The 2007 Caribbean Community Port-of-Spain Declaration on noncommunicable diseases: an overview of a multidisciplinary evaluation.

OBJECTIVES: Noncommunicable diseases (NCDs) are a threat to social and economic development, including in the Caribbean. In 2007 the Caribbean Community (CARICOM) held the world's first-ever summit of heads of government on NCD prevention and control and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. The objectives of this paper are to provide an overview of a formal evaluation of the Declaration and to highlight key findings that could inform further implementation of the Declaration's 15 mandates.
METHODS: The evaluation's six research objectives were decided through stakeholder engagement and assessed by concurrent quantitative and qualitative research methods, using the following four themes: 1) trends in risk factors, morbidity, and mortality; 2) national and Caribbean-wide policy responses, and factors associated with policy successes and difficulties; 3) the international impact of the Declaration; and 4) the potential for raising revenue from tobacco and alcohol taxation in order to support NCD prevention and control.
RESULTS: There are marked disparities in NCD mortality and trends among the 20 CARICOM member countries and territories. No CARICOM member had fully implemented all of the Declaration's 15 mandates (which were monitored by 26 indicators), with 10 CARICOM members implementing fewer than half of the indicators, and with most members lacking a well-functioning multisectoral NCD Commission. Larger CARICOM members tended to have higher levels of implementation than did smaller members. Mandates that received active support from regional institutions tended to be better implemented by the CARICOM members than did mandates that lacked that kind of support. Feasible national tobacco and alcohol tax increases could more than cover the cost of implementing the World Health Organization NCD "best buy" interventions in the CARICOM member countries and territories.
CONCLUSIONS: Priorities for further implementation of the mandates from the Port-of-Spain Declaration include establishing throughout the CARICOM member countries and territories fully functioning national bodies to support multisectoral action for NCD prevention; greater regional support in policy development and implementation for smaller countries; and greater targeted use of taxes on tobacco and alcohol to support NCD control and prevention.

The epidemic of chronic noncommunicable diseases (NCDs) in the Caribbean is worse than in any other region of the Americas, with premature mortality (for those 30–69 years old) being double the rates in North America (1, 2). NCDs are clearly a threat to Caribbean social and economic development (3).

Underlying the high rates of premature NCD mortality in the Caribbean are high levels of risk factors, particularly unhealthy diet and physical inactivity, which lead to high rates of obesity, diabetes, and hypertension (1, 2, 4–6). Tobacco smoking and excessive alcohol consumption, particularly in men, are additional drivers of the epidemic (1, 4, 5).

The Caribbean Community (CARICOM) is a political grouping of 20 small island developing states (https://caricom.org/about-caricom/who-we-are/our-governance/members-and-associate-members/). The 20 consist of 15 full members and 5 associate members, with all the 5 associate members being overseas territories of the United Kingdom. Of the 15 full members, 14 are independent states; the 15th is Montserrat, which is a full member of CARICOM despite being an overseas territory of the United Kingdom. Most of the 20 are English-speaking members of the Commonwealth, along with French- and Creole-speaking Haiti and Dutch-speaking Suriname. For historical reasons, the mainland countries of Belize, Guyana, and Suriname are full members of CARICOM.

There has been a long tradition of cooperation in health in CARICOM, resulting, for example, in the region being the first in the world to eliminate measles (7, 8).

The Caribbean has undergone the epidemiological and demographic transition (9–11), and it has the highest rates of premature cardiovascular mortality in the Region of the Americas (12, 13).

Advocacy by Sir George Alleyne and others on the health, social, and economic impacts of NCDs promoted “upstream” multisectoral interventions to address the underlying determinants of the behavioral risk factors (10). In response, in 2007, CARICOM held the world's first-ever summit of heads of government on NCD prevention and control and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs (14). The Declaration contained 15 actionable mandates.

CARICOM and the Pan American Health Organization (PAHO) were responsible for monitoring and evaluating the Declaration. Regular, annual monitoring of CARICOM members' responses has been conducted through the reporting on 26 indicators from the 15 mandates (Table 1). The reporting is done annually by NCD focal points in the ministries of health, reviewed by each country's Chief Medical Officer (CMO) in the ministry of health, and presented to the annual caucus of CARICOM health ministers. A monitoring reporting grid was developed in 2008 and revised in 2010 (15).

