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T&T needs Universal Health Coverage to face ‘CNCD’ challenge

By Dr Kenwyn Nicholls

In Trinidad and Tobago, the major disease burden is chronic noncommunicable diseases (CNCDs): heart disease, stroke, cancer, diabetes and chronic lung disease, accounting for over 62 per cent of deaths each year, three quarters occurring in people under age 70.

Over half the country’s population has three or more of the risk factors common to those four diseases: poor nutrition, physical inactivity and harmful use of alcohol and tobacco (WHO 20 OCT 2021: Empowering T&T Communities to Prevent and Self-Manage NCDs).

By most accepted definitions, CNCD is T&T’s 21st century public health problem.

This situation is aggravated by the accelerated growth of the population in the 65+ age bracket which in the past three decades (1990–2020) went from 5.4 per cent to 11.5 per cent and is projected to more than double to 26.2 per cent by 2060.

As people age, the likelihood of developing preventable CNCDs increases, signalling continued social and economic disaster not just for the individual and his/her household, but for T&T.

The astronomically high rates of hospitalisations and deaths in the pandemic, are mainly of aged persons with CNCDs, a grim reminder of how inadequate access to quality health care impacts the quality of life as well as life expectancy itself.

Had Universal Health Coverage (UHC) been in place, T&T’s pandemic outcomes would have been greatly mitigated. UHC, firmly endorsed by the World Health Assembly (WHA) in 2005, is defined as “access to key promotive, preventive, curative and rehabilitative health interventions for all at affordable cost”. The United Nations General Assembly endorsed UHC as a Sustainable Development Goal (SDG) on December 12, 2012.

In 2013, T&T joined some 115 countries that signed on to the UHC Partnership, a WHO initiative, to deliver support and technical expertise to member countries in advancing UHC with a primary health care (PHC) approach.

After almost two decades of continual increases in the US, the incidence of newly diagnosed cases of diabetes decreased from 9.3 per 1,000 adults in 2009 to 5.9 per 1,000 adults in 2019.

Of significance as well was the finding that even though the prevalence of diabetes remained steady in the time frame, notification of prediabetes status nearly tripled from 6.5 per cent to 17.4 per cent. With a proper diet, weight loss and exercise, only 20 per cent of persons designated as prediabetic go on to Type 2 diabetes.

Much credit for this success story should be given to the passage of the Affordable Care Act (Obamacare) in March 2010; it made health care affordable and thus accessible to many of the chronically disadvantaged – American Indian, Hispanic, non-Hispanic Black and Asian, etc, the very groups more likely to be diagnosed with diabetes than Whites.

Research has shown that for people with diabetes, blood pressure management can reduce the risk of heart disease and stroke by 12 per cent to 27 per cent, progression of kidney disease to renal insufficiency/failure by 30 per cent to 70 per cent; and along with cholesterol management – cardiovascular complications by 20 per cent to 50 per cent (CDC: Diabetes Report Card 2021).

In the T&T health system, hospital beds are dominantly occupied by patients with strokes, heart attacks, renal failure, and retinal and peripheral neuropathy (persons so afflicted are at significant risk for blindness and limb amputation), all potentially preventable with development of an efficient, effective public health programme based on PHC.

Failure to confront and control the CNCDs already at epidemic levels in T&T means a continuation of excess morbidity and mortality, and inevitably overburdened public hospitals.

Lengthy wait times for hospital beds, long delays in receiving critical diagnoses, results and reports, and all the constraints reiterated by President Paula-Mae Weekes in her address at the Presidential Symposium hosted by the UWI medical fraternity and the Trinidad & Tobago Medical Association on Saturday, January 14, are manifestations of overburdened public hospitals.

Those are availability, accessibility, equitability, and affordability issues, all amenable to a T&T health system based on UHC using a public health and PHC approach.

Government must act with deliberate speed to implement the UHC using a public health and PHC approach. Leadership at the highest level, the lawmakers, will be required. Transformation from the current health system to UHC is a multi-sectoral challenge; all Ministers must get involved.

Dr Kenwyn Nicholls practiced as a medical doctor in the USA for more than 40 years and returned to T&T in 2009. He worked with the Catholic Commission for Social Justice on a wellness project to raise awareness in various parishes on issues relating to diabetes.