• HEALTH SITUATION ANALYSIS AND TRENDS SUMMARY
  GENERAL SITUATION AND TRENDS| SPECIFIC HEALTH PROBLEMS | THE RESPONSE OF THE HEALTH SYSTEM
  

GENERAL SITUATION AND TRENDS

The Republic of Trinidad and Tobago, a twin island democratic republic, is the most southerly of the Caribbean islands. It has a total area of 5,128 km2 of which Trinidad covers 4,828 km2 and Tobago 300 km2. The climate is tropical marine with temperature that varies between 22 -32 degrees celsius, with a dry (January-April) and a rainy (May-December) season.

Demography: The country is a multi-ethnic, multi-cultural society. It is estimated that 39.5 % of the population is of African descent, 40.3 % are of East Indian descent, 18.4 % are of mixed racial ancestry and the remaining are Caucasian, Asian, and others. The population based on the 2000 census is of 1,262,366 of which 95.72 % are located in Trinidad; 50.2 % are males; an estimated 70. 6% of the population is between 15-64 years old, 8.1 % are over 65 years and 21.4 % below 14 years. Population density was 246 km2. Approximately 74 % of the population is urban and net migration rate is estimated at -10.83 migrants/1,000 population for 2004. The population of East Indian descent predominates in rural and more agriculturally oriented localities.

The country is in a stage of advanced demographic transition. For 2004 the estimated birth rate is 12.75 births/1,000 population and death rate is of 9.02 deaths/1,000 population. Population growth rate is estimated at -0.71 births/1,000 population; total estimated fertility rate is of 1.77 children born/woman. This is in part due to the decline in fertility rates and crude birth rates since 1997. 15 % of live births were due to teenage pregnancies.

Life expectancy at birth is estimated at 69.28 years with 66.86 years for men and 71.82 years for female. However, much of the gain in life expectancy at birth has been in the under 15 year’s age group. Over the last twenty years the proportion of population below 15 years has declined while the proportion over the age of 60 years has increased steadily. The dependency ratio showed a steady decline from 61% per 100 populations in 1995 to 44.4 in 2001 to 42.6 in 2003.

Economy: Unemployment rates have experimented changes in 2000. The overall rate was of 11.4 % and was estimated in 2002 at 10 %. In 2001, of the total unemployed population 8.8 % were males and 14.4 % were females.

The percentage of the population living in poverty was 22 % in 1997. The highest levels of poverty were seen among the unemployed, particularly in female with lowest education levels and female headed households 31 % of which 19 % are single parent female headed.

The TT$ dollar was allowed to float since 1993 and has maintained a relative stable exchange rate at 1US$=6.12TT$ at the end of 2003. The country projected population growth is above 4 % annually peaking in 2005 at 9 %. . Inflation rates declined from 5.3 % (1995) to 2.3 % (1999) and was estimated at 3.8 % based on consumer prices in 2003. The major job generators include construction, services, and manufacturing sectors. Since 1995 to 2000 the country’s economy based on an open market–driven economy policy has grown positively with services accounting for an increasing 54 % of the GDP, it is sustained by the petroleum, natural gas, chemicals, tourism industry among others. GDP growth was 2.7 % in 2002 a declined compared to 3.3 % in 2001. Total public debt at the end of 2002 was 66 % of the GDP with an estimated decline to 55.9 % in 2003. Investment (gross fixed) was estimated at 14.8 % of GDP in 2003 and the GDP composition per sector was agriculture (2.6 %), industry (49 %) and services (48.4%).

Even though the country’s economical indicators are positive, health indicators indicate a degree of variability related to equitable access to services and behavioral issues as a common leading factor determining the health profile and burden of disease. Social housing public health related living conditions indicate that urban areas have the major amount of services provided with an overall availability of 96 % of sewerage and waste disposal, 69.4 % of households with water piped into dwelling and or yard, 86% of the population have access to drinking water, 67 % have toilet facilities, 92 % have electricity and 35.35 % have a motor vehicle.

