ac io us es se nt ia l N CD m ed ic in es , in cl ud in g ge ne ric s, a nd b as ic te ch no lo gi es in b ot h pu bl ic a nd pr iv at e fa ci lit ie s. M HW /B DS re po rt Ac ce ss to p al lia tiv e ca re as se ss ed b y m or ph in e eq ui va le nt c on su m pt io n of st ro ng o pi oi d an al ge sic s (e xc lu di ng m et ha do ne ) p er de at h fr om c an ce r. M HW /B DS re po rt Ba rb ad os A ss oc ia tio n fo r Pa lli at iv e Ca re (B AP C) re po rt At le as t 9 0% o f g irl s a ge d 9 13 y ea rs re ce iv e HP V va cc in at io n (tw o do se s) . Pr op or tio n of g irl s a ge d 9 13 ye ar s r ec ei vi ng H PV va cc in at io n. Ba se lin e (2 01 6) : 5 0. 0% M HW re po rt At le as t 8 0% o f w om en ag ed 3 0– 49 y ea rs sc re en ed fo r c er vi ca l c an ce r a t l ea st Pr op or tio n of w om en a ge d 30 49 y ea rs sc re en ed fo r c er vi ca l ca nc er a t l ea st o nc e, u sin g M HW re po rt 58 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 3 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns on ce , t hr ou gh Pa p sm ea r (c er vi ca l c yt ol og y) e ve ry 3 5 ye ar s l in ke d w ith ti m el y tr ea tm en t o f p re c an ce ro us le sio ns , o r HP V te st e ve ry 5 y ea rs lin ke d w ith ti m el y tr ea tm en t o f p re c an ce ro us le sio ns . ce rv ic al c yt ol og y or H PV te st in g. 22 3 At le as t 8 0% o f w om en ag ed 5 0 69 y ea rs sc re en ed w ith m am m og ra ph y at le as t o nc e ev er y tw o ye ar s. Pr op or tio n of w om en a ge d 50 69 y ea rs sc re en ed w ith m am m og ra ph y at le as t o nc e ev er y tw o ye ar s. 22 4 M HW re po rt 6. M ul ti se ct or al w ho le o f go ve rn m en t, w ho le o f so ci et y, a nd h ea lth in a ll po lic ie s a pp ro ac he s t o N CD pr ev en tio n an d co nt ro l st re ng th en ed . At le as t t hr ee m in ist rie s ot he r t ha n he al th , a nd th re e en tit ie s w ith re pr es en ta tio n fr om c iv il so ci et y an d th e pr iv at e se ct or , i nv ol ve d in le ad er sh ip , s tr at eg ic pl an ni ng , i m pl em en ta tio n, m on ito rin g, a nd e va lu at io n fo r N CD p re ve nt io n an d co nt ro l. N um be r o f m in ist rie s, an d en tit ie s w ith c iv il so ci et y an d pr iv at e se ct or re pr es en ta tio n, in vo lv ed in le ad er sh ip , s tr at eg ic pl an ni ng , i m pl em en ta tio n, m on ito rin g, a nd e va lu at io n fo r N CD p re ve nt io n an d co nt ro l. N N CD C/ M HW re po rt Re po rt s f ro m o th er m in ist rie s Im pr ov ed a pp re ci at io n by m in ist rie s o th er th an H ea lth , ci vi l s oc ie ty , a nd th e pr iv at e se ct or o f t he im po rt an ce o f th ei r c on tr ib ut io n to h ea lth , an d th ei r s us ta in ed a nd ef fe ct iv e pa rt ic ip at io n in in te rv en tio ns fo r N CD pr ev en tio n an d co nt ro l. M ec ha ni sm fo r e ffe ct iv e en ga ge m en t w ith N GO s es ta bl ish ed a nd fu nc tio ni ng in th e M HW . N GO e ng ag em en t m ec ha ni sm es ta bl ish ed in M HW a nd fu nc tio ni ng . M HW re po rt 7. Ad eq ua te re so ur ce s al lo ca te d an d m ob ili se d fo r en ha nc ed fu nc tio ni ng o f th e na tio na l N CD pr og ra m m e. Es ta bl ish m en t o f a li ne ite m in th e na tio na l h ea lth bu dg et sp ec ifi c to N CD pr ev en tio n an d co nt ro l a nd at le as t a 1 0% in cr ea se in Li ne it em in h ea lth b ud ge t f or N CD p re ve nt io n an d co nt ro l, an d pr op or tio n of n at io na l he al th b ud ge t a llo ca te d to N CD pr og ra m m e. M HW re po rt Co py o f n at io na l b ud ge t Re so ur ce s u se d ef fic ie nt ly an d ef fe ct iv el y fo r N CD pr ev en tio n an d co nt ro l, w ith pe rf or m an ce a ss es sm en ts co nd uc te d in a re su lts b as ed 22 3 B as el in e to b e es ta bl ish ed . 22 4 B as el in e to b e es ta bl ish ed . 59 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 4 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns th e fin an ci al re so ur ce s al lo ca te d to th e M HW N CD pr og ra m m e. m an ag em en t f ra m ew or k an d su st ai ne d al lo ca tio n an d m ob ili sa tio n of a de qu at e re so ur ce s. At le as t t w o fu ll tim e te ch ni ca l s ta ff an d on e fu ll tim e ad m in ist ra tiv e st af f as sig ne d to th e M HW N CD U ni t. N um be r o f f ul l-t im e te ch ni ca l an d ad m in ist ra tiv e st af f i n th e M HW N CD U ni t. M HW re po rt At le as t t hr ee m in ist rie s ot he r t ha n M HW w ith N CD re la te d ob je ct iv es /a ct iv iti es in cl ud ed in th ei r op er at io na l p la ns , su pp or te d by fi na nc ia l re so ur ce s f ro m th ei r o w n bu dg et s. N um be r o f m in ist rie s o th er th an M HW w ith N CD r el at ed ob je ct iv es /a ct iv iti es in cl ud ed in th ei r o pe ra tio na l p la ns a nd re le va nt b ud ge ta ry a llo ca tio ns . Ca bi ne t r ep or t Re po rt s f ro m o th er m in ist rie s 8. In cr ea se d aw ar en es s a nd un de rs ta nd in g am on g ke y st ak eh ol de rs o f t he m aj or N CD s, th ei r m ai n ris k fa ct or s, th ei r i m pa ct , a nd re sp on se s. At le as t a 1 0% in cr ea se in th e pr op or tio n of p er so ns ex pr es sin g co nc er n ab ou t ob es ity a nd c hi ld ho od ob es ity . Pr op or tio n of p er so ns ex pr es sin g co nc er n ab ou t ob es ity a nd c hi ld ho od o be sit y. Ba se lin e (2 01 8) : 8 3. 0% o be sit y, 88 .0 % c hi ld ho od o be sit y. 22 5 Re su lts fr om fo llo w u p to th e 20 18 H SF B pu bl ic op in io n po ll. Aw ar en es s m es sa ge s a nd in te rv en tio ns ta ilo re d to va rio us a ud ie nc es a s ap pr op ria te , s us ta in ed , a nd tr ig ge r d es ire d be ha vi ou rs . 9. In fo rm at io n sy st em s re la te d to N CD s st re ng th en ed . De ve lo pm en t o f a fr am ew or k fo r s ys te m at ic N CD su rv ei lla nc e an d re se ar ch th at id en tif ie s co re a re as , s ou rc es o f in fo rm at io n, k ey a ct or s, re so ur ce s n ee de d, a nd po ss ib le so ur ce s o f fu nd in g/ re so ur ce s. Ex ist en ce o f a fr am ew or k fo r sy st em at ic , p er io di c N CD su rv ei lla nc e an d re se ar ch , t ha t id en tif ie s c or e ar ea s, so ur ce s o f in fo rm at io n, k ey a ct or s, re so ur ce s n ee de d, a nd p os sib le so ur ce s o f f un di ng /r es ou rc es . M HW re po rt Co py o f f ra m ew or k In fo rm at io n sy st em s i nc lu de da ta fr om p ub lic a nd p riv at e se ct or s; m ai nt ai ne d; p ro vi de tim el y, q ua lit y da ta ; a nd d at a us ed fo r d ec isi on m ak in g, ev id en ce b as ed p ol ic y de ve lo pm en t, m on ito rin g, an d ev al ua tio n. At le as t t hr ee p op ul at io n ba se d su rv ey s/ st ud ie s N um be r o f s ur ve ys /s tu di es im pl em en te d to d et ec t N CD M HW re po rt 22 5 H SF B pu bl ic o pi ni on p ol l 2 01 8. h tt ps :/ /w w w .h ea lth yc ar ib be an .o rg /w p co nt en t/ up lo ad s/ 20 19 /0 3/ CA DR ES In fo gr ap hi c FL YE R. pd f. 60 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 5 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns im pl em en te d to d et ec t N CD a nd ri sk fa ct or tr en ds . an d ris k fa ct or tr en ds . Su rv ey /s tu dy re po rt s 10 .N at io na l l ea de rs hi p an d go ve rn an ce o f N CD pr ev en tio n an d co nt ro l en ha nc ed . At le as t o ne fo ru m o f k ey st ak eh ol de rs co nv en ed /c oo rd in at ed b y th e N N CD C an d M HW an nu al ly to p ro vi de up da te s o n N CD p re ve nt io n an d co nt ro l. N um be r o f f or a of k ey st ak eh ol de rs c on ve ne d an nu al ly b y th e N N CD C an d M HW . N N CD C an d M HW re po rt s Re po rt s o f t he fo ra M ul ti se ct or al le ad er sh ip fo r N CD p re ve nt io n an d co nt ro l su st ai ne d an d ef fe ct iv e. O ut pu ts /E xp ec te d re su lts 1. 1 Im pl em en ta tio n of th e W HO F CT C ac ce le ra te d. To ba cc o co nt ro l l eg isl at io n or re gu la tio ns a m en de d, o r ne w le gi sla tio n/ re gu la tio ns in tr od uc ed , t o fa ci lit at e im pl em en ta tio n of a t l ea st th re e ad di tio na l co m po ne nt s o f t he F CT C, in cl ud in g in cr ea se in to ba cc o ta xa tio n to a t l ea st 75 % o f t he re ta il pr ic e; b an on to ba cc o pr od uc t ad ve rt isi ng , p ro m ot io n, an d sp on so rs hi p; a nd m ea su re s t o el im in at e ill ic it tr ad e in to ba cc o pr od uc ts . N um be r o f a m en dm en ts to th e to ba cc o co nt ro l l eg isl at io n or re gu la tio ns , a nd /o r n um be r o f ne w le gi sla tio n/ re gu la tio ns in tr od uc ed , t o im pr ov e co m pl ia nc e w ith th e W HO FC TC . M HW re po rt To ba cc o or re la te d le gi sla tio n/ re gu la tio ns W HO R ep or t o n th e Gl ob al To ba cc o Ep id em ic PA HO R ep or t o n To ba cc o Co nt ro l i n th e Re gi on o f t he Am er ic as Su cc es sf ul a dv oc ac y, a nd am en dm en t a nd /o r de ve lo pm en t a nd en fo rc em en t o f l eg isl at io n an d re gu la tio ns re la te d to th e W HO F CT C an d to ba cc o co nt ro l, in cl ud in g m ea su re s to p re ve nt to ba cc o in du st ry in te rf er en ce . 2. 1. St ra te gi es a nd m ec ha ni sm s fo r h ea lth y nu tr iti on en ha nc ed . At le as t t hr ee in te rv en tio ns im pl em en te d fo r s al t re du ct io n ba se d on th e W HO S HA KE te ch ni ca l pa ck ag e. N um be r o f i nt er ve nt io ns im pl em en te d ba se d on th e W HO S HA KE te ch ni ca l p ac ka ge . M HW re po rt Su cc es sf ul a dv oc ac y, a nd su st ai ne d pr io rit y gi ve n to he al th y nu tr iti on a nd re du ct io n of o be sit y, ov er w ei gh t, an d th e ob es og en ic e nv iro nm en t ac ro ss se ct or s, in cl ud in g m an da to ry im pl em en ta tio n of F oP W L. At le as t t w o in te rv en tio ns im pl em en te d to re du ce su ga r c on su m pt io n, in cl ud in g in cr ea se in ta xa tio n on S SB s f ro m th e N um be r o f i nt er ve nt io ns im pl em en te d to re du ce su ga r co ns um pt io n, a nd le ve l o f ta xa tio n on S SB s. M HW re po rt 61 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 6 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns cu rr en t l ev el o f 1 0% to a t le as t 3 0% a nd a dv oc ac y fo r re fo rm ul at io n of fo od s a nd be ve ra ge s t o lo w er th ei r su ga r c on te nt . At le as t t hr ee in te rv en tio ns im pl em en te d fo r t he el im in at io n of tr an s f at ba se d on th e W HO RE PL AC E te ch ni ca l p ac ka ge . N um be r o f i nt er ve nt io ns im pl em en te d ba se d on th e W HO R EP LA CE te ch ni ca l pa ck ag e. M HW re po rt At le as t t hr ee in te rv en tio ns im pl em en te d pr om ot in g in cr ea se d fr ui t a nd ve ge ta bl e co ns um pt io n, in cl ud in g m es sa ge s i n m as s an d so ci al m ed ia ; e nh an ce d pr om ot io n an d im pl em en ta tio n of n at io na l fo od b as ed d ie ta ry gu id el in es ; a nd co lla bo ra tio n w ith th e M in ist ry o f A gr ic ul tu re a nd Fo od S ec ur ity (M AF S) to im pr ov e ac ce ss to lo ca l fr ui ts a nd v eg et ab le s. N um be r o f i nt er ve nt io ns pr om ot in g in cr ea se d fr ui t a nd ve ge ta bl e co ns um pt io n, a nd m in ist rie s i nv ol ve d. M HW a nd M AF S re po rt s Fr on t of p ac ka ge ‘h ig h in ’ nu tr iti on w ar ni ng la be ls im pl em en te d an d en fo rc ed on a t l ea st 5 0% o f l oc al ly pr od uc ed a nd im po rt ed pa ck ag ed fo od s. Pr op or tio n of lo ca l a nd im po rt ed p ac ka ge d fo od s w ith fr on t of p ac ka ge ‘h ig h in ’ nu tr iti on w ar ni ng la be ls. M HW re po rt Pr od uc t l ab el lin g m on ito rin g At le as t t hr ee in te rv en tio ns to p ro m ot e ex cl us iv e br ea st fe ed in g fo r t he fi rs t six m on th s o f l ife N um be r o f i nt er ve nt io ns to pr om ot e ex cl us iv e br ea st fe ed in g fo r t he fi rs t s ix m on th s o f l ife . M HW re po rt BC N F re po rt 62 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 7 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns im pl em en te d, in cl ud in g ex pa ns io n of th e Ba by Fr ie nd ly H os pi ta l i ni tia tiv e to in cl ud e th e pr iv at e se ct or ; p ro m ot io n, a nd as se ss m en t o f t he im pl em en ta tio n, o f t he In te rn at io na l C od e of M ar ke tin g of B re as t m ilk Su bs tit ut es ; a nd p ro m ot io n of b re as tf ee di ng in th e w or kp la ce . 2. 2 Im pl em en ta tio n of st ra te gi es a nd in te rv en tio ns fo r c hi ld ho od ob es ity p re ve nt io n en ha nc ed . At le as t f iv e st ra te gi es a nd in te rv en tio ns fo r C O P im pl em en te d, in cl ud in g re st ric tio n on th e sa le a nd m ar ke tin g of u nh ea lth y co m m od iti es to c hi ld re n, an d, in th e sc ho ol se tt in g: ba n on S SB s; u pd at in g an d im pl em en ta tio n of nu tr iti on g ui de lin es sp ec ifi c to th e sc ho ol e nv iro nm en t; m an da to ry p hy sic al ac tiv ity ; a nd im pr ov ed ac ce ss to p ot ab le w at er . N um be r o f s tr at eg ie s a nd in te rv en tio ns d ev el op ed a nd im pl em en te d ad dr es sin g ch ild ho od o be sit y pr ev en tio n. M HW re po rt HC C re po rt Su cc es sf ul a dv oc ac y, a nd su st ai ne d pr io rit y gi ve n to he al th y nu tr iti on a nd pr ev en tio n of c hi ld ho od ob es ity a cr os s s ec to rs , in cl ud in g Ed uc at io n an d Tr ad e. 3. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d fo r i nc re as ed ph ys ic al a ct iv ity . At le as t t hr ee in te rv en tio ns fo r i nc re as in g ph ys ic al ac tiv ity b as ed o n th e W HO AC TI VE te ch ni ca l p ac ka ge im pl em en te d. N um be r o f i nt er ve nt io ns im pl em en te d ba se d on th e W HO A CT IV E te ch ni ca l pa ck ag e. M HW re po rt Su cc es sf ul a dv oc ac y, a nd su st ai ne d pr io rit y gi ve n to re du ct io n of p hy sic al in ac tiv ity a cr os s s ec to rs , in cl ud in g ur ba n pl an ni ng . 4. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to re du ce th e ha rm fu l u se o f a lc oh ol . At le as t t hr ee in te rv en tio ns im pl em en te d to re du ce th e ha rm fu l u se o f a lc oh ol ba se d on th e SA FE R N um be r o f i nt er ve nt io ns im pl em en te d to re du ce th e ha rm fu l u se o f a lc oh ol . M HW re po rt HC C re po rt Su cc es sf ul a dv oc ac y, a nd su st ai ne d pr io rit y gi ve n to re du ct io n of th e ha rm fu l u se of a lc oh ol a cr os s s ec to rs , 63 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 8 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns te ch ni ca l p ac ka ge (W HO BB s) a nd th e po lic y op tio ns an d in te rv en tio ns re co m m en de d in th e 20 10 W HO G lo ba l S tr at eg y fo r Re du ct io n of th e Ha rm fu l U se o f A lc oh ol ,22 6 in cl ud in g Bu sin es s, Co m m er ce , T ra de , a nd Tr an sp or ta tio n. in cl ud in g pr om ot in g an d en fo rc in g dr in k dr iv in g co un te r m ea su re s; e nf or ci ng ba ns /c om pr eh en siv e re st ric tio ns o n al co ho l ad ve rt isi ng , s po ns or sh ip , an d pr om ot io n; a nd ra isi ng pr ic es o n al co ho l t hr ou gh ex ci se ta xe s a nd p ric in g po lic ie s. 5. 1 In te rv en tio ns im pl em en te d to re du ce h ig h bl oo d pr es su re a nd im pr ov e sc re en in g fo r, an d/ or in te gr at ed m an ag em en t of , C VD , d ia be te s, ch ro ni c re sp ira to ry d ise as es , a nd ca nc er a t t he fi rs t l ev el o f ca re , t ak in g m ul ti m or bi di ty in to c on sid er at io n. Pr ot oc ol fo r t he m an ag em en t o f hy pe rt en sio n at th e fir st le ve l o f c ar e re vi ew ed a nd up da te d to u se a to ta l r isk ap pr oa ch c on sis te nt w ith W HO H EA RT S gu id an ce , an d im pl em en te d in a ll ni ne p ol yc lin ic s. N um be r o f p ol yc lin ic s im pl em en tin g pr ot oc ol fo r hy pe rt en sio n m an ag em en t up da te d to u se th e to ta l r isk ap pr oa ch , c on sis te nt w ith W HO HE AR TS g ui da nc e. M HW re po rt Ca pa ci ty b ui lt, a nd c on tin ue d ac ce ss to q ua lit y, co m pr eh en siv e se rv ic es fo r sc re en in g an d m an ag em en t of h yp er te ns io n an d pr io rit y N CD s a t t he fi rs t l ev el o f c ar e, w ith a cc es s t o es se nt ia l m ed ic in es a nd te ch no lo gi es , ap pr op ria te ly tr ai ne d, qu al ifi ed h um an re so ur ce s fo r h ea lth , a nd e ffi ci en t a nd ef fe ct iv e re fe rr al sy st em s, w ith in su pp or tiv e po lic y, le gi sla tiv e, a nd re gu la to ry fr am ew or ks . W HO H EA RT S gu id an ce fo r CV D m an ag em en t ad op te d/ ad ap te d as ne ed ed a nd p ro to co ls fo r CV D m an ag em en t, in cl ud in g dr ug th er ap y an d co un se lli ng , i m pl em en te d in a ll ni ne p ol yc lin ic s. N um be r o f p ol yc lin ic s im pl em en tin g pr ot oc ol fo r C VD m an ag em en t, in cl ud in g dr ug th er ap y an d co un se lli ng , ad op te d/ ad ap te d fr om th e W HO H EA RT S gu id an ce . M HW re po rt 22 6 ht tp s: // ap ps .w ho .in t/ iri s/ bi ts tr ea m /h an dl e/ 10 66 5/ 44 39 5/ 97 89 24 15 99 93 1 en g. pd f? se qu en ce =1 . 64 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 7 9 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns Pr ot oc ol fo r m an ag em en t of T yp e 2 di ab et es re vi ew ed a nd u pd at ed , in cl ud in g pr ev en tiv e fo ot ca re a nd sc re en in g fo r re tin op at hy , a nd im pl em en te d in a ll ni ne po ly cl in ic s. N um be r o f p ol yc lin ic s im pl em en tin g up da te d pr ot oc ol fo r m an ag em en t o f Ty pe 2 d ia be te s, in cl ud in g pr ev en tiv e fo ot c ar e, sc re en in g fo r r et in op at hy , a nd se as on al in flu en za v ac ci na tio n. M HW re po rt Pr ot oc ol fo r m an ag em en t of c hr on ic re sp ira to ry di se as es re vi ew ed a nd up da te d, a nd im pl em en te d in a ll ni ne p ol yc lin ic s. N um be r o f p ol yc lin ic s im pl em en tin g up da te d pr ot oc ol fo r m an ag em en t o f ch ro ni c re sp ira to ry d ise as es , in cl ud in g se as on al in flu en za va cc in at io n fo r p er so ns w ith CO PD . M HW re po rt Pr ot oc ol s, in cl ud in g a ca ll an d re ca ll sy st em , de ve lo pe d fo r s cr ee ni ng fo r br ea st , c er vi ca l, an d co lo re ct al c an ce rs , a nd a pp lie d in a ll ni ne p ol yc lin ic s. N um be r o f p ol yc lin ic s a pp ly in g pr ot oc ol s, in cl ud in g a ca ll an d re ca ll sy st em , f or b re as t, ce rv ic al , a nd c ol o re ct al c an ce r sc re en in g. M HW re po rt Pr in te d in fo rm at io n an d au di ov isu al m es sa ge s re ga rd in g pr os ta te c an ce r sc re en in g av ai la bl e in a ll ni ne p ol yc lin ic s. N um be r o f p ol yc lin ic s w ith pr in te d in fo rm at io n an d au di ov isu al m es sa ge s a va ila bl e. M HW re po rt Ba sic p al lia tiv e ca re fo r ca nc er a va ila bl e th ro ug h ho m e ba se d an d ho sp ita l ca re , w ith a cc es s t o op ia te s an d es se nt ia l s up po rt iv e m ed ic in e. N um be r o f f ac ili tie s o r e nt iti es pr ov id in g ho m e a nd h os pi ta l ba se d pa lli at iv e ca re fo r c an ce r. M HW re po rt BA PC a nd C an ce r S up po rt Se rv ic es (C SS ) r ep or ts Im pl em en ta tio n of th e se lf ca re /s el f-m an ag em en t co m po ne nt o f t he C hr on ic Ca re M od el (C CM ) i n al l N um be r o f p ol yc lin ic s im pl em en tin g th e se lf ca re m an ag em en t c om po ne nt o f th e CC M . M HW re po rt 65 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 0 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns ni ne p ol yc lin ic s. 22 7 In te gr at io n of N CD m an ag em en t u sin g th e PH C ap pr oa ch in to c ur ric ul a fo r tr ai ni ng h ea lth a nd a lli ed he al th p ro fe ss io na ls. N um be r o f t ra in in g cu rr ic ul a at U W I a nd B CC a da pt ed to in cl ud e/ st re ng th en a sp ec ts re la te d to N CD m an ag em en t us in g th e PH C ap pr oa ch . M HW , M in ist ry o f Ed uc at io n, T ec hn ol og ic al an d Vo ca tio na l T ra in in g (M ET VT ), an d BC C re po rt s 6. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to p ro m ot e an d st re ng th en m ul ti se ct or al w or k an d pa rt ne rs hi ps fo r N CD pr ev en tio n an d co nt ro l. Pa rt ne rs hi ps /c ol la bo ra tio n be tw ee n M HW a nd a t l ea st th re e ot he r m in ist rie s t o de ve lo p an d im pl em en t in te rv en tio ns re la te d to N CD p re ve nt io n an d co nt ro l i n sp ec ifi c se tt in gs — sc ho ol s a nd /o r w or kp la ce s a nd /o r co m m un iti es . N um be r o f pa rt ne rs hi ps /c ol la bo ra tio n in vo lv in g th e M HW a nd o th er m in ist rie s f or th e im pl em en ta tio n of in te rv en tio ns fo r N CD pr ev en tio n an d co nt ro l i n sc ho ol , w or kp la ce , a nd co m m un ity se tt in gs . M HW a nd N N CD C re po rt s Ca pa ci ty b ui lt, a nd es ta bl ish m en t o f s us ta in ed , ef fe ct iv e m ul ti se ct or al co lla bo ra tio n an d pa rt ne rs hi ps fo r N CD pr ev en tio n an d co nt ro l. At le as t t hr ee e nt iti es w ith re pr es en ta tio n fr om go ve rn m en t, ci vi l s oc ie ty an d he al th s up po rt in g pr iv at e se ct or de m on st ra tin g le ad er sh ip in N CD p re ve nt io n an d co nt ro l a dv oc ac y, p ol ic y de ve lo pm en t, pl an ni ng , im pl em en ta tio n, m on ito rin g, a nd e va lu at io n. N um be r o f e nt iti es w ith go ve rn m en t, ci vi l s oc ie ty , a nd he al th s up po rt in g pr iv at e se ct or re pr es en ta tio n le ad in g N CD p re ve nt io n an d co nt ro l ad vo ca cy , p ol ic y de ve lo pm en t, pl an ni ng , i m pl em en ta tio n, m on ito rin g, a nd e va lu at io n. M HW re po rt M ec ha ni sm fo r e ffe ct iv e en ga ge m en t w ith N GO s es ta bl ish ed a t t he M HW an d at le as t o ne in te rv en tio n an nu al ly Es ta bl ish m en t o f t he N GO en ga ge m en t m ec ha ni sm in th e M HW a nd n um be r o f in te rv en tio ns im pl em en te d th ro ug h M HW a nd N GO M HW re po rt 22 7 In fo rm at io n an d to ol s f or th e im pl em en ta tio n of th is co m po ne nt o f t he C CM , w hi ch c an b e ad ap te d as a pp ro pr ia te , i nc lu di ng to c on sid er at io n of m ul ti m or bi di ty , a re av ai la bl e fr om th e In st itu te fo r H ea lth ca re Im pr ov em en t a t h tt p: // w w w .ih i.o rg /T op ic s/ Ch ro ni cC ar e/ Pa ge s/ de fa ul t.a sp x. A dd iti on al in fo rm at io n is av ai la bl e fr om th e CA RI CO M Ch ro ni c Ca re P ol ic y an d M od el o f C ar e at h tt ps :/ /c ar ic om .o rg /d oc um en ts /1 20 61 c hr on ic c ar e po lic y m od el o f ca re f or t he c ar ib be an c om m un ity .p df . 66 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 1 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns at tr ib ut ab le to co lla bo ra tio n be tw ee n th e M HW a nd N GO s a s a re su lt of th e m ec ha ni sm . co lla bo ra tio n. 7. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to im pr ov e re so ur ce a llo ca tio n an d m ob ili sa tio n (fi na nc ia l a nd hu m an re so ur ce s) to st re ng th en th e N CD pr og ra m m e an d fa ci lit at e ex ec ut io n of th e N SP N CD 20 2 5. Pr es en ta tio n of G re en Pa pe r a nd W hi te P ap er to Ca bi ne t/ Pa rli am en t t o ad vo ca te fo r, ju st ify , a nd re qu es t, in cr ea se d al lo ca tio n of h um an re so ur ce s t o th e N CD U ni t an d fin an ci al re so ur ce s t o th e N CD p ro gr am m e. N um be r o f p ap er s p re se nt ed to Ca bi ne t/ la id in P ar lia m en t t o ad vo ca te fo r, ju st ify , a nd re qu es t i nc re as ed a llo ca tio n of re so ur ce s f or N CD p re ve nt io n an d co nt ro l. M HW re po rt Ca bi ne t r ep or t Ca pa ci ty b ui lt, su cc es sf ul ad vo ca cy , a nd ju st ifi ca tio n fo r i nc re as ed a llo ca tio n of re so ur ce s, w ith in cr ea se in he al th a nd N CD b ud ge ts , a nd ef fe ct iv e re so ur ce m ob ili sa tio n. At le as t t w o st ra te gi es p er ye ar d ev el op ed a nd im pl em en te d to m ob ili se fin an ci al a nd h um an re so ur ce s f or th e ex ec ut io n of th e N SP N CD 2 0 25 . N um be r o f s tr at eg ie s de ve lo pe d an d im pl em en te d an nu al ly to m ob ili se fi na nc ia l an d hu m an re so ur ce s f or th e ex ec ut io n of th e N SP N CD 2 0 25 . M HW re po rt 8. 