- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Although geographically it is part of the Central American Isthmus, Belize has historical ties with the Anglophone Caribbean; as such, it is the only English-speaking country in Central America. In 2016, Belize’s estimated population was 375,900 (). The country’s multi-ethnic population includes a majority Mestizo (52.9%), followed by Afro-descendant Creoles (26%), Garifuna (6.1%), and indigenous Maya (11.3%). Belize stretches for 22,966 km2 and has a low population density of 16.4 persons per km2. An estimated 31% of the population lives along the coast, with the remainder scattered widely throughout the country’s interior. These characteristics make it difficult and expensive to provide health care services.
Belize’s population is young and growing rapidly. According to the 2010 census, 46% of the population was under 19 years old and 6.5% was 60 years old and older (Figure 1 shows the country’s population structure in 1990 and 2015). The country’s population increased roughly 40% between 2000 and 2010 (); at this rate, the population will double by 2036. Life expectancy is estimated at 73.7 years, with the male/female rate breakdown being 71.1/76.6 years, respectively.
Figure 1. Population structure, by age and sex, Belize, 1990 and 2015
Officially, 45% of the population resides in urban areas (). But such urban-rural designation is subjective, however, since “urban” is regarded as any city or district town, while everywhere else is considered “rural.” Moreover, the population’s distribution is very fluid, with many suburban communities growing rapidly and haphazardly outside the main district towns and cities. Further, unplanned urbanization, coupled with the ongoing rural-to-urban flight in search of employment, fuels the expansion of the cities and main district towns. For example, in Belize City, the largest population center and the commercial capital, surrounding wetlands and mangrove areas are being encroached upon for housing. This practice further degrades the environment, increasing associated health related risks.
The 2010 census also showed that 14.2% of the country’s population is foreign born, with the single largest majority being from neighbouring Guatemala (). The country’s porous borders facilitate the unregulated cross-border movement of undocumented migrants. In under five years, a migrant village, Bella Vista, expanded from a marginal settlement to being one of the largest villages in the country (). Rapid population growth imposes undue burdens on the public health infrastructure.
Belize is considered to be a small, upper middle-income developing country with a GDP per capita of US$ 4,829 (), a Human Development Index (HDI) rank of 101 among 188 countries, and an HDI Index of 0.715 (). The national unemployment rate of 8% for 2016 () masks substantial age and gender differences, with unemployment among youth and women being more than three times the national average. The economy is overly dependent on a narrow range of mostly agricultural-based exports to a few preferential markets. To varying degrees, these export industries employ seasonal, mostly migrant labor from neighboring republics. And while there is a work permit system in place to regulate the inflow of seasonal laborers, monitoring procedures are weak, and many laborers remain in the country.
Tourism is gaining importance in the national economy: in 2015, overnight tourist and cruise arrivals were 341,145 (an increase of 6.2% compared to 2014) and 957,975, respectively ().
The literacy rate among the adult population is marginally less than 80%, with females having a higher literacy rate than males at 84.1% compare to 75.2% (). No comprehensive study on poverty has been undertaken in the recent past, but the last study, in 2009, found that 41.3% of the population was at or below the poverty line, a percentage that included 15.8% regarded as indigent or extremely poor ().
Among vulnerable populations are those living in poverty, including children and the elderly, as well as indigenous and Afro-descendant peoples and the LGBT population. Belize’s 2009 Country Poverty Assessment found a child poverty rate of 50%, which exceeded the national average of 41.3%. The report noted that children are more prone to poverty, and that their poverty rate was higher than for any other age group. The poverty rate among the elderly was lower than the national average, possibly reflecting some success of targeted programs designed to assist the elderly. Among these are the non-contributory pension financed by the Belize Social Security Board and the government’s programs for the poor, such as the Conditional Cash Transfer and the Food Pantry Program. The former provides cash to select recipients and has a countrywide coverage; the latter provides basic food items at subsidized rates but has a more limited coverage. Above average poverty rates were also noted among the indigenous Maya, with a poverty rate of 68%, the worst among all ethnic groups ().