Literacy: In 2003, adult literacy rate was estimated at 98.6 % (99.1 % for males and 98 % for females). However, the combined primary, secondary and tertiary gross enrolment, which is predominantly female, continues to drop since the last decade largely due to socio-economical factors such as structural adjustment, unemployment, and parent migration, among others.

Mortality: Crude death rate increased from 7.2 per 1,000 population in 1997 to 7.8 in 1999. The five leading causes of deaths for 1999 in the country were: heart disease, diabetes mellitus, malignant neoplasm, cerebrovascular disease and HIV/AIDS; leading causes among the 15-34 age group were HIV/AIDS, transport accidents, assault, intentional self harm, and heart disease in the same order. Of total deaths registered in 1998, males accounted for 55.5 % with the majority of events among the 65+ year old.

Mortality data over the last decade (1989-1998) indicate an increase in 10 selected causes (in descending orders by number of deaths): heart disease, diabetes mellitus, malignant neoplasm, AIDS, suicides, pneumonia, motor vehicle accidents, homicides, cirrhosis of the liver and bronchitis/emphysema, and asthma. Rates continue to be higher for males than females over the same period. Death rates per 100,000 were highest in 1998 for: certain conditions originating in the perinatal period (1,201.25), congenital anomalies (558.72), diseases of the circulatory system (297.88), malignant neoplasm 995.17), diabetes mellitus (95.25), birth trauma (50.28), injury and poisoning (48.68), infectious and parasitic diseases (47.74) direct obstetric deaths ( 38.93) and pneumonia (27.63).



SPECIFIC HEALTH PROBLEMS

Analysis by population group
Children (0-4 years, 5-9 years): Infant mortality was stable at a rate of 17.1 per 1,000 live births during the period 1995-1997 but increased to 21,1 in 2004; neonatal mortality has steadily increased from 13.9 and 13.1 per 1000 live births in 1995 and 1997 respectively to 17.1 in 2004, perinatal mortality increased from to 22.4 per 1000 live births in 1997 to an estimated 26.2 for 2004.

Schoolchildren (5-9 years): Children 5-9 years old experienced 38 deaths (0.4%) 1997. The mortality rate among children 5-9 years in 1997 was 32 per 100,000 population. The leading causes of death were external causes (40%), neoplasms (21%), communicable diseases (21%), and diseases of the circulatory system (3%).

Adolescents (10-14 and 15-19 years): There were 48 deaths among 10-14 year olds (0.5%) and 92 deaths or 1% among 15-19 year olds. The leading causes of death in the 10-14 years age group were external causes (46%), malignant neoplasms (15%), communicable diseases (10%), and diseases of the circulatory system (4%). The leading causes of death in the 15-19 years age group were external causes (44%), communicable diseases (14%), diseases of the circulatory system (8%), and malignant neoplasms (7%). Suicide is also an important cause of death in the age group 15-19 years. Teenage girls outnumbered boys 5 to 1 for new HIV infections and 4.5:1 for AIDS cases, 1996. In 1997, the age group 15-19 years accounted for 14% of all pregnancies, with an age-specific fertility rate for 11.5 births per 1,000 population.

Adults (20-59 years): Adults 20-59 years old accounted for 30% of deaths, 1997; the Crude death rate was 394 per 100,000 population. The major causes of death were diseases of the circulatory system (27%) communicable diseases (17%), malignant neoplasms (15%) external causes (14%). AIDS is an important contributor to deaths due to communicable diseases. Persons between the ages 25-44 accounted for 70% of inpatient care from 1994-1997. Maternal mortality ratio was 70.4 in 1997 and decreased to 54 per 100,000 live births in 2004 (10 maternal deaths);

Elderly (60 years and older): Persons aged 60 years and older accounted for 64% of deaths, 1997. The mortality rate for this group was 5,058 per 100,000 pop., 1997. Diseases of the circulatory system were responsible for 49% of deaths, malignant neoplasms (15%), communicable diseases (5%), signs and external causes (2%).

