Pan American Health Organization

Trinidad and Tobago

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of Trinidad and TobagoThe Republic of Trinidad and Tobago is a twin-island state at the southern end of the Caribbean. Trinidad and Tobago’s landmass covers 5,127 km2. Since its independence from Great Britain in 1962, the country has evolved into a well-developed, multicultural society. Abundant reserves of natural gas and oil drive its economic wealth, making it a country with a relatively high gross domestic product (GDP) for the Caribbean and recognized by the World Bank as a higher-income economy ().

Demographics

In 2011,the country’s population was 1,328,019 (). The population’s ethnic composition comprises 35.4% East Indians, 34.2% of African descent, 23.0% mixed races, and 8.4% of other ethnic groups (Asian, European, Middle Eastern); the male-to-female ratio is roughly 1:1 ().

Figure 1 shows the country’s population structure, by age and sex, for 1990 and 2015. Between 1990 and 2010, the population 60 years old and older increased an average of 4% annually, compared to an annual 2.5% decrease seen in the age group 5-19 years old and a 0.9% increase in the age group under 5 years old. Life expectancy at birth is 71 years. Trinidad and Tobago is experiencing a demographic shift involving a declining fertility rate (estimated at 1.78 in 2014), an aging population, a decrease in communicable diseases and an increase in noncommunicable diseases (NCDs), and the emergence of new vector-borne diseases. For the health sector, these epidemiological changes call for greater focus on primary health care.

Figure 1. Population structure, by age and sex, Trinidad and Tobago, 1990 and 2015

Trinidad and Tobago’s population increased 11.3% between 1990 and 2015. In 1990, the population structure had an expansive structure. By 2015, the pyramidal structure had shifted to ages older than 50 years, while the structure under that age became stationary with slower growth. These changes were due to to decreases in birth rate and mortality, especially in the last three decades.

Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 2015.

The Economy

The economy is predominantly industrial, with a heavy reliance on the energy sector, which has been transitioning from a reliance on oil to primarily a natural gas–based economy. In 2015, the gross national income (GNI) per capita was US$ 18,600 (). Health expenditure per capita was US$ 1,136.31 in 2014 (). The economy experienced a slowing in GDP growth after 2007, a weak recovery in 2012-2014, and a contraction in 2015 due to declining oil and gas prices (). Reliance on natural gas and limited economic diversification has led to several initiatives to revitalize other economic sectors such as manufacturing, tourism, agriculture, finance, and the creative industries (). Health expenditure accounted for 5.9% of the GDP, compared to the 43% that represented the share for the petroleum and petrochemical industry (). Approximately US$ 1.5 billion was spent on health care (US$ 1,156 per capita), of which 38% was spent by households and 54% by the government ().

In 2015, with the economy operating at full employment, the labor force participation rate was 60.6% and unemployment rates were down to 3.4% from a high of 5.9% in 2010 (). However, among the younger workers (15-24 years old), rates were higher (): youth unemployment averaged around 12.1% during 2010-2015, compared to 4.4% overall. Women also experienced relatively higher unemployment rates in 2010-2015 averaging 18.6% for 15-19-year-old and 11.8% for 20-24-year-old women, compared to 12.2% and 7.9% among males in the same age categories (). Rates for these age groups in 2015 were at 13.1% and 7.3%, respectively. High unemployment rates among younger populations may trigger unintended social problems such as harm to health outcomes, poverty, and crime and violence (). There are no current data for assessing the country’s poverty; however, in 2009 it was estimated that 18.9% of the population was living in poverty, a figure expected to drop by 2% in 2015 ().

Social Determinants of Health

Free education is available to all citizens; however, the 2011 census reports that as much as 38.7% of the population aged 15 years or older may have attended school or vocational training, but had either not completed the schooling or failed to receive a certification (). Primary level education was attained by 29.8% of the population, 43.5% had attained secondary and post-secondary, and 14.6%, had attained tertiary education (university and non-university) ().

The Health System

Trinidad and Tobago’s health system includes public and private sectors and nongovernmental organizations (NGOs); the public sector is dominant. All public sector health services are free, funded by the government and taxpayers.

The public health system operates along two tiers. At the first level is the Ministry of Health, which oversees the system, and is responsible for financing, regulation, and governance, and for setting any necessary policies and enacting legislation. The Ministry of Health’s work is set by the Strategic Plan for fiscal years 2012-2016, which states that the Ministry’s mission is “… to provide effective leadership for the health sector by focusing on evidence-based policy making; planning; monitoring; evaluation; collaboration and regulation” (). To that end, the Ministry operates under 12 core strategic priorities, seven of which are discussed in this review: chronic NCDs; communicable diseases; maternal and child health; mental health and wellness; human resource planning and development, the integration of information and communication technology in the health sector; and improved health sector management ().