Data on the health status of Belize’s LGBT community can be gleaned from the Central American Behavioural Surveillance Survey (BSS) of HIV/STI Prevalence and Risk Behaviour in Most-at-risk Populations in Belize (). The report noted an HIV prevalence rate of 13.9% among men having sex with men, which was noted to be the highest in Central America. That group was also found to have a prevalence rate of 28% for the herpes simplex virus type 2. While the prevalence rate among female sex workers is much lower, at 1%, this group shows high levels of sexually transmitted diseases, including a 50% prevalence for herpes simplex virus type 2 and a 20% prevalence for chlamydia and trichomonas. The survey also reported that one-third of men and 13% of women admitted to using illegal drug in the 12 months prior to the survey. Marijuana, cocaine, crack, and ecstasy were the most widely used illegal drugs.
Leading Health Challenges
Critical Health Problems
Belize confronts various emerging health threats, including the Zika virus, chikungunya, dengue, and H1N1 (influenza A) virus. The first case of Zika was confirmed in Belize in May 2016, and since that time, there has been a notable increase in confirmed cases. By the end of September 2016, there were 46 confirmed cases of Zika, including six pregnant women (). At that time, three of the women had birthed babies who were normal but remained under constant monitoring by Ministry of Health. The Ministry is countering the spread of this virus with more aggressive spraying to control the mosquito population, national public information campaigns to elicit public support to reduce insect breeding sites, and targeted assistance to pregnant women.
Infant and Maternal Mortality
Belize’s 2013 Millennium Development Goals (MDGs) Report noted that the country did not meet its goal of reducing infant mortality by two-thirds (). From a baseline of 17.6/1,000 live births in 1990, the infant mortality rate averaged 15/1,000 between 2001 and 2005, increasing to 18/1,000 between 2006 and 2010.
In 2012, the rate was 15.7/1,000 live births, a noteworthy decline, but still above the two-thirds reduction required by the MDGs. Regarding the maternal mortality ratio, from a baseline of 41.7/100,000 in 1990, this indicator trended upwards, reaching 55.3/100,000 in 2010. In 2011, a milestone was achieved, in that for the first time Belize recorded no maternal deaths in a calendar year. A year later, however, there were three maternal deaths, for a 42/100,000 ratio in 2012 ().
Trend analyses of the leading causes of death over the past years confirms that noncommunicable diseases are among the most critical health problems facing the country. Diseases of the heart, malignant neoplasms, and diabetes have been the three leading causes of death in Belize (Table 1). The International Diabetes Federation notes that with an age-adjusted comparative prevalence of 16.5%, and a raw prevalence rate of 14.2%, Belize has the highest prevalence of diabetes in North America and the Caribbean ().
Table 1. Number of deaths for the ten leading causes of death, Belize, 2008 – 2015
|Diseases of the heart||196||211||203||217||209||193||206||245||1,680|
|Human immunodeficiency virus (HIV) disease||62||106||114||99||109||110||100||110||810|
|Influenza and pneumonia||50||71||61||80||68||73||72||85||560|
|Certain conditions originating in the perinatal period||41||66||43||83||69||65||47||76||490|
|Chronic liver disease and cirrhosis||42||31||34||49||29||52||49||45||331|
Source: Belize, Ministry of Health, Administrative data, 2016
In an effort to cope with the rise in chronic conditions, the Ministry of Health provides economic support to NGOs that cater to diabetics, the HIV-positive population and cancer patients, and the elderly, among others. Other government agencies undertake multiple and diverse intervention methods to reduce the incidence of homicides, gang violence, and personal injury that consume an undetermined portion of the public health budget. The Government is also implementing a road safety demonstration project to help reduce the incidence of fatal traffic accidents. From a high of 90 deaths in 2001 (), fatal traffic accidents have gradually decreased to 60 road fatalities in 2015, for a per capita rate of 18/100,000, considered to be the fourth highest in Central America ().