The disabled: A survey of 7,892 persons 0-18 years of age showed that 2% had disabilities. The 0-4 years age group accounted for 16% of those with disabilities, 5-9 year olds, (39%), 10-14 year olds (29%), and 15-18 year olds (16%). Disabilities were related to learning (25%), sight (24%), and speech and hearing (18%).


Analysis by health problems
HIV/AIDS: By 2000 there were 9,070 cumulative cases diagnosed with HIV/AIDS since the epidemic started in 1983. Prevalence was estimated in 1.2 % of the population in 2001 for an estimated number of 16,217 HIV positive persons, it is estimated to be at 3 % among adults and at 2.5 % among pregnant females. The percentage of women infected has increased consistently to 37 % in 2000, of these 82 % are among those aged 15-45 year.

Current male to female ratio of 1:1 and high female to male ratio among youths suggest that higher prevalence rates are being recorded also among groups with high risk behavior and factors such as men who have sex with other men (MSM), commercial sex workers (CSWs) drug users and persons attending the sexually transmitted infections (STI) clinics.

Tuberculosis (TB): The retrospective cohort study of 1995-1999 indicated a decrease in prevalence of 14.4 %, there was a 7.5 % increase of new cases with an increase of M:F ratio 2.3:1 to 2.7:1 respectively. The study revealed an increase from 47.8 to 54.8 % among the group of 15-44 years old, with the highest percentage (23.5 %) of new cases occurring among the 35-44 years group.

Pulmonary TB increased in 1.5 % and accounted for 89.5 % of new cases, military TB went from 0 to 2.5 %, and extra pulmonary cases fell from 9.1 % to 7.2 % respectively. 32.5 % of these cases were co-infected with HIV/AIDS in 1995 and increased to 39.1 in 1999, while total cases tested went up in 25.9 % in 1999 in comparison to 1995, a 33.3 % of cases were not tested in 1999. The disease poses a matter of serious concern and more so when associated to the growing trend in HIV/AIDS together with limitations in the surveillance capacity, the absence of a DOTS programme and the presence of Multi Drug Resistance (MDR). Risk factors other than HIV/AIDS were not significant except for the groups of substance abusers, prisoners and juveniles in special homes. TB related mortality was highest among substance abusers with 59.4 %, among TB/HIV with 48.9 %, among prisoners 43 %, inmates in/from juvenile facilities 44 %, and among diabetics with 22 % of deaths.

Vaccine-preventable diseases: There were no cases reported of diphtheria, polio, rubella, and neonatal tetanus, and vaccination coverage for 2003 was 91 % for DPT, 91 % for OPV, 88 % for MMR, 92 % for HIB, 76 % for HEPB, and 88 % for YF.

Sexually transmitted diseases (STI): Total number of diagnosed STI cases decreased in the decade of 1991-2000 in 46 %. Incidence rates decreased per 100,000 from 50 to 30 for syphilis, and 194 to 48 for gonorrhea. Males continue to be the predominant group affected, with 59 % of diagnosed cases in 2000. Overall, syphilis diagnosed cases increased from 15.8 % to 21.8 % in the decade and gonorrhea decreased from 62.1 % to 34.7 %. Since 1992 there has been no notified case of congenital syphilis.

Vector borne disease: In 2003 there were 2,289 reported cases of dengue based on clinical diagnosis (176.08 per 100,000 pop.) and 80 cases of dengue hemorrhagic fever (DHF). During January and August 2004 there have been 286 clinically diagnosed cases, and 16 DHF cases with no deaths.

In 1965 Trinidad and Tobago was declared malaria free; even though vector borne diseases are monitored through surveillance and managed with prevention and treatment interventions; there are still residual cases of P. Malariae recorded in south Trinidad. In 2003, 10 cases of malaria were reported with four of them being imported, one a relapse case and five described as cryptic. Additionally there has been discreet decrease in the number of cases of leptospirosis over 2002 2003 from 20 to 16 respectively.