At the next level, the health care delivery system is decentralized into five semiautonomous Regional Health Authorities (RHAs): four in Trinidad and one in Tobago. Health care services are delivered through a network of 96 health centers, nine district health facilities, and nine hospitals. Each RHA in Trinidad has at least one district health facility and a referral hospital. Approximately two-thirds of the health centers are located in Trinidad’s western half, where most of the population lives. The Ministry of Health continues to manage some vertical services and national programs, such as the Insect Vector Control Programme, the National Blood Transfusion Service, and the National Oncology Programme.

The private sector operates on a fee-for-service model, which is often expensive and beyond the reach of most low-income earners. Information on utilization and cost for clinical and ancillary services provided to the paying public is limited. The Ministry of Health runs an external patient program, whereby some services such as diagnostic scans; cataract, knee, and hip replacement surgery; and radiation oncology services are outsourced to private health care institutions.

The Ministry bolsters its work through partnerships with regional and international entities and NGOs. The development of policies and guidelines are further guided by the government being signatory to a number of international and subregional health-related conventions and agreements, for example: the UN Sustainable Development Goals (SDGs); the World Health Organization (WHO) Framework Convention on Tobacco Control; the UN Convention on the Rights of the Child; the UN International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families; the UN Declaration on Diabetes and Chronic Non-communicable Diseases (2011); and subregionally: the Caribbean Cooperation in Health IV (CCH IV); Port of Spain Declaration on chronic NCDs (2007); the WHO Health Agenda for the Americas 2008–2017; the Nassau Declaration; and the Pan Caribbean Partnership against HIV/AIDS (PANCAP).

Leading Health Challenges

Critical Health Problems

Emerging Diseases

In 2016, up to the end of September, there were 243 confirmed chikungunya cases and 498 confirmed Zika cases, which included 294 pregnant women infected with the latter virus (). Measures were adopted to prevent, control, and reduce associated risk of emerging and reemerging diseases, including strengthening core public health capacities. Chikungunya and Zika virus were detected in Trinidad and Tobago in July 2014 and February 2016, respectively.

Tuberculosis

Based on information from the health care services and hospital data submitted to the Ministry of Health, tuberculosis (TB) deaths declined from 2.1 per 100,000 population in 2010 to 1.1 in 2015. This decrease notwithstanding, TB surveillance remains active. There were 218 notified cases and 196 new and relapsed cases (). The incidence of TB was 17 per 100,000 population (including HIV coinfection) and 2.9 for those with HIV coinfection (). Treatment and coverage was relatively high, at 87%, but multidrug- resistant TB was present and 16% of the new or relapsed cases were positive for HIV().

A nationwide approach is needed to combat TB and TB/HIV coinfection that takes into account how socioeconomic conditions (e.g., poverty, patient location, drug and alcohol addiction) affect treatment outcome and follow-up (). A TB treatment program has been put in place as a way to address the fact that about 15% of TB and TB/HIV coinfected patients do not comply with their treatment regimens. However, TB screening among the HIV-positive population is not standard and isoniazid preventive therapy is very limited.

Maternal and Infant Mortality

The country has yet to achieve its Millennium Development Goal (MDG) target of 14 maternal deaths per 100,000 live births (). In fact, the high rates of maternal and infant mortality in 2015¾46.9 and 10.4 per 100,000 live births, respectively¾has placed the improvement of maternal and child health high on the list of the Ministry of Health’s priorities ().

To that end, maternity services have been reviewed and, as a result, the government has agreed to form a Directorate for Women’s Health that can provide leadership and policy formulation aimed at reducing the maternal and perinatal mortality rates. Guidelines and protocols also have been developed, such as the Standard Operating Procedure Manual for Obstetrics and Midwifery Services, which became operational in June 2011, and the 2012 Standards for Neonatal Care. In 2015, a Maternal and Child Health Manual was also produced; it is based on the work of a multidisciplinary team, with technical collaboration from the University of the West Indies (UWI), the Caribbean Public Health Association (CARIPHA), Pan American Health Organization (PAHO), the UN Population Fund (UNFPA), and UNICEF.