Table 2 shows the breakdown of registered medical personnel and per capita health personnel (). Belize’s levels of health professionals have remained unchanged despite the country’s population increase, which has reduced the ratio of health care professionals serving the population. This scarcity is aggravated by the geographic distribution of these professionals: most are based in urban areas, particularly in Belize City, likely due to the fact that the country’s only tertiary health facility is there. The country has no medical facility where physicians are trained, although some categories of nurses, laboratory technicians, pharmacists, and social workers are trained at the University of Belize. The chronic shortage and low retention rates of certain categories of health care professionals requires that Belize import its medical personnel, leading to recurrent expenditures to acclimatize newly arrived health workers. Of the few nurses trained, many leave the country to work in Caribbean countries. Continuing education for health workers includes workshops, seminars, and other courses that are financed by the health budget or by cooperation agencies such as the Pan American Health Organization. Recently, continuing medical education programs for doctors and nurses have been launched by the Belize Medical and Dental Association.
Table 2. Number and density (per 10,000 population) of registered medical personnel, by category, Belize, 2010-2015
|Community health workers||Number||208||208||287||282||282||282|
Sources: Belize, Statistics Institute of Belize, Abstract of Statistics 2013 and Belize, Ministry of Health, Administrative data 2016
Health Knowledge, Technology, and Information
The Ministry of Health relies on a nationwide health information system (Belize Health Information System) to record patient data and to integrate data sources electronically, thus facilitating analysis and reporting of health information. The National Health Insurance, on the other hand, uses a different system, known as the Registration and Clinical Activity Web Application (RAWA). The two systems do not work together, and there is room for improving the coordination between the two systems. According to Stanley Lalta (2013)(), having an up-to-date and comprehensive health information system would facilitate the country’s timely and systematic collection, organization, and retrieval of data for a broad range of purposes, including the ability to conduct prompt monitoring and reviews to inform decision making. Moreover, the Ministry of Health reports that despite the existence of its information system, physicians do not yet make full use of it ().
The Environment and Human Security
Belize is vulnerable to rising sea levels, with its concomitant health consequences such as a rise in temperature at sea and inland, changes in water quality and availability, increased frequency and intensity of extreme weather events, and potential economic loss from high food and energy costs. To one extent or another, many of these effects are being experienced in Belize, with additional challenges for the health system such as heightened risks for a range of infectious diseases. Specifically, nearly one in three Belizeans live near the country’s long, low-lying coastline, and large areas of Belize City, the main population center, are already below sea level. Belize’s territory includes more than 1,060 offshore islands, with virtually all the larger ones having permanent habitation, and all of these settlements are under direct threat or rising sea levels.
More than half of the country’s population is covered by a modern system of solid waste disposal that is environmentally sound. The system serves a continuum of population centers that start in San Pedro to the east, go through Belize City, and end at the western border, having passed through the towns of San Ignacio and Santa Elena. More than 29,000 metric tons of garbage were recycled through this system in 2015. Additional corridors in other areas of the country are planned. While illegal dumpsites remain a problem, vigorous monitoring, prosecution, and public education campaigns have reduced the number of these sites.
Data from the Multiple Indicator Cluster Survey () indicate that 96.1% of the population has access to potable water and 87.1% has access to improved sanitary facilities that are not shared ().
According to a 2013 study on homicides worldwide conducted by the United Nations Office on Drugs and Crime, Belize’s homicide rate was 44.7 per 100,000 population, one of the highest in Central America (). Since then, the homicide count has escalated, continuing to stress the country’s underfunded and understaffed public health system. Most homicides are the result of internecine gang warfare and mainly occur in Belize City. There is evidence of the presence of regional gangs in the migrant communities outside Belmopan.