1C om m un ic at io n st ra te gi es de ve lo pe d an d im pl em en te d to p ro m ot e th e N SP N CD 2 0 25 a nd en ab le N CD ri sk fa ct or re du ct io n an d im pr ov ed m an ag em en t o f N CD s. At le as t t w o do cu m en te d an d de m on st ra bl e co m m un ic at io n st ra te gi es de ve lo pe d an d im pl em en te d an nu al ly to pr om ot e th e N SP N CD 2 0 25 a nd e na bl e N CD ri sk fa ct or re du ct io n an d im pr ov ed m an ag em en t o f N CD s, in cl ud in g ta rg et in g sp ec ifi c po pu la tio ns su ch a s ch ild re n, y ou th , a nd m en . N um be r o f c om m un ic at io n st ra te gi es d ev el op ed a nd im pl em en te d an nu al ly to pr om ot e th e N SP N CD 2 0 25 an d en ab le N CD ri sk fa ct or re du ct io n an d im pr ov ed m an ag em en t o f N CD s, in cl ud in g ta rg et in g sp ec ifi c po pu la tio ns su ch a s c hi ld re n, yo ut h, a nd m en . M HW re po rt Co pi es o f c om m un ic at io n pr od uc ts Co m m un ic at io n pr od uc ts ef fe ct iv el y di ss em in at ed v ia va rio us m ed ia a nd p la tfo rm s an d re su lt in w id e kn ow le dg e an d us e of th e N SP N CD 2 0 25 a s a fr am ew or k fo r a ct io n ac ro ss se ct or s a nd so ci et y fo r N CD p re ve nt io n an d co nt ro l. 9. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to st re ng th en N CD su rv ei lla nc e an d re se ar ch , i nc lu di ng Al l m od ul es o f M ed Da ta el ec tr on ic m ed ic al re co rd s (E M R) sy st em im pl em en te d in a ll po ly cl in ic s i n ke ep in g N um be r o f p ol yc lin ic s w ith a ll m od ul es o f M ed Da ta E M R sy st em im pl em en te d. M HW re po rt Ca pa ci ty b ui lt, ti m el y da ta co lle ct io n an d an al ys is (in cl ud in g fr om th e pr iv at e se ct or ), an d pr od uc tio n, 67 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 2 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns as se ss m en t o f m ul ti m or bi di ty . w ith fr am ew or k fo r N CD su rv ei lla nc e. di ss em in at io n, a nd u se o f re po rt s, in cl ud in g to id en tif y in eq ui tie s i n he al th . Ex pl or at io n w ith p riv at e he al th c ar e pr ov id er s o f th ei r u se o f M ed Da ta to im pr ov e da ta c ol le ct io n fr om th at se ct or . N um be r o f f or m al di sc us sio ns /in te ra ct io ns h el d w ith p riv at e he al th c ar e pr ov id er s a nd th e ou tc om es o f th e di sc us sio ns /in te ra ct io ns . M HW re po rt At le as t t w o M ed Da ta re po rt s g en er at ed a nn ua lly to c on tr ib ut e to p la nn in g an d po lic y de ve lo pm en t. N um be r o f r ep or ts g en er at ed fr om M ed Da ta p er y ea r. M HW re po rt Co pi es o f M ed Da ta re po rt s Im pr ov ed c ap ac ity o f M HW Pl an ni ng a nd R es ea rc h U ni t an d BN R to e xt ra ct ra w da ta fr om M ed Da ta fo r HE AR TS m on ito rin g N um be r o f p er so ns fr om M HW Pl an ni ng a nd R es ea rc h U ni t a nd BN R tr ai ne d in e xt ra ct in g ra w da ta fr om M ed Da ta fo r H EA RT S m on ito rin g. M HW re po rt At le as t t hr ee su rv ey s/ st ud ie s im pl em en te d am on g ad ol es ce nt s a nd a du lts , in cl ud in g th e GS HS , G YT S, an d ST EP S to d et er m in e tr en ds in p rio rit y N CD s, N CD ri sk fa ct or s, a nd m ul ti m or bi di ty . N um be r o f s ur ve ys /s tu di es am on g ad ol es ce nt s a nd a du lts to d et er m in e tr en ds in p rio rit y N CD s, ri sk fa ct or s, an d m ul ti m or bi di ty . M HW re po rt Re su lts o f t he su rv ey s/ st ud ie s 10 .1 S tr at eg ie s a nd m ec ha ni sm s s tr en gt he ne d fo r t he e ffi ci en t a nd ef fe ct iv e m an ag em en t,m on ito rin g, an d ev al ua tio n of th e N CD pr og ra m m e an d th e N SP N CD 2 0 25 . An nu al im pl em en ta tio n pl an s d ev el op ed fo r t he N SP N CD 2 0 25 , w ith si x m on th ly m on ito rin g of th ei r p ro gr am m at ic a nd fin an ci al e xe cu tio n, pr od uc tio n of si x m on th ly an d an nu al p ro gr es s re po rt s, an d fin al in te rn al an d ex te rn al e va lu at io n of N um be r o f i m pl em en ta tio n pl an s, p ro gr es s r ep or ts , a nd ev al ua tio n re po rt s r el at ed to th e N SP N CD 2 0 25 . M HW re po rt Co pi es o f t he p ro gr es s a nd ev al ua tio n re po rt s Ca pa ci ty b ui lt, a nd su st ai ne d ef fic ie nt a nd e ffe ct iv e m an ag em en t o f t he N CD pr og ra m m e an d im pl em en ta tio n of th e N SP N CD 2 0 25 , w ith a dj us tm en ts as n ee de d to a tt ai n ag re ed ou tp ut s a nd o ut co m es . 68 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 3 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns th e im pl em en ta tio n of th e N SP N CD 2 0 25 . Ca pa ci ty b ui ld in g in te rv en tio ns h el d at le as t an nu al ly fo r t he N N CD C, N TF W , a nd M HW N CD U ni t to fa ci lit at e th ei r e ffi ci en t an d ef fe ct iv e fu nc tio ni ng , m an ag em en t, an d ov er sig ht o f N CD pr ev en tio n an d co nt ro l i n Ba rb ad os . N um be r o f c ap ac ity b ui ld in g in te rv en tio ns h el d fo r t he N N CD C, N TF W , a nd M HW N CD U ni t a nn ua lly . M HW , N N CD C, a nd N TF W re po rt s 7. 2 O ut pu ts /e xp ec te d re su lts ,m ai n ac tiv iti es , i np ut s/ es tim at ed re so ur ce s, in di ca tiv e tim el in es ,a nd p ro po se d pa rtn er s Th e O PT s/ ER s an d th ei rin di ca to rs , m ai n ac tiv iti es , e st im at ed in pu ts /r es ou rc es , i nd ic at iv e tim el in es , a nd p ro po se dp ar tn er s to a ch ie ve t he s pe ci fic ou tc om es a re p re se nt ed in T ab le 1 1 be lo w .T he e st im at ed in pu ts /r es ou rc es co ve r th e 5 ye ar p er io d of th e Pl an a nd d o no t i nc lu de e st im at es fo r in k in d co st s, w hi ch c om pr ise , am on g ot he r ite m s, p er so nn el s al ar ie s an d tim e, a nd u se o f go ve rn m en t in fr as tr uc tu re ; th e es tim at ed b ud ge t am ou nt s f or e ac h ac tiv ity a ss um e bo th re so ur ce a llo ca tio n an d re so ur ce m ob ili sa tio n. Ta bl e 11 . O ut pu ts /e xp ec te d re su lts , m ai n ac tiv iti es , i np ut s/ es tim at ed re so ur ce s, in di ca tiv e tim el in es , a nd p ro po se d pa rt ne rs O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s 1. 1 Im pl em en ta tio n of th e W HO FC TC ac ce le ra te d . 1. 1. 1 Co nd uc t a n FC TC n ee ds a ss es sm en t, as re co m m en de d by th e 20 15 U N IA TF m iss io n. M HW , N N CD C Co ns ul ta nt 6 ,0 00 M at er ia ls 2, 00 0 20 20 U N IA TF /U N S ub re gi on al Te am HS FB , B CS 1. 1. 2 Im pl em en t a t l ea st tw o of th e m aj or re co m m en da tio ns o f t he F CT C ne ed s a ss es sm en t. M HW , N N CD C, o th er m in ist rie s a s i nd ic at ed Im pl em en ta tio n 24 ,0 00 20 21 2 3 U N IA TF /U N S ub re gi on al Te am HS FB , B CS 1. 1. 3 Co nd uc t e vi de nc e ba se d ad vo ca cy w ith th e M FE I fo r i nc re as e in ta xa tio n on to ba cc o pr od uc ts fr om th e cu rr en t l ev el o f 4 7. 1% to a t l ea st 7 5% , a nd ap pl ic at io n of a t l ea st a p or tio n of th e ta x re ve nu e M HW , N N CD C Ad vo ca cy m at er ia ls an d in te rv en tio ns 2 ,0 00 20 20 PA HO /W HO HS FB , B CS , H CC 7.2 Outputs/expected results, main activities, inputs/estimated resources, indicative timelines, and proposed partners The OPTs/ERs and theirindicators, main activities, estimated inputs/resources, indicative timelines, and proposedpartners to achieve the specific outcomes are presented in Table 11 below. The estimated inputs/resourcescover the 5-year period of the Plan and do not include estimates for in-kind costs, which comprise, among other items, personnel salaries and time, and use of government infrastructure; the estimated budget amounts for each activity assume both resource allocation and resource mobilisation. 69 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 3 of 1 34 O bj ec tiv es N ar ra tiv e Su m m ar y Ta rg et s In di ca to rs M ea ns o f v er ifi ca tio n As su m pt io ns th e im pl em en ta tio n of th e N SP N CD 2 0 25 . Ca pa ci ty b ui ld in g in te rv en tio ns h el d at le as t an nu al ly fo r t he N N CD C, N TF W , a nd M HW N CD U ni t to fa ci lit at e th ei r e ffi ci en t an d ef fe ct iv e fu nc tio ni ng , m an ag em en t, an d ov er sig ht o f N CD pr ev en tio n an d co nt ro l i n Ba rb ad os . N um be r o f c ap ac ity b ui ld in g in te rv en tio ns h el d fo r t he N N CD C, N TF W , a nd M HW N CD U ni t a nn ua lly . M HW , N N CD C, a nd N TF W re po rt s 7. 2 O ut pu ts /e xp ec te d re su lts ,m ai n ac tiv iti es , i np ut s/ es tim at ed re so ur ce s, in di ca tiv e tim el in es ,a nd p ro po se d pa rtn er s Th e O PT s/ ER s an d th ei rin di ca to rs , m ai n ac tiv iti es , e st im at ed in pu ts /r es ou rc es , i nd ic at iv e tim el in es , a nd p ro po se dp ar tn er s to a ch ie ve t he s pe ci fic ou tc om es a re p re se nt ed in T ab le 1 1 be lo w .T he e st im at ed in pu ts /r es ou rc es co ve r th e 5 ye ar p er io d of th e Pl an a nd d o no t i nc lu de e st im at es fo r in k in d co st s, w hi ch c om pr ise , am on g ot he r ite m s, p er so nn el s al ar ie s an d tim e, a nd u se o f go ve rn m en t in fr as tr uc tu re ; th e es tim at ed b ud ge t am ou nt s f or e ac h ac tiv ity a ss um e bo th re so ur ce a llo ca tio n an d re so ur ce m ob ili sa tio n. Ta bl e 11 . O ut pu ts /e xp ec te d re su lts , m ai n ac tiv iti es , i np ut s/ es tim at ed re so ur ce s, in di ca tiv e tim el in es , a nd p ro po se d pa rt ne rs O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s 1. 1 Im pl em en ta tio n of th e W HO FC TC ac ce le ra te d . 1. 1. 1 Co nd uc t a n FC TC n ee ds a ss es sm en t, as re co m m en de d by th e 20 15 U N IA TF m iss io n. M HW , N N CD C Co ns ul ta nt 6 ,0 00 M at er ia ls 2, 00 0 20 20 U N IA TF /U N S ub re gi on al Te am HS FB , B CS 1. 1. 2 Im pl em en t a t l ea st tw o of th e m aj or re co m m en da tio ns o f t he F CT C ne ed s a ss es sm en t. M HW , N N CD C, o th er m in ist rie s a s i nd ic at ed Im pl em en ta tio n 24 ,0 00 20 21 2 3 U N IA TF /U N S ub re gi on al Te am HS FB , B CS 1. 1. 3 Co nd uc t e vi de nc e ba se d ad vo ca cy w ith th e M FE I fo r i nc re as e in ta xa tio n on to ba cc o pr od uc ts fr om th e cu rr en t l ev el o f 4 7. 1% to a t l ea st 7 5% , a nd ap pl ic at io n of a t l ea st a p or tio n of th e ta x re ve nu e M HW , N N CD C Ad vo ca cy m at er ia ls an d in te rv en tio ns 2 ,0 00 20 20 PA HO /W HO HS FB , B CS , H CC 70 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 4 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s to N CD p re ve nt io n an d co nt ro l i nt er ve nt io ns , in cl ud in g he al th fi na nc in g. 1. 1. 4 Co nd uc t e vi de nc e ba se d ad vo ca cy w ith th e M in ist ry o f I nf or m at io n, B ro ad ca st in g an d Pu bl ic Af fa irs (M IB P) fo r a b an o n to ba cc o ad ve rt isi ng , pr om ot io n, a nd sp on so rs hi p. M HW , N N CD C, M IB P Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 20 20 PA HO /W HO HS FB , B CS , H CC 1. 1. 5 Co nt rib ut e to , a nd a do pt /a da pt a s n ee de d, re gi on al (C AR IC O M ) e ffo rt s t o el im in at e ill ic it tr ad e in to ba cc o pr od uc ts . M HW , N N CD C, M in ist ry o f Fo re ig n Af fa irs a nd F or ei gn Tr ad e (M FA ) M ee tin g an d ot he r s up po rt co st s 5 ,0 00 20 20 2 2 PA HO /W HO 1. 1. 6 Re vi ew a nd m on ito r e m er gi ng e vi de nc e an d cu rr en t s m ok in g re gu la tio ns to a dv oc at e fo r, an d en ab le , l eg isl at io n an d re gu la tio ns th at re st ric t o r ba n in ha la bl e su bs ta nc es /p ro du ct s o th er th an to ba cc ot ha t h av e a ne ga tiv e im pa ct o n he al th . M HW , N N CD C Ev id en ce re vi ew , do cu m en ta tio n, a dv oc ac y 8, 00 0 20 20 2 5 PA HO /W HO Co st O PT 1 .1 : U S$ 5 2, 00 0 2. 1 St ra te gi es a nd m ec ha ni sm s f or he al th y nu tr iti on en ha nc ed . 2. 1. 1 Re vi ew th e SH AK E te ch ni ca l p ac ka ge fo r s al t re du ct io n an d ad vo ca te fo r a nd im pl em en t a t l ea st th re e of th e fiv e su gg es te d po lic ie s a nd in te rv en tio ns ,22 8 20 15 PA HO /U ni ve rs ity o f S ou th F lo rid a/ HC C so ci al m ar ke tin g ca m pa ig n bu ild in g on th e 22 9 M HW , N N CD C, N N C M in ist ry o f S m al l B us in es s, En tr ep re ne ur sh ip a nd Co m m er ce (M SB EC ) Co ns ul ta tio ns 5 ,0 00 Im pl em en ta tio n 25 ,0 00 a nd in te gr at in g th em in to ot he r N CD p re ve nt io n an d co nt ro l s tr at eg ie s a s ap pr op ria te . 20 21 2 2 PA HO /W HO 2. 1. 2 U nd er ta ke e vi de nc e ba se d ad vo ca cy w ith th e M FE I an d M SB EC fo r a n in cr ea se in th e SS B ta x fr om th e cu rr en t l ev el o f 1 0% to a t l ea st 3 0% . M HW , N N CD C Ad vo ca cy m at er ia ls an d in te rv en tio ns 5, 00 0 20 20 HC C 2. 1. 3 U nd er ta ke e vi de nc e ba se d ad vo ca cy w ith th e M HW , N N CD C, N N C 20 20 PA HO /W HO 22 8 Su rv ei lla nc e— m ea su re a nd m on ito r s al t u se ; H ar ne ss In du st ry — pr om ot e th e re fo rm ul at io n of fo od s a nd m ea ls to c on ta in le ss sa lt; A do pt st an da rd s f or la be lli ng a nd m ar ke tin g— im pl em en t s ta nd ar ds fo r e ffe ct iv e an d ac cu ra te la be lli ng a nd m ar ke tin g of fo od ; K no w le dg e— ed uc at e an d co m m un ic at e to e m po w er in di vi du al s t o ea t l es s s al t; En vi ro nm en t— su pp or t s et tin gs to p ro m ot e he al th y ea tin g (e .g . s ch oo ls, w or kp la ce s, h os pi ta ls) . 22 9 ht tp s: // w w w .h ea lth yc ar ib be an .o rg /p ah ou sf hc c so ci al m ar ke tin g di et ar y sa lt re du ct io n/ . 71 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 5 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s M SB EC a nd th e Ba rb ad os C ha m be r o f C om m er ce an d In du st ry 23 0 Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 a nd o ffe r i nc en tiv es to p ro du ce rs an d m an uf ac tu re rs fo r r ef or m ul at io n of fo od s a nd be ve ra ge s t o lo w er th ei r s ug ar c on te nt . 2. 1. 4 Re vi ew th e RE PL AC E te ch ni ca l p ac ka ge fo r el im in at io n of tr an s f at re du ct io n, a nd a dv oc at e fo r an d im pl em en t a t l ea st th re e of th e six a re as o f ac tio n, 23 1 M HW , N N CD C, N N C Co ns ul ta tio ns 5 ,0 00 Im pl em en ta tio n 30 ,0 00 in te gr at in g th em in to o th er N CD pr ev en tio n an d co nt ro l s tr at eg ie s a s a pp ro pr ia te . 20 21 2 3 PA HO /W HO 2. 1. 5 De ve lo p an d di ss em in at e m es sa ge s p ro m ot in g in cr ea se d fr ui t a nd v eg et ab le c on su m pt io n us in g m as s a nd so ci al m ed ia . M HW , N N C, M AF S De ve lo pm en t a nd di ss em in at io n of m as s a nd so ci al m ed ia m es sa ge s 30 ,0 00 20 20 2 5 PA HO /W HO , F AO HS FB , H CC Yo ut h gr ou ps 2. 1. 6 Pr om ot e an d su pp or t i m pl em en ta tio n of th e na tio na l f oo d ba se d di et ar y gu id el in es (F BD Gs ) .23 2 M HW , N N C, M AF S FB DG s p ro m ot io n an d im pl em en ta tio n 6, 00 0 20 20 2 5 FA O 2. 1. 7 Co lla bo ra te w ith th e M AF S to im pl em en t m ec ha ni sm s f or in cr ea se d ac ce ss to lo ca l f ru its a nd ve ge ta bl es , i nc lu di ng th ro ug h th e an nu al A gr of es t fa ir an d th e “b uy lo ca l” c am pa ig n. M HW , N N C, M AF S Im pl em en ta tio n 20 ,0 00 20 20 2 5 FA O 2. 1. 8 De ve lo p a lo ca l s ta nd ar d fo r i nt er pr et iv e ‘h ig h in ’ Fo PW L, h ol di ng m ee tin gs w ith re le va nt st ak eh ol de rs ; c on su lti ng , s en sit isi ng , a nd e du ca tin g th e pu bl ic ; d ev el op in g an d su bm itt in g a Ca bi ne t Pa pe r; an d, a s n ee de d, p re se nt in g ev id en ce to M HW , M FA , M AF S, Ba rb ad os N at io na l St an da rd s I ns tit ut e (B N SI ), De pa rt m en t o f C om m er ce an d Co ns um er A ffa irs , N N C 20 20 2 3 PA HO /W HO , F AO 23 0 ht tp s: // w w w .b ar ba do sc ha m be ro fc om m er ce .c om /. 23 1 Re vi ew d ie ta ry so ur ce s o f i nd us tr ia lly p ro du ce d tr an s f at a nd th e la nd sc ap e re qu ire d fo r p ol ic y ch an ge ; P ro m ot e th e re pl ac em en t o f i nd us tr ia lly p ro du ce d tr an s f at w ith he al th ie r f at s a nd o ils ; L eg isl at e or e na ct re gu la to ry a ct io ns to e lim in at e in du st ria lly p ro du ce d tr an s f at ; A ss es s a nd m on ito r t ra ns fa t c on te nt in th e fo od su pp ly a nd c ha ng es in tr an s f at c on su m pt io n in th e po pu la tio n; C re at e aw ar en es s o f t he n eg at iv e he al th im pa ct o f t ra ns fa t a m on g po lic ym ak er s, p ro du ce rs , s up pl ie rs a nd th e pu bl ic ; E nf or ce co m pl ia nc e w ith p ol ic ie s a nd re gu la tio ns . 23 2 ht tp :/ /w w w .fa o. or g/ 3/ I9 68 0E N /i9 68 0e n. pd f. 72 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 6 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s co un te r I nd us tr y ar gu m en ts , a lig ni ng w ith C od ex Al im en ta riu s C om m iss io n st an da rd s, 23 3 W TO A gr ee m en t o n Te ch ni ca l B ar rie rs to T ra de a nd ta ki ng ad va nt ag e of h ea lth s up po rt in g ex em pt io ns to th e 23 4 M ee tin gs w ith st ak eh ol de rs 5 ,0 00 Pu bl ic c on su lta tio ns , se ns iti sa tio n, ed uc at io n2 5, 00 0 (T BT ). 2. 1. 9 Ad vo ca te w ith th e M FA a nd th e M SB EC fo r t he ‘h ig h in ’ F oP W L to b e m an da to ry a nd e nf or ce ab le ; im pl em en t t he st an da rd a nd c on du ct m on ito rin g of its fu lfi llm en t. M HW , M FA , S BE C, B N SI , N N C Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 Im pl em en ta tio n an d m on ito rin g of st an da rd 20 ,0 00 20 20 2 3 PA HO /W HO 2. 1. 10 D ev el op a nd im pl em en t s tr at eg ie s i n nu rs er ie s, pr iv at e pr ac tic es , a nd w or kp la ce st o im pr ov e br ea st m ilk a cc ep ta nc e, in cl ud in g tr ai ni ng o f nu rs er y/ da y ca re o w ne rs a nd o pe ra to rs in b ot h th e pr iv at e an d pu bl ic se ct or , a nd o f p riv at e ph ys ic ia ns . M HW , B N SI Ad vo ca cy , s up po rt , a nd tr ai ni ng 2 0, 00 0 20 20 2 2 Br ea st fe ed in g an d Ch ild N ut rit io n Fo un da tio n (B CN F) U N IC EF , P AH O /W HO 2. 1. 11 E xp lo re a nd su pp or t e xp an sio n of th e Ba by fr ie nd ly H os pi ta l I ni tia tiv e23 5 a nd e xc lu siv e br ea st fe ed in g fo r t he fi rs t s ix m on th s o f l ife to pr iv at e se ct or in st itu tio ns , a lig ne d w ith W HO gu id el in es .23 6, 23 7 M HW , B N SI Ad vo ca cy a nd su pp or t 5, 00 0 20 20 2 2 BC N F U N IC EF , P AH O /W HO 2. 1. 12 Pr om ot e br ea st fe ed in g be ne fit s a nd th e In te rn at io na l C od e of M ar ke tin g of B re as t m ilk Su bs tit ut es 23 8 M HW M as s m ed ia a nd so ci al m ed ia p ro m ot io n 25 ,0 00 a nd su bs eq ue nt re le va nt W HA 20 20 2 5 BC N F U N IC EF , P AH O /W HO 23 3 T ho w A M , J on es A , H aw ke s C , A li I, La bo nt é R. N ut rit io n la be lli ng is a tr ad e po lic y iss ue : l es so ns fr om a n an al ys is of sp ec ifi c tr ad e co nc er ns a t t he W or ld T ra de O rg an iza tio n. He al th P ro m ot In t 2 01 8; 3 3( 4) : 5 61 5 71 . h tt ps :/ /d oi .o rg /1 0. 10 93 /h ea pr o/ da w 10 9. 23 4 ht tp s: // w w w .w to .o rg /e ng lis h/ tr at op e /t bt e /t bt e .h tm . 23 5 ht tp s: // w w w .w ho .in t/ nu tr iti on /b fh i/e n/ . 23 6 W HO . G ui de lin e: p ro te ct in g, p ro m ot in g an d su pp or tin g br ea st fe ed in g in fa ci lit ie s p ro vi di ng m at er ni ty a nd n ew bo rn se rv ic es . G en ev a: W HO ; 2 01 7. ht tp s: // bi t.l y/ 2K 6E jM x. 23 7 W HO . I m pl em en ta tio n gu id an ce : p ro te ct in g, p ro m ot in g an d su pp or tin g br ea st fe ed in g in fa ci lit ie s p ro vi di ng m at er ni ty a nd n ew bo rn se rv ic es — th e re vi se d Ba by fr ie nd ly Ho sp ita l I ni tia tiv e. G en ev a: W HO ; 2 01 8. h tt ps :/ /a pp s. w ho .in t/ iri s/ bi ts tr ea m /h an dl e/ 10 66 5/ 27 29 43 /9 78 92 41 51 38 07 e ng .p df ?u a= 1. 23 8 ht tp s: // w w w .w ho .in t/ nu tr iti on /p ub lic at io ns /c od e en gl ish .p df . 73 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 7 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s re so lu tio ns (T he C od e) , i nc lu di ng th ro ug h an nu al ob se rv an ce o f ‘ Br ea st fe ed in g W ee k’ . 2. 1. 13 A ss es s i m pl em en ta tio n of T he C od e23 9 M HW Co de a ss es sm en t 1 0, 00 0 In te rv en tio ns 2 0, 00 0 a nd de ve lo p an d im pl em en t s el ec te d st ra te gi es to fi ll th e ga ps . 20 20 2 2 BC N F U N IC EF , P AH O /W HO 2. 1. 14 Fi na lis e an d im pl em en tb re as tf ee di ng w or kp la ce po lic y in th e fr am ew or k of th e N at io na l W or kp la ce W el ln es s P ol ic y an d th e In te rn at io na l La bo ur O rg an iza tio n (IL O ) M at er ni ty P ro te ct io n Co nv en tio n (N o. 1 83 ).24 0 M HW , M LS P Co ns ul ta nt /m ee tin gs 5 ,0 00 Po lic y im pl em en ta tio n 15 ,0 00 20 20 2 1 BC N F U N IC EF , P AH O /W HO Co st O PT 2 .1 : U S$ 2 86 ,0 00 2. 2 Im pl em en ta tio n of st ra te gi es a nd in te rv en tio ns fo r ch ild ho od o be si ty pr ev en tio n en ha nc ed . 2. 2. 1 Ad vo ca te fo r a nd im pl em en t p ol ic y fo r r es tr ic tio ns on th e sa le a nd m ar ke tin g of u nh ea lth y co m m od iti es to c hi ld re n. M HW , M SB EC Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 Po lic y im pl em en ta tio n 10 ,0 00 20 20 2 1 HC C, H SF B, B ar ba do s Co al iti on fo r C O P (B CC O P) , U N IC EF , P AH O /W HO Yo ut h gr ou ps 2. 2. 2 Ad vo ca te fo r a nd im pl em en t a b an o n th e sa le a nd m ar ke tin g of S SB s i n an d ar ou nd sc ho ol s. M HW , M ET VT Ad vo ca cy m at er ia ls an d in te rv en tio ns 8 ,0 00 20 20 HC C, H SF B, B CC O P, B ar ba do s As so ci at io n of R et ai le rs , Ve nd or s, a nd E nt re pr en eu rs (B AR VE N ), Yo ut h gr ou ps U N IC EF , P AH O /W HO 2. 2. 3 Co lla bo ra te in th e up da te , f in al isa tio n, di ss em in at io n, a nd im pl em en ta tio n of n ut rit io n gu id el in es sp ec ifi c to th e sc ho ol e nv iro nm en t, in cl ud in g Fr am ew or k fo r F oo d an d N ut rit io n Po lic y in P riv at e an d Pu bl ic N ur se ry , P rim ar y an d Se co nd ar y Sc ho ol s ( in d ra ft) a nd G ui de lin es fo r Ca nt ee n Co nc es sio na ire s ( in d ra ft ), an d in th e im pl em en ta tio n of o th er in te rv en tio ns ta rg et in g ch ild re n, su ch a s q ui zz es a nd c om pe tit io ns re la te d to fo od , n ut rit io n, a nd h ea lth . M HW , M ET VT , N N C Fi na lis at io n an d di ss em in at io n of g ui de lin es 5, 00 0 Im pl em en ta tio n 2 0, 00 0 20 20 2 1 HS FB , B CC O P, B AR VE N , Yo ut h gr ou ps U N IC EF , P AH O /W HO 23 9 N et Co de T oo lk it. M on ito rin g th e m ar ke tin g of b re as t m ilk su bs tit ut es : P ro to co l f or p er io di c as se ss m en t. Ge ne va : W HO ; 2 01 7. h tt ps :/ /b it. ly /3 4L Xe U R. 24 0 ht tp s: // w w w .il o. or g/ gl ob al /a bo ut t he il o/ ne w sr oo m /n ew s/ W CM S 18 63 25 /la ng e n/ in de x. ht m . 