Chronic Conditions

Chronic NCDs are the leading causes of death in Trinidad and Tobago; as such, they are a national priority. On average, approximately 53% of hospital admissions between 2010 and 2015 had an NCD as a discharge diagnosis. Of these, injuries, cardiovascular diseases, and diseases of the digestive system were the most frequently reported conditions, as well as the most frequent causes of death.

The Ministry of Health has adopted an integrated, multi-sector, public/private, “whole of society” approach to cope with the prevention and management of NCDs. In 2014, various initiatives in this regard were launched, such as the “Healthy Me” childhood obesity prevention camp that fosters healthy lifestyles for children 7-13 years old; to date, it has benefited 160 children. Other efforts designed to address risk factors for NCDs include the“Fight the Fat” “Healthy Communities” initiative, which has benefited approximately 5,000 people; the Workplace Wellness Programme; and the “Annual Wellness Campaign” (“Health for All” initiative), a nationwide campaign that raises awareness about chronic diseases and their risk factors and has benefited some 11,000 persons (). The government will also be implementing an NCD surveillance project as part of a US$ 48.4 million loan from the Inter-American Development Bank (IDB). Trinidadians also benefit from a Chronic Disease Assistance Programme (CDAP) that provides free drugs and pharmaceutical items to combat 12 targeted diseases; these inputs are distributed through over 250 public and private pharmacies nationwide. Finally, the Extended Patient Programme (EPP) also manages the Medical Aid, Cardiac Care, and Dialysis Programme to facilitate the care of patients in the private system that cannot be accommodated in the public system.

Human Resources

Workforce shortages are problematic across all health personnel categories in Trinidad and Tobago. The Ministry of Health has drafted a 10-year human resource plan (2016-2025) that will ensure that the public health sector is both adequately and appropriately staffed for the optimal delivery of quality health care. Funding under the IDB-sponsored NCD surveillance project mentioned above will also contribute toward this recruitment and retention strategy.

To fill some of the shortages, the Ministry of Health recruits health care professionals from overseas. Since 2011, 446 health foreign professionals have been recruited: 228 Cuban nurses; 109 Cuban doctors; 17 Cuban pharmacists; 1 biomedical engineer; 35 nurses from Grenada; 74 nurses from Saint Vincent and the Grenadines; and 19 nurses from Saint Lucia. The Ministry has pursued various bilateral and multilateral agreements with such agencies and countries as the UN Volunteers (UNV) Programme, the Donation and Transplantation Institute (DTI) (Spain), Shriners Hospitals for Children (USA), the United Kingdom, and the People’s Republic of China. Negotiations are under way to finalize agreements with Colombia, Nigeria, Uganda, and the Philippines. As part of its effort to solve the health personnel shortages, the Ministry also pursues traditional recruitment methods, such as strengthening partnerships with academic and training institutions and granting study leave to employees.

There are several health-related, educational opportunities in-country: UWI (St. Augustine campus in Trinidad) offers medical (across various specialties), biomedical, nursing, and public health programs at all degree levels; the College of Science, Technology, and Applied Arts of Trinidad and Tobago (COSTAATT) offers nursing and health science technology degrees; and the University of Trinidad and Tobago (UTT) offers a degree program in biomedical engineering and a postgraduate degree in health administration. PAHO provides numerous online training opportunities for various health workers through its Virtual Campus for Public Health (VCPH).

The Ministry of Health worked with the former Ministry of Tertiary Education and Skills Training and the Schools of Nursing and Midwifery to graduate additional nurses, midwives, and nursing assistants. The two ministries have signed a memorandum of understanding with the nursing and midwifery schools to have students work as interns at RHA facilities to gain clinical experience; discussions regarding clinical experience and the expansion of postgraduate specializations are ongoing with UTT and UWI, respectively. The Ministry of Health and the RHAs offer scholarships in critical-need areas, with beneficiaries required to serve in the health care system upon completion of their study programs. Enforcement of this provision is weak, however, and leads to broken contracts, in part due to the sector’s inability to immediately absorb returning scholars. The 10-year Human Resources for Health (HRH) Strategic Plan addresses these and other areas.