Human trafficking also is of grave concern. The United States States Department now rates Belize as a Tier 3 country, the worst rating by that department in that regard. According to the U. S. State Department’s 2016 Trafficking in Persons Report, “Belize is a source, transit, and destination country for men, women, and children subjected to sex trafficking and forced labor…. Sex trafficking and forced labor of Belizean and foreign women and girls, primarily from Central American, occur in bars, nightclubs, brothels, and domestic service. LGBTI men, women, and children are vulnerable to sex and labor trafficking. Foreign men, women, and children-particularly from Central America, Mexico, and Asia-migrate voluntarily to Belize in search of work and are often exploited by traffickers who recruit victims using false promises of relatively high-paying jobs.” ().
As life expectancy increases, so does the percentage of the population older than 60 years. The most recent information from the Statistical Institute of Belize shows that the population 60 years old and older accounted for 5.9% of the total population, or 22,196 persons (11,498 males and 10,698 females) in 2015. This segment of the population has a higher hospital utilization rate as well as a higher cost per capita.
Monitoring the Health System’s Organization, Provision of Care, and Performance
As part of the health sector reform initiative which started in 1998, the Ministry of Health reorganized its services into four health regions (Northern Region, Central Region, Western Region and Southern Region), headed by regional health managers. All regional hospitals are urban, with the rural population being served by a network of health clinics, health posts, and mobile health clinics. The introduction of the National Health Insurance Scheme, initially as a pilot in the south side of Belize City (2002), later extended to the Southern Region (2006), and more recently extended to the Corozal District (2016), focused on primary care services delivered through a network of primary care providers that focused on the health of a defined geographic and population base that was identified as poor.
Belize’s health system is substantially dependent upon public financing. For the ongoing financial year, the government has budgeted some $ 126.4 million to the Ministry of Health, which equates to some 11% of the national budget and 3.5% of GDP (). Though there continue to be nominal increases in the budgetary allocations to the Ministry, a deeper analysis of the budget data reveals that the Ministry actually has received a reduced allocation, when measured in terms of real non-personnel revenues. This is because the budget data cited reflects salary increases that averaged 7% over the financial years 2014/15 and 2015/16. Since such percentage salary increases exceed the percentage increase in the Ministry’s budget, it can be surmised that salary increases accounted for the entire increase in the ministry’s budget. Further, given that employment in the Ministry is on a rising trend from 2014/15, it can be further surmised that an increasing percentage of the ministry’s budget is skewed towards salaries and personnel expenditure () (Table 3).
The above notwithstanding, Lalta (2013), focusing specifically on Effectiveness of Health Spending, defined as using aggregate measures of health status and health financing indicators, states that “the evidence suggests that Belize’s health system is performing quite creditably compared to other countries in Central America and the Caribbean” ().
Table 3: Select health financial indicators, Belize, 2012/13 to 2016/17
|GDP ($ B)||3,147.2||3,251.7||3,435.7||3,557.0||3,640.0 (est.)|
|Belize government budget, by FY||854,001,007||1,022,900,244||1,072,391,771||1,211,126,349||1,148,597,600|
|Allocation to Ministry of Health||93,782,927||107,221,181||118,380,028||120,710,128||126,426,342|
|Ministry of Health allocation of GDP (%)||3.0||3.3||3.4||3.4||3.5|
|Ministry of Health allocation as percentage of budget||11.0||10.5||11.0||10.0||11.0|
|No. of Ministry of Health employees||NA||1,740||1,740||1,815||2,084|
Sources: Belize, Ministry of Finance and author’s calculations
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
The leading cause for almost half of all hospitalizations in the country is complications of pregnancy, childbirth, and the puerperium; 94% of mothers deliver in a health care facility ().
Health of Children (0 14 Years Old)
The leading causes of death among children under 1 year old are hypoxia, birth asphyxia, respiratory conditions, and other conditions originating in the perinatal period and congenital anomalies. Among infants under 1 year old, the leading causes for hospitalization are conditions originating in the perinatal period and acute respiratory infections, followed by hypoxia and birth asphyxia. For children 1 4 years old, acute respiratory infections; bronchitis, chronic and unspecified; emphysema and asthma are the major causes of hospitalizations. Children 5-to-14 years old are at greater risk of dying from accidents related to fire, drowning, and transport ().