74 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 8 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s 2. 2. 4 Ad vo ca te fo r a nd su pp or t t he in tr od uc tio n of m an da to ry p hy sic al a ct iv ity in sc ho ol s. M ET VT , M HW , M in ist ry o f Cr ea tiv e Ec on om y, C ul tu re an d Sp or ts (M CC S) Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 20 20 2 1 Yo ut h gr ou ps U N IC EF , P AH O /W HO HS FB 2. 2. 5 Ad vo ca te fo r a nd su pp or t i m pr ov ed a cc es s t o po ta bl e w at er in sc ho ol s, in cl ud in g th e pl ac em en t of w at er fo un ta in s. M ET VT , M HW , M in ist ry o f En er gy a nd W at er Re so ur ce s ( M EW R) Ad vo ca cy m at er ia ls an d in te rv en tio ns 1 0, 00 0 20 20 2 1 Ba rb ad os M us lim As so ci at io n, H SF B, Y ou th gr ou ps U N IC EF 2. 2. 6 Re vi ew , u pd at e, a nd a pp ly th e He al th a nd F am ily Li fe E du ca tio n (H FL E) c ur ric ul um 24 1 a nd th e Sc ho ol s Po sit iv e Be ha vi ou r M an ag em en t P ro gr am m e24 2 M ET VT , M HW Cu rr ic ul um re vi ew , u pd at e, an d ap pl ic at io n 10 ,0 00 to , re sp ec tiv el y, st re ng th en a nd in cl ud e N CD ri sk re du ct io n, fo cu sin g on h ea lth y nu tr iti on a nd re gu la r p hy sic al a ct iv ity ; p ar tic ip at e in C AR IC O M re gi on al e ffo rt s t o up da te th e HF LE c ur ric ul um . 20 20 2 2 U N IC EF , P AH O /W HO , CA RI CO M S ec re ta ria t, U W I, HS FB , Y ou th g ro up s Co st O PT 2 .2 : U S$ 7 3, 00 0 3. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d fo r in cr ea se d ph ys ic al ac tiv ity . 3. 1. 1 Re vi ew a nd a na ly se th e W HO A CT IV E te ch ni ca l pa ck ag e an d im pl em en t i nt er ve nt io ns fr om a t l ea st th re e of th e fo ur p ol ic y ac tio n ar ea s, 24 3 vi sio n an d re le va nt p rin ci pl es o f th e Ba rb ad os P hy sic al D ev el op m en t P la n 20 17 in te gr at in g th em in to o th er N CD p re ve nt io n an d co nt ro l st ra te gi es a s a pp ro pr ia te , a nd ta ki ng in to co ns id er at io n th e .24 4 M HW , N N CD C, N TF W , To w n an d Co un tr y De ve lo pm en t P la nn in g O ffi ce ; M CC S; N at io na l Sp or ts C ou nc il; M LS P Ad vo ca cy , a na ly sis , a nd co ns ul ta tio ns 1 0, 00 0 Im pl em en ta tio n 25 ,0 00 20 21 2 2 PA HO /W HO HS FB , S po rt s o rg an isa tio ns , Gy m s, Y ou th g ro up s 24 1 ht tp s: // hi vh ea lth cl ea rin gh ou se .u ne sc o. or g/ sit es /d ef au lt/ fil es /r es ou rc es /b ie h fle cu rr ic ul um r eg io na l.p df . 24 2 M ar sh al l I e t a l. M on ito rin g th e im pl em en ta tio n of th e SP BM P in B ar ba do s. J Ed uc a nd D ev C ar ib be an . 2 01 8; 1 7( 1) : 1 61 1 92 . h tt ps :/ /b it. ly /3 3A 9m rU . 24 3 Ac tiv e so ci et ie s— im pl em en t b eh av io ur c ha ng e co m m un ic at io n ca m pa ig ns a nd b ui ld w or kf or ce c ap ac ity to c ha ng e so ci al n or m s; A ct iv e en vi ro nm en ts — pr om ot e sa fe , w el l m ai nt ai ne d in fr as tr uc tu re , f ac ili tie s a nd p ub lic o pe n sp ac es th at p ro vi de e qu ita bl e ac ce ss to p la ce s f or w al ki ng , c yc lin g an d ot he r p hy sic al a ct iv ity ; A ct iv e pe op le — en su re a cc es s to o pp or tu ni tie s, p ro gr am m es , a nd se rv ic es a cr os s m ul tip le se tt in gs to e ng ag e pe op le o f a ll ag es a nd a bi lit ie s i n re gu la r p hy sic al a ct iv ity ; A ct iv e sy st em s— st re ng th en le ad er sh ip , go ve rn an ce , m ul ti se ct or al p ar tn er sh ip s, w or kf or ce , r es ea rc h, a dv oc ac y, a nd in fo rm at io n sy st em s t o su pp or t e ffe ct iv e co or di na te d po lic y im pl em en ta tio n. 24 4 ht tp :/ /w w w .to w np la nn in g. go v. bb /p dp /O ve rv ie w /V isi on . 75 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 9 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s 3. 1. 2 En ha nc e th e im pl em en ta tio n of th e ‘B ar ba do s M ov es ’ a nd ‘G et W om en M ov in g’ in iti at iv es in co m m un iti es a nd a s p ar t o f W or kp la ce W el ln es s in iti at iv es . M HW , N N CD C, N TF W M YC E, M CC S, M LS P Im pl em en ta tio n 15 ,0 00 20 20 2 5 PA HO /W HO HS FB , S po rt s o rg an isa tio ns , Gy m s, Y ou th g ro up s 3. 1. 3 Ad vo ca te fo r, an d ex pl or e th e fe as ib ili ty o f, cr ea tin g sp ac e an d op po rt un ity fo r C ab in et m em be rs to ta ke p ar t i n re gu la r p hy sic al a ct iv ity a s a g ro up , o n th ei r t ur f, gu id ed b y ex pe rt p hy sic al a ct iv ity tr ai ne rs , a s a n ex am pl e to th e pe op le o f B ar ba do s; im pl em en t a s i nd ic at ed , a t l ea st m on th ly . M HW , N N CD C, N TF W Pr im e M in ist er ’s O ffi ce (P M O ) Ca bi ne t O ffi ce Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 Im pl em en ta tio n 10 ,0 00 20 20 2 5 Sp or ts o rg an isa tio ns , G ym s Co st O PT 3 .1 : U S$ 6 5, 00 0 4. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to re du ce th e ha rm fu l us e of a lc oh ol . 4. 1. 1 U nd er ta ke a p ub lic o pi ni on p ol l t o in fo rm a dv oc ac y fo r t he im pl em en ta tio n of th e fiv e hi gh im pa ct st ra te gi es o f t he W HO S AF ER te ch ni ca l p ac ka ge fo r al co ho l h ar m re du ct io n. 24 5 M HW Im pl em en ta tio n of p ol l 20 ,0 00 20 20 2 1 PA HO /W HO HS FB , H CC 4. 1. 2 Ba se d on th e re su lts o f t he p ub lic o pi ni on p ol l, ad vo ca te w ith th e M FE I, M IB P, a nd o th er re le va nt m in ist rie s, an d co lla bo ra te w ith P AH O /W HO , t o im pl em en t a t l ea st th re e of th e fiv e hi gh im pa ct st ra te gi es fo r a lc oh ol h ar m re du ct io n, fo cu sin g on in cr ea se d ta xa tio n, p ric in g po lic ie s, an d en fo rc em en t o f b an s/ co m pr eh en siv e re st ric tio ns on a lc oh ol a dv er tis in g, sp on so rs hi p, a nd pr om ot io n, w ith in te gr at io n in to o th er N CD pr ev en tio n an d co nt ro l s tr at eg ie s a s a pp ro pr ia te . M HW , N N CD C Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 Im pl em en ta tio n 25 ,0 00 20 21 2 2 PA HO /W HO HC C Pr of es sio na l a ss oc ia tio ns Yo ut h gr ou ps He al th s up po rt in g pr iv at e se ct or (P S) 4. 1. 3 Co lla bo ra te w ith th e Ba rb ad os R oy al P ol ic e Fo rc e an d th e M in ist ry o f W or ks a nd M ai nt en an ce (M TW M ) t o m on ito r t he im pa ct o f b re at ha ly se r te st in g on a lc oh ol r el at ed ro ad tr af fic in ju rie s. M HW , N N CD C M on ito rin g m ec ha ni sm s 5, 00 0 20 20 2 5 PA HO /W HO HC C He al th s up po rt in g PS 4. 1. 4 De ve lo p an d di ss em in at e m es sa ge s t hr ou gh m as s M HW , N N CD C, M TW M , 20 20 2 5 HC C 24 5 St re ng th en re st ric tio ns o n al co ho l a va ila bi lit y; A dv an ce a nd e nf or ce d rin k dr iv in g co un te r m ea su re s; F ac ili ta te a cc es s t o sc re en in g, b rie f i nt er ve nt io ns , a nd tr ea tm en t; En fo rc e ba ns /c om pr eh en siv e re st ric tio ns o n al co ho l a dv er tis in g, sp on so rs hi ps , a nd p ro m ot io n; R ai se p ric es o n al co ho l t hr ou gh e xc ise ta xe s a nd p ric in g po lic ie s. 76 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 8 9 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s 3. 1. 2 En ha nc e th e im pl em en ta tio n of th e ‘B ar ba do s M ov es ’ a nd ‘G et W om en M ov in g’ in iti at iv es in co m m un iti es a nd a s p ar t o f W or kp la ce W el ln es s in iti at iv es . M HW , N N CD C, N TF W M YC E, M CC S, M LS P Im pl em en ta tio n 15 ,0 00 20 20 2 5 PA HO /W HO HS FB , S po rt s o rg an isa tio ns , Gy m s, Y ou th g ro up s 3. 1. 3 Ad vo ca te fo r, an d ex pl or e th e fe as ib ili ty o f, cr ea tin g sp ac e an d op po rt un ity fo r C ab in et m em be rs to ta ke p ar t i n re gu la r p hy sic al a ct iv ity a s a g ro up , o n th ei r t ur f, gu id ed b y ex pe rt p hy sic al a ct iv ity tr ai ne rs , a s a n ex am pl e to th e pe op le o f B ar ba do s; im pl em en t a s i nd ic at ed , a t l ea st m on th ly . M HW , N N CD C, N TF W Pr im e M in ist er ’s O ffi ce (P M O ) Ca bi ne t O ffi ce Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 Im pl em en ta tio n 10 ,0 00 20 20 2 5 Sp or ts o rg an isa tio ns , G ym s Co st O PT 3 .1 : U S$ 6 5, 00 0 4. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to re du ce th e ha rm fu l us e of a lc oh ol . 4. 1. 1 U nd er ta ke a p ub lic o pi ni on p ol l t o in fo rm a dv oc ac y fo r t he im pl em en ta tio n of th e fiv e hi gh im pa ct st ra te gi es o f t he W HO S AF ER te ch ni ca l p ac ka ge fo r al co ho l h ar m re du ct io n. 24 5 M HW Im pl em en ta tio n of p ol l 20 ,0 00 20 20 2 1 PA HO /W HO HS FB , H CC 4. 1. 2 Ba se d on th e re su lts o f t he p ub lic o pi ni on p ol l, ad vo ca te w ith th e M FE I, M IB P, a nd o th er re le va nt m in ist rie s, an d co lla bo ra te w ith P AH O /W HO , t o im pl em en t a t l ea st th re e of th e fiv e hi gh im pa ct st ra te gi es fo r a lc oh ol h ar m re du ct io n, fo cu sin g on in cr ea se d ta xa tio n, p ric in g po lic ie s, an d en fo rc em en t o f b an s/ co m pr eh en siv e re st ric tio ns on a lc oh ol a dv er tis in g, sp on so rs hi p, a nd pr om ot io n, w ith in te gr at io n in to o th er N CD pr ev en tio n an d co nt ro l s tr at eg ie s a s a pp ro pr ia te . M HW , N N CD C Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 Im pl em en ta tio n 25 ,0 00 20 21 2 2 PA HO /W HO HC C Pr of es sio na l a ss oc ia tio ns Yo ut h gr ou ps He al th s up po rt in g pr iv at e se ct or (P S) 4. 1. 3 Co lla bo ra te w ith th e Ba rb ad os R oy al P ol ic e Fo rc e an d th e M in ist ry o f W or ks a nd M ai nt en an ce (M TW M ) t o m on ito r t he im pa ct o f b re at ha ly se r te st in g on a lc oh ol r el at ed ro ad tr af fic in ju rie s. M HW , N N CD C M on ito rin g m ec ha ni sm s 5, 00 0 20 20 2 5 PA HO /W HO HC C He al th s up po rt in g PS 4. 1. 4 De ve lo p an d di ss em in at e m es sa ge s t hr ou gh m as s M HW , N N CD C, M TW M , 20 20 2 5 HC C 24 5 St re ng th en re st ric tio ns o n al co ho l a va ila bi lit y; A dv an ce a nd e nf or ce d rin k dr iv in g co un te r m ea su re s; F ac ili ta te a cc es s t o sc re en in g, b rie f i nt er ve nt io ns , a nd tr ea tm en t; En fo rc e ba ns /c om pr eh en siv e re st ric tio ns o n al co ho l a dv er tis in g, sp on so rs hi ps , a nd p ro m ot io n; R ai se p ric es o n al co ho l t hr ou gh e xc ise ta xe s a nd p ric in g po lic ie s. 77 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 0 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s an d so ci al m ed ia to re du ce th e im pa ct o f m ar ke tin g of a lc oh ol ic b ev er ag es , p ar tic ul ar ly o n ad ol es ce nt s an d yo ut h, in cl ud in g an nu al o bs er va nc e of Ca rib be an A lc oh ol R ed uc tio n Da y (C AR D) . M in ist ry o f Y ou th a nd Co m m un ity E m po w er m en t (M YC E) M ed ia m es sa ge s a nd C AR D ob se rv at io n 20 ,0 00 An nu al ly in N ov em be r PA HO /W HO , U N IC EF Yo ut h gr ou ps He al th s up po rt in g PS 4. 1. 5 Es ta bl ish a su rv ei lla nc e sy st em to tr ac k al co ho l re la te d m or bi di ty a nd m or ta lit y, in cl ud in g in y ou ng pe op le . M HW , M TW M , B N R Ex pa ns io n of B N R ca pa bi lit y 25 ,0 00 20 22 2 5 PA HO /W HO , U N IC EF CA RP HA Yo ut h gr ou ps Co st o f O PT 4 .1 : U S$ 1 00 ,0 00 5. 1 In te rv en tio ns im pl em en te d to re du ce h ig h bl oo d pr es su re a nd im pr ov e sc re en in g fo r, an d in te gr at ed m an ag em en t o f, CV D, di ab et es , c hr on ic re sp ira to ry d ise as es , an d ca nc er a t t he fi rs t le ve l o f c ar e, ta ki ng m ul ti m or bi di ty in to co ns id er at io n. 5. 1. 1 Re vi ew a nd u pd at e pr ot oc ol s f or th e m an ag em en t of h yp er te ns io n, e xp lo rin g al ig nm en t w ith b ot h th e HE AR TS te ch ni ca l p ac ka ge 24 6 a nd th e U ni te d Ki ng do m N at io na l I ns tit ut e of C ar e an d Ex ce lle nc e (N IC E) 2 01 9 ar tic le 24 7 a nd in fo gr ap hi c; 24 8 M HW Co ns ul ta tio ns 5 ,0 00 Tr ai ni ng 2 0, 00 0 tr ai n re le va nt st af f i n al l p ol yc lin ic s i n th e ap pl ic at io n of th e up da te d hy pe rt en sio n m an ag em en t p ro to co l. 20 20 2 1 PA HO /W HO HS FB Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 5. 1. 2 Re vi ew th e HE AR TS te ch ni ca l p ac ka ge fo r C VD m an ag em en t, an d im pl em en t a t l ea st fi ve o f t he si x el em en ts ,24 9 in te gr at in g th em in to o th er N CD pr ev en tio n an d co nt ro l s tr at eg ie s a s a pp ro pr ia te .25 0 M HW Co ns ul ta tio ns a nd im pl em en ta tio n co st s in cl ud ed w ith A ct iv ity 5. 1. 1. 20 20 2 1 PA HO /W HO HS FB Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 5. 1. 3 Re vi ew a nd u pd at e pr ot oc ol fo r t he m an ag em en t of T yp e 2 di ab et es , a lig ne d w ith th e HE AR TS te ch ni ca l p ac ka ge a nd in cl ud in g pr ev en tiv e fo ot ca re a nd , r et in op at hy sc re en in g; tr ai n re le va nt st af f M HW Co ns ul ta tio ns 5 ,0 00 Tr ai ni ng 2 0, 00 0 20 20 2 1 PA HO /W HO BD F, D AB Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 24 6 T he W HO T oo l f or th e de ve lo pm en t o f a c on se ns us p ro to co l f or tr ea tm en t o f h yp er te ns io n (2 01 8) is a va ila bl e at h tt ps :/ /b it. ly /2 Cv zo ki . 24 7 B of fa R J, Co ns ta nt i M , F lo yd C N , W ie rz bi ck i A S on b eh al f o f t he G ui de lin e Co m m itt ee . H yp er te ns io n in a du lts : s um m ar y of u pd at ed N IC E gu id an ce . B M J 2 01 9; 3 67 : I 53 10 . ht tp s: // do i.o rg /1 0. 11 36 /b m j.l 53 10 . 24 8 ht tp s: // w w w .b m j.c om /c on te nt /3 67 /b m j.l 53 10 /in fo gr ap hi c. 24 9 He al th y lif es ty le — co un se lli ng o n to ba cc o ce ss at io n, d ie t, ph ys ic al a ct iv ity , a lc oh ol u se , a nd se lf ca re ; E vi de nc e ba se d tr ea tm en t p ro to co ls— sim pl e st an da rd ise d al go rit hm s f or cl in ic al c ar e; A cc es s t o es se nt ia l m ed ic in es a nd te ch no lo gy — ac ce ss to a c or e se t o f a ffo rd ab le m ed ic in es a nd b as ic te ch no lo gy ; R isk b as ed m an ag em en t— to ta l c ar di ov as cu la r as se ss m en t, tr ea tm en t a nd re fe rr al ; T ea m c ar e an d ta sk s ha rin g— de ce nt ra lis ed , c om m un ity b as ed a nd p at ie nt c en tr ed c ar e; S ys te m s f or m on ito rin g— pa tie nt d at a co lle ct io n an d pr og ra m m e ev al ua tio n. 25 0 T he H EA RT S te ch ni ca l m od ul es a nd Im pl em en ta tio n Gu id e ar e av ai la bl e at h tt ps :/ /b it. ly /3 6Q yZ GK . 78 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 1 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s in a ll po ly cl in ic s i n th e ap pl ic at io n of th e up da te d pr ot oc ol . 5. 1. 4 Re vi ew a nd u pd at e pr ot oc ol fo r t he m an ag em en t of c hr on ic re sp ira to ry d ise as es — as th m a an d CO PD ; tr ai n re le va nt st af f i n al l p ol yc lin ic s a nd in th e Q EH Ac ci de nt a nd E m er ge nc y De pa rt m en t i n th e ap pl ic at io n of th e up da te d pr ot oc ol . M HW Co ns ul ta tio ns 5 ,0 00 Tr ai ni ng 1 5, 00 0 20 21 2 2 PA HO /W HO As th m a As so ci at io n of Ba rb ad os (A AB ) 5. 1. 5 Co nd uc t c os t a na ly sis st ud y re ga rd in g th e in tr od uc tio n of se as on al in flu en za v ac ci ne in to pr ot oc ol s f or m an ag em en t o f T yp e 2 di ab et es ,a t le as t f or p er so ns a bo ve 6 5 or u nd er 1 6 ye ar s o f ag e, an d fo r C O PD fo r p er so ns a bo ve 6 5 ye ar s o f ag e, to in fo rm re le va nt d ec isi on m ak in g. M HW , B DS Co st a na ly sis st ud y 8, 00 0 20 20 2 1 PA HO /W HO DA B, B DF , A AB 5. 1. 6 U pd at e an d w id el y di ss em in at e ev id en ce b as ed pr ot oc ol s f or sc re en in g fo r b re as t, ce rv ic al , a nd co lo r ec ta l c an ce rs , e m ph as isi ng h ig h ris k an d vu ln er ab le g ro up s, in cl ud in g a ca ll an d re ca ll sy st em b as ed o n th e el ec tr on ic m ed ic al re co rd s sy st em , M ed Da ta .25 1 M HW Co ns ul ta tio ns 5 ,0 00 Pr ot oc ol a nd sy st em de ve lo pm en t 2 0, 00 0 20 22 2 4 PA HO /W HO BC S, C SS Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 5. 1. 7 Tr ai n re le va nt st af f i n al l p ol yc lin ic s i n th e ap pl ic at io n of th e up da te d ca nc er sc re en in g pr ot oc ol s a nd o ffe r t he tr ai ni ng to N GO s a nd pr iv at e pr ov id er s t ha t o ffe r s cr ee ni ng se rv ic es , in cl ud in g th ro ug h m ed ic al a nd n ur sin g pr of es sio na l as so ci at io ns . M HW Tr ai ni ng 2 5, 00 0 20 22 2 4 PA HO /W HO Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 5. 1. 8 Id en tif y pr ov id er s o f m am m og ra ph y sc re en in g in th e pu bl ic a nd p riv at e se ct or s, a nd c on du ct a st ud y to d et er m in e th e nu m be r o f w om en a ge d 50 6 9 ye ar s s cr ee ne d by m am m og ra ph y ov er th e pe rio d 20 15 2 01 9. M HW , B NR St ud y 8, 00 0 20 20 PA HO /W HO BC S, C SS He al th s up po rt in g PS 5. 1. 9 Pr oc ur e or p ro du ce , d iss em in at e, a nd h av e av ai la bl e in a ll po ly cl in ic s p rin te d an d au di ov isu al M HW M at er ia ls 5, 00 0 20 20 2 1 PA HO /W HO BC S, C SS 25 1 In fo rm at io n on c an ce r s cr ee ni ng is a va ila bl e fr om si te s s uc h as th e N at io na l C an ce r I ns tit ut e ht tp s: // w w w .c an ce r.g ov /a bo ut c an ce r/ sc re en in g/ sc re en in g te st s 79 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 2 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s in fo rm at io n on p ro st at e ca nc er a nd re la te d sc re en in g, e m ph as isi ng g ro up s a t h ig he r r isk o f de ve lo pi ng th e di se as e. He al th s up po rt in g PS 5. 1. 10 A ss es s t he a va ila bi lit y of h om e a nd n on Q EH ba se d in st itu tio na l p al lia tiv e ca re , i nc lu di ng fo r N CD s o th er th an c an ce r, an d de ve lo p st ra te gi es to ad dr es s t he g ap s, in cl ud in g tr ai ni ng o f a lli ed h ea lth pr of es sio na ls, c om m un ity w or ke rs , a nd fa m ily m em be rs . M HW As se ss m en t 1 0, 00 0 Im pl em en ta tio n, in cl ud in g tr ai ni ng 3 5, 00 0 20 24 2 5 PA HO /W HO BA PC , C SS , F BO s Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 5. 1. 11 D ev el op a st an da rd ise d m od el fo r p at ie nt se lf ca re /s el f-m an ag em en t, ba se d on th e fiv e ‘c ha ng es fo r i m pr ov em en t’25 2 id en tif ie d in th e In st itu te fo r He al th ca re Im pr ov em en t’s c hr on ic c ar e m od el ; t he th re e ac tio ns in th e CA RI CO M C CM P ol ic y an d M od el o f C ar e; 25 3 an d th e St an fo rd U ni ve rs ity Ch ro ni c Di se as e Se lf M an ag em en t P ro gr am m e (C DS M P) ,25 4 M HW Co ns ul ta nt , c on su lta tio ns , de ve lo pm en t o f m od el 20 ,0 00 em ph as isi ng a sp ec ts re la te d to o ld er pe rs on s a nd m ul ti m or bi di ty . 20 24 2 5 PA HO /W HO HS FB , D AB , B DF , B CS , C SS Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 5. 1. 12 S up po rt th e im pl em en ta tio n of th e st an da rd ise d m od el fo r p at ie nt se lf ca re /s el f-m an ag em en t i n al l po ly cl in ic s a nd in o th er h ea lth fa ci lit ie s, in cl ud in g tr ai ni ng o f h ea lth c ar e pr ov id er s. M HW Im pl em en ta tio n 35 ,0 00 20 24 2 5 PA HO /W HO HS FB , D AB , B DF , B CS , C SS 5. 1. 13 H ol d di sc us sio ns w ith tr ai ni ng in st itu tio ns re ga rd in g cu rr ic ul um re vi sio n fo r h ea lth a nd a lli ed he al th p ro fe ss io na ls to im pr ov e m an ag em en t o f N CD s a t t he fi rs t l ev el o f c ar e, ta ki ng in to co ns id er at io n m ul ti m or bi di ty a nd th e ne ed s o f ol de r p er so ns a nd P LW N CD s; re vi se a nd im pl em en t M HW , M ET VT , B CC Cu rr ic ul um re vi sio n an d im pl em en ta tio n 20 ,0 00 20 21 2 5 U W I, PA HO /W HO , As so ci at io n of C ar ib be an Te rt ia ry In st itu tio ns (A CT I) 25 2 T ra in p ro vi de rs a nd o th er k ey st af f o n ho w to h el p pa tie nt s w ith se lf m an ag em en t g oa ls; u se se lf m an ag em en t t oo ls th at a re b as ed o n ev id en ce o f e ffe ct iv en es s; u se g ro up vi sit to su pp or t s el f-m an ag em en t s et a nd d oc um en t s el f-m an ag em en t g oa ls co lla bo ra tiv el y w ith p at ie nt s; fo llo w u p an d m on ito r s el f-m an ag em en t go al s. ht tp :/ /w w w .ih i.o rg /r es ou rc es /P ag es /C ha ng es /S el fM an ag em en t.a sp x. 25 3 E m ph as ise th e pa tie nt ’s c en tr al ro le in m an ag in g hi s/ he r h ea lth ; u se e ffe ct iv e se lf m an ag em en t s up po rt st ra te gi es th at in cl ud e go al se tt in g, a ct io n pl an ni ng , a nd p ro bl em so lv in g; o rg an ise in te rn al a nd c om m un ity re so ur ce to p ro vi de o ng oi ng se lf m an ag em en t s up po rt to p at ie nt s. ht tp s: // bi t.l y/ 2N O So iE (p ag e 10 ). 25 4 ht tp s: // w w w .s el fm an ag em en tr es ou rc e. co m /p ro gr am s/ sm al l-g ro up /c hr on ic d ise as e se lf m an ag em en t/ . 80 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 3 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s th e up da te d cu rr ic ul a. Co st O PT 5 .1 : U S$ 2 61 ,0 00 6. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to pr om ot e an d st re ng th en m ul ti se ct or al w or k an d pa rt ne rs hi ps fo r N CD pr ev en tio n an d co nt ro l. 6. 1. 1 En su re c ol la bo ra tio n am on g ke y m in ist rie s i n im pl em en tin g th e N at io na l W or kp la ce W el ln es s Po lic y; im pr ov in g th e sc ho ol fo od e nv iro nm en t; an d im pr ov in g ac ce ss to h ea lth y fo od . N N CD C, M HW , M LS P, M ET VT , M AF S Co ns ul ta tio ns 5 ,0 00 20 20 2 5 PA HO /W HO Pr of es sio na l a ss oc ia tio ns He al th s up po rt in g PS 6. 1. 2 Id en tif y an d an al ys e th e to p fiv e po lic y pr io rit ie s o f th e M ET VT , M AF S, a nd M YC E, to d et er m in e th ei r he al th im pa ct a nd a re as o f c om m on al ity w ith he al th ; d ev el op c om m on o bj ec tiv es a nd co lla bo ra tiv e st ra te gi es , i nc lu di ng p oo lin g of re so ur ce s o r r es ou rc e m ob ili sa tio n, to fa ci lit at e a Hi AP a pp ro ac h an d ac hi ev e co b en ef its . M HW , M ET VT , M AF S, M YC E Co ns ul ta nt , a na ly sis , a nd de ve lo pm en t o f H iA P pl an 10 ,0 00 20 21 2 2 PA HO /W HO , U N S ub re gi on al Te am , U N IA TF 6. 1. 3 Ad vo ca te w ith th e M LS P fo r N CD p re ve nt io n an d co nt ro l t o be a st an di ng it em o n th e ag en da o f t he So ci al P ar tn er sh ip , a lig ne d w ith P ro to co l V I o f t he Pa rt ne rs hi p, a nd c ol la bo ra te in p la nn in g an d ex ec ut in g in te rv en tio ns a gr ee d w ith th e Pa rt ne rs hi p. M HW , N N CD C M ee tin g su pp or t 2 ,0 00 Im pl em en ta tio n 5, 00 0 20 20 PA HO /W HO , U N S ub re gi on al Te am , U N IA TF 6. 1. 4 Li ai se w ith th e Ca bi ne t S ub c om m itt ee o n N CD s t o di sc us s a nd id en tif y op po rt un iti es fo r a dv oc ac y to su pp or t p ol ic y de ve lo pm en t a nd re so ur ce m ob ili sa tio n fo r N CD p re ve nt io n an d co nt ro l. M HW , N N CD C M ee tin gs su pp or t 3 ,0 00 20 20 2 5 PA HO /W HO , U N S ub re gi on al Te am , U N IA TF 6. 1. 5 Bu ild N N CD C an d NW TF c ap ac ity , i nc lu di ng in rig ht s ba se d an d Hi AP a pp ro ac he s; m an ag em en t o f Co I; pr in ci pl es o f p ro gr am p la nn in g, im pl em en ta tio n, m on ito rin g, a nd e va lu at io n; a nd th e pr io rit y ar ea s o f f oc us o f t he N SP N CD 2 0 25 . M HW Tr ai ni ng 1 0, 00 0 20 20 2 5 PA HO /W HO U N S ub re gi on al T ea m , U N IA TF 6. 