Health Knowledge, Technology, and Information

Independent entities, such as academic institutions and NGOs, often are the ones undertaking health-related research in the country, with the Ministry of Health acting as a collaborating partner. Among studies undertaken under this modality were the 2015 National Eye Survey of Trinidad and Tobago (NESTT), which analyzed visual impairments in the country; the 2014 Burden of Obstructive Lung Disease (BOLD) initiative, which explored the prevalence of chronic obstructive pulmonary disease (COPD) and its risk factors; and the 2011 NCD risk factor (STEPS) survey (), which assessed the risk factors for chronic diseases. All health research requires ethical approval from the Ministry’s Ethics Committee or other relevant Ethics Committees. Research skills are developed through various collaborative efforts, such as the Trinidad and Tobago Health Sciences Initiative (TTHSI) (2007–2014) developed jointly with Johns Hopkins Medicine International; UWI, UTT; the Ministry of Health; the former Ministry of Science, Technology, and Tertiary Education; and other government ministries and local organizations, which aimed at improving the health care sector through academics and research ().

While there is no single repository for local research data, the Ministry of Health has a medical library service that provides e-resources for all staff and members of the public through InfoMed Plus, the first Caribbean e-Medical Portal offering access to thousands of medical e-journals.

The existing health information system (HIS) is predominantly manual and inefficient(). Cellma, an administrative electronic linked tool, is used by most RHAs to capture basic patient data. The RHAs submit quarterly reports to the Ministry, along with manually compiled treatment and care data. The slow modernization of the HIS has contributed to difficulties in accessing up-to-date information. The government is committed to implementing a nationwide electronic health information management system as part of the NCD surveillance project (); the first modules to be procured and implemented will be patient registration, electronic health records, and appointment and scheduling software.

The HIS also has progressed in other areas: the National Health Card System, for example, has been set up for cloud-based electronic management of the dispensing of select, free prescription medications for certain diseases such as cancer and HIV, and to allow access to multiple public health services. The Ministry of Health and the Ministry of Industry and Trade, the Port Health Department, and the MOH Chemistry, Food and Drugs Division worked to implement an electronic single window to issue clearance certificates for shipping and airline cargo, and for passengers.

The Environment and Human Security

The country is vulnerable to the direct and indirect effects of climate change on the population’s health.

Natural and Manmade Disasters

Trinidad and Tobago is at low risk for hurricanes, but is more vulnerable to earthquakes. The country is usually affected by the indirect impact of tropical waves in the form of heavy rainfall, flooding, and landslides. The country’s Office of Disaster Preparedness and Management (ODPM), which is responsible for disaster preparedness, response, prevention, and mitigation, in 2010 developed a comprehensive disaster management policy framework that sets forth the strategic direction for the government’s comprehensive approach for all hazards (). As a way to streamline climate services, the government is developing a National Framework for Climate Services within the National Disaster Risk Reduction Platform coordinated by ODPM; the Ministry of Health serves as a core member of the Climate Services Panel.

Based on data supplied by ODPM, there were 271 hazard events reported between 2010 and 2014, with more natural disaster occurrences than man-made disasters, and floods, landslides, fires, and damaging high winds dominating. As the public’s awareness of the ODPM’s role increased, data capture improved, with 582 hazards reported between January 2015 to March 2016 (). In 2015 alone, there were 14 earthquakes, ranging from 3.4 to 6.5 on the Richter scale, all of which directly or indirectly affected the population’s health and well-being. In 2010, the impact of countrywide flooding and landslides resulted in the loss of crops to over 2,000 farmers and compensation estimated at TT$ 13 million; a 2012 flood resulted in two reported deaths, two missing persons, and several injuries requiring hospitalization; and in December 2013, the largest oil spill in the history of Trinidad and Tobago harmed air quality, tourism, and the marine ecosystem.

Food Safety and Security

The consequences of climate change, coupled with shortages of arable land and agricultural labor, threaten the population’s food security and food safety. Under the aegis of several UN agencies, the Ministry of Health and the Ministry of Agriculture, Land, and Fisheries have been working together to ensure the safety and quality of Trinidad and Tobago’s food supply, while building capacity in addressing food safety, quality control, and quality assurance (). For example, in 2016, with support from the UN Development Assistance Framework (UNDAF), the Food and Agriculture Organization (FAO), and PAHO, a Food Safety Policy and Communications Project was launched to conduct a food safety situation analysis, develop a national food safety policy, and prepare a manual for risk-based food safety inspection. PAHO also partnered with the Ministry of Health and national senior public health inspectors to harmonize the requirements to register food handlers and food premises.

A multi-sector Food Advisory Committee is responsible for developing food-safety standards and regulations; this body advises the Minister of Health on food safety and quality matters and on trade issues. Medical officers and public health inspectors monitor all public facilities and ports of entry to detect and control risks to human health and enforce the public health laws. Food fraud has also become a national concern and a Joint Select Committee on food fraud was formed in May 2016.