The leading causes of morbidity among 10 14-year-olds are injury, poisoning, and certain other consequences of external causes; appendicitis; hernia of abdominal cavity; intestinal obstruction; and complications of pregnancy, childbirth, and the puerperium (). The fact that the last cause is among the leading causes for hospitalization indicates that teen pregnancy in Belize occurs at an early age, despite the fact that the age of legal sexual consent in Belize is 16 years. According to the 2016 Multiple Indicator Cluster Survey, 5.8% of females aged 15 24 years old reported having had sexual intercourse before the age of 15 years ().
Health of Adolescents and Young Adults (15 19 and 20 29 Years Old)
The leading causes of death among adolescents aged 15 19 years are related to road traffic accidents, homicide, and injury purposely inflicted by other persons and injury undetermined whether accidentally or purposely inflicted. For young adults aged 20 29 years, the leading causes of death mirror those of adolescents, along with advanced HIV ().
The leading cause of hospitalization among adolescents and young adults aged 15 19 and 20 29 years old is related to pregnancy, childbirth, and the puerperium, accounting for approximately 70% of hospitalizations in Belize. Other causes of hospitalization in this age cohort are diseases of the urinary system, appendicitis, hernia of abdominal cavity, and intestinal obstruction ().
Health of Adults and the Elderly (30 39, 40 49, 50 59, and 60 Years Old and Older)
The leading causes of death among persons 30 39 years old are advanced HIV infection, homicide and injury purposely inflicted by other persons, and road traffic accidents. These same causes feature prominently in the leading causes of death among persons 40 49 years old, along with diabetes and heart disease. The leading cause of death in persons 50 59 years old is diabetes and its complications, followed by ischemic heart disease, hypertension, advanced HIV infection, and chronic liver disease and cirrhosis. Among the elderly 60 years old and older, diabetes and its complications, followed by ischemic heart disease, and hypertension are the leading causes of death ().
Among 30 40-year-olds, the leading cause of hospitalization is due to pregnancy, childbirth, and the puerperium, followed by injury, poisoning, and certain other consequences of external causes, mainly among males. Among 40-year-olds, diabetes begins to feature as a cause of hospitalization, becoming the leading cause of hospitalization among 50-year-olds. Other main causes of hospitalizations among 50-year-olds are diseases of the digestive system, the urinary system, and hypertensive diseases ().
The major causes of morbidity among persons 60 years and older is diabetes, diseases of the pulmonary circulation and other forms of heart diseases, hypertensive diseases, cerebrovascular diseases, and acute respiratory infections ().
Noncommunicable diseases have consistently increased in importance as causes of death in Belize for well over a decade. Diabetes, cardiovascular diseases, cancers and chronic respiratory diseases are now responsible for around 40% of deaths annually (see Table 1), considerably higher than the 28% for injuries and external causes, and 20% for communicable diseases including HIV and acute respiratory tract infections. Further, 47% of the deaths due to NCDs were regarded as premature deaths in persons less than 70 years of age. Females have a higher mortality rate than males from diabetes, while the leading causes of mortality for males are homicide, HIV and road traffic accidents ().
Complications of pregnancy, childbirth, and the puerperium account for nearly 50% of hospitalizations, followed by injury, poisoning and certain other consequences of external causes, and then by acute respiratory infections ().
Vector-borne diseases are of great concern in Belize. All four serotypes of dengue have been confirmed in the country, and the disease’s prevalence in urban communities is threefold that in rural communities (). Belize is in the pre-elimination phase for malaria control. The disease has decreased approximately 95% between 2007 and 2015, from 845 cases to 22. From those 22, only 9 were autochthonous cases. The yearly incidence of tuberculosis has remained stable over the past decade (). There have been no confirmed cases of Chagas disease, and continuous screening for blood donors enhanced the surveillance for the disease. While HIV/AIDS remains problematic, other sexually transmitted Infections are not important causes of morbidity (13.