1. 6 Id en tif y op po rt un iti es a nd im pl em en t a ct io ns th at pr ov id e gr ea te r v isi bi lit y fo r t he N N CD C an d N W TF , an d th at sh ow ca se th ei r w or k an d ac hi ev em en ts to ke y st ak eh ol de rs , i nc lu di ng th e pu bl ic . M HW , N N CD C, N W TF , M IP B Pr om ot io n/ pu bl ic re la tio ns m at er ia ls an d ve nu es 15 ,0 00 20 20 2 5 PA HO /W HO , U N S ub re gi on al Te am , U N IA TF He al th s up po rt in g PS 6. 1. 7 Id en tif y N GO s t o be in vo lv ed in c ol la bo ra tio n w ith M HW , N N CD C 20 21 2 2 PA HO /W HO , U N S ub re gi on al 81 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 4 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s th e M HW fo r N CD p re ve nt io n an d co nt ro l, de ve lo p a m em or an du m o f u nd er st an di ng o r o th er co lla bo ra tiv e in st ru m en t w ith th em , i de nt ify so ur ce s o f f un di ng a nd st ra te gi es fo r r es ou rc e m ob ili sa tio n, a nd e st ab lis h a fu nc tio ni ng N GO en ga ge m en t m ec ha ni sm in th e M HW . N GO e ng ag em en t s up po rt 15 ,0 00 Te am , U N IA TF 6. 1. 8 Ex pl or e pa rt ne rs hi ps , a lli an ce s, a nd re so ur ce m ob ili sa tio n w ith th e di as po ra to su pp or t a nd ex ec ut e N SP N CD 2 0 25 a ct iv iti es th ro ug h th e “W e Ga th er in ’” in iti at iv e ta ki ng p la ce in B ar ba do s i n 20 20 . M HW , M FA , N N CD C, N TW F (In k in d) PA HO /W HO , U N S ub re gi on al Te am , U N IA TF HC C Co st O PT 6 .1 : U S$ 6 5, 00 0 7. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to im pr ov e re so ur ce al lo ca tio n an d m ob ili sa tio n (fi na nc ia l a nd h um an re so ur ce s) to st re ng th en th e N CD pr og ra m m e an d fa ci lit at e ex ec ut io n of th e N SP N CD 2 0 25 . 7. 1. 1 U nd er ta ke e vi de nc e ba se d ad vo ca cy w ith th e Ca bi ne t S ub c om m itt ee o n N CD s, in cl ud in g th e us e of in fo rm at io n fr om th e 20 15 In ve st m en t C as e fo r N CD P re ve nt io n an d Co nt ro l i n Ba rb ad os a nd de ve lo pm en t o f G re en a nd W hi te P ap er s f or su bm iss io n to C ab in et /P ar lia m en t, to ju st ify a nd re qu es t i nc re as es in st af fin g in th e N CD U ni t a nd in al lo ca tio n of fi na nc ia l r es ou rc es to th e M HW fo r th e N CD p ro gr am m e. M HW , N N CD C, M FE I, PM O Ad vo ca cy m at er ia ls an d in te rv en tio ns 5 ,0 00 20 20 2 1 PA HO /W HO , U N S ub re gi on al Te am , U N IA TF CD B, ID B 7. 1. 2 De ve lo p an d su bm it to a pp ro pr ia te fu nd in g ag en ci es p ro je ct p ro po sa ls to su pp or t e xe cu tio n of th e N SP N CD 2 0 25 , i nc lu di ng to U N IA TF fo r a n FC TC n ee ds a ss es sm en t a nd o th er re co m m en da tio ns fr om th e 20 15 U N IA TF Jo in t M iss io n; to U ND P fo r a fo llo w u p st ud y to th e 20 15 N CD In ve st m en t C as e; to P AH O /W HO re ga rd in g st re ng th en in g IS 4H ; a nd to in te rn at io na l f in an ci ng in st itu tio ns fo r o th er o ut pu ts o f t he N SP , o bt ai ni ng bu y in a nd su pp or t f ro m th e Ca bi ne t S ub co m m itt ee o n N CD s w he re a pp ro pr ia te to a dd cr ed en ce to th e ef fo rt s. M HW , N N CD C De ve lo pm en t o f p ro je ct pr op os al s 5 ,0 00 20 20 2 4 PA HO /W HO , U N S ub re gi on al Te am , U N IA TF CD B, ID B 7. 1. 3 Ex pl or e op po rt un iti es , a nd d ev el op a nd su bm it M HW , N N CD C, M AF S 20 20 2 4 PA HO /W HO , U N S ub re gi on al 82 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 5 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s pr op os al s f or fu nd in g to th e Gr ee n Cl im at e Fu nd ,25 5 W HO S pe ci al In iti at iv e on Cl im at e Ch an ge a nd H ea lth in S ID S ad dr es sin g th e im pa ct o f c lim at e ch an ge o n N CD s, in c ol la bo ra tio n w ith th e Ca bi ne t S ub c om m itt ee on N CD s, an d/ or M AF S an d/ or M EW R, in th e fr am ew or ks o f t he 25 6 Ca rib be an A ct io n Pl an o n He al th a nd Cl im at e Ch an ge a nd th e re la te d .25 7 De ve lo pm en t o f p ro je ct pr op os al s 5 ,0 00 Te am , U N IA TF CD B, ID B Co st O PT 7 .1 : U S$ 1 5, 00 0 8. 1C om m un ic at io n st ra te gi es d ev el op ed an d im pl em en te d to pr om ot e th e N SP N CD 20 2 5 an d en ab le N CD ris k fa ct or re du ct io n an d im pr ov ed m an ag em en t o f N CD s. 8. 1. 1 De ve lo p an d im pl em en t m as s m ed ia a nd so ci al m ed ia c am pa ig ns re la te d to th e m ai n N CD ri sk fa ct or s, m an ag em en t o f t he m aj or N CD s, an d th e sp ec ifi c ou tc om es a nd o ut pu ts o f t he N SP N CD 2 0 25 , e ns ur in g th e ap pr op ria te in vo lv em en t o f ch ild re n an d yo ut h, e sp ec ia lly fo r C O P, a nd o f PL W N CD s. M HW , M IB P, N N CD C M as s a nd so ci al m ed ia ca m pa ig ns 1 00 ,0 00 20 20 2 5 HC C, Y ou th g ro up s, HS FB , DA B, B DF , B CS , C SS , F BO s He al th s up po rt in g PS 8. 1. 2 De ve lo p an d di ss em in at e, in cl ud in g el ec tr on ic al ly , a su m m ar y br oc hu re o f t he N SP N CD 2 0 25 to pr om ot e th e N SP a nd fa ci lit at e ad vo ca cy a nd re so ur ce m ob ili sa tio n; u nd er ta ke a n of fic ia l l au nc h of th e N SP ; a nd e ns ur e th at b ot h th e su m m ar y br oc hu re a nd th e N SP it se lf ar e po st ed o n th e M HW w eb sit e. M HW , N N CD C, C ab in et Su b co m m itt ee o n N CD s Br oc hu re d ev el op m en t an d pr in tin g 8, 00 0 La un ch o f t he N SP 3 ,0 00 20 20 PA HO /W HO 8. 1. 3 Co nd uc t h ig h le ve l a dv oc ac y na tio na lly , r eg io na lly , an d in te rn at io na lly to p ro m ot e th e N SP N CD 2 0 25 an d fa ci lit at e re so ur ce m ob ili sa tio n. M HW , N N CD C, M in ist ry o f Fo re ig n Af fa irs a nd F or ei gn Tr ad e (M FA ) Su pp or t f or a dv oc ac y in te rv en tio ns 8 ,0 00 20 20 2 4 PA HO /W HO , U N IC EF , U ND P, U N su br eg io na l T ea m , U N IA TF HC C, N GO s 8. 1. 4 Pr om ot e an d en co ur ag e th e de ve lo pm en t o f C SO co al iti on s, in cl ud in g of y ou th a nd P LW N CD s, to ad vo ca te fo r N CD p re ve nt io n an d co nt ro l, an d th e M HW , N N CD C, M ET VT Su pp or t f or co al iti on s/ ad vo ca cy 1 0, 00 0 20 20 2 1 HS FB , H CC , N GO s 25 5 ht tp s: // w w w .g re en cl im at e. fu nd /h om e. 25 6 ht tp s: // w w w .w ho .in t/ gl ob al ch an ge /s id s in iti at iv e/ 18 06 12 g lo ba l in iti at iv e sid s cl ea n v2 .p df ?u a= 1; . 25 7 ht tp :/ /ir is. pa ho .o rg /x m lu i/b its tr ea m /h an dl e/ 12 34 56 78 9/ 38 56 6/ PA H O CD E1 90 07 e ng .p df ?s eq ue nc e= 19 . 83 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 6 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s ex ec ut io n of th e N SP N CD 2 0 25 . 8. 1. 5 O bs er ve C ar ib be an W el ln es s D ay a nn ua lly , in vo lv in g se ct or s o th er th an h ea lth , c iv il so ci et y, an d th e he al th s up po rt in g pr iv at e se ct or . M HW CW D ob se rv an ce 7 5, 00 0 20 20 2 5 an nu al ly HC C, H SF B, D AB , B DF , B CS , CS S, B CC I PA HO /W HO , C AR PH A Co st O PT 8 .1 : U S$ 2 04 ,0 00 9. 1 St ra te gi es a nd m ec ha ni sm s im pl em en te d to st re ng th en N CD su rv ei lla nc e an d re se ar ch , i nc lu di ng as se ss m en t o f m ul ti m or bi di ty . 9. 1. 1 De ve lo p a fr am ew or k ou tli ni ng le gi sla tiv e ne ed s an d ke y in fo rm at io n ne ed ed fo r m or e co m pr eh en siv e N CD su rv ei lla nc e an d re se ar ch to m on ito r t re nd s a nd m ul ti m or bi di tie s i n N CD pr ev en tio n an d co nt ro l, tr ac k ou tc om es o f t he N SP N CD 2 0 25 , a nd fa ci lit at e in te rn at io na l r ep or tin g, id en tif yi ng c rit ic al su rv ey s/ st ud ie s, ti m el in es , so ur ce s, an d ac to rs a nd re so ur ce s. M HW , N N CD C Fr am ew or k de ve lo pm en t 5, 00 0 20 20 PA HO /W HO , C AR PH A 9. 1. 2 Co nd uc t G YT S, G SH S, H oT N S/ ST EP S, a nd fo llo w u p to th e 20 15 In ve st m en t C as e fo r N CD P re ve nt io n an d Co nt ro l, en su rin g th e in cl us io n of th e us e of e ci ga re tt es /v ap in g in th e su rv ey s, an d pr od uc e an d pu bl ish re po rt s o n th e re su lts w ith in a y ea r o f co m pl et io n of d at a co lle ct io n, a s w el l a s a nn ua l BN R re po rt s o n tr en ds in C VD , d ia be te s, a nd ca nc er . M HW , G A CD RC , B N R Im pl em en ta tio n an d re po rt in g on su rv ey s/ st ud ie s 1 50 ,0 00 20 20 2 5 PA HO /W HO , C AR PH A 9. 1. 3 En su re d isa gg re ga tio n of d at a by k ey v ar ia bl es — at m in im um a ge , s ex , e th ni ci ty , g eo gr ap hi c lo ca tio n, an d so ci oe co no m ic st at us — to fa ci lit at e id en tif ic at io n of in eq ui tie s a nd g ap s, a nd de ve lo pm en t o f s tr at eg ie s t o ad dr es s t he m . M HW , G A CD RC , B N R Sy st em a dj us tm en ts fo r ad di tio na l a na ly sis 5 ,0 00 20 20 2 5 PA HO /W HO , C AR PH A 9. 1. 4 As se ss th e fu nc tio ni ng o f t he e le ct ro ni c m ed ic al re co rd sy st em (M ed Da ta ) i n th e po ly cl in ic s a nd su pp or t t he im pl em en ta tio n of a ll m od ul es in a ll po ly cl in ic s, w ith ti m el y da ta c ol le ct io n, a na ly sis , an d us e of in fo rm at io n fo r d ec isi on m ak in g. M HW , G A CD RC , B N R As se ss m en t a nd e xp an sio n 30 ,0 00 20 21 2 3 PA HO /W HO , C AR PH A 9. 1. 5 Ho ld d isc us sio ns w ith th e Ba rb ad os A ss oc ia tio n of M ed ic al P ra ct iti on er s ( BA M P) , o th er g ro up in gs o f pr iv at e he al th c ar e pr ov id er s, a nd p riv at e ho sp ita ls M HW , G A CD RC , B N R M ee tin g co st s 5 ,0 00 20 20 2 1 PA HO /W HO , C AR PH A 84 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 9 7 of 1 34 O PT s/ ER s M ai n ac tiv iti es In pu ts /e st im at ed re so ur ce s ( U S$ ) In di ca tiv e tim el in es Pr op os ed p ar tn er s re ga rd in g th ei r i nc lu sio n in th e us e of M ed Da ta . 9. 1. 6 An al ys e da ta , a nd p re pa re a nd d iss em in at e re po rt s fr om M ed Da ta tw ic e an nu al ly to c on tr ib ut e to m on ito rin g, e va lu at io n, a nd p la nn in g/ ad ju st m en t of N CD r el at ed in te rv en tio ns . M HW , G A CD RC , B N R Da ta a na ly sis , r ep or t pr ep ar at io n an d di ss em in at io n 10 ,0 00 20 21 2 5 PA HO /W HO , C AR PH A 9. 1. 7 Fa ci lit at e tr ai ni ng o f s el ec te d pe rs on ne l f ro m th e M HW P la nn in g an d Re se ar ch U ni t a nd th e BN R in ex tr ac tio n of ra w d at a fr om M ed Da ta to fa ci lit at e m on ito rin g of H EA RT S im pl em en ta tio n. M HW Tr ai ni ng 1 0, 00 0 20 20 2 1 PA HO /W HO , C AR PH A Co st O PT 9 .1 : U S$ 2 15 ,0 00 10 .1 S tr at eg ie s a nd m ec ha ni sm s st re ng th en ed fo r t he ef fic ie nt a nd e ffe ct iv e m an ag em en t,m on ito rin g, a nd e va lu at io n of th e N CD pr og ra m m e an d th e N SP N CD 2 0 25 . 10 .1 .1 D ev el op a nd e xe cu te a nn ua l c os te d Im pl em en ta tio n Pl an s f or th e N SP N CD 2 0 25 . M HW , N N CD C (In k in d) 20 20 2 4 PA HO /W HO 10 .1 .2 M on ito r p ro gr am m at ic a nd fi na nc ia l e xe cu tio n of th e Im pl em en ta tio n Pl an s, p ro du ci ng su m m ar y re po rt s s ix m on th ly fo r d iss em in at io n to th e Ca bi ne t S ub c om m itt ee o n N CD a nd to a llo w ad ju st m en ts to e xe cu tio n as n ee de d. M HW , N N CD C (In k in d) 20 20 2 5 PA HO /W HO 10 .1 .3 D ev el op a nd d iss em in at e an nu al re po rt s o n th e ex ec ut io n of th e N SP N CD 2 0 25 to k ey st ak eh ol de rs a cr os s s ec to rs . M HW , N N CD C Pr od uc tio n, p ub lic at io n, di ss em in at io n of re po rt s 10 ,0 00 20 20 2 5 PA HO /W HO 10 .1 .4 E ns ur e fin al e va lu at io n of th e im pl em en ta tio n of th e N SP N CD 2 0 25 , b ot h in te rn al a nd e xt er na l, w ith id en tif ic at io n of su cc es se s/ ac hi ev em en ts , ch al le ng es /g ap s, an d le ss on s l ea rn ed , t o in fo rm th e ne xt st ra te gi c pl an ni ng c yc le fo r N CD pr ev en tio n an d co nt ro l, an d in te rn at io na l re po rt in g; p ub lis h re su lts o f e va lu at io n. M HW , N N CD C Ex te rn al e va lu at io n, pr od uc tio n an d pu bl ic at io n of re po rt 5 0, 00 0 20 25 PA HO /W HO Co st O PT 1 0. 1: U S$ 60 ,0 00 To ta l c os t o f O PT s/ ER s U S$ 1 ,3 96 ,0 00 Th e to ta l e st im at ed b ud ge t f or th e N SP N CD 2 0 25 is U S$ 1 ,3 96 ,0 00 (a pp ro xi m at el y Bd s$ 2 ,7 92 ,0 00 )— th is fi gu re e xc lu de s s ta ff sa la rie s; in fr as tr uc tu re d ev el op m en t a nd m ai nt en an ce ; p ro cu re m en t o f e ss en tia l m ed ic in es , s up pl ie s, a nd te ch no lo gi es ;a nd o th er in k in d co st s. 85 Final deliverable - 31 Dec 2019 The distribution of the estimated budget by output is summarised in Annex 9, and underscores the GoB’s and MHW’s focus on risk factor reduction (41.3% of the budget) and improved detection and management of NCDs (18.7%). The outputs addressing communication, and surveillance and research, account for, respectively, 14.6% and 15.4% of the estimated budget, with the other outputs accounting for smaller proportions. 8. Implementation Strategies Key strategies for the successful implementation of the NSP-NCD 20-25 include: • Taking advantage of national high-level multi-sectoral structures such as the Cabinet Sub-committee on NCDs and the Social Partnership to advance the WoG, WoS, HiAP approaches that are critical for NCD reduction. Involvement of these structures enableseffective utilisation of the strengths of civil society and the private sector, while managing possible CoI; drives advocacy, decision-making, and policy development; fosters interaction with international development agencies; and facilitates resource allocation and mobilisation. • Convening key government sectors to make a case for networking and joint action, discuss the respective needs and constraints, and create a shared language for decision-making;258 show the co-benefits of joint action to achieve sectoral objectives; demonstrate Health’s added value; and identify the impact on health—positive or negative—of policies and actions in other sectors. • Strengthening engagement with public and private health care providers, especially through their various groupings, including professional associations. • Using key global and regional declarations, agreements, and mandates to frame national responses to NCDs; make greater use of fiscal measures to support health; and demonstrate Barbados’ commitment to the health of its people, sustainable national development, and fulfillment of its role as an important regional and international voice for equity. • Strengthening communication, utilising advances in information and communication technology to improve health literacy, promote the Strategic Plan,and facilitate its use as a reference by key stakeholders for their relevant planning, activities, and resource allocation and mobilisation. • Ensuring greater use of the settings approach, particularly schools and workplaces, with school health policy development, and the implementation of the National Workplace Wellness Policy. • Enhancing involvement of, and collaboration with, civil society, including youth and PLWNCDs in advocacy, policy development, and other NCD prevention and control interventions. • Fostering involvement of, and collaboration with, the private sector, focusing on the health-promoting private sector, and identifying and managing CoI. • Strengthening IS4H, including more active participation in the PAHO IS4H initiative and the use of data disaggregated by at least age, sex, ethnicity, geographic location, and socio-economic status to identify groups in conditions of vulnerability. • Enhancing resource mobilisation, both financial and human, taking advantage of support provided by, and available from, regional and international technical cooperation agencies and other development partners, including those based in Barbados, such as UN agencies and regional and international financing institutions. • Improvinghuman resources capacity and functioning, especially in leadership and oversight structures, and at the first level of care, with more efficient functioning of those whose capacity has been built and taking advantage of virtual platforms for cost-efficiency. • Ensuring monitoring, evaluation, and accountability for outputs/expected results and outcomes, and for resources allocated and mobilised. 258 Robert Wood Johnson Foundation. Health Impact Assessment: A Tool for Promoting the Health-in-All-Policies Approach. Issue Brief, May 2011.https://rwjf.ws/2q098Mb. 86 9. Risk Analysis and Risk Mitigation Strategies Table 12 below lists the main risks to successful NSP-NCD 20-25 execution and strategies to prevent or mitigate them, based on key stakeholder input and the assumptions in Table 8. Final deliverable – 31 Dec 2019 Page 100 of 134 • Improvinghuman resources capacity and functioning, especially in leadership and oversight structures, and at the first level of care, with more efficient functioning of those whose capacity has been built and taking advantage of virtual platforms for cost-efficiency. • Ensuring monitoring, evaluation, and accountability for outputs/expected results and outcomes, and for resources allocated and mobilised. 9. Risk analysis and risk mitigation strategies Table 12 below lists the main risks to successful NSP-NCD 20-25 execution and strategies to prevent or mitigate them, based on key stakeholder input and the assumptions in Table 8. Table 12. Main risks and risk mitigation strategies Main risks Risk mitigation strategies 1. “Policy inertia”, described by The Lancet journal as “thecollective effects of inadequate political leadership andgovernance to enact policies to respond to the GlobalSyndemic (of obesity, undernutrition, and climate change); strong opposition to those policies bypowerful commercial interests; and a lack of demandfor policy action by the public.”259 • Intensify high-level advocacy, presenting evidence to policymakers and involving the public, youth, and PLWNCDs, to strengthen their voices and the demand for creation of supportive environments for NCD prevention and control through relevant policy development and implementation. • Increase activities and visibility of NCD champions, taking advantage of the publicly stated intent of the Prime Minister, Minister of Health and Wellness, and Minister of Education, Technical and Vocational Training, to “walk the talk” regarding NCD prevention and control. • Continue advocacy with key stakeholders, including the public and health-promoting private sector to change attitudes, beliefs, and behaviour, and shift cultural norms and standards towards healthier options. • Take advantage of Barbados’ leadership of CARICOM for the period January-June 2020 to advocate for evidence-based policies for NCD reduction. 2. Inadequate measures to counter Industry interference in interventions for healthy nutrition and tobacco control. 3. Reduction in political will to address NCDs for various reasons, including shifts in attention and resources to deal with national crises, including emergencies and disasters. • Sensitise political stakeholders across all sectors using evidence-based information, strategies, and interventions. • Ensure sustained functioning of the NNCDC and accountability mechanisms. • Ensure evidence-based planning, implementation, monitoring, and evaluation for NCD prevention and control that keeps policymakers “in the loop”. 4. Limited financial resources • Encourage and advocate for increases in resource 259 Swinburn BA, Kraak VI, Allender S, et al. The Global Syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393: 791-846. https://bit.ly/2LrgNLY. 259Swinburn BA, Kraak VI, Allender S, et al. The Global Syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393: 791 846. https://bit.ly/2LrgNLY. 87 Final deliverable – 31 Dec 2019 Page 101 of 134 Main risks Risk mitigation strategies allocation within a results-based management framework, demonstrate cost-efficiency, cost effectiveness, and value for money. • Strengthen capacity of health and other sectors to develop project proposals and undertake resource mobilisation in the framework of the NSP-NCD 20-25 and international mandates and agreements. • Collaborate with other ministries to identify co benefits and undertake joint resource mobilisation. 5. Limited human resources • Expandcollaboration with CSOs, including NGOs, faith-based organisations, and academia. • Explore and implement, to the extent feasible, task shifting, including increased utilisation of allied health professionals and training community workers in advocacy and in carrying out appropriate tasks for NCD prevention and control at the first level of care. • Take advantage of needed expertise available through ministries other than health, through secondments and other mutually agreed mechanisms. • Recruit part-time personnel and volunteers as appropriate, and continue to tap into technical expertise available through regional and international agencies such as CARICOM, CARPHA, PAHO/WHO, and other UN agencies. • Include human resources—short- and/or medium term—in resource mobilisation proposals. 6. Limited intersectoral work, with perceptions of NCDs as being a health issue only. • Intensify high-level advocacy and dialogue to demonstrate the tangible benefits of NCD prevention and control not only on health, but also on productivity, the economy, and sustainable development through the use of investment cases. • Strengthen the awareness of all sectors on the co benefits of the HiAP approach and joint actions, and build capacity for use of health impact assessments in policy development. 7. Inadequate promotion and awareness of the NSP-NCD 20-25, its implementation, and M&E results. • Ensure provision of adequate resources to launch the Plan early in 2020, making it a feature of the “We Gatherin’” initiative and other such events throughout the year; promote it widely; and disseminate the results of M&E using a variety of media, requesting technical cooperation in doing so if needed, including from PAHO/WHO. 10. Monitoring, evaluation, and accountability framework 88 Monitoring, Evaluation and Accountability Framework The M&E and accountability framework provides the basis for the development of an M&E and accountability plan, aligned with output/expected result 10.1 in Tables 10 and 11 above. The MHW is the main entity accountable for execution of the NSP-NCD 20-25, with operational oversight by the SMOH-NCDs and the NCD Unit; technical oversight by the SMOH NCDs and the CMO; and administrative oversight by the Permanent Secretary. Advisory oversight is provided by the NNCDC,withpolicy and political oversight by the Minister of Health and Wellness, who keeps the Cabinet Sub-committee on NCDs informed and ultimately reports to the Prime Minister. The CMO and SMOH-NCDs are ex-officio members of the NNCDC, enabling strong links between the MHW and the NNCDC, and facilitating partnerships and shared responsibility for NCD prevention and control among sectors, on behalf of the GoB. The objectives (goal, purpose/overall outcome, specific outcomes, outputs/expected results), and their targets, indicators, activities, inputs/estimated resources, indicative timelines, and proposed partners in the Logical Framework Matrices for the NSP-NCD 20-25—Tables10 and 11—provide the M&E and accountability framework for the Plan. The means of verification provide the sources of information for corroborationof the indicators, and the assumptions suggest the factors that should hold true for the higher level objectives in the matrix to be achieved. Specific outcome 10 and output/ expected result 10.1 outline the development, frequency, and dissemination of progress reports, suggesting the types of reports to be produced, their contents, and their dissemination, while the summary of the main activities, inputs/estimated resources (the total of which provides an estimated budget), and indicative timelines for their completion facilitate the development of implementation plans and the tracking of both programmatic and financial execution. It will be critical for the assumptions and risks identified in, respectively, Tables 10 and 12 to be monitored,and risk mitigation strategies implemented as needed to ensure achievement of the outputs and specific outcomes. Documentation, key stakeholder participation, communication, and dissemination of the M&E reports are emphasised. The M&E andaccountability framework anticipates the next strategic planning cycle, which should build on the successes/ achievements and lessons learned during the implementation of the NSP-NCD 20-25, address challenges/gaps, and take into considerationchanges in the NCD situation, as well as new, innovative, and evidence-based strategies for NCD prevention and control. 