Other communicable and emerging and re-emerging diseases: Cases of Meningococcal infections continue to be registered with no evident trend suggesting an epidemiological outbreak The majority of confirmed cases in each year were in the under 19 year old age group. Acute hemorrhagic conjunctivitis registered an increase during 2003. There were no cases of SARS reported in 2003.

Salmonellosis, shigellosis, influenza and viral hepatitis B have shown an increasing registry from 2002 to 2004. Prevalence rates for Hansen disease have remained unchanged since 1999.

No cases of Lymphatic Filariasis (LF) have been reported since 1982. A national survey conducted in 2002 in school children 6-12 using ICT (immunochromatographic card tests) provided evidence of the interruption of LF transmission.

Accidents and violence: The number of reports on serious criminal and violent events (traffic accidents excluded) increased from 16,783 in 1995 to 17,132 in 2000. Offenses over the same period such as murder, manslaughter, and other crimes against the person and narcotic related offences increased while wounding showed a discreet reduction.

Deaths associated to domestic violence increased over the last decade with a consistent pattern of lethal events involving homicide/suicide and a growing pattern of sexual abuse including rape and incest. Counseling services and shelters for domestic abuse victims are available at NGO and public institutions, the latter with more limited access.

From 1998 to 2002, the number of traffic related accidents has remain almost the same, but related deaths and injuries increased by 10.3 %, the risk of deaths due to this cause went from 5.9 per 1,000 accidents in 1998 to 11.2 in 2003; children accounted for 11 % of deaths in 1990 and decrease to 8.3 % in 2003.



RESPONSE OF THE HEALTH SYSTEM

National health policies and plans: The Government of the Republic of Trinidad and Tobago (GORTT) allocation for health was TT$ 1,263 billion in 2003, which is a per capita amount of approximately $TT 10,000 or US$ 1,754 (exchange rate of US$1.00 – TT$ 6.00). In recent years, a considerable proportion of the allocation has remained unspent. The source of the government health expenditure is general taxation revenues. A health surcharge is deducted from the monthly salaries of all wage earners; however, it is not directed to a fund for health care but goes to the Government Consolidated Fund.

In Trinidad and Tobago the share of the health budget has declined over the period from 12 % of the budget in the early 1970s to about 7 % in 2003. The average Total Health Expenditure (THE) per capita (THE pc) for the period 1997-2001 was US$239. As a percentage of GDP, the THE was 4.3 %. In terms of the public-private mix, private and government health expenditures as a percentage of THE were 55 % and 45 % respectively. Government has recognized the potential of social health insurance as a means of providing additional funding. As a result of PAHO/WHO technical assistance, a Master Plan and a task force is being established to guide this process.

A National Health Accounts system has not yet been implemented and it is difficult to find accurate data on expenditure by type of service. Cabinet in 2002 appointed a National Health Accounts Committee which has now been revitalized.

Institutional Organization of the Health Systems: The foundation of the health sector in Trinidad and Tobago is the public health system, which includes several hospitals (8), a large network of primary health care and community clinics (107), and other services. A significant private health care sector exists. However, relatively little formal information is available on its performance and financial condition. The private sector is composed of a number of hospitals, nursing homes, clinics, numerous pharmacies, bio-medical laboratories and radiological- image diagnostic services.

Health Sector Reform: The GORTT remains committed to health sector reform. The Implementation Steering Committee Re-profiling and Extension Sub-committee July 2001 Report indicated that the original programme content of the Health Sector Reform Program (HSRP) remained substantially relevant but the schedule was overly optimistic. The Report recommended a three year extension that was approved until 2006 to complete the HSRP as originally designed.