Chronic, Noncommunicable Diseases
The incidence of all cancers in 2012 was 59 per 100,000 population. Breast and cervical cancer were 29.9 and 21.4 per 100,000 respectively; while prostate cancer incidence was 15.3 per 100,000. However, breast cancer, prostate, colon cancer, and childhood cancers do not appear as leading causes of mortality ().
Accidents and Violence
The increase in homicides, primarily in Belize City, has a great impact on the mortality trends for males. That the homicide victims almost invariably interface with the country’s only tertiary care facility, the Karl Heusner Memorial Hospital, which is located in Belize City, poses additional challenges to the public health system ().
Mental health is an area of concern in Belize: Issues such as depression, suicide, drug addiction, alcohol consumption, violence and sexual abuse are growing concerns and the prescription and sale of antidepressants feature high on the country’s pharmacologic utilization profile.
Despite the many successes the country has seen in terms of health, Belize’s health system will face daunting challenges in the short and medium term. The list is long. On the one hand, NCDs will continue to rise in importance as leading causes of mortality, emerging viral diseases also will continue to pose a threats, and the costs of trauma and urban violence will continue to escalate, all of them burdening the health system. And the health system itself must address the difficulty in attracting and retaining crucial health personnel. Further, given Belize’s vulnerability to environmental stressors, climate change will pose additional risks to the health and other sectors.
Box 1: Selected Successes in Health, Belize
- Polio and measles have been nearly eradicated. There have been no reported cases of measles or poliomyelitis since 1981 in Belize. The last cases of neonatal tetanus, non-neonatal tetanus, and congenital rubella syndrome were reported in 1997. No confirmed cases of diphtheria have been documented since 1982 ().
- Given Belize’s total expenditures in health on a per capita basis, as a percentage of the national budget, and as a percentage of GDP the country’s health system achieves regionally comparable outcomes in terms of life expectancy and other health status indicators. This is regarded as efficiency ().
- The country has consistently attained high immunization rates: According to the 2015 Multiple Indicator Cluster Survey, immunization rates were: tuberculosis, 97.6%; measles, 90.2%; polio, 83.1%; and pentavalent (DPT3), 83.4%. Full immunization coverage, defined as the percentage of children aged 24 to 35 months who received all vaccinations recommended in the national immunization schedule by their first birthday, was 77.5% ().
Tourism will continue to increase over time, and while this will bring revenue and be good for the country’s economy, the added influx of people may force the health sector to respond to identified public health threats and emergencies. Migration, too, will likely further stress the health system’s capability to respond. Belize’s depends largely on export industries that employ large numbers of seasonal workers, functioning as a magnet to migrant workers that easily cross the country’s porous borders. Undocumented migrants also come in search of employment, settling in far-flung communities where access to health care remains problematic. The health system will have to absorb the care of all these people.
The country also must strive to consolidate any health gains made, including those gains in achieving health-related Millennium Development Goals. This will be difficult considering the Ministry’s dependence on public financing, the negative developments in government’s revenues ushered in by adverse macro circumstances, unbudgeted contingent liabilities, and rapidly rising public debt.
Finally, given the current climate of fiscal austerity and shrinking financial resources, coupled with the fact that an increasing percentage of Ministry of Health’s budget goes towards salaries, the Ministry ought to undertake a Public Expenditure Review. Such a review would be able to objectively ascertain if its budgetary allocations reflect its policy priorities. In addition, while seeking to compare efficiency levels among similar decision making units such as regional hospitals, community hospitals, health centres, and clinics it would also seek to identify areas where savings are possible and would redirect saved resources to areas where they are likely to have a greater impact.
1. Statistical Institute of Belize. Annual report 2016. Belmopan: SIB; 2016. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/AnnualReport_2016.pdf.
2. Statistical Institute of Belize. Belize population & housing census: country report 2010. Belmopan: SIB; 2013. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/Census_Report_2010.pdf.
3. Statistical Institute of Belize. Abstract of statistics 2013. Belmopan: SIB; 2013. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/2013_Abstract_of_Statistics.pdf.