89 Annex 1: Bibliography National • Manifesto of the Barbados Labour Party260 • Barbados Growth and Development Strategy 2013-2020 • Barbados Global School-based Student Health Survey 2011 • Barbados Global Youth Tobacco Survey 2013 • Chief Medical Officer’s Report 2010-2012. https://bit.ly/2Ctw1Ky • Guell C, Samuels TA, Hassell TA, Unwin N. Chronic disease policy in Barbados : analysis and evaluation of policy initiatives. September 2013. https://bit.ly/2sWnCLM • Barbados 2012-2013 Health Accounts Report. • Barbados Strategic Plan for the Prevention and Control of NCDs 2015-2019 • Barbados Action Plan for the Prevention and Control of NCDs 2015-2019 • WHO. Joint mission of the United Nations Interagency Task Force on the Prevention and Control of NCDs, April 2015. Geneva: WHO; 2017.https://bit.ly/34MWqyS • Barbados Health of the Nation Survey—Core Findings Policy Brief 2015 • Ministry of Health (2015). Discussion Paper on Health Financing Reform in Barbados 2015 • Ministry of Health Planning and Research Unit (2016). Report on the Ministry of Health consultations on health care financing in 2015 and 2016 • WHO, UNDP, and Ministry of Health. The Investment Case for NCD Prevention and Control in Barbados, September 2015. WHO, UNDP, 2017 • Unwin N, Samuels TA, Hassell T, Brownson RC, Guell C. The development of public policies to address NCDs in the Caribbean country of Barbados: the importance of problem framing and policy entrepreneurs. Int Journal Health Policy Manag. 2017; 6(2):71-82. doi:10.15171/ijhpm.2017.74 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5287932/pdf/ ijhpm-6-71.pdf • Barbados Childhood Obesity Prevention Programme (BCHOPP) • National Plan of Action for Childhood Obesity Prevention and Control 2015-2018 • Barbados NCD country profile 2018 (WHO) • Draft Barbados Health Report 2017-2018: ‘Healthy productive people and communities’ • Draft Barbados National Strategic Plan for Health 2018-2022: Working Together for a Healthier Nation • Draft National Cancer Control Plan for Barbados 2019-2024 • National Workplace Wellness Policy 2019 • Theodore K. Real cost of NCDs and health system sustainability (presentation). BNR 10th Anniversary Seminar: Multidisciplinary stakeholder engagement in the management of NCDs. Bridgetown, Barbados, April 2019. • Minutes of the NNCDC during the current strategic planning period Regional (Caribbean) • 2007 Port of Spain Declaration (POSD), made by CARICOM Heads of State and Government. • CARPHA Plan of Action for Promoting Healthy Weights in the Caribbean: Prevention and Control of Childhood Obesity 2014-2019 • Caribbean Cooperation in Health Phase IV (CCH IV) 2016-2025 • Port of Spain Declaration Evaluation Research Group. Accelerating Action on NCDs: Evaluation of the 2007 CARICOM Heads of Government Port of Spain NCD Summit Declaration – Report on behalf of PAHO/WHO and CARICOM. September 2016 • Ten years of the Port of Spain Declaration on NCDs261 • Healthy Caribbean Coalition (HCC) Strategic Plan 2017-2021 • HCC Civil Society Action Plan 2017-2021: Preventing Childhood Obesity in the Caribbean 260The Barbados Labour Party was elected to government in May 2018. 261Pan American Journal of Public Health, special issue, December 2018. 90 • UN Multi-country Sustainable Development Framework in the Caribbean 2017-2021 • Communiques issued after Conferences of CARICOM Heads of State and Government several of which reference NCD prevention and control, including the communique issued after their 39th Regular Meeting in July 2018 Regional (Region of the Americas) • PAHO Strategy for the Prevention and Control of NCDs 2012-2025 • PAHO Plan of Action for Prevention and Control of NCDs in the Americas 2013-2019, • PAHO/WHO Plan of Action for the Prevention of Obesity in Children and Adolescents • PAHO Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022 • PAHO Sustainable Health Agenda for the Americas 2018-2030 (SHAA2030), especially Goal 9 • PAHO. In-depth Qualitative Assessment of Noncommunicable Diseases:Multisectoral Action Plans in the Caribbean. Washington, D.C.: PAHO; 2018. https://bit.ly/2E7ovqR Global • WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 • WHO NCD Global Monitoring Framework • UN Sustainable Development Goals (SDGs) 2030, especially SDG 3, the goal most directly related to health. • Report of the WHO Commission on Ending Childhood Obesity (ECHO) 2016 • Tackling NCDs: “Best Buys” and Other Recommended Interventions for the Prevention and Control of NCDs, WHO 2017. Geneva: WHO; 2017. • Wright A, Smith KE, Hellowell M. Policy lessons from health taxes: a systematic review of empirical studies. BMC Public Health 2017; 17(1):583. https://bit.ly/2M6yCAM. • Political Declaration of the Third High-level Meeting of the UN General Assembly on the Prevention and Control of NCDs, October 2018. • Bertram MY, Sweeny K, Lauer JA, Chisholm D, Sheehan P, Rasmussen B, Upreti SR, Dixit LP, George K, and Deane S. Investing in non-communicable diseases: an estimation of the return on investment for prevention and treatment services. The Lancet 2018; 391 (10134): 2071-78. https://bit.ly/2MKoRI6.262 • The Task Force on Fiscal Policy for Health. Health taxes to save lives: Employing effective excise taxes on tobacco, alcohol, and sugary beverages. April 2019. https://www.bbhub.io/dotorg/sites/2/2019/04/Health-Taxes-to-Save-Lives-Report.pdf. 262This is one of five papers developed by the Lancet Taskforce on NCDs and economics. https://bit.ly/2wP5qYh. 91 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 1 05 o f 1 34 A nn ex 2 : W H O B es t B uy s an d O th er R ec om m en de d In te rv en tio ns fo r N C D P re ve nt io n an d C on tro l, in cl ud in g no n fin an ci al c on si de ra tio ns 26 3 Ri sk fa ct or /D is ea se to b e ad dr es se d Be st B uy s a nd E ffe ct iv e/ O th er Re co m m en de d In te rv en tio ns De ta ile d de sc rip tio n N on fi na nc ia l co ns id er at io ns RE D U CE T O BA CC O U SE Be st B uy s Ta x • In cr ea se e xc ise ta xe s a nd p ric es o n to ba cc o pr od uc ts • Be st B uy s 2 5 re qu ire ca pa ci ty fo r i m pl em en tin g an d en fo rc in g re gu la tio n an d le gi sla tio n Pa ck ag in g • Im pl em en t p la in /s ta nd ar di ze d pa ck ag in g an d/ or la rg e gr ap hi c he al th w ar ni ng s o n al l t ob ac co p ac ka ge s Ad ve rt isi ng , pr om ot io n, a nd sp on so rs hi p • En ac t a nd e nf or ce c om pr eh en siv e ba ns o n to ba cc o ad ve rt isi ng , pr om ot io n an d sp on so rs hi p Sm ok e fr ee p ub lic pl ac es • El im in at e ex po su re to se co nd h an d to ba cc o sm ok e in a ll in do or w or kp la ce s, pu bl ic p la ce s, p ub lic tr an sp or t Ed uc at io n • Im pl em en t e ffe ct iv e m as s m ed ia c am pa ig ns th at e du ca te th e pu bl ic a bo ut th e ha rm s o f s m ok in g/ to ba cc o us e an d se co nd ha nd sm ok e Ef fe ct iv e in te rv en tio ns Su pp or t • Pr ov id e co st c ov er ed , e ffe ct iv e an d po pu la tio n w id e su pp or t (in cl ud in g br ie f a dv ic e, n at io na l t ol l-f re e qu it lin e se rv ic es ) f or to ba cc o ce ss at io n to a ll th os e w ho w an t t o qu it • Re qu ire s s uf fic ie nt tr ai ne d pr ov id er s a nd a b et te r fu nc tio ni ng h ea lth sy st em O th er re co m m en de d in te rv en tio ns fr om W HO gu id an ce Tr ad e • Im pl em en t m ea su re s t o m in im ize il lic it tr ad e in to ba cc o pr od uc ts Ad ve rt isi ng • Ba n cr os s bo rd er a dv er tis in g, in cl ud in g us in g m od er n m ea ns o f co m m un ic at io n Su pp or t • Pr ov id e m ob ile p ho ne b as ed to ba cc o ce ss at io n se rv ic es fo r a ll th os e w ho w an t t o qu it RE D U CE H AR M FU L U SE O F AL CO H O L Be st B uy s Ta x • In cr ea se e xc ise ta xe s o n al co ho lic b ev er ag es • In cr ea se in e xc ise ta xe s re qu ire s a n ef fe ct iv e sy st em fo r t ax ad m in ist ra tio n an d sh ou ld be c om bi ne d w ith e ffo rt s to p re ve nt ta x av oi da nc e an d ta x ev as io n Ad ve rt isi ng • En ac t a nd e nf or ce b an s o r c om pr eh en siv e re st ric tio ns o n ex po su re to a lc oh ol a dv er tis in g (a cr os s m ul tip le ty pe s o f m ed ia ) • Re qu ire s c ap ac ity fo r im pl em en tin g an d 26 3 A da pt ed fr om W HO . T ac kl in g N CD s: B es t b uy s a nd o th er re co m m en de d in te rv en tio ns fo r t he p re ve nt io n an d co nt ro l o f N CD s. G en ev a: W HO ; 2 01 7. h tt ps :/ /b it. ly /2 M cz 3t o an d W HO . N on co m m un ic ab le d ise as es c ou nt ry p ro fil es 2 01 8. G en ev a: W HO ; 2 01 8. ht tp s: // w w w .w ho .in t/ nm h/ pu bl ic at io ns /n cd p ro fil es 2 01 8/ en /. A nn ex 2 : W ho B es t B uy s a nd O th er R ec om m en de d In te rv en tio ns fo r N C D P re ve nt io n an d C on tr ol , I nc lu di ng N on F in an ci al C on sid er at io ns 26 3 92 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 1 06 o f 1 34 Ri sk fa ct or /D is ea se to b e ad dr es se d Be st B uy s a nd E ffe ct iv e/ O th er Re co m m en de d In te rv en tio ns De ta ile d de sc rip tio n N on fi na nc ia l co ns id er at io ns Av ai la bi lit y • En ac t a nd e nf or ce re st ric tio ns o n th e ph ys ic al a va ila bi lit y of re ta ile d al co ho l ( vi a re du ce d ho ur s o f s al e) en fo rc in g re gu la tio ns a nd le gi sla tio n • Fo rm al c on tr ol s o n sa le ne ed to b e co m pl em en te d by a ct io ns a dd re ss in g ill ic it or in fo rm al ly p ro du ce d al co ho l Ef fe ct iv e in te rv en tio ns Le gi sla tio n an d en fo rc em en t • En ac t a nd e nf or ce d rin k dr iv in g la w s a nd b lo od a lc oh ol co nc en tr at io n lim its v ia so br ie ty c he ck po in ts • Re qu ire s a llo ca tio n of su ffi ci en t h um an re so ur ce s an d eq ui pm en t • Re qu ire s t ra in ed p ro vi de rs at a ll le ve ls of h ea lth c ar e Co un se lli ng • Pr ov id e br ie f p sy ch os oc ia l i nt er ve nt io n fo r p er so ns w ith ha za rd ou s a nd h ar m fu l a lc oh ol u se O th er re co m m en de d in te rv en tio ns fr om W HO gu id an ce Pr ic in g • Ca rr y ou t r eg ul ar re vi ew s o f p ric es in re la tio n to le ve l o f i nf la tio n an d in co m e • Es ta bl ish m in im um p ric es fo r a lc oh ol w he re a pp lic ab le Ag e an d ou tle t re st ric tio ns • En ac t a nd e nf or ce a n ap pr op ria te m in im um a ge fo r p ur ch as e or co ns um pt io n of a lc oh ol ic b ev er ag es a nd re du ce d en sit y of re ta il ou tle ts Pr om ot io n an d sp on so rs hi p • Re st ric t o r b an p ro m ot io ns o f a lc oh ol ic b ev er ag es in c on ne ct io n w ith sp on so rs hi ps a nd a ct iv iti es ta rg et in g yo un g pe op le Pr ev en tio n, tr ea tm en t, an d ca re • Pr ov id e pr ev en tio n, tr ea tm en t a nd c ar e fo r a lc oh ol u se d iso rd er s an d co m or bi d co nd iti on s i n he al th a nd so ci al se rv ic es Ed uc at io n • Pr ov id e co ns um er in fo rm at io n ab ou t, an d la be l, al co ho lic be ve ra ge s t o in di ca te , t he h ar m re la te d to a lc oh ol RE D U CE U N H EA LT HY D IE T Be st B uy s Re fo rm ul at io n of fo od s • Re du ce sa lt in ta ke th ro ug h th e re fo rm ul at io n of fo od p ro du ct s t o co nt ai n le ss sa lt an d th e se tt in g of ta rg et le ve ls fo r t he a m ou nt of sa lt in fo od s a nd m ea ls • Re qu ire s m ul ti se ct or al ac tio ns w ith re le va nt m in ist rie s a nd su pp or t b y ci vi l s oc ie ty Pr ov isi on o f su pp or tiv e en vi ro nm en ts • Re du ce sa lt in ta ke th ro ug h th e es ta bl ish m en t o f a su pp or tiv e en vi ro nm en t i n pu bl ic in st itu tio ns su ch a s h os pi ta ls, sc ho ol s, w or kp la ce s a nd n ur sin g ho m es , t o en ab le lo w er so di um o pt io ns to b e pr ov id ed Ed uc at io n • Re du ce sa lt in ta ke th ro ug h a be ha vi ou r c ha ng e co m m un ic at io n an d m as s m ed ia c am pa ig n Pa ck ag in g • Re du ce sa lt in ta ke th ro ug h th e im pl em en ta tio n of fr on t o f-p ac k • Re gu la to ry c ap ac ity a lo ng 93 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 1 07 o f 1 34 Ri sk fa ct or /D is ea se to b e ad dr es se d Be st B uy s a nd E ffe ct iv e/ O th er Re co m m en de d In te rv en tio ns De ta ile d de sc rip tio n N on fi na nc ia l co ns id er at io ns la be lli ng w ith m ul ti se ct or al a ct io n is ne ed ed Ef fe ct iv e in te rv en tio ns Le gi sla tio n • El im in at e in du st ria l t ra ns fa ts th ro ug h th e de ve lo pm en t o f le gi sla tio n to b an th ei r u se in th e fo od c ha in • Re gu la to ry c ap ac ity a lo ng w ith m ul ti se ct or al a ct io n is ne ed ed Ta x • Re du ce su ga r c on su m pt io n th ro ug h ef fe ct iv e ta xa tio n on su ga r sw ee te ne d be ve ra ge s O th er re co m m en de d in te rv en tio ns fr om W HO gu id an ce Pr om ot io n • Pr om ot e an d su pp or t e xc lu siv e br ea st fe ed in g fo r t he fi rs t 6 m on th s o f l ife , i nc lu di ng p ro m ot io n of b re as tf ee di ng Pr ic in g • Im pl em en t s ub sid ie s t o in cr ea se th e in ta ke o f f ru its a nd ve ge ta bl es Re fo rm ul at io n of fo od , p ol ic ie s • Re pl ac e tr an s fa ts a nd sa tu ra te d fa ts w ith u ns at ur at ed fa ts th ro ug h re fo rm ul at io n, la be lli ng , f isc al p ol ic ie s o r a gr ic ul tu ra l po lic ie s Pa ck ag in g, p or tio n siz e • Li m it po rt io n an d pa ck ag e siz e to re du ce e ne rg y in ta ke a nd th e ris k of o ve rw ei gh t/ ob es ity Ed uc at io n • Im pl em en t n ut rit io n ed uc at io n an d co un se lli ng in d iff er en t se tt in gs (f or e xa m pl e, in p re sc ho ol s, sc ho ol s, w or kp la ce s a nd ho sp ita ls) to in cr ea se th e in ta ke o f f ru its a nd v eg et ab le s La be lli ng • Im pl em en t n ut rit io n la be lli ng to re du ce to ta l e ne rg y in ta ke (k ca l), su ga rs , s od iu m a nd fa ts Ed uc at io n • Im pl em en t m as s m ed ia c am pa ig n on h ea lth y di et s, in cl ud in g so ci al m ar ke tin g to re du ce th e in ta ke o f t ot al fa t, sa tu ra te d fa ts , su ga rs a nd sa lt, a nd p ro m ot e th e in ta ke o f f ru its a nd v eg et ab le s RE D U CE P H YS IC AL IN AC TI VI TY Be st B uy s Ed uc at io n • Im pl em en t c om m un ity w id e pu bl ic e du ca tio n an d aw ar en es s ca m pa ig n fo r p hy sic al a ct iv ity w hi ch in cl ud es a m as s m ed ia ca m pa ig n co m bi ne d w ith o th er c om m un ity b as ed e du ca tio n, m ot iv at io na l a nd e nv iro nm en ta lp ro gr am m es a im ed a t su pp or tin g be ha vi ou ra l c ha ng e of p hy sic al a ct iv ity le ve ls 26 4 Ef fe ct iv e in te rv en tio ns Co un se lli ng a nd re fe rr al • Pr ov id e ph ys ic al a ct iv ity c ou ns el lin g an d re fe rr al a s p ar t o f ro ut in e pr im ar y he al th c ar e se rv ic es th ro ug h th e us e of a b rie f • Re qu ire s s uf fic ie nt , t ra in ed ca pa ci ty in p rim ar y ca re 26 4 Th e w or di ng h as b ee n up da te d fr om d oc um en t A 70 /2 7 to fu lly a lig n w ith th e te ch ni ca l b rie fin g en tit le d “P hy sic al in ac tiv ity in te rv en tio ns fo r t he A pp en di x 3 of th e W HO Gl ob al N CD A ct io n Pl an ”, w hi ch w as m ad ea va ila bl e to M em be r S ta te s o n 24 A pr il 20 17 a s p ar t o f W HO ’s e ffo rt to p ro vi de a dd iti on al te ch ni ca l b rie fin gs on th e ev id en ce un de rly in g th e Be st B uy s a nd o th er re co m m en de d in te rv en tio ns (s ee h tt p: // w w w .w ho .in t/ nc ds /g ov er na nc e/ ap pe nd ix 3 up da te /e n/ ) 26 4 Th e w or di ng h as b ee n up da te d fro m d oc um en t A 70 /2 7 to fu lly a lig n w ith th e te ch ni ca l b rie fin g en tit le d “P hy sic al in ac tiv ity in te rv en tio ns fo r t he A pp en di x 3 of th e W H O G lo ba l N C D A ct io n Pl an ”, w hi ch w as m ad ea va ila bl e to M em be r S ta te s on 2 4 Ap ril 2 01 7 as p ar t o f W H O ’s ef fo rt to p ro vi de a dd iti on al te ch ni ca l b rie fin gs on th e ev id en ce u nd er ly in g th e Be st B uy s an d ot he r r ec om m en de d in te rv en tio ns (s ee h ttp :// w w w .w ho .in t/n cd s/ go ve rn an ce / ap pe nd ix 3 up da te /e n/ ) 94 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 1 08 o f 1 34 Ri sk fa ct or /D is ea se to b e ad dr es se d Be st B uy s a nd E ffe ct iv e/ O th er Re co m m en de d In te rv en tio ns De ta ile d de sc rip tio n N on fi na nc ia l co ns id er at io ns in te rv en tio n O th er re co m m en de d in te rv en tio ns fr om W HO gu id an ce Su pp or tiv e en vi ro nm en ts • En su re th at m ac ro le ve l u rb an d es ig n in co rp or at es th e co re el em en ts o f r es id en tia l d en sit y, c on ne ct ed st re et n et w or ks th at in cl ud e sid ew al ks , e as y ac ce ss to a d iv er sit y of d es tin at io ns a nd ac ce ss to p ub lic tr an sp or t • Re qu ire s i nv ol ve m en t a nd ca pa ci ty o f o th er se ct or s ap ar t f ro m h ea lth • Im pl em en t w ho le o f-s ch oo l p ro gr am m e th at in cl ud es q ua lit y ph ys ic al e du ca tio n, a va ila bi lit y of a de qu at e fa ci lit ie s a nd pr og ra m s t o su pp or t p hy sic al a ct iv ity fo r a ll ch ild re n • Pr ov id e co nv en ie nt a nd sa fe a cc es s t o qu al ity p ub lic o pe n sp ac e an d ad eq ua te in fr as tr uc tu re to su pp or t w al ki ng a nd c yc lin g • Im pl em en t m ul ti co m po ne nt w or kp la ce p hy sic al a ct iv ity pr og ra m m es Pr om ot io n • Pr om ot e ph ys ic al a ct iv ity th ro ug h or ga ni ze d sp or t g ro up s a nd cl ub s, p ro gr am m es a nd e ve nt s M AN AG E CA RD IO VA SC U LA R D IS EA SE A N D D IA BE TE S Be st B uy s Dr ug th er ap y an d co un se lli ng • Dr ug th er ap y (in cl ud in g gl yc ae m ic c on tr ol fo r d ia be te s m el lit us an d co nt ro l o f h yp er te ns io n us in g a to ta l r isk 26 5 o Dr ug th er ap y (in cl ud in g gl yc ae m ic c on tr ol fo r d ia be te s m el lit us a nd c on tr ol o f h yp er te ns io n us in g a to ta l r isk ap pr oa ch ) a nd c ou ns el lin g to in di vi du al s w ho h av e ha d a he ar t a tt ac k or st ro ke an d to p er so ns w ith m od er at e to h ig h ris k (≥ 2 0% ) o f a fa ta l a nd n on fa ta l c ar di ov as cu la r e ve nt in th e ne xt 1 0 ye ar s a pp ro ac h) a nd co un se lli ng to in di vi du al s w ho h av e ha d a he ar t a tt ac k or st ro ke an d to p er so ns w ith h ig h ris k (≥ 3 0% ) o f a fa ta l a nd n on fa ta l ca rd io va sc ul ar e ve nt in th e ne xt 1 0 ye ar s • Fe as ib le in a ll re so ur ce se tt in gs , i nc lu di ng b y no n ph ys ic ia n he al th w or ke rs • Ap pl yi ng lo w er ri sk th re sh ol d in cr ea se s h ea lth ga in b ut a lso in cr ea se s im pl em en ta tio n co st Ef fe ct iv e in te rv en tio ns Dr ug th er ap y • Tr ea tm en t o f n ew c as es o f a cu te m yo ca rd ia l i nf ar ct io n26 6 o Tr ea tm en t o f n ew c as es o f a cu te m yo ca rd ia l i nf ar ct io n w ith as pi rin , i ni tia lly tr ea te d in a h os pi ta l s et tin g w ith fo llo w u p ca rr ie d ou t t hr ou gh P HC fa ci lit ie s a t a 9 5% c ov er ag e ra te w ith ei th er : a ce ty lsa lic yl ic a ci d, o r a ce ty lsa lic yl ic a ci d an d cl op id og re l, or th ro m bo ly sis , o r p rim ar y pe rc ut an eo us c or on ar y in te rv en tio ns (P CI )1 8 • Se le ct io n of o pt io n de pe nd s o n he al th sy st em ca pa ci ty 26 5 To ta l r isk is d ef in ed a s t he p ro ba bi lit y of a n in di vi du al e xp er ie nc in g a ca rd io va sc ul ar d ise as e ev en t ( fo re xa m pl e, m yo ca rd ia l i nf ar ct io n or st ro ke ) o ve r a g iv en p er io d of ti m e, fo r ex am pl e 10 y ea rs . 26 6 Co st in g as su m es h os pi ta l c ar e in a ll sc en ar io s. 26 5 To ta l r isk is d ef in ed a s th e pr ob ab ilit y of a n in di vi du al ex pe rie nc in g a ca rd io va sc ul ar d ise as e ev en t ( fo re xa m pl e, m yo ca rd ial in fa rc tio n or s tro ke ) o ve r a g iv en p er io d of ti m e, fo r e xa m pl e 10 y ea rs . 