Access to Clean Water and Sanitation

Data from Trinidad and Tobago’s Water and Sewerage Authority (WASA) shows that access to improved clean drinking water was 94% in 2015, and access to chlorinated water increased from 91% in 2011 to 99% in 2015. As many as 88% of households had direct access to piped water while 12% had to utilize indirect access (i.e., a standpipe in the yard or community). Nearly 70% of the population received water 24 hours a day 7 days a week in 2015, which represents a significant improvement in service when compared to 31% of the population receiving water on a 24/7 basis in 2011. Gaps in 24/7 water supply and reliance on indirect sources of water is an indication that storage of water is common. Most of the water supplied (more than 55%) in both Trinidad and Tobago is from reservoirs and springs, followed by groundwater (wells). Trinidad also derives some water (20%) from desalination. Access to improved sanitation facilities is available to 94% of the population. Trinidad and Tobago fully met MDG 7 standards for safe drinking water and moderately met standards for sanitation ().

Aging

Trinidad and Tobago has an aging population. According to the 2011 census, approximately 13% of the population was over age 60; that age cohort was estimated to be 14.2% in 2015 and projected to be 28.2% by 2050 (). Hypertension, diabetes, arthritis, Alzheimer’s disease, and heart disease are reported as some of the leading causes of hospitalization among the elderly. The expected growth of this population segment, with the accompanying increase in chronic diseases, will tax the health system, particularly primary care services. The government has put in place programs to improve the well-being of the elderly and the quality of care they receive. Aside from the CDAP, which has already benefitted 25,000 patients, the government gives out food-subsidy grants and provides homecare, free medical equipment, and home improvements; in addition, it operates a senior citizens bureau and a geriatric/adolescent partnership program. Furthermore, a National Policy on Aging was developed that targets priority areas for action such as health care and standards for facilities, social security, income security and employment, housing, and legislation ().

Prospects

The Government of Trinidad and Tobago, through its Policy Framework, has embarked upon a strategy for achieving universal health care. As part of that overarching goal, there are ongoing assessments to identify various health service gaps. As the country continues to strengthen its primary health care system, these gaps are expected to be significantly reduced.

Trinidad and Tobago has been making efforts towards the accreditation of all its health facilities, a process that will be done every three years. This accreditation, in turn, bolsters the primary health care system, which is the main driver for being able to offer the population efficient, equitable, and accessible health services. As part of this vision, the Ministry of Health also is pursuing strategies and interventions that focus on population health and the role of community, health promotion, and preventive care. Embracing this multi-sector, whole-of-government approach will be critical to address NCDs and gaps in human resources for health.

Over the next 5 to 10 years, the country will focus on lowering NCDs and tackling their risk factors. To this end, the Ministry of Health will work across sectors and with various partners to roll out the National Strategic Plan for the Prevention of Non Communicable Disease. Efforts will track along four key strategic objectives: multi-sectoral policies and partnerships for NCD prevention and control, understanding NCD risk and protective factors, the health system’s response to NCDs and their risk factors, and NCD surveillance and research. Adequate and effective human resources for health are critical to success. The 10-year HRH Plan must address current gaps, foresee future needs, and build in sustainability. Primary health care facilities also must be refurbished and modernized so they can offer access to comprehensive services and ensure that facilities are IT-ready for health information systems. Finally, the Ministry of Health must ensure that its management plan for the workforce will lead to a smooth transition.

References

1. World Bank. The World Bank in Trinidad and Tobago: overview [Internet]. Washington, D.C.: International Bank for Reconstruction and Development/World Bank; 2016. Available from: http://www.worldbank.org/en/country/trinidadandtobago/overview. Accessed on 18 November 2016.

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Reference/Note:

1. Some of these entities include the Caribbean Community (CARICOM) Secretariat, the Caribbean Public Health Agency (CARPHA), the Pan American Health Organization, various other United Nations (UN) agencies, the World Bank, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the European Union, among others.

2. For additional information on this issue, please refer to the subsections on “Maternal and Reproductive Health” and Child Health” under the section “Health Situation and Trends.”

3. See the subsection on “Mortality” under the section “Health Situation and Trends.”

4. Trinidad & Tobago dollars (TT$ 1 = US$ 0.15).

5. MDG 7: reducing by half the number of people without access to safe drinking water and improved sanitation.

6. As defined by the United Nations (10% or more of a population over the age of 60 years).

7. Risk factors include daily smoking, inadequate daily servings of fruits and vegetables, low level of physical activity, overweight, and elevated blood pressure.

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