4. Ministry of Finance (Belize). Approved estimates of revenue and expenditure for fiscal year 2016/2017. Belmopan: Ministry of Finance; 2016. Available from: http://cdn.gov.bz/belize.gov.bz/files/ApprovedBudget%202016-17.pdf. Accessed on 9 July 2016.
5. United Nations Development Programme. Human development reports: Belize. New York: UNDP; 2016. Available from: http://hdr.undp.org/en/countries/profiles/BLZ.
6. Statistical Institute of Belize. Labour force survey (LFS) April 2016. Belmopan: SIB; 2016. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/LabourForce_2016-04.pdf.
7. Belize Tourism Board. Belize travel and tourism statistics digest 2015. Belize City: BTB; 2015. Available from: http://belizetourismboard.org/wp-content/uploads/2016/09/BTB-TRAVEL-DIGEST-2015-FINAL.pdf.
8. Halcrow Group Limited. Belize country poverty assessment 2009. Final report. Volume 1. Belmopan: Caribbean Development Bank; 2010. Available from: http://www.caribank.org/countries/country-poverty-assessment-reports.
9. Ministry of Health (Belize). Central American Behavioural Surveillance Survey (BSS) of HIV/STI prevalence and risk behaviour in most-at-risk populations in Belize. Belmopan: Ministry of Health; 2014.
10. Channel 5 News (Belize). MOH hold press conference to give update on Zika in Belize [Internet]. 28 Sept 2016. Belize City: Great Belize Productions Limited; 2016. Available from: http://edition.channel5belize.com/archives/135617. Accessed on 28 September 2016.
11. United Nations Development Programme. Millennium Development Goals report and post-2015 agenda. Belmopan: UNDP; 2013. Available from: http://www.bz.undp.org/content/dam/belize/docs/Millennium%20Development%20Goals/MDG%20Report%20and%20Post%202015%20Agenda%20Belize%202013.pdf.
12. International Diabetes Federation. IDF diabetes atlas. 7th ed. Brussels: IDF; 2015. p. 83. Available from: http://www.diabetesatlas.org.
13. Ministry of Health (Belize). Belize health sector strategic plan 2014-2024. Belmopan: Ministry of Health; 2014. Available from: http://health.gov.bz/www/attachments/article/801/Belize%20Health%20Sector%20Strategic%20Plan%202014-2024-April%202014.pdf.
14. Pan American Health Organization. PAHO/WHO country cooperation strategy: Belize 2017-2021. Washington, D.C.:PAHO; 2017. Available from: https://www.paho.org/blz/index.php?option=com_docman&view=download&alias=248-ccs-2017-2021&category_slug=mandates-and-strategies&Itemid=250.
15. Lalta S. Final report on analysis of existing health accounts of the Ministry of Health, Belize. Consultancy report prepared for PAHO–Belize. Belize City: Pan American Health Organization; 2013.
16. Statistical Institute of Belize; Government of Belize; United Nations Children’s Fund. Belize Multiple Indicator Cluster Survey 2015: key findings. Belmopan: SIB; 2016. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/MICS5_KeyFindingsReport_2015.pdf.
17. United Nations Office on Drugs and Crime. Global study on homicide 2013: trends, contexts, data. Vienna: UNODC; 2014. Available from: https://www.unodc.org/documents/gsh/pdfs/2014_GLOBAL_HOMICIDE_BOOK_web.pdf.
18. Department of State (United States). Trafficking in persons report 2016. Washington, D.C.: U.S. Department of State; 2016. Available from: https://www.state.gov/j/tip/rls/tiprpt/2016/.
19. Gayle H, Mortis N. Male social participation and violence in urban Belize: an examination of their experiences with goals, guns, gangs, gender, God and governance. Belize City: RESTORE Belize; 2010. Available from: http://dbzchild.org/uploads/docs/complete_pgmale_social_participation_and_violence_in_urban_belize_grand.pdf.