26 6 C os tin g as su m es h os pi ta l c ar e in a ll sc en ar io s. 95 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 1 09 o f 1 34 Ri sk fa ct or /D is ea se to b e ad dr es se d Be st B uy s a nd E ffe ct iv e/ O th er Re co m m en de d In te rv en tio ns De ta ile d de sc rip tio n N on fi na nc ia l co ns id er at io ns o Tr ea tm en t o f n ew c as es o f a cu te m yo ca rd ia l i nf ar ct io n w ith as pi rin a nd th ro m bo ly sis , i ni tia lly tr ea te d in a h os pi ta l se tt in g w ith fo llo w u p ca rr ie d ou t t hr ou gh P HC fa ci lit ie s a t a 95 % c ov er ag e ra te o Tr ea tm en t o f n ew c as es o f m yo ca rd ia l i nf ar ct io n w ith pr im ar y pe rc ut an eo us c or on ar y in te rv en tio ns (P CI ), as pi rin an d cl op id og re l, in iti al ly tr ea te d in a h os pi ta l s et tin g w ith fo llo w u p ca rr ie d ou t t hr ou gh P HC fa ci lit ie s a t a 9 5% co ve ra ge ra te Dr ug th er ap y • Tr ea tm en t o f a cu te is ch em ic st ro ke w ith in tr av en ou s th ro m bo ly tic th er ap y • N ee ds c ap ac ity to di ag no se is ch ae m ic st ro ke Pr im ar y pr ev en tio n • Pr im ar y pr ev en tio n of rh eu m at ic fe ve r a nd rh eu m at ic h ea rt di se as es b y in cr ea sin g ap pr op ria te tr ea tm en t o f s tr ep to co cc al ph ar yn gi tis a t t he p rim ar y ca re le ve l • De pe nd in g on p re va le nc e in sp ec ifi c co un tr ie s o r su b po pu la tio ns Se co nd ar y pr ev en tio n • Se co nd ar y pr ev en tio n of rh eu m at ic fe ve r a nd rh eu m at ic h ea rt di se as e by d ev el op in g a re gi st er o f p at ie nt s w ho re ce iv e re gu la r pr op hy la ct ic p en ic ill in O th er re co m m en de d in te rv en tio ns fr om W HO gu id an ce Tr ea tm en t • Tr ea tm en t o f c on ge st iv e ca rd ia c fa ilu re w ith a ng io te ns in co nv er tin g e nz ym e in hi bi to r, be ta b lo ck er a nd d iu re tic Re ha bi lit at io n • Ca rd ia c re ha bi lit at io n po st m yo ca rd ia l i nf ar ct io n Tr ea tm en t • An tic oa gu la tio n fo r m ed iu m a nd h ig h ris k no n va lv ul ar a tr ia l fib ril la tio n an d fo r m itr al st en os is w ith a tr ia l f ib ril la tio n Tr ea tm en t • Lo w d os e ac et yl sa lic yl ic a ci d fo r i sc he m ic st ro ke Re ha bi lit at io n • Ca re o f a cu te st ro ke a nd re ha bi lit at io n in st ro ke u ni ts M AN AG E D IA BE TE S Ef fe ct iv e in te rv en tio ns Pr ev en tiv e m ea su re s • Pr ev en tiv e fo ot c ar e fo r p eo pl e w ith d ia be te s ( in cl ud in g ed uc at io na l p ro gr am m es , a cc es s t o ap pr op ria te fo ot w ea r, m ul ti di sc ip lin ar y cl in ic s) • Re qu ire s s ys te m s f or pa tie nt re ca ll Sc re en in g • Di ab et ic re tin op at hy sc re en in g fo r a ll di ab et es p at ie nt s a nd la se r ph ot oc oa gu la tio n fo r p re ve nt io n of b lin dn es s Co nt ro l a nd m on ito rin g • Ef fe ct iv e gl yc ae m ic c on tr ol fo r p eo pl e w ith d ia be te s, al on g w ith st an da rd h om e gl uc os e m on ito rin g fo r p eo pl e tr ea te d w ith in su lin to re du ce d ia be te s c om pl ic at io ns O th er re co m m en de d in te rv en tio ns Pr ev en tio n • Li fe st yl e in te rv en tio ns fo r p re ve nt in g ty pe 2 d ia be te s Pr ev en tio n • In flu en za v ac ci na tio n fo r p at ie nt s w ith d ia be te s Ed uc at io n an d • Pr ec on ce pt io n ca re a m on g w om en o f r ep ro du ct iv e ag e w ho ha ve 96 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 1 10 o f 1 34 Ri sk fa ct or /D is ea se to b e ad dr es se d Be st B uy s a nd E ffe ct iv e/ O th er Re co m m en de d In te rv en tio ns De ta ile d de sc rip tio n N on fi na nc ia l co ns id er at io ns fr om W HO gu id an ce m an ag em en t di ab et es in cl ud in g pa tie nt e du ca tio n an d in te ns iv eg lu co se m an ag em en t Sc re en in g • Sc re en in g of p eo pl e w ith d ia be te s f or p ro te in ur ia a nd tr ea tm en t w ith a ng io te ns in c on ve rt in g en zy m e in hi bi to r f or th e pr ev en tio n an d de la y of re na l d ise as e M AN AG E CA N CE R Be st B uy s Va cc in at io n • Va cc in at io n ag ai ns t h um an p ap ill om av iru s ( 2 do se s) o f 9 –1 3 ye ar ol d gi rls Sc re en in g • Pr ev en tio n of c er vi ca l c an ce r b y sc re en in g w om en a ge d 30 –4 9 ye ar s, ei th er th ro ug h: o Vi su al in sp ec tio n w ith a ce tic a ci d lin ke d w ith ti m el y tr ea tm en t o f p re c an ce ro us le sio ns o Pa p sm ea r ( ce rv ic al c yt ol og y) e ve ry 3 –5 y ea rs li nk ed w ith tim el y tr ea tm en t o f p re c an ce ro us le sio ns o Hu m an p ap ill om av iru s t es t e ve ry 5 y ea rs li nk ed w ith ti m el y tr ea tm en t o f p re c an ce ro us le sio ns • Vi su al in sp ec tio n w ith ac et ic a ci d is fe as ib le in lo w re so ur ce se tt in gs , in cl ud in g w ith n on ph ys ic ia n he al th w or ke rs • Pa p sm ea r r eq ui re s cy to pa th ol og y ca pa ci ty • HP V te st re qu ire s s ys te m s fo r o rg an ize d, p op ul at io n ba se d sc re en in g an d qu al ity c on tr ol Ef fe ct iv e in te rv en tio ns Sc re en in g • Sc re en in g w ith m am m og ra ph y (o nc e ev er y 2 ye ar s f or w om en ag ed 5 0 69 y ea rs ) l in ke d w ith ti m el y di ag no sis a nd tr ea tm en t o f br ea st c an ce r • Re qu ire s s ys te m s f or or ga ni ze d, p op ul at io n ba se d sc re en in g an d qu al ity c on tr ol Tr ea tm en t • Tr ea tm en t o f c ol or ec ta l c an ce r s ta ge s I a nd II w ith su rg er y +/ ch em ot he ra py a nd ra di ot he ra py • Tr ea tm en t o f c er vi ca l c an ce r s ta ge s I a nd II w ith e ith er su rg er y or ra di ot he ra py + / c he m ot he ra py • Tr ea tm en t o f b re as t c an ce r s ta ge s I a nd II w ith su rg er y +/ sy st em ic th er ap y Pa lli at io n • Ba sic p al lia tiv e ca re fo r c an ce r: ho m e ba se d an d ho sp ita l c ar e w ith m ul ti di sc ip lin ar y te am a nd a cc es s t o op ia te s a nd e ss en tia l su pp or tiv e m ed ic in e • Re qu ire s a cc es s t o co nt ro lle d m ed ic in es fo r pa in re lie f O th er re co m m en de d in te rv en tio ns fr om W HO Pr ev en tio n • Pr ev en tio n of li ve r c an ce r t hr ou gh h ep at iti s B im m un iza tio n Sc re en in g • O ra l c an ce r s cr ee ni ng in h ig h ris k gr ou ps (f or e xa m pl e, to ba cc o us er s, b et el n ut c he w er s) li nk ed w ith ti m el y tr ea tm en t • Po pu la tio n ba se d co lo r ec ta l c an ce r s cr ee ni ng , i nc lu di ng th ro ug h 97 Fi na l d el iv er ab le – 3 1 De c 20 19 Pa ge 1 11 o f 1 34 Ri sk fa ct or /D is ea se to b e ad dr es se d Be st B uy s a nd E ffe ct iv e/ O th er Re co m m en de d In te rv en tio ns De ta ile d de sc rip tio n N on fi na nc ia l co ns id er at io ns gu id an ce a fa ec al o cc ul t b lo od te st , a s a pp ro pr ia te , a t a ge > 50 , l in ke d w ith tim el y tr ea tm en t M AN AG E CH RO N IC RE SP IR AT O RY D IS EA SE S Ef fe ct iv e in te rv en tio ns Re lie f o f s ym pt om s • Sy m pt om re lie f f or p at ie nt s w ith a st hm a w ith in ha le d sa lb ut am ol • Sy m pt om re lie f f or p at ie nt s w ith c hr on ic o bs tr uc tiv e pu lm on ar y di se as e w ith in ha le d sa lb ut am ol Tr ea tm en t • Tr ea tm en t o f a st hm a us in g lo w d os e in ha le d be cl om et ha so ne an d sh or t ac tin g be ta a go ni st O th er re co m m en de d in te rv en tio ns fr om W HO gu id an ce Pr ev en tio n • Ac ce ss to im pr ov ed st ov es a nd c le an er fu el s t o re du ce in do or a ir po llu tio n • Co st e ffe ct iv e in te rv en tio ns to p re ve nt o cc up at io na l l un g di se as es , f or e xa m pl e, fr om e xp os ur e to si lic a, a sb es to s • In flu en za v ac ci na tio n fo r p at ie nt s w ith c hr on ic o bs tr uc tiv e pu lm on ar y di se as e 98 Annex 3: Survey Instrument/Interview Guide for Key Stakeholder Input DEVELOPMENT OF BARBADOS NATIONAL NCD STRATEGIC PLAN 2020-2025 Introduction As part of the Barbados Ministry of Health and Wellness’ preparation of the Barbados Strategic Plan for the Prevention and Control of Non-communicable Diseases (NCDs) 2020-2025 (NSP-NCD 20-25) on behalf of the Government of Barbados, a qualitative assessment is being conducted among key stakeholders of the extent to which the main strategies and objectives/ expected results of the Barbados NCD Strategic Plan 2015-2019 (SP-NCD 15-19) were achieved. The SP-NCD 15-19 had four strategies: 1. Strengthening strategic management; 2. Surveillance and research; 3. Risk factor reduction; and 4. Integrated disease management and patient education. Stakeholders are also being asked to provide inputs that will be invaluable in informing the development of the NSP-NCD 20-25: • Information on past, current, and planned major projects and activities for NCD prevention and control, to get a sense of how they have been contributing to NCD reduction, and possible roles they may play in the planning, implementation, monitoring, and evaluation of the NSP-NCD 20-25; • Their perspectives on major successes/achievements over the period 2015-2019; • Major challenges and gaps over the period of the SP-NCD 15-19; • Lessons learned; • Strengths and weaknesses of, opportunities for, and threats to (SWOT analysis) the national NCD prevention and control programme; and • Their suggestions/recommendations on priorities/themes for inclusion in the NSP-NCD 20-25. Methodology Section I contains a matrix summarising the main strategies and relevant objectives (OBJs)/expected results (ERs) of the SP NCD 15-19. Stakeholders are asked to provide their perspectives on the extent to which the OBJs/ERs have been achieved (fully, partially, not, don’t know, using a tick ( ) or an “x” in the appropriate box, and provide related comments, including past, current, or planned projects and major activities relating to the respective OBJ/ER. Focus should be on the OBJs/ERs most relevant to the stakeholder’s main area(s) or scope of work, but responses may be provided for other areas, as the stakeholder sees fit. Sections II, III, and IV determine, respectively, major successes/achievements, challenges/gaps, and lessons learned; Section V requests a SWOT analysis of the NCD prevention and control programme in Barbados; and Section VI seeks to obtain the stakeholders’ views on priorities/themes for inclusion in the NSP-NCD 20-25. NOTE: INFORMATION PROVIDED WILL BE REPORTED ANONYMOUSLY. 99 Fi na l Pa ge 1 13 o f 1 34 N AM E O F PE RS O N C O M PL ET IN G T O O L N AM E O F EN TI TY SE CT IO N I – Q ua lit at iv e as se ss m en t o f S P N CD 1 5 19 O BJ s/ ER s Le ve l o f a ch ie ve m en t Co m m en ts , i nc lu di ng p as t, cu rr en t, an d pl an ne d pr oj ec ts /m aj or a ct iv iti es Fu lly Pa rt ia lly N ot Do n’ t k no w St ra te gy 1 : S tr en gt he ni ng st ra te gi c m an ag em en t 1. 1 G ov er na nc e an d ad m in ist ra tio n of N CD pr og ra m m es im pr ov ed . • 1. 2 Fi na nc ia l r es ou rc es su ffi ci en t t o ad dr es s p rio rit y he al th n ee ds id en tif ie d. • 1. 3 Hu m an re so ur ce s a de qu at e fo r m ul ti se ct or al N CD re sp on se id en tif ie d. • St ra te gy 2 : S ur ve ill an ce a nd re se ar ch 2. 1 M or bi di ty a nd m or ta lit y ra te s f ro m N CD s re du ce d. • 2. 2 Ac ce ss to re lia bl e an d ac cu ra te d at a on N CD s in cr ea se d, in cl ud in g da ta fr om th e pr iv at e se ct or . • 2. 3 In fo rm at io n on N CD ri sk fa ct or s a nd b ur de n of di se as e av ai la bl e an d ut ili ze d fo r p la nn in g an d ev al ua tio n. • 2. 4 Su rv ei lla nc e ca pa ci ty o f t he M oH e nh an ce d. • 2. 5 Re se ar ch in iti at iv es im pl em en te d to a ss es s di se as e bu rd en , r isk fa ct or s, a nd d et er m in an ts o f ch ro ni c di se as es . • St ra te gy 3 : R is k fa ct or re du ct io n 3. 1 FC TC 26 7 c om pl ia nt le gi sla tio n en ac te d an d en fo rc ed . • 3. 2 St ra te gi es to re du ce th e ha rm fu l u se o f a lc oh ol su pp or te d. • 3. 3 Fo od se cu rit y an d he al th y ea tin g pr om ot ed . • 3. 4 He al th y pr od uc ts p ro vi de d an d pr om ot ed b y fo od m an uf ac tu re rs • 26 7 Fr am ew or k Co nv en tio n on T ob ac co C on tr ol (W HO ). 100 Fi na l Pa ge 1 14 o f 1 34 O BJ s/ ER s Le ve l o f a ch ie ve m en t Co m m en ts , i nc lu di ng p as t, cu rr en t, an d pl an ne d pr oj ec ts /m aj or a ct iv iti es Fu lly Pa rt ia lly N ot Do n’ t k no w 3. 5 Su pp or t f or p op ul at io n ba se d sa lt re du ct io n in cr ea se d. • 3. 6 Tr an s fa t i n fo od su pp ly e lim in at ed . • 3. 7 Hi gh fa t c on te nt fo od s r ed uc ed . • 3. 8 Da ily c on su m pt io n of fr ui ts a nd v eg et ab le s in cr ea se d. • 3. 9 Co m m un ity a nd p op ul at io n in iti at iv es to pr om ot e ph ys ic al a ct iv ity a nd e xe rc ise su pp or te d. • 3. 10 B ui ld in g ca pa ci ty w ith m ed ia a nd o th er pa rt ne rs to p ro m ot e he al th y lif es ty le s. • 3. 11 S ch oo l-b as ed p re ve nt io n in iti at iv es fa ci lit at ed an d pr om ot ed . • 3. 12 H ea lth P ro m ot in g Sc ho ol s p ro gr am m e im pl em en te d. • 3. 13 W or kp la ce w el ln es s p ro gr am m es su pp or te d an d em br ac ed . • 3. 14 F ai th b as ed o rg an iza tio ns a nd c om m un iti es (in vo lv ed in h ea lth p ro m ot io n pr og ra m m es ). • St ra te gy 4 : I nt eg ra te d di se as e m an ag em en t a nd p at ie nt e du ca tio n 4. 1 Pa tie nt e du ca tio n en ha nc ed . • 4. 2 Ef fe ct iv e, in te gr at ed m an ag em en t f or a ll ch ro ni c di se as es e nh an ce d. • 4. 3 Cl in ic al q ua lit y of c ar e fo r c hr on ic d ise as es en ha nc ed . • 4. 4 Sc re en in g an d ea rly d et ec tio n en ha nc ed . • 4. 5 Pr io rit y ca nc er s a dd re ss ed — ce rv ic al c an ce r, br ea st , p ro st at e, a nd c ol on . • 4. 6 Ho sp ita l m an ag em en t e nh an ce d to d el iv er qu al ity c ar e an d tr ea tm en t. • 4. 7 Ac ce ss to te ch no lo gi es a nd sa fe , a ffo rd ab le , a nd ef fic ac io us e ss en tia l m ed ic in es a nd c ou ns el lin g. • 4. 8 Pa lli at iv e ca re e nh an ce d. • 101 SECTION II – Major successes/achievements Please list the top five (5) successes/achievement in NCD prevention and control in Barbados over the period 2015-2019. 1. 2. 3. 4. 5. SECTION III – Major challenges/gaps What were the top five (5) challenges/gaps in NCD prevention and control in Barbados over the period 2015-2019? 1. 2. 3. 4. 5. SECTION IV – Lessons learned What were the top five (5) major lessons learned for NCD prevention and control in Barbados over the period 2015-2019? 1. 2. 3. 4. 5. 102 SECTION V – SWOT analysis Please list the top five (5) strengths and weaknesses of, opportunities for, and threats to, the NCD prevention and control programme in Barbados. SECTION VI – Priorities/themes for the NSP-NCD 20-25 Please indicate no more than five (5) priorities/themes for inclusion in the Barbados Strategic Plan for the Prevention and Control of NCDs 2020-2025. 1. 2. 3. 4. 5. THANK YOU FOR YOUR TIME AND INPUT! Final Page 116 of 134 SECTION V – SWOT analysis Please list the top five (5) strengths and weaknesses of, opportunities for, and threats to, the NCD prevention and control programme in Barbados. Strengths Weaknesses Opportunities Threats 1. 2. 3. 4. 5. SECTION VI – Priorities/themes for the NSP-NCD 20-25 Please indicate no more than five (5) priorities/themes for inclusion in the Barbados Strategic Plan for the Prevention and Control of NCDs 2020-2025. 1. 2. 3. 4. 5. THANK YOU FOR YOUR TIME AND INPUT! 103 Annex 4: List of Key Stakeholder Agencies/Entities/Organisations That Provided Input Government ministries/bodies • Barbados National Standards Institute • Ministry of Health and Wellness • Ministry of Labour and Social Partnership Relations • National NCD Commission • National Nutrition Centre Academia • Barbados National Registry-George Alleyne Chronic Disease Research Centre, University of the West Indies Non-governmental organisations (disease-specific) • Barbados Alzheimer’s Association • Barbados Cancer Society • Barbados Diabetes Foundation • Diabetes Association of Barbados • Healthy Caribbean Coalition Faith-based organisations • East Caribbean Conference of Seventh Day Adventists Other civil society organisations • Our Views, Our Voices Barbados International technical cooperation/development entities • Pan American Health Organization/World Health Organization 104 Pa ge 1 18 o f 1 34 A nn ex 5 : P os si bl e ro le s of k ey s ta ke ho ld er s26 8 Se ct or s/ St ak eh ol de rs Po ss ib le ro le s M in ist ry o f H ea lth • Co or di na te , a dv oc at e an d fa ci lit at e th e co nt rib ut io n of o th er m in ist rie s, go ve rn m en t a ge nc ie s a nd st ak eh ol de rs ; le ad a nd fa ci lit at e de ve lo pm en t o f n at io na l N CD p ol ic y, p la ns a nd p ro gr am m es M in ist ry o f A gr ic ul tu re • En su re n at io na l f oo d an d ag ric ul tu ra l p ol ic ie s p ro m ot e an d pr ot ec t p ub lic h ea lth M in ist ry o f E du ca tio n • De ve lo p sc ho ol h ea lth p ol ic ie s a nd p ro gr am m es th at p ro m ot e he al th y di et s, p hy sic al a ct iv ity a nd sm ok e fr ee en vi ro nm en ts M in ist ry o f T ra ns po rt • De ve lo p tr an sp or t p ol ic ie s t ha t p ro m ot e w al ki ng a nd n on m ot or ize d op tio ns M in ist ry o f F in an ce • En su re fi na nc e is av ai la bl e to su pp or t N CD p ol ic y im pl em en ta tio n; e nc ou ra ge u se o f f isc al a nd ta xa tio n po lic ie s t ha t pr om ot e an d pr ot ec t p ub lic h ea lth M in ist ry o f S po rt s • De ve lo p po lic y fo r p ro m ot in g ph ys ic al a ct iv ity De pa rt m en t o f R ev en ue /C us to m s • En su re th e co lle ct io n of ta xe s l ev ie d on to ba cc o an d al co ho l t o ac hi ev e th e ob je ct iv es o f p ub lic h ea lth a nd p ub lic fin an ce ; e ns ur e th e pr ev en tio n of Il lic it tr ad e of to ba cc o an d al co ho l a nd o th er su bs ta nc e ab us e th at im pa ct s N CD s M in ist ry o f C om m er ce /D ep ar tm en ts of T ra de , I nv es tm en t e tc . • En su re th e ad op tio n of m ul til at er al a nd b ila te ra l t ra de a nd in ve st m en t i ns tr um en ts th at a re c om pl ia nt w ith a ll gl ob al h ea lth la w s a nd k ee p th e he al th o f c iti ze ns a s a p rio rit y M in ist ry o f C on su m er Af fa irs /I nf or m at io n an d Br oa dc as tin g/ Pu bl ic A ffa irs • En su re th e di ss em in at io n of re le va nt p ub lic h ea lth in fo rm at io n to a ll st ak eh ol de rs th ro ug h ap pr op ria te m ea ns , in cl ud in g th ro ug h pa ck ag in g an d la be lli ng o f p ro du ct s a nd p ub lic se rv ic e an no un ce m en ts M in ist ry o f L ab ou r/ Em pl oy m en t • En su re th e ad op tio n of la bo ur la w s t ha t e nc ou ra ge p ub lic h ea lth m ea su re s p ro m ot in g he al th y lif es ty le s a t w or kp la ce s; e ns ur e th e ge ne ra tio n of a lte rn at iv e liv el ih oo ds to w or ke rs e ng ag ed in to ba cc o gr ow in g or in re la te d en te rp ris es th at a re li ke ly to b e im pa ct ed b y th e fu ll im pl em en ta tio n of p ub lic h ea lth p ol ic ie s o n N CD s M in ist ry o f U rb an D ev el op m en t • En su re th e de ve lo pm en t o f b ui ld in g co de s a nd to w n pl an s t ha t k ee p a pu bl ic h ea lth fo cu s M in ist ry o f F or ei gn A ffa irs • N eg ot ia te , a na ly se a nd e ns ur e ad op tio n of n or m at iv e in te rn at io na l a gr ee m en ts a nd fr am ew or ks th at m ay b e di re ct ly li nk ed to p ub lic h ea lth r el at ed is su es N on g ov er nm en ta l o rg an iza tio ns • Ad vo ca te a ct io n to p re ve nt N CD s, m ob ili ze c om m un ity su pp or t, or ga ni ze in fo rm at io n an d ed uc at io n ca m pa ig ns an d de liv er N CD se rv ic es Ci vi l s oc ie ty • Cr ea te e xp ec ta tio ns fo r g ov er nm en t a nd th e pr iv at e se ct or to ta ke a ct io n Ac ad em ic in st itu tio ns • Pr ov id e ex pe rt a dv ic e on p ub lic h ea lth , N CD ri sk fa ct or s a nd c os t ef fe ct iv e in te rv en tio ns He al th p ro fe ss io na ls • Ad vo ca te a ct io n, p ro vi de c lin ic al a nd p ub lic h ea lth in fo rm at io n, a nd su pp or t p ol ic y an d pl an ni ng p ro ce ss es ; a ss ist in im pl em en ta tio n of p la ns a nd p ro gr am m es M ed ia • Pr ov id e su st ai ne d ne w s c ov er ag e of c hr on ic d ise as e pr ev en tio n to h el p ra ise a w ar en es s, p ro m ot e di sc us sio n an d fa ci lit at e ch an ge ; j ou rn al ist s c an b e ke y st ak eh ol de rs fo r a dv oc ac y an d pu bl ic e du ca tio n in N CD p re ve nt io n 26 8 W HO . N CD M AP T oo l: St ak eh ol de r e ng ag em en t a nd m ul tis ec to ra l g ov er na nc e m ec ha ni sm s. h tt p: // ap ps .w ho .in t/ nc d m ul tis ec to ra l-p la nt oo l/h om e. ht m l. 26 8 W H O . N C D M AP T oo l: St ak eh ol de r e ng ag em en t a nd m ul tis ec to ra l g ov er na nc e m ec ha ni sm s. h ttp :// ap ps .w ho .in t/n cd m ul tis ec to ra l-p lan to ol /h om e. ht m l. A nn ex 5 : P os sib le R ol es o f K ey S ta ke ho ld er s2 68 105 Pa ge 1 19 o f 1 34 Se ct or s/ St ak eh ol de rs Po ss ib le ro le s Th e pr iv at e se ct or w he n th er e is no co nf lic t o f i nt er es t a nd e xc lu di ng th e to ba cc o in du st ry • Ta ke m ea su re s t o im pl em en t t he W or ld H ea lth O rg an iza tio n se t o f r ec om m en da tio ns to re du ce th e im pa ct o f t he m ar ke tin g of u nh ea lth y fo od s a nd n on a lc oh ol ic b ev er ag es to c hi ld re n, w hi le ta ki ng in to a cc ou nt e xi st in g na tio na l le gi sla tio n an d po lic ie s • Co ns id er p ro du ci ng a nd p ro m ot in g m or e fo od p ro du ct s c on sis te nt w ith a h ea lth y di et , i nc lu di ng b y re fo rm ul at in g pr od uc ts to p ro vi de h ea lth ie r o pt io ns th at a re a ffo rd ab le a nd a cc es sib le a nd th at fo llo w re le va nt n ut rit io n fa ct s an d la be lli ng st an da rd s, in cl ud in g in fo rm at io n on su ga rs , s al t a nd fa ts a nd , w he re a pp ro pr ia te , t ra ns fa t c on te nt • Pr om ot e an d cr ea te a n en ab lin g en vi ro nm en t f or h ea lth y be ha vi ou rs a m on g w or ke rs , i nc lu di ng b y es ta bl ish in g to ba cc o fr ee w or kp la ce s a nd sa fe a nd h ea lth y w or ki ng e nv iro nm en ts th ro ug h oc cu pa tio na l s af et y an d he al th m ea su re s, in cl ud in g, w he re a pp ro pr ia te , t hr ou gh g oo d co rp or at e pr ac tic es , w or kp la ce w el ln es s p ro gr am m es a nd he al th in su ra nc e pl an s • W or k to w ar ds re du ci ng th e us e of sa lt in th e fo od in du st ry in o rd er to lo w er so di um c on su m pt io n • Co nt rib ut e to e ffo rt s t o im pr ov e ac ce ss to a nd a ffo rd ab ili ty o f m ed ic in es a nd te ch no lo gi es in th e pr ev en tio n an d co nt ro l o f N CD s 106 Pa ge 1 20 o f 1 34 A nn ex 6 : M H W O rg an is at io na l C ha rt A nn ex 6 : M H W O rg an isa tio na l C ha rt 107 Pa ge 1 21 o f 1 34 A nn ex 7 : P ro gr es s to w ar ds W H O B es t B uy s an d E ffe ct iv e an d O th er R ec om m en de d In te rv en tio ns Th e m at rix b el ow s um m ar ise s Ba rb ad os ’ pr og re ss t ow ar ds t he B es t Bu ys ( BB s) , Ef fe ct iv e In te rv en tio ns ( EI s) , an d O th er R ec om m en de d In te rv en tio ns (O RI s) .26 9 O f t he 4 0 BB s, E Is , a nd O RI s a ss oc ia te d w ith th e fo ur m ai n ris k fa ct or s, B ar ba do s h as fu lly im pl em en te d se ve n (1 7. 5% ), w hi le it ha s i m pl em en te d 18 (5 6. 3% ) o f t he 3 227 0 Ri sk fa ct or /D is ea se B Bs , E Is , a nd O RI s a ss oc ia te d w ith m an ag em en t o f t he fo ur m aj or N CD s. BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts Re du ce to ba cc o us e BB s In cr ea se e xc ise ta xe s a nd p ric es o n to ba cc o pr od uc ts Pa rt ia l. Ex ci se ta xe s i m po se d; ta x co m pr ise s 4 7. 1% o f t he p ric e of th e m os t so ld b ra nd o f c ig ar et te s. F CT C re co m m en ds ta x at le as t 7 5% o f r et ai l pr ic e. Im pl em en t p la in /s ta nd ar di se d pa ck ag in g an d/ or la rg e gr ap hi c he al th w ar ni ng s o n al l t ob ac co p ac ka ge s Fu ll. T hi s a sp ec t o f l eg isl at io n w as e na ct ed in 2 01 7, b ut it s e nf or ce m en t i s no t o pt im al . En ac t a nd e nf or ce c om pr eh en siv e ba ns o n to ba cc o ad ve rt isi ng , p ro m ot io n an d sp on so rs hi p N on e. H ow ev er , t he re is li tt le o ve rt e vi de nc e of to ba cc o ad ve rt isi ng , pr om ot io n, o r s po ns or sh ip , d ue to th e ef fo rt s o f t he N N CD C an d N CD “c ha m pi on s” , w ho e xe rt m or al su as io n on m ed ia a nd e ve nt or ga ni se rs .H ow ev er , t he N SP N CD 2 0 25 a dd re ss es th is le gi sla tiv e/ re gu la to ry g ap . El im in at e ex po su re to se co nd h an d to ba cc o sm ok e in a ll in do or w or kp la ce s, p ub lic p la ce s, p ub lic tr an sp or t Fu ll. Im pl em en t e ffe ct iv e m as s m ed ia c am pa ig ns th at e du ca te th e pu bl ic a bo ut th e ha rm s o f s m ok in g/ to ba cc o us e an d se co nd h an d sm ok e Pa rt ia l. Ca m pa ig ns im pl em en te d, b ut n ot su st ai ne d. EI Pr ov id e co st c ov er ed , e ffe ct iv e an d po pu la tio n w id e su pp or t ( in cl ud in g br ie f a dv ic e, n at io na l t ol l-f re e qu it lin e se rv ic es ) f or to ba cc o ce ss at io n to a ll th os e w ho w an t t o qu it Pa rt ia l. To ba cc o de pe nd en ce tr ea tm en t i s a va ila bl e in so m e pr iv at e do ct or ’s o ffi ce s a nd o th er p riv at e se ct or fa ci lit ie s, a nd n ic ot in e re pl ac em en t t he ra py is a va ila bl e, b ut th es e in te rv en tio ns a re n ot c os t co ve re d in a ll ca se s; th er e is no q ui t l in e se rv ic e. O RI s Im pl em en t m ea su re s t o m in im ise il lic it tr ad e in to ba cc o pr od uc ts N on e. S om e di sc us sio n is ta ki ng p la ce a t r eg io na l l ev el , a nd P AH O /W HO is en co ur ag in g co un tr ie s i n th e re gi on to si gn o n to th e re le va nt F CT C Pr ot oc ol .27 1 26 9 In fo rm at io n on p ro gr es s w as o bt ai ne d fr om th e SM O H N CD s, a nd , w he re a pp ro pr ia te , f ro m W HO a nd P AH O re po rt s. M os t o f t he in fo rm at io n on p ro gr es s i n to ba cc o co nt ro l w as o bt ai ne d fr om W HO . R ep or t o n th e gl ob al to ba cc o ep id em ic 2 01 9: C ou nt ry p ro fil e Ba rb ad os . G en ev a: W HO ; 2 01 9. ht tp s: // w w w .w ho .in t/ to ba cc o/ su rv ei lla nc e/ po lic y/ co un tr y pr of ile /b rb .p df ?u a= 1. 