Trinidad and Tobago participated in the Essential Public Health Functions (EPHF) exercise in early 2002. EPHF 2 (Public Health Surveillance, Research, and Control of Risks and Harm to Public Health) had the highest score. This could be interpreted as the result of the country's emphasis on surveillance, in terms of both training and operations. EPHF 11 (Reducing the Impact of Emergencies and Disasters on Health) had the second highest score. At the other end of the spectrum, EPHF 8 (Human Resources Development and Training in Public Health) and EPHF 10 (Research in Public Health) received low scores. The low score assigned to each of these two functions (8 and 10) might reflect neglect of investments in human capital and the scientific apparatus to sustain the development of public health in the country. Likewise, EPHF 6 (Strengthening of Institutional Capacity for Regulation and Enforcement in Public Health) scored in the below average performance quartile. In general, the remaining functions obtained scores that place them in the quartile of above average performance, not the optimum proposed in the objective vision of the process.

Organization of Regulatory Actions: Considerable work is needed in the area of regulatory framework, i.e. the creation or updating of laws and regulations. Recent activities have been in the areas of mental health, tissue transplant, emergency ambulance services, Regional Health Authority (RHA) employee discipline, and various aspects of foods and drugs. Improved management of pharmaceuticals is a priority with the MoH.

Absence of adequate information systems to provide data for planning, policy development and management decision-making is another key hindrance. There is a need for updated information systems that can be used to monitor and evaluate RHA performance, internally and externally. A Virtual Health Library is in the process of development.

Quality Management is the most productive component of the Health Sector Reform Program (HSRP) in terms of impact. Unfortunately, quality of care will not improve unless the human and other resources are available to implement developed policies and standards. Systems and procedures continue to be developed at the national level for implementation of quality improvement program, despite the slow rate of implementation.

Organization and Function of Individual Health Care Services: A 100-bed secondary care hospital is being constructed in Scarborough, Tobago. Plans are also in place to improve selected facilities at existing hospitals. The Government has decided to renovate the Eric Williams Medical Sciences Complex (EWMSC) and rationalize services to fully utilize its capacity including integrating the Mt. Hope Maternity Hospital and housing the National Oncology Centre into the renovated facilities at the EWMSC.

Facilities and biomedical equipment maintenance continue to be an area of weakness. Equipment enhancement projects are underway in various stages. According to an evaluation performed in 2001, the National Public Health Laboratories and Blood Transfusion Service are in poor condition. Physical facilities, equipment, policies and procedures, in addition to management and organization of the services, were considered to be of poor quality.

Disease Prevention and Control: The Ministry of Health and the Regional Health Authorities are in the process of mainstreaming health promotion initiatives and integrated management of NCDs including health promoting schools. Policies are in place for the majority of these issues but require further reinforcing and compliance at all levels together with improved monitoring and surveillance systems.

The Insect Vector Control Division of the Ministry of Health provides services for its mosquito vector control programme based on comprehensive house to house inspections using a large workforce. The relatively low level of educational attainment of some of the field staff means that intensive ongoing training in basic behavior and communication skills for meaningful public interaction is required.

Regarding SARS, prevention measures and response plans were in place at all ports of entry and public institutions, surveillance continue to date in the system.

The expanded response to the HIV/AIDS epidemic currently framed in the context of the national strategic plan includes care and treatment programs such as the provision of ART free of cost to those infected, maternal to child transmission (MTCT) service, improving surveillance and monitoring systems and prevention interventions among al those infected and affected by the virus. To date over 3,120 (adults and minors) persons are receiving care and treatment with approximately 1,620 on ART treatment.

Environmental Health: Environmental health services within the MoH remains focused on inspections and registrations for food safety and the monitoring for mosquito vector control and general sanitation within communities and institutions Environmental Health is an integral part of the Ministry of Health, although eventual decentralization to the RHA under the Health Sector Reform Programme is planned.