27 0 T he re a re 3 3 BB s, E Is , a nd O RI s r el at ed to m an ag em en t o f t he fo ur p rio rit y N CD s, b ut th e M HW d ee m ed th e O RI “ Ac ce ss to im pr ov ed st ov es a nd c le an er fu el s t o re du ce in do or a ir po llu tio n” in ap pl ic ab le in th e Ba rb ad os c on te xt , a nd it w as o m itt ed in th is an al ys is. 27 1 W HO . P ro to co l t o El im in at e Ill ic it Tr ad e in T ob ac co P ro du ct s. G en ev a: W HO ; 2 01 3. ht tp s: // w w w .w ho .in t/ fc tc /p ro to co l/e n/ . 26 9 In fo rm at io n on p ro gr es s w as o bt ain ed fr om th e SM O H N C D s, a nd , w he re a pp ro pr iat e, fr om W H O a nd P AH O re po rts . M os t o f t he in fo rm at io n on p ro gr es s in to ba cc o co nt ro l w as o bt ain ed fr om W H O . R ep or t o n th e gl ob al to ba cc o ep id em ic 20 19 : C ou nt ry p ro file B ar ba do s. G en ev a: W H O ; 2 01 9. h ttp s: //w w w .w ho .in t/t ob ac co /s ur ve illa nc e/ po lic y/ co un try p ro file /b rb .p df ?u a= 1. 27 0 Th er e ar e 33 B Bs , E Is, a nd O RI s re lat ed to m an ag em en t o f t he fo ur p rio rit y N C D s, b ut th e M H W d ee m ed th e O RI “A cc es s to im pr ov ed s to ve s an d cle an er fu el s to re du ce in do or a ir po llu tio n” in ap pl ica bl e in th e Ba rb ad os co nt ex t, an d it w as o m itt ed in th is an aly sis . 27 1 W H O . P ro to co l t o El im in at e Illi cit T ra de in T ob ac co P ro du ct s. G en ev a: W H O ; 2 01 3. ht tp s: //w w w .w ho .in t/f ct c/ pr ot oc ol /e n/ . A nn ex 7 : P ro gr es s To w ar ds W H O B es t B uy s an d Ef fe ct iv e an d O th er R ec om m en de d In te rv en tio ns 108 Pa ge 1 22 o f 1 34 Ri sk fa ct or /D is ea se BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts Ba n cr os s bo rd er a dv er tis in g, in cl ud in g us in g m od er n m ea ns o f c om m un ic at io n N on e. Pr ov id e m ob ile p ho ne b as ed to ba cc o ce ss at io n se rv ic es fo r a ll th os e w ho w an t t o qu it N on e. Re du ce ha rm fu l u se o f al co ho l BB s In cr ea se e xc ise ta xe s o n al co ho lic b ev er ag es N on e. En ac t a nd e nf or ce b an s o r c om pr eh en siv e re st ric tio ns o n ex po su re to a lc oh ol a dv er tis in g (a cr os s m ul tip le ty pe s o f m ed ia ) Fu ll. N ew d ra ft b ill o n liq uo r l ic en se s b an s s al es a nd a dv er tis in g to m in or s, an d m in im um a ge w ill m ov e fr om 1 6 to 1 8 ye ar s. N o su pp or t f ro m M HW /C ou nc il on S ub st an ce A bu se o r I nd us tr y fo r p ar en ta l e xe m pt io ns be tw ee n 16 a nd 1 8 ye ar s. En ac t a nd e nf or ce re st ric tio ns o n th e ph ys ic al a va ila bi lit y of re ta ile d al co ho l ( vi a re du ce d ho ur s o f s al e) Pa rt ia l. Ba n on sa le to m in or s ( se e ab ov e) ; n ot re la te d to re du ce d ho ur s o f sa le . EI s En ac t a nd e nf or ce d rin k dr iv in g la w s a nd b lo od a lc oh ol co nc en tr at io n lim its v ia so br ie ty c he ck po in ts Pa rt ia l. Re gu la tio ns in p la ce u nd er tr af fic sa fe ty re gu la tio ns , b ut a re n ot cu rr en tly e nf or ce d; a w ai tin g eq ui pm en t a nd tr ai ni ng fo r p ol ic e. S up po rt ed by a lc oh ol in du st ry . Pr ov id e br ie f p sy ch os oc ia l i nt er ve nt io n fo r p er so ns w ith ha za rd ou s a nd h ar m fu l a lc oh ol u se Pa rt ia l. Li m ite d to p sy ch ia tr ic /d ru g re ha bi lit at io n se tt in gs . O RI s Ca rr y ou t r eg ul ar re vi ew s o f p ric es in re la tio n to le ve l o f in fla tio n an d in co m e N on e. Es ta bl ish m in im um p ric es fo r a lc oh ol w he re a pp lic ab le N on e. En ac t a nd e nf or ce a n ap pr op ria te m in im um a ge fo r pu rc ha se o r c on su m pt io n of a lc oh ol ic b ev er ag es a nd re du ce d en sit y of re ta il ou tle ts Pa rt ia l. M in im um a ge fo r p ur ch as e en ac te d, m os tly e nf or ce d; n o re du ct io n in d en sit y of re ta il ou tle ts . C om m er ce is se ek in g to e xp ed ite /s tr ea m lin e liq uo r l ic en sin g w hi le p ro te ct in g m in or s. Re st ric t o r b an p ro m ot io ns o f a lc oh ol ic b ev er ag es in co nn ec tio n w ith sp on so rs hi ps a nd a ct iv iti es ta rg et in g yo un g pe op le Pa rt ia l. Pr om ot io n to y ou ng p eo pl e is no t e nc ou ra ge d, b ut th er e ha s n ot be en m uc h po lic y su pp or t f or th is; H CC , i n co lla bo ra tio n w ith P AH O , p la ns an d im pl em en ts a ct iv iti es fo r a nn ua l C ar ib be an A lc oh ol R ed uc tio n Da y in N ov em be r. Pr ov id e pr ev en tio n, tr ea tm en t a nd c ar e fo r a lc oh ol u se di so rd er s a nd c om or bi d co nd iti on s i n he al th a nd so ci al se rv ic es Pa rt ia l. Tr ea tm en t f or a lc oh ol u se c om pl ic at io ns a nd c o m or bi d co nd iti on s is av ai la bl e w he n th ey o cc ur , a nd is o ffe re d in p sy ch ia tr ic /d ru g re ha bi lit at io n/ cl in ic al c ar e se tt in gs . Pr ov id e co ns um er in fo rm at io n ab ou t, an d la be l, al co ho lic be ve ra ge s t o in di ca te , t he h ar m re la te d to a lc oh ol Pa rt ia l.I nd us tr y ha s m ov ed a he ad w ith th is; th er e ha s b ee n no M HW in te rv en tio n on th is re co m m en da tio n. Re du ce un he al th y di et BB s Re du ce sa lt in ta ke th ro ug h th e re fo rm ul at io n of fo od pr od uc ts to c on ta in le ss sa lt an d th e se tt in g of ta rg et le ve ls fo r t he a m ou nt o f s al t i n fo od s a nd m ea ls Pa rt ia l. Co ns ul ta tio ns w ith , a nd v ol un ta ry re fo rm ul at io n of so m e pr od uc ts by , I nd us tr y. Re du ce sa lt in ta ke th ro ug h th e es ta bl ish m en t o f a su pp or tiv e en vi ro nm en t i n pu bl ic in st itu tio ns su ch a s Pa rt ia l. Lo w s al t d ie ts a va ila bl e in h os pi ta ls, n ur sin g ho m es a s p ar t o f cl in ic al m an ag em en t; lo w s od iu m o pt io ns fo r s om e pr od uc ts a va ila bl e in 109 Pa ge 1 23 o f 1 34 Ri sk fa ct or /D is ea se BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts ho sp ita ls, sc ho ol s, w or kp la ce s a nd n ur sin g ho m es , t o en ab le lo w er so di um o pt io ns to b e pr ov id ed su pe rm ar ke ts . Re du ce sa lt in ta ke th ro ug h a be ha vi ou r c ha ng e co m m un ic at io n an d m as s m ed ia c am pa ig n Pa rt ia l. Sa lt re du ct io n in fo rm at io n an d ca m pa ig n im pl em en te d th ro ug h HC C, N N CD C, a nd M HW . Re du ce sa lt in ta ke th ro ug h th e im pl em en ta tio n of fr on t of p ac k la be lli ng N on e. T hi s i s c ur re nt ly u nd er d isc us sio n at th e re gi on al le ve l, re la te d to re vi sio n by C RO SQ o f t he C ar ib be an R eg io na l S ta nd ar d on P re p ac ka ge d Fo od L ab el lin g (C RS 5 )t o in cl ud e Fo PW L. H ow ev er , B ar ba do s i nt en ds to ad va nc e w ith F oP W L, in fa ce o f r eg io na l d el ay s. EI s El im in at e in du st ria l t ra ns fa ts th ro ug h th e de ve lo pm en t o f le gi sla tio n to b an th ei r u se in th e fo od c ha in N on e. T hi s i s u nd er d isc us sio n, su pp or te d by N N CD C in th e fr am ew or k of th e CA RP HA 6 P oi nt P ol ic y Pa ck ag e fo r h ea lth ie r f oo d en vi ro nm en ts a nd th e PA HO P la n of A ct io n fo r t he E lim in at io n of In du st ria lly p ro du ce d Tr an s fa tt y Ac id s 2 02 0 20 25 ,27 2 Re du ce su ga r c on su m pt io n th ro ug h ef fe ct iv e ta xa tio n on SS Bs a nd re la te d re so lu tio n CD 57 .R 12 , a pp ro ve d at th e 57 th P AH O D ire ct in g Co un ci l i n Se pt em be r 2 01 9. Th e M in ist er o f H ea lth a nd W el ln es s h as a sk ed fo r a b rie f o n th e iss ue , w hi ch b en ef itt ed fr om N at io na l N ut rit io n Ce nt re g ui da nc e on u sin g th e W HO R EP LA CE te ch ni ca l pa ck ag el oc al ly . Pa rt ia l. A 10 % ta x on S SB s w as in tr od uc ed in 2 01 5; th e le ve l i s m uc h lo w er th an th e W HO r ec om m en de d 20 % m in im um . T he re is n o ap pa re nt p ol ic y ap pe tit e to in cr ea se th e ta x to a le ve l t ha t i s l ik el y to h av e sig ni fic an t im pa ct — th er e ap pe ar s t o be a b el ie f i n th e in du st ry ta lk in g po in ts , d es pi te sh ar in g th e ev id en ce . O RI s Pr om ot e an d su pp or t e xc lu siv e br ea st fe ed in g fo r t he fi rs t six m on th s o f l ife , i nc lu di ng p ro m ot io n of b re as tfe ed in g Fu ll. T he re is a M HW B re as tf ee di ng C om m itt ee ; b re as tfe ed in g is an in te rv en tio n in th e BC HO PP ; t he Q EH is a c er tif ie d “B ab y Fr ie nd ly H os pi ta l” ; th e Br ea st fe ed in g an d Ch ild N ut rit io n Fo un da tio n of B ar ba do s, a n N G O , pr om ot es b re as tf ee di ng ; a nd th er e ar e gu id el in es fo r g ov er nm en t op er at ed p rim ar y ca re se tt in gs o n ch ild a nd in fa nt fe ed in g. Im pl em en t s ub sid ie s t o in cr ea se th e in ta ke o f f ru its a nd ve ge ta bl es N on e. T he G oB ’s M an ife st o sp ea ks to w el ln es s g ra nt s a nd a d isc us sio n pa pe r h as b ee n w rit te n an d su bm itt ed , a s w el l a s a sp ec ifi c pa pe r o n in ce nt iv es fo r h yp er te ns io n an d di ab et es c on tr ol , a s r eq ue st ed . Re pl ac e tr an sf at s a nd sa tu ra te d fa ts w ith u ns at ur at ed fa ts th ro ug h re fo rm ul at io n, la be lli ng , f isc al p ol ic ie s o r ag ric ul tu ra l p ol ic ie s N on e. P ro po sin g to u se R EP LA CE fr am ew or k w ith su pp or t f ro m Co m m iss io n an d po ss ib ly fr om M in ist er , a s a bo ve . Li m it po rt io n an d pa ck ag e siz e to re du ce e ne rg y in ta ke an d th e ris k of o ve rw ei gh t/ ob es ity N on e. T he re a re p la ns to d o th is in th e sc ho ol e nv iro nm en t. 27 2 ht tp s: // w w w .p ah o. or g/ hq /in de x. ph p? op tio n= co m d oc m an & vi ew =d ow nl oa d& al ia s= 49 61 2 cd 57 8 e p oa t ra ns fa tt y& ca te go ry s lu g= cd 57 e n& Ite m id =2 70 & la ng =e n/ 27 2 ht tp s: //w w w .p ah o. or g/ hq /in de x. ph p? op tio n= co m d oc m an & vi ew = do w nl oa d& ali as = 49 61 2 cd 57 8 e p oa t ra ns fa tty & ca te go ry s lu g= cd 57 e n& Ite m id = 27 0& lan g= en / 110 Pa ge 1 24 o f 1 34 Ri sk fa ct or /D is ea se BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts Im pl em en t n ut rit io n ed uc at io n an d co un se lli ng in di ffe re nt se tt in gs (f or e xa m pl e, in p re sc ho ol s, sc ho ol s, w or kp la ce s a nd h os pi ta ls) to in cr ea se th e in ta ke o f f ru its an d ve ge ta bl es Fu ll. T hi s i s t he re m it of th e M HW ’s N at io na l N ut rit io n Ce nt re .27 3 Im pl em en t n ut rit io n la be lli ng to re du ce to ta l e ne rg y in ta ke (k ca l), su ga rs , s od iu m a nd fa ts N on e. N o na tio na l s ta nd ar d fo r n ut rit io n la be lli ng e xi st s. H ow ev er , t hi s i s cu rr en tly u nd er d isc us sio n th ro ug h th e Ba rb ad os N at io na l S ta nd ar ds In st itu tio n (B N SI ),27 4 Im pl em en t m as s m ed ia c am pa ig n on h ea lth y di et s, in cl ud in g so ci al m ar ke tin g to re du ce th e in ta ke o f t ot al fa t, sa tu ra te d fa ts , s ug ar s a nd sa lt, a nd p ro m ot e th e in ta ke o f fr ui ts a nd v eg et ab le s re la te d to re vi sio n by th e CA RI CO M R eg io na l O rg an isa tio n fo r S ta nd ar ds a nd Q ua lit y (C RO SQ ) o f t he C AR IC O M R eg io na l St an da rd o n N ut rit io n La be lli ng (C RS 5 ) f or p re p ac ka ge d fo od s, to in cl ud e Fo PW L. B ar ba do s w ill a dv an ce F oP W L in fa ce o f r eg io na l d el ay s. Pa rt ia l. Th e HP U p er fo rm s t hi s f un ct io n as re so ur ce s p er m it, a nd a co ns ul ta nt w as e ng ag ed to p ro vi de re le va nt p ro je ct a dv ic e in 2 01 9. Re du ce ph ys ic al in ac tiv ity BB s Im pl em en t c om m un ity w id e pu bl ic e du ca tio n an d aw ar en es s c am pa ig n fo r p hy sic al a ct iv ity w hi ch in cl ud es a m as s m ed ia c am pa ig n co m bi ne d w ith o th er c om m un ity ba se d ed uc at io n, m ot iv at io na l a nd en vi ro nm en ta lp ro gr am m es a im ed a t s up po rt in g be ha vi ou ra l c ha ng e of p hy sic al a ct iv ity le ve ls Fu ll. A N at io na l T as k Fo rc e on P hy sic al A ct iv ity a nd E xe rc ise w as es ta bl ish ed in 2 00 9; th e do cu m en t “ Ph ys ic al A ct iv ity G ui de lin es fo r Ba rb ad ia ns ” w as p ub lis he d in 2 01 3; a nd th e ‘B ar ba do s M ov es ’ i ni tia tiv e an d th e N TF W w er e la un ch ed in 2 01 8. T he N TF W is se ek in g to im pl em en t ‘B ar ba do s M ov es ’ p ar ish b y pa ris h, th ro ug h di re ct a ct iv iti es a nd th ro ug h en do rs in g ac tiv iti es . E ffo rt s a re a lso b ei ng m ad e to st re ng th en th e “G et W om en M ov in g” 27 5 EI s p ro gr am m e, a c om m un ity b as ed , M HW s up po rt ed in iti at iv e la un ch ed in 2 01 6 th at p ro vi de s o pp or tu ni tie s f or a er ob ic se ss io ns at a ffo rd ab le ra te s, ta rg et in g w om en . Pr ov id e ph ys ic al a ct iv ity c ou ns el lin g an d re fe rr al a s p ar t o f ro ut in e pr im ar y he al th c ar e se rv ic es th ro ug h th e us e of a br ie fin te rv en tio n N on e. T er m s o f r ef er en ce fo r c on su lta nc y dr af te d; fu nd in g an d co ns ul ta nt to b e id en tif ie d. O RI s En su re th at m ac ro le ve l u rb an d es ig n in co rp or at es th e co re e le m en ts o f r es id en tia l d en sit y, c on ne ct ed st re et ne tw or ks th at in cl ud e sid ew al ks , e as y ac ce ss to a d iv er sit y of d es tin at io ns a nd a cc es s t o pu bl ic tr an sp or t N on e. C om m en ts o n ne w d ra ft p hy sic al d ev el op m en t p la n su bm itt ed b y SM O H N CD s a nd N N CD C. Im pl em en t w ho le o f-s ch oo l p ro gr am m e th at in cl ud es qu al ity p hy sic al e du ca tio n, a va ila bi lit y of a de qu at e N on e. O ng oi ng d isc us sio ns w ith M ET VT ; M HW c on tr ib ut io n to re vi sio n of CA RI CO M /C XC c ur ric ul um to in cl ud e N CD s, b ei ng u nd er ta ke n th ro ug h U W I. 27 3 ht tp :/ /n ut rit io nc en tr e. he al th .g ov .b b/ . 27 4 ht tp :/ /w w w .b ns i.b b/ . 27 5 ht tp s: // on ec ar ib be an he al th .o rg /g et w om en m ov in g ca m pa ig n la un ch ed o n w or ld h ea lth d ay /. 27 3 ht tp :// nu tri tio nc en tre .h ea lth .g ov .b b/ . 27 4 ht tp :// w w w .b ns i.b b/ . 27 5 ht tp s: //o ne ca rib be an he alt h. or g/ ge t w om en m ov in g ca m pa ig n lau nc he d on w or ld h ea lth d ay /. 111 Pa ge 1 25 o f 1 34 Ri sk fa ct or /D is ea se BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts fa ci lit ie s a nd p ro gr am s t o su pp or t p hy sic al a ct iv ity fo r a ll ch ild re n Pr ov id e co nv en ie nt a nd sa fe a cc es s t o qu al ity p ub lic o pe n sp ac e an d ad eq ua te in fr as tr uc tu re to su pp or t w al ki ng a nd cy cl in g N on e. N ew p hy sic al d ev el op m en t p la n al re ad y in cl ud es re qu ire m en t f or ne w d ev el op m en ts o f a p ar tic ul ar si ze to re se rv e gr ee n sp ac e; su bm iss io ns m ad e fo r i nc lu sio n of o th er a sp ec ts , e .g . b ik e la ne s, si de w al ks . Im pl em en t m ul ti co m po ne nt w or kp la ce p hy sic al a ct iv ity pr og ra m m es N on e. T hi s i s I nc lu de d in th e 20 19 N at io na l W or kp la ce W el ln es s P ol ic y27 6 Pr om ot e ph ys ic al a ct iv ity th ro ug h or ga ni ze d sp or t g ro up s an d cl ub s, p ro gr am m es a nd e ve nt s un de r t he M in ist ry o f L ab ou r; M HW is re pr es en te d on n ew N at io na l Co m m itt ee fo r W or kp la ce W el ln es s Fu ll. M an y sp or ts g ro up s a nd c lu bs e xi st , a s w el l a s a S po rt s C ou nc il, a nd to pi c is on th e ag en da o f t he C ab in et S ub c om m itt ee o n N CD s. M an ag e CV D an d di ab et es BB Dr ug th er ap y (in cl ud in g gl yc ae m ic c on tr ol fo r d ia be te s m el lit us a nd c on tr ol o f h yp er te ns io n us in g a to ta l r isk 27 7 • Dr ug th er ap y (in cl ud in g gl yc ae m ic c on tr ol fo r d ia be te s m el lit us a nd c on tr ol o f h yp er te ns io n us in g a to ta l r isk ap pr oa ch ) a nd c ou ns el lin g to in di vi du al s w ho h av e ha d a he ar t a tt ac k or st ro ke an d to p er so ns w ith m od er at e to h ig h ris k (≥ 2 0% ) o f a fa ta l a nd n on fa ta l ca rd io va sc ul ar e ve nt in th e ne xt 1 0 ye ar s ap pr oa ch ) a nd c ou ns el lin g to in di vi du al s w ho h av e ha d a he ar t a tt ac k or st ro ke a nd to p er so ns w ith h ig h ris k (≥ 30 % ) o f a fa ta l a nd n on fa ta l c ar di ov as cu la r e ve nt in th e ne xt 1 0 ye ar s Pa rt ia l. Dr ug th er ap y is pr ov id ed ; t he re is li m ite d ris k as se ss m en t a nd pr ev en tio n us in g th e W HO H EA RT S te ch ni ca l p ac ka ge fo r C VD ri sk re du ct io n at fo ur p ilo t s ite s. EI Tr ea tm en t o f n ew c as es o f a cu te m yo ca rd ia l i nf ar ct io n27 8 • Tr ea tm en t n ew c as es o f a cu te m yo ca rd ia l i nf ar ct io n w ith a sp iri n, in iti al ly tr ea te d in a h os pi ta l s et tin g w ith fo llo w u p ca rr ie d ou t t hr ou gh P HC fa ci lit ie s a t a 9 5% co ve ra ge ra te w ith e ith er : a ce ty lsa lic yl ic a ci d, o r a ce ty lsa lic yl ic a ci d an d cl op id og re l, or th ro m bo ly sis , o r p rim ar y pe rc ut an eo us co ro na ry in te rv en tio ns (P CI ) • Tr ea tm en t o f n ew c as es o f a cu te m yo ca rd ia l Fu ll. A N at io na l P ro to co l h as b ee n co m m iss io ne d, in cl ud in g ca re p at hw ay s. Th e BN R tr ac ks a ch ie ve m en t o f t he se ta rg et s a nd p ub lic se rv ic e an no un ce m en ts (P SA s) fo r h ea rt a tt ac k ha ve b ee n de ve lo pe d to p ro m ot e aw ar en es s o f s ym pt om s a nd th e ap pr op ria te re sp on se . 27 6 ht tp s: // w w w .h ea lth yc ar ib be an .o rg /w p co nt en t/ up lo ad s/ 20 19 /0 3/ N at io na l-W or kp la ce W el ln es s Po lic y fo r Ba rb ad os 2 01 9. pd f. 27 7 To ta l r isk is d ef in ed a s t he p ro ba bi lit y of a n in di vi du al e xp er ie nc in g a ca rd io va sc ul ar d ise as e ev en t ( fo re xa m pl e, m yo ca rd ia l i nf ar ct io n or st ro ke ) o ve r a g iv en p er io d of ti m e, fo r ex am pl e 10 y ea rs . 27 8 Co st in g as su m es h os pi ta l c ar e in a ll sc en ar io s. 27 6 ht tp s: //w w w .h ea lth yc ar ib be an .o rg /w p co nt en t/u pl oa ds /2 01 9/ 03 /N at io na l-W or kp lac e W el ln es s Po lic y fo r Ba rb ad os 2 01 9. pd f. 27 7 To ta l r isk is d ef in ed a s th e pr ob ab ilit y of a n in di vi du al ex pe rie nc in g a ca rd io va sc ul ar d ise as e ev en t ( fo re xa m pl e, m yo ca rd ial in fa rc tio n or s tro ke ) o ve r a g iv en p er io d of ti m e, fo r e xa m pl e 10 y ea rs . 27 8 C os tin g as su m es h os pi ta l c ar e in a ll sc en ar io s. 112 Pa ge 1 26 o f 1 34 Ri sk fa ct or /D is ea se BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts in fa rc tio n w ith a sp iri n an d th ro m bo ly sis , i ni tia lly tr ea te d in a h os pi ta l s et tin g w ith fo llo w u p ca rr ie d ou t th ro ug h PH C fa ci lit ie s a t a 9 5% c ov er ag e ra te • Tr ea tm en t o f n ew c as es o f m yo ca rd ia l i nf ar ct io n w ith pr im ar y pe rc ut an eo us c or on ar y in te rv en tio ns (P CI ), as pi rin a nd c lo pi do gr el , i ni tia lly tr ea te d in a h os pi ta l se tt in g w ith fo llo w u p ca rr ie d ou t t hr ou gh P HC fa ci lit ie s a t a 9 5% c ov er ag e ra te Tr ea tm en t o f a cu te is ch em ic st ro ke w ith in tr av en ou s th ro m bo ly tic th er ap y Fu ll. T he re is a S tr ok e pr ot oc ol a nd a S tr ok e U ni t a t t he Q EH . PS As fo r s tr ok e pr om ot in g aw ar en es s o f s ym pt om s a nd a pp ro pr ia te re sp on se h av e be en d ev el op ed , a nd th e BN R tr ac ks a ch ie ve m en t o f t he se ta rg et s. Pr im ar y pr ev en tio n of rh eu m at ic fe ve r a nd rh eu m at ic he ar t d ise as es b y in cr ea sin g ap pr op ria te tr ea tm en t o f st re pt oc oc ca l p ha ry ng iti s a t t he p rim ar y ca re le ve l U nc le ar . A ss um ed , b ut n o sp ec ifi c gu id el in e cu rr en tly in p la ce . Se co nd ar y pr ev en tio n of rh eu m at ic fe ve r a nd rh eu m at ic he ar t d ise as e by d ev el op in g a re gi st er o f p at ie nt s w ho re ce iv er eg ul ar p ro ph yl ac tic p en ic ill in N on e. T hi s w ou ld b e fa ci lit at ed b y a na tio nw id e el ec tr on ic d isp en sin g sy st em . O RI s Tr ea tm en t o f c on ge st iv e ca rd ia c fa ilu re w ith a ng io te ns in co nv er tin g e nz ym e in hi bi to r, be ta b lo ck er a nd d iu re tic U nc le ar . A ss um ed st an da rd o f p ra ct ic e, n o sp ec ifi c pr ot oc ol in p la ce . Ca rd ia c re ha bi lit at io n po st m yo ca rd ia l i nf ar ct io n Fu ll. S er vi ce s p ro vi de d by th e HS FB su pp or te d by g ov er nm en t f un di ng . An tic oa gu la tio n fo r m ed iu m a nd h ig h ris k no n va lv ul ar at ria l f ib ril la tio n an d fo r m itr al st en os is w ith a tr ia l fib ril la tio n U nc le ar . A ss um ed st an da rd o f p ra ct ic e, n o sp ec ifi c pr ot oc ol in p la ce . Lo w d os e ac et yl sa lic yl ic a ci d fo r i sc he m ic st ro ke Fu ll. S ta nd ar d pr ac tic e. Ca re o f a cu te st ro ke a nd re ha bi lit at io n in st ro ke u ni ts Fu ll. S tr ok e un it es ta bl ish ed a t t he Q EH . M an ag e di ab et es EI s Pr ev en tiv e fo ot c ar e fo r p eo pl e w ith d ia be te s ( in cl ud in g ed uc at io na l p ro gr am m es , a cc es s t o ap pr op ria te fo ot w ea r, m ul ti di sc ip lin ar y cl in ic s) Pa rt ia l. So m e el em en ts in p la ce in p ub lic fi rs t l ev el o f c ar e fa ci lit ie s a nd a t th e Ba rb ad os D ia be te s F ou nd at io n (B DF ), w hi ch re ce iv es a su bv en tio n fr om th e M HW . Di ab et ic re tin op at hy sc re en in g fo r a ll di ab et es p at ie nt s an d la se r p ho to co ag ul at io n fo r p re ve nt io n of b lin dn es s Fu ll. S cr ee ni ng is o ffe re d at th e Q EH a nd B DF , a nd tr ea tm en t i s p ro vi de d at th e Q EH . Ef fe ct iv e gl yc ae m ic c on tr ol fo r p eo pl e w ith d ia be te s, al on g w ith st an da rd h om e gl uc os e m on ito rin g fo r p eo pl e tr ea te dw ith in su lin to re du ce d ia be te s c om pl ic at io ns Fu ll. G ui de lin es a re in p la ce , a nd g lu co m et er st rip s a re in cl ud ed in th e N at io na l F or m ul ar y, fa ci lit at in g ac ce ss to th em . O RI s Li fe st yl e in te rv en tio ns fo r p re ve nt in g ty pe 2 d ia be te s Fu ll, th ro ug h ef fo rt s t o re du ce N CD ri sk fa ct or s a nd th e ob es og en ic en vi ro nm en t. 113 Pa ge 1 27 o f 1 34 Ri sk fa ct or /D is ea se BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts In flu en za v ac ci na tio n fo r p at ie nt s w ith d ia be te s U ns ur e. N o sp ec ifi c pr ot oc ol in p la ce . Pr ec on ce pt io n ca re a m on g w om en o f r ep ro du ct iv e ag e w ho h av e di ab et es in cl ud in g pa tie nt e du ca tio n an d in te ns iv e gl uc os e m an ag em en t Pa rt ia l. So m e el em en ts a re in p la ce , b ut th er e ar e no n at io na l g ui de lin es . Sc re en in g of p eo pl e w ith d ia be te s f or p ro te in ur ia a nd tr ea tm en t w ith a ng io te ns in c on ve rt in g en zy m e in hi bi to r fo r t he p re ve nt io n an d de la y of re na l d ise as e Pa rt ia l. N ot in p rim ar y ca re o r o th er g ui de lin es , b ut o bs er ve d as st an da rd pr ac tic e. M an ag e ca nc er BB s Va cc in at io n ag ai ns t h um an p ap ill om av iru s ( 2 do se s) o f 9 – 13 y ea r o ld g irl s Fu ll. Pr ev en tio n of c er vi ca l c an ce r b y sc re en in g w om en a ge d 30 –4 9, e ith er th ro ug h: • Vi su al in sp ec tio n w ith a ce tic a ci d lin ke d w ith ti m el y tr ea tm en t o f p re c an ce ro us le sio ns , • Pa p sm ea r ( ce rv ic al c yt ol og y) e ve ry 3 –5 y ea rs li nk ed w ith ti m el y tr ea tm en t o f p re c an ce ro us le sio ns , o r • Hu m an p ap ill om av iru s t es t e ve ry 5 y ea rs li nk ed w ith tim el y tr ea tm en t o f p re c an ce ro us le sio ns Fu ll. G ui de lin es d ev el op ed fo r u se a t t he fi rs t a nd se co nd le ve ls of c ar e fo r sc re en in g us in g ce rv ic al c yt ol og y an d HP V te st in g. T he B ar ba do s C an ce r So ci et y (B CS ) o ffe rs c er vi ca l c an ce r s cr ee ni ng . EI s Sc re en in g w ith m am m og ra ph y (o nc e ev er y 2 ye ar s f or w om en a ge d 50 6 9 ye ar s) li nk ed w ith ti m el y di ag no sis a nd tr ea tm en t o f b re as t c an ce r Pa rt ia l. M am m og ra ph y sc re en in g se rv ic es a re a va ila bl e in th e pu bl ic a nd pr iv at e se ct or s, a nd a re o ffe re d by th e BC S, b ut th er e ar e no n at io na l gu id el in es , d at ab as e, o r c al l a nd re ca ll sy st em . Tr ea tm en t o f c ol or ec ta l c an ce r s ta ge s I a nd II w ith su rg er y +/ c he m ot he ra py a nd ra di ot he ra py Fu ll. Tr ea tm en t o f c er vi ca l c an ce r s ta ge s I a nd II w ith e ith er su rg er y or ra di ot he ra py + / c he m ot he ra py Fu ll. Tr ea tm en t o f b re as t c an ce r s ta ge s I a nd II w ith su rg er y +/ sy st em ic th er ap y Fu ll. Ba sic p al lia tiv e ca re fo r c an ce r: ho m e ba se d an d ho sp ita l ca re w ith m ul ti di sc ip lin ar y te am a nd a cc es s t o op ia te s an d es se nt ia l s up po rt iv e m ed ic in e Pa rt ia l. Pr ov id ed o n a lim ite d ba sis th ro ug h pu bl ic a nd p riv at e se ct or s, a nd th e Ba rb ad os A ss oc ia tio n of P al lia tiv e Ca re ,27 9 O RI s a n N G O . Pr ev en tio n of li ve r c an ce r t hr ou gh h ep at iti s B im m un isa tio n Fu ll. O ra l c an ce r s cr ee ni ng in h ig h ris k gr ou ps (f or e xa m pl e, to ba cc o us er s, b et el n ut c he w er s) li nk ed w ith ti m el y tr ea tm en t N on e. 27 9 ht tp :/ /w w w .b ar ba do sp al lia tiv e. or g/ . 27 9 ht tp :// w w w .b ar ba do sp all iat iv e. or g/ . 114 Pa ge 1 28 o f 1 34 Ri sk fa ct or /D is ea se BB s, E Is , O RI s De sc rip tio n Pr og re ss /C om m en ts Po pu la tio n ba se d co lo re ct al c an ce r s cr ee ni ng , i nc lu di ng th ro ug h a fa ec al o cc ul t b lo od te st , a s a pp ro pr ia te , a t a ge >5 0, li nk ed w ith ti m el y tr ea tm en t N on e. T he re is n o po pu la tio n ba se d sc re en in g pr og ra m m e, b ut th er e is ea rly d et ec tio n an d ca se fi nd in g th ro ug h sc re en in g of h ig h ris k an d sy m pt om at ic p er so ns . M an ag e ch ro ni c re sp ira to ry di se as es EI s Sy m pt om re lie f f or p at ie nt s w ith a st hm a w ith in ha le d sa lb ut am ol Fu ll. Sy m pt om re lie f f or p at ie nt s w ith c hr on ic o bs tr uc tiv e pu lm on ar y re lie f w ith in ha le d sa lb ut am ol Fu ll. Tr ea tm en t o f a st hm a us in g lo w d os e in ha le d be cl om et ha so ne a nd sh or t ac tin g be ta a go ni st Fu ll. O RI s Ac ce ss to im pr ov ed st ov es a nd c le an er fu el s t o re du ce in do or a ir po llu tio n N ot re le va nt in th e Ba rb ad os c on te xt . Co st e ffe ct iv e in te rv en tio ns to p re ve nt o cc up at io na l l in g di se as es , f or e xa m pl e, e xp os ur e to si lic a, a sb es to s Fu ll. G en er al ly c ov er ed u nd er o cc up at io n he al th a nd sa fe ty re gu la tio ns . In flu en za v ac ci na tio n fo r p at ie nt s w ith c hr on ic o bs tr uc tiv e pu lm on ar y di se as e U ns ur e. N o na tio na l p ro to co l e xi st s. 115 Pa ge 1 29 o f 1 34 A nn ex 8 : P ro gr es s to w ar ds th e G lo ba l M on ito rin g Fr am ew or k ta rg et s an d in di ca to rs Fr am ew or k el em en ts Ta rg et s In di ca to rs Da ta tr en ds /C om m en ts M O RT AL IT Y AN D M O RB ID IT Y Pr em at ur e m or ta lit y fr om N CD s 1. A 25 % re la tiv e re du ct io n in th e ov er al l m or ta lit y fr om ca rd io va sc ul ar d ise as es , ca nc er , d ia be te s, o r c hr on ic re sp ira to ry d ise as es U nc on di tio na l p ro ba bi lit y of d yi ng be tw ee n ag es o f 3 0 an d 70 fr om ca rd io va sc ul ar d ise as es , c an ce r, di ab et es or c hr on ic re sp ira to ry d ise as es W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 6 da ta :28 0 W HO N CD C ou nt ry P ro fil es 2 01 1, 2 00 8 da ta : Ri sk o f pr em at ur e de at h be tw ee n 30 a nd 7 0 ye ar s o f a ge : 1 6. 0% ris k (m al es 2 0. 0% , f em al es 1 3. 0% ) 28 1 Ad di tio na l i nd ic at or N CD de at hs < a ge 6 0 (% o f a ll N CD d ea th s) : m al es 2 2. 7% , fe m al es 1 7. 3% ) Ca nc er in ci de nc e, b y ty pe o f c an ce r, pe r 10 0, 00 0 po pu la tio n In te rn at io na l A ge nc y fo r R es ea rc h on C an ce r ( IA RC ) G lo bo ca n 20 18 :28 2 Ba rb ad os N at io na l R eg is tr y 20 14 : Ag e st an da rd ise d (w or ld ) c an ce r in ci de nc e pe r 1 00 ,0 00 p op ul at io n: P ro st at e 12 9. 3; B re as t 72 .8 ; C ol or ec tu m 3 8. 9 (m al es 2 2. 8, fe m al es 1 6. 2) ; C or pu s ut er i ( ut er in e bo dy ) 1 8. 6; C er vi x ut er i 1 5. 5; L un g 9. 4 (m al es 13 .7 , f em al es 5 .8 ) 28 3 Ag e st an da rd ise d (w or ld ) c an ce r i nc id en ce p er 1 00 ,0 00 p op ul at io n: P ro st at e 11 1. 4; B re as t 7 4. 5; C ol on 2 8. 4 fe m al es , 2 8. 0 m al es ; C or pu s ut er i 2 5. 4; C er vi x ut er i 1 8. 2; L un g 7. 4 (m al es 1 0. 4) H ar m fu l u se o f al co ho l28 4 2. At le as t 1 0% re la tiv e re du ct io n in th e ha rm fu l u se of a lc oh ol , a s a pp ro pr ia te , w ith in th e na tio na l co nt ex t 28 5 To ta l ( re co rd ed a nd u nr ec or de d) a lc oh ol pe r c ap ita (a ge d 15 +y ea rs o ld ) co ns um pt io n w ith in a c al en da r y ea r i n lit re s o f p ur ea lc oh ol , a s a pp ro pr ia te , w ith in th e na tio na l c on te xt W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 6d at a: 1 0 lit re s/ ye ar (m al es 1 7 lit re s/ ye ar , f em al es 3 li tr es /y ea r) Ag e st an da rd ize d pr ev al en ce o f h ea vy ep iso di c dr in ki ng am on g ad ol es ce nt s 20 11 G SH S (s tu de nt s 1 3 15 y ea rs o f a ge ): Pe rc en ta ge w ho dr an k so m uc h al co ho l t ha t t he y w er e re al ly d ru nk o ne o f 28 0 ht tp s: // w w w .w ho .in t/ nm h/ co un tr ie s/ 20 18 /b rb e n. pd f? ua =1 . 28 1 ht tp s: // w w w .w ho .in t/ nm h/ co un tr ie s/ 20 11 /b rb e n. pd f? ua =1 . 28 2 ht tp s: // gc o. ia rc .fr /t od ay /d at a/ fa ct sh ee ts /p op ul at io ns /5 2 ba rb ad os fa ct s he et s. pd f. 28 3 B ar ba do s N at io na l R eg ist ry . C an ce r i n Ba rb ad os 2 01 4. B rid ge to w n: G eo rg e Al le yn e Ch ro ni c Di se as e Re se ar ch C en tr e, U W I; 20 14 . 28 4 Co un tr ie s w ill se le ct in di ca to r( s) o f h ar m fu l u se a s a pp ro pr ia te to na tio na l c on te xt a nd in li ne w ith W HO ’s g lo ba l s tr at eg y to re du ce th e ha rm fu l u se o f a lc oh ol a nd th at m ay in cl ud e pr ev al en ce o fh ea vy e pi so di c dr in ki ng , t ot al a lc oh ol p er c ap ita c on su m pt io n, a nd al co ho l-r el at ed m or bi di ty a nd m or ta lit y, a m on g ot he rs . 28 5 In W HO ’s g lo ba l s tr at eg y to re du ce th e ha rm fu l u se o f a lc oh ol th e co nc ep to f t he h ar m fu l u se o f a lc oh ol e nc om pa ss es th e dr in ki ng th at c au se sd et rim en ta l h ea lth a nd so ci al co ns eq ue nc es fo r t he d rin ke r, th e pe op le ar ou nd th e dr in ke r a nd so ci et y at la rg e, a s w el l a s t he p at te rn s o f d rin ki ng th at a re a ss oc ia te d w ith in cr ea se d ris k of a dv er se he al th ou tc om es . 28 0 ht tp s: //w w w .w ho .in t/n m h/ co un tri es /2 01 8/ br b en .p df ?u a= 1. 28 1 ht tp s: //w w w .w ho .in t/n m h/ co un tri es /2 01 1/ br b en .p df ?u a= 1. 28 2 ht tp s: //g co .ia rc .fr /to da y/ da ta /fa ct sh ee ts /p op ul at io ns /5 2 ba rb ad os fa ct s he et s. pd f. 28 3 Ba rb ad os N at io na l R eg ist ry . C an ce r i n Ba rb ad os 2 01 4. B rid ge to w n: G eo rg e Al le yn e C hr on ic D ise as e Re se ar ch C en tre , U W I; 20 14 . 28 4 C ou nt rie s w ill se le ct in di ca to r( s) o f h ar m fu l u se a s ap pr op ria te to na tio na l c on te xt a nd in li ne w ith W H O ’s gl ob al st ra te gy to re du ce th e ha rm fu l u se o f a lco ho l a nd th at m ay in clu de p re va le nc e of he av y ep iso di c dr in kin g, to ta l alc oh ol p er c ap ita c on su m pt io n, a nd alc oh ol r el at ed m or bi di ty a nd m or ta lit y, am on g ot he rs . 28 5 In W H O ’s gl ob al st ra te gy to re du ce th e ha rm fu l u se o f a lco ho l t he c on ce pt of th e ha rm fu l u se o f a lco ho l e nc om pa ss es th e dr in kin g th at c au se sd et rim en ta l h ea lth a nd s oc ial c on se qu en ce s fo r t he d rin ke r, th e pe op le ar ou nd th e dr in ke r a nd s oc ie ty a t l ar ge , a s w el l a s th e pa tte rn s of d rin kin gt ha t a re a ss oc iat ed w ith in cr ea se d ris k of a dv er se h ea lth ou tc om es . A nn ex 8 : P ro gr es s To w ar ds th e G lo ba l M on ito rin g Fr am ew or k Ta rg et s an d In di ca to rs 116 Pa ge 1 30 o f 1 34 Fr am ew or k el em en ts Ta rg et s In di ca to rs Da ta tr en ds /C om m en ts an da du lts , a s a pp ro pr ia te , w ith in th en at io na l c on te xt m or e tim es in th ei r l ife : 2 4. 1% (m al es 2 9. 0% , f em al es 19 .0 % ) 20 15 H oT N S (≥ 25 y ea rs o f a ge ): Pe rc en ta ge b in ge d rin ki ng : 14 .5 % (m al es 25 .4 % , f em al es 5. 4% ) 20 07 B RF S (≥ 25 y ea rs o f a ge ): Pe rc en ta ge o f m en w ho h ad 5 or m or e dr in ks /w om en w ho h ad 4 o r m or e dr in ks o n an y da y in th e la st w ee k: m al es 2 1. 9% , f em al es 9 .7 % Al co ho l-r el at ed m or bi di ty a nd m or ta lit y am on g ad ol es ce nt sa nd a du lts , a s ap pr op ria te , w ith in th e na tio na l c on te xt Da ta n ot c ol le ct ed . Ph ys ic al in ac tiv ity 3. A 10 % re la tiv e re du ct io n in pr ev al en ce o f i ns uf fic ie nt ph ys ic al a ct iv ity Pr ev al en ce o f i ns uf fic ie nt ly p hy sic al ly ac tiv e ad ol es ce nt s, de fin ed a s l es s t ha n 60 m in ut es o f m od er at e to vi go ro us in te ns ity a ct iv ity d ai ly G SH S 20 11 (s tu de nt s 1 3 15 y ea rs of a ge ): Pe rc en ta ge w ho w er e ph ys ic al ly a ct iv e fo r a to ta l o f a t l ea st 6 0 m in ut es /d ay o n 5 or m or e da ys d ur in g th e pa st 7 d ay s) : 29 .1 % (m al es 3 4. 5% , f em al es 2 3. 3% ) Ag e st an da rd ize d pr ev al en ce o f in su ffi ci en tly p hy sic al ly a ct iv ep er so ns ag ed 1 8+ y ea rs (d ef in ed a s l es s t ha n 15 0 m in ut es o fm od er at e in te ns ity a ct iv ity p er w ee k, o r e qu iv al en t) W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 6 da ta :P hy sic al in ac tiv ity a m on g ad ul ts a ge d 18 + ye ar s: 44 .0 % (m al es , 30 .0 % , f em al es 5 7. 0% ) 20 15 H oT N S (≥ 25 y ea rs o f a ge ): Pr ev al en ce o f p hy sic al in ac tiv ity : 4 9. 9% (m al es 3 0. 0% , f em al es 6 7. 2% ) 20 07 BR FS (≥ 25 y ea rs o f a ge ): Pe rc en ta ge w ith lo w p hy sic al ac tiv ity : 5 1. 3% (m al es 4 2. 5% , f em al es 5 9. 9% ) Sa lt/ so di um in ta ke 4. A 30 % re la tiv e re du ct io n in m ea n po pu la tio n in ta ke o f sa lt/ so di um 28 6 Ag e st an da rd ize d m ea n po pu la tio n in ta ke o f s al t ( so di um ch lo rid e) p er da y in gr am s i n pe rs on s a ge d 18 + ye ar s W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 0 da ta : M ea n po pu la tio n sa lt in ta ke in a du lts a ge d 20 + ye ar s: 9 .0 g /d ay (m al es 9. 0 g/ da y, fe m al es 8 .0 g /d ay ) To ba cc o us e 5. A 30 % re la tiv e re du ct io n in pr ev al en ce o f c ur re nt to ba cc o us e in p er so ns a ge d 15 + ye ar s Pr ev al en ce o f c ur re nt to ba cc o us e am on g ad ol es ce nt s G YT S 20 13 (S tu de nt s 1 3 15 y ea rs o f a ge ): Pe rc en ta ge w ho cu rr en tly u se d an y to ba cc o pr od uc ts : 1 4. 5% (m al es 17 .4 % , f em al es 1 1. 4% ); Pe rc en ta ge w ho cu rr en tly sm ok ed ci ga re tt es : 7 .0 % (m al es 8 .8 % , f em al es 5 .0 % ) G YT S 20 07 (S tu de nt s 1 3 15 y ea rs o f a ge ): Pe rc en ta ge w ho cu rr en tly u se d an y to ba cc o pr od uc ts : 2 8. 6% (m al es 3 4. 5% , fe m al es 2 3. 2% ); Pe rc en ta ge w ho cu rr en tly sm ok ed ci ga re tt es : 1 1. 6% (m al es 1 4. 3% , f em al es 9 .3 % ) Ag e st an da rd ize d pr ev al en ce o f c ur re nt to ba cc o us e am on g pe rs on s a ge d 18 + ye ar s W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 6 da ta : C ur re nt to ba cc o sm ok in g am on g ad ul ts a ge d 15 + ye ar s: 8 .0 % (m al es 1 4. 0% , f em al es 2 .0 % ) 28 6 W HO ’s re co m m en da tio n is le ss th an 5 g ra m s o f s al t o r 2 g ra m s o fs od iu m p er p er so n pe r d ay . 28 6 W H O ’s re co m m en da tio n is le ss th an 5 g ra m s of s alt o r 2 g ra m s of s od iu m p er p er so n pe r d ay . 117 Pa ge 1 31 o f 1 34 Fr am ew or k el em en ts Ta rg et s In di ca to rs Da ta tr en ds /C om m en ts 20 15 H oT N S (≥ 25 y ea rs o f a ge ): Cu rr en t s m ok er s 9 .2 % (m al es 1 5. 5% , f em al es 3 .7 % ) BI O LO G IC AL R IS K FA CT O RS Ra is ed b lo od p re ss ur e 6. A 25 % re la tiv e re du ct io n in th e pr ev al en ce o f r ai se d bl oo d pr es su re o r c on ta in th e pr ev al en ce o f r ai se d bl oo d pr es su re , a cc or di ng to na tio na l c irc um st an ce s Ag e st an da rd ize d pr ev al en ce o f r ai se d bl oo d pr es su re a m on g pe rs on s a ge d 18 + ye ar s ( de fin ed a s s ys to lic b lo od p re ss ur e ≥ 14 0 m m Hg a nd /o r d ia st ol ic b lo od pr es su re ≥ 90 m m Hg ) a nd m ea n sy st ol ic bl oo d pr es su re W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 5d at a: R ai se d bl oo d pr es su re a m on g ad ul ts a ge d 18 + ye ar s: 2 8. 0% (m al es 29 .0 % , f em al es 2 7. 0% ) Di ab et es a nd o be si ty 28 7 7. Ha lt th e ris e in d ia be te s a nd ob es ity Ag e st an da rd ize d pr ev al en ce o f r ai se d bl oo d gl uc os e/ di ab et es a m on g pe rs on s ag ed 1 8+ y ea rs (d ef in ed a s f as tin g pl as m a gl uc os e co nc en tr at io n ≥ 7 .0 m m ol /l (1 26 m g/ dl ) o r o n m ed ic at io n fo r r ai se d bl oo d gl uc os e) W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 4 da ta : R ai se d bl oo d gl uc os e am on g ad ul ts a ge d 18 + ye ar s: 14 .0 % (m al es 1 2. 0% , fe m al es 1 6. 0% ) 20 15 H oT N S (≥ 25 y ea rs o f a ge ): Pe rc en ta ge w ith ra ise d bl oo d gl uc os e O R se lf re po rt ed d ia be te s: 1 8. 7% (m al es 15 .9 % , f em al es 2 1. 0% ) 20 07 BR FS (≥ 25 y ea rs o f a ge ): Pe rc en ta ge w ith ra ise d bl oo d pr es su re O R cu rr en tly o n m ed ic at io n fo r r ai se d bl oo d pr es su re : 2 0. 5% (m al es 2 5. 9% , f em al es 1 5. 3% ) Pr ev al en ce o f o ve rw ei gh t a nd o be sit y in ad ol es ce nt s ( de fin ed a cc or di ng to th e W HO g ro w th re fe re nc e fo r s ch oo l-a ge d ch ild re n an d ad ol es ce nt s, o ve rw ei gh t – on e st an da rd d ev ia tio n bo dy m as s i nd ex fo r a ge a nd se x, a nd o be se – tw o st an da rd d ev ia tio ns b od y m as s i nd ex fo r ag e an d se x) W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 6 da ta : O be sit y am on g ad ol es ce nt s a ge d 10 1 9 ye ar s: 11 .0 % (m al es 1 1. 0% , fe m al es 1 1. 0% ) G SH S 20 11 (1 3 15 y ea r o ld st ud en ts ): Pe rc en ta ge w ho w er e ov er w ei gh t: 31 .9 % (m al es 3 2. 1, fe m al es 3 1. 8% ) ; Pe rc en ta ge w ho w er e ob es e: 1 4. 2% (m al es 1 3. 9% ,fe m al es 14 .6 % ) Ag e st an da rd ize d pr ev al en ce o f ov er w ei gh t a nd o be sit y in p er so ns a ge d 18 + ye ar s ( de fin ed a s b od y m as s i nd ex ≥ 25 k g/ m 2 fo r o ve rw ei gh t a nd b od y m as s in de x ≥ 3 0 kg /m ² fo r o be sit y) W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 6 da ta : O be sit y am on g ad ul ts a ge d 18 + ye ar s: 25 .0 % (m al es 1 6. 0% , f em al es 34 .0 % ) 20 15 H oT N S (≥ 25 y ea rs o f a ge ): O be se : 3 3. 8% (m al es 23 .4 % , f em al es 4 3. 4% ) 20 07 B RF S( ≥2 5 ye ar s o f a ge ): O be se : 2 8. 5% (m al es 2 0. 3% , fe m al es 3 5. 5% ) 20 15 H oT N S (≥ 25 y ea rs o f a ge ): O ve rw ei gh t o r o be se : 66 .2 % (m al es 5 7. 5% , f em al es 7 4. 2% ) 28 7 Co un tr ie s w ill se le ct in di ca to r( s) a pp ro pr ia te to n at io na l c on te xt . 28 7 C ou nt rie s w ill se le ct in di ca to r( s) a pp ro pr iat e to n at io na l c on te xt . 118 Pa ge 1 32 o f 1 34 Fr am ew or k el em en ts Ta rg et s In di ca to rs Da ta tr en ds /C om m en ts 20 07 B RF S( ≥2 5 ye ar s o f a ge ): O ve rw ei gh t o r o be se : 6 5. 2% (m al es 5 4. 6% , f em al es 7 4. 3% Ad di tio na l i nd ic at or s Ag e st an da rd ize d m ea n pr op or tio n of to ta l e ne rg y in ta ke fr om sa tu ra te d fa tt y ac id s i n pe rs on s a ge d 18 + ye ar s Da ta n ot c ol le ct ed . Ag e st an da rd ize d pr ev al en ce o f r ai se d to ta l c ho le st er ol a m on g pe rs on s a ge d 18 + ye ar s ( de fin ed a s t ot al c ho le st er ol ≥ 5. 0 m m ol /l or 1 90 m g/ dl ); an d m ea n to ta l c ho le st er ol c on ce nt ra tio n 20 15 H oT N S (≥ 25 y ea rs o f a ge ): Pe rc en ta ge w ith ra ise d to ta l c ho le st er ol : 3 5. 0% (m al es 3 8. 6% , f em al es 3 2. 1% ) 20 07 B RF S (≥ 25 y ea rs o f a ge ): Pe rc en ta ge w ith ra ise d to ta l ch ol es te ro l: 21 .2 % (m al es 1 9. 3% , f em al es 2 2. 9% ) Ag e st an da rd ize d pr ev al en ce o f p er so ns (a ge d 18 + ye ar s) co ns um in g le ss th an fi ve to ta l s er vi ng s ( 40 0 gr am s) o f f ru it an dv eg et ab le s p er d ay 20 15 H oT N S (≥ 25 y ea rs o f a ge ): 90 .0 % (m al es 9 1. 9% , fe m al es 8 8. 5% ) 20 07 B RF S (≥ 25 y ea rs o f a ge ): 95 .4 % (m al es 9 6. 6% , fe m al es 9 4. 3% ) Pr ev al en ce o f a do le sc en ts d rin ki ng o ne or m or e ca rb on at ed so ft d rin ks (o r o th er SS Bs ) o ne o r m or e tim es p er d ay G SH S 20 11 (1 3 15 y ea r o ld st ud en ts ): Pe rc en ta ge w ho us ua lly d ra nk c ar bo na te d be ve ra ge s o ne o r m or e tim es pe r d ay d ur in g th e pa st 3 0 da ys : 7 3. 3% (m al es 7 4. 0% , fe m al es 7 1. 5% ) N AT IO N AL S YS TE M S RE SP O N SE Dr ug th er ap y to p re ve nt he ar t a tt ac ks a nd st ro ke s 8. At le as t 5 0% o f e lig ib le pe op le re ce iv e dr ug th er ap y an d co un se lli ng (i nc lu di ng gl yc ae m ic c on tr ol ) t o pr ev en t h ea rt a tt ac ks a nd st ro ke s Pr op or tio n of e lig ib le p er so ns (d ef in ed a s ag ed 4 0 ye ar s a nd ol de r w ith a 1 0 ye ar ca rd io va sc ul ar ri sk ≥ 30 % , i nc lu di ng th os ew ith e xi st in g ca rd io va sc ul ar di se as e) re ce iv in g dr ug th er ap ya nd co un se lli ng (i nc lu di ng gl yc ae m ic c on tr ol ) t o pr ev en t he ar ta tt ac ks a nd st ro ke s W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 7 da ta : Pr op or tio n of p rim ar y he al th c ar e ce nt re s o ffe rin g CV D ris k st ra tif ic at io n: L es s t ha n 25 % Re po rt ed h av in g CV D gu id el in es u se d in a t l ea st 5 0% o f he al th fa ci lit ie s: Y es Es se nt ia l N CD m ed ic in es a nd b as ic te ch no lo gi es to tr ea t m aj or N CD s 9. An 8 0% a va ila bi lit y of th e af fo rd ab le b as ic te ch no lo gi es a nd e ss en tia l m ed ic in es , i nc lu di ng ge ne ric s, re qu ire d to tr ea t m aj or N CD s i n bo th p ub lic an d pr iv at e fa ci lit ie s Av ai la bi lit y an d af fo rd ab ili ty o f q ua lit y, sa fe a nd e ffi ca ci ou se ss en tia l N CD m ed ic in es , i nc lu di ng ge ne ric s, an d ba sic te ch no lo gi es in b ot h pu bl ic a nd pr iv at ef ac ili tie s W HO N CD C ou nt ry P ro fil es 2 01 8, 2 01 7 da ta : Pr op or tio n of p rim ar y he al th c ar e ce nt re s o ffe rin g CV D ris k st ra tif ic at io n: L es s t ha n 25 % N um be r o f e ss en tia l N CD m ed ic in es re po rt ed a s “g en er al ly a va ila bl e” : 1 0 ou t o f 1 0 N um be r o f e ss en tia l N CD te ch no lo gi es re po rt ed a s “g en er al ly a va ila bl e” : 6 o ut o f 6 119 Pa ge 1 33 o f 1 34 Fr am ew or k el em en ts Ta rg et s In di ca to rs Da ta tr en ds /C om m en ts Ad di tio na l i nd ic at or s Ac ce ss to p al lia tiv e ca re a ss es se d by m or ph in e eq ui va le nt c on su m pt io n of st ro ng o pi oi d an al ge sic s ( ex cl ud in g m et ha do ne ) p er d ea th fr om c an ce r W HO C an ce r C ou nt ry P ro fil es 2 01 4. 28 8 Ad op tio n of n at io na l p ol ic ie s t ha t l im it sa tu ra te d fa tt y ac id sa nd v irt ua lly el im in at e pa rt ia lly h yd ro ge na te d ve ge ta bl e oi ls in th e fo od su pp ly , a s ap pr op ria te , w ith in th e na tio na l c on te xt an dn at io na l p ro gr am m es O ra l m or ph in e, (fo rm ul at io n no t s pe ci fie d) is g en er al ly a va ila bl e in th e pu bl ic h ea lth sy st em . In p ro ce ss o f d ev el op in g pl an s f or R EP LA CE fr am ew or k to fa ci lit at e ad op tio n of re le va nt p ol ic ie s. Av ai la bi lit y, a s a pp ro pr ia te , i f c os t ef fe ct iv e an d af fo rd ab le , o fv ac ci ne s ag ai ns t h um an p ap ill om av iru s ( HP V) , ac co rd in g to n at io na lp ro gr am m es a nd po lic ie s HP V va cc in at io n ha s b ee n in co rp or at ed in to th e im m un isa tio n sc he du le fo r g irl s a ge d 9 13 y ea rs a nd co ve ra ge is a pp ro xi m at el y 50 % . Po lic ie s t o re du ce th e im pa ct o n ch ild re n of m ar ke tin g of fo od sa nd n on a lc oh ol ic be ve ra ge s h ig h in sa tu ra te d fa ts , t ra ns fa tt ya ci ds , f re e su ga rs , o r s al t N ot y et in p la ce – u nd er d isc us sio n. Va cc in at io n co ve ra ge a ga in st h ep at iti s B vi ru s m on ito re d by nu m be r o f t hi rd d os es of H ep B v ac ci ne (H ep B3 ) a dm in ist er ed to in fa nt s He pa tit is B va cc in at io n ha s b ee n in co rp or at ed in to th e im m un isa tio n sc he du le fo r c hi ld re n an d th ird d os e co ve ra ge is a pp ro xi m at el y 95 % Pr op or tio n of w om en b et w ee n th e ag es of 3 0– 49 sc re en ed fo rc er vi ca l c an ce r a t le as t o nc e, o r m or e of te n, a nd fo r l ow er or hi gh er a ge g ro up s a cc or di ng to na tio na l p ro gr am m es o r p ol ic ie s Ba se lin e to b e de te rm in ed . 28 8 ht tp s: // w w w .w ho .in t/ ca nc er /c ou nt ry p ro fil es /b rb e n. pd f. 28 8 ht tp s: //w w w .w ho .in t/c an ce r/ co un try p ro file s/ br b en .p df . 120 Page 134 of 134 Annex 9: NSP-NCD 20-25, Estimated Budget by Output 3.7 20.5 5.2 4.7 7.2 18.7 4.7 1 14.4 15.4 4.3 % budget OPT 1.1 FCTC OPT 2.1 Nutrition OPT 2.2 COP OPT 3.1 Phys act OPT 4.1 Alcohol OPT 5.1 NCD Mx OPT 6.1 Multisect OPT 7.1 Res all/mob OPT 8.1 Comm OPT 9.1 Surv/res OPT 10.1 Mx/M&E Annex 9: NSP-NCD 20-25, Estimated Budget by Output