Human Resources: The Ministry of Health - Public Health Inspectorate consists of 131 Public Health Inspectors of which less than 10 are in senior ranges that require qualification to a full degree level, thus there are vacancies in key management positions due to shortage of staff. Since the PAHO Fellowship arrangement ended over the last decade, no further Public Health Inspectors have been trained to the full degree level. Efforts are being made regionally to implement degree training in Trinidad and Tobago; the main stumbling block has been delays in identifying the training institution. Unfortunately, no human resource assessment or planning has been done for some time in the Ministry of Health for Environmental Health.

Occupational Health and Safety: In January 2004 the Occupational Health and Safety Act was passed in Parliament. It calls for the establishment of an Occupational Health and Safety Authority and an Occupational Health Safety Agency. The former is to be a policy making body and the latter an agency for implementation of the legislation. Once the Act is proclaimed, the process of developing appropriate regulations will require technical inputs. Regulation for the safe use of ionizing radiation for health and industrial purposes is one priority area. Another is for the handling of hazardous wastes and chemicals. Laboratory and testing equipment needed to support occupational health conditions do not now exist.

Waste Management: With technical inputs from PAHO a Code of Practice for Biomedical Waste Management was produced in 2004.

Food Safety: Collaboration between the Health and Agricultural sectors exists in a joint Food Safety Committee. Even though responsibilities are clearly demarcated and enshrined in existing legislation, there is need to enhance institutional capacity of both sectors to carry out comprehensive food safety programmes and projects. Poor sanitation practices at food preparation establishments have contributed to periodic food illness outbreaks, especially in hotels. Preparation of local instructional materials for food handlers would assist food inspectors to more effectively communicate with the public and introduce the application HACCP.

Emergency Preparedness and Response: Heightened awareness of the impacts of hurricanes and floods during the 2004 hurricane season in the Caribbean show the need for up-dating response plans and conduct simulation exercises from lessons learned. Supply Management System (SUMA) and EOC (Emergency Operations Centre) training is also required.

Due to the presence of communities in close vicinity to petrochemical and gas based industries, Trinidad is also at risk to industrial disasters. The UNEP APELL (Awareness and Preparedness to Emergencies at the local Level) programme was introduced to all major stakeholders during 2004 and technical training support is required to enhance its implementation.

Potable water and sewerage services: In 2000 there was considerable expansion of potable water supplies with the upgrading of the Caroni Arena Plant to produce an additional 15 million gallons per day. In 2001 the commissioning of twenty-two million gallons per day desalination plant increased the total production of potable water to two hundred and six million gallons per day. In spite of these impressive figures, there is still a shortfall in access to a regular supply of potable water to most households. Only 65 % of the population has water piped to their homes, and not on a 24 hour basis, while another 15 % have access through community standpipes and truck-borne supplies. The shortfall in access to water has been attributed to large losses of water in the aged distribution system. Beginning in 2005, 1.3 billion Trinidad and Tobago dollars have been allocated to pipeline replacement over the next three years.

Central Sewerage collection and treatment facilities are only available in the major city and urban centers. Maintenance of these facilities is the responsibility of the Water and Sewerage Authority (WASA). In the recent past, several agencies and private operators maintained small Sewerage Treatment Plans (STPs) unsuccessfully. However, during 2004 most of these plants were put under the responsibility of Water and Sewage Authority (WASA).

Although sewerage age facilities are available to over 95% of the population, this is mainly on lot systems in the form of septic tanks and pit latrines (75-80%).

Sectorial expenditure and financing: The public health sector is financed through general taxation and user fees. MOH level of expenditure increased by about 20 % during the 1990s, from US$ 83.6 million in 1991 to US$ 105.6 million in 1997. In 1997, primary care expenditure accounted for 10.9% of total health expenditure.

External health and technical cooperation and financing: MOH receives external financing from bilateral and multilateral sources for the implementation of projects, including health sector reform. External agencies providing technical cooperation and/or financing in the health sector include UNAIDS, UNDP, PAHO/WHO, and IDB, which is a principal financer of health sector reform. Bilateral development agencies, such as CIDA and GTZ, also contribute through CAREC.