TABLE 1

Caribbean Community (CARICOM) 2007 Port-of-Spain Declaration mandates and related national and regional indicators

Declaration mandate	Regional indicator(s) and national indicator(s)a
1. Our full support for the initiatives and mechanisms aimed at strengthening regional health institutions, to provide critical leadership required for implementing our agreed strategies for the reduction of the burden of Chronic, Non-Communicable Diseases as a central priority of the Caribbean Cooperation in Health Initiative Phase III (CCH III), being coordinated by the CARICOM Secretariat, with able support from the Pan American Health Organization/World Health Organization (PAHO/WHO) and other relevant partners	Regional action:- Caribbean Cooperation in Health convened
2. That we strongly encourage the establishment of National Commissions on NCDs or analogous bodies to plan and coordinate the comprehensive prevention and control of chronic NCDs	1) NCD plan2) NCD summit convened3) Multi-sectoral NCD Commission appointed and functional
3. Our commitment to pursue immediately a legislative agenda for passage of the legal provisions related to the International Framework Convention on Tobacco Control; urge its immediate ratification in all States which have not already done so and support the immediate enactment of legislation to limit or eliminate smoking in public places, ban the sale, advertising and promotion of tobacco products to children, insist on effective warning labels and introduce such fiscal measures as will reduce accessibility of tobacco	4) FCTC ratified5) Tobacco taxes > 50% sale price6) Smoke-free indoor public places7) Advertising, promotion & sponsorship bans
4. That public revenue derived from tobacco, alcohol or other such products should be employed, inter alia for preventing chronic NCDs, promoting health and supporting the work of the Commissions	8) NCD budget
5. That our Ministries of Health, in collaboration with other sectors, will establish by mid-2008 comprehensive plans for the screening and management of chronic diseases and risk factors so that by 2012, 80% of people with NCDs would receive quality care and have access to preventive education based on regional guidelines	9) Chronic Care Model/NCD treatment protocols in = 50% PHC facilities10) Quality of care in cardio-vascular disease or diabetes demonstration project
6. That we will mandate the re-introduction of physical education in our schools where necessary, provide incentives and resources to effect this policy and ensure that our education sectors promote programmes aimed at providing healthy school meals and promoting healthy eating	11) Mandatory physical activity in all grades in schools12) Policy & standards promoting healthy eating in schools implemented
7. Our endorsement of the efforts of the Caribbean Food and Nutrition Institute (CFNI), Caribbean Agricultural Research and Development Institute (CARDI) and the regional inter-governmental agencies to enhance food security and our strong support for the elimination of trans-fats from the diet of our citizens, using the CFNI as a focal point for providing guidance and public education designed toward this end	13) Multi-sector food & nutrition plan implemented14) Trans fat–free food supply
8. Our support for the efforts of the Caribbean Regional Negotiating Machinery (CRNM) to pursue fair trade policies in all international trade negotiations thereby promoting greater use of indigenous agricultural products and foods by our populations and reducing the negative effects of globalisation on our food supply	15) Trade agreements utilized to meet national food security & health goals
9. Our support for mandating the labelling of foods or such measures as are necessary to indicate their nutritional content through the establishment of the appropriate regional capability	16) Mandatory labeling of packaged foods for nutrition content
10. That we will promote policies and actions aimed at increasing physical activity in the entire population, e.g. at work sites, through sport, especially mass activities, as vehicles for improving the health of the population and conflict resolution and in this context we commit to increasing adequate public facilities such as parks and other recreational spaces to encourage physical activity by the widest cross-section of our citizens	17) Mandatory provision for physical activity in new housing developments18) Ongoing, mass physical activity or new public physical activity spaces19) ≥ 50% of public and private institutions with physical activity and healthy eating programmes
11. Our commitment to take account of the gender dimension in all our programmes aimed at the prevention and control of NCDs	Regional action:- Gender considerations are included in surveillance and analyses
12. That we will provide incentives for comprehensive public education programmes in support of wellness, healthy life-style changes, improved self-management of NCDs and embrace the role of the media as a responsible partner in all our efforts to prevent and control NCDs	20) NCD communications plan21) ≥ 30 days per year media broadcasts on NCD control (risk factors and treatment)
13. That we will establish, as a matter of urgency, the programmes necessary for research and surveillance of the risk factors for NCDs with the support of our Universities and the Caribbean Epidemiology Centre/Pan American Health Organization (CAREC/PAHO)	Surveillance:22) STEPS or equivalent survey23) Minimum Data Set reporting24) Global Youth Tobacco Survey25) Global School Health Survey
14. Our continuing support for CARICOM and PAHO as the joint Secretariat for the Caribbean Cooperation in Health (CCH) Initiative to be the entity responsible for revision of the regional plan for the prevention and control of NCDs, and the monitoring and evaluation of this Declaration	Regional actions:- Updated Regional NCD plan- Monitoring grid of CARICOM 2007 Port-of-Spain Declaration mandates completed annually- Evaluation of CARICOM 2007 Port-of-Spain Declaration mandates
15. We hereby declare the second Saturday in September “Caribbean Wellness Day,” in commemoration of this landmark Summit.	26) Caribbean Wellness Day multi-sectoral, multi-focal celebrations

The national indicators are numbered, and the regional indicators are unnumbered. The abbreviations used in the Indicator(s) column are: FCTC = Framework Convention on Tobacco Control; NCD = noncommunicable disease; PHC = primary health care.

Given the central role of the 2007 Port-of-Spain Declaration in shaping NCD policy and programs in the Caribbean and beyond, it was important to more thoroughly evaluate the degree of implementation of the Declaration's mandates. To this end, in 2013, the University of the West Indies drew up detailed plans for an evaluation. In March 2014, the Canadian International Development Research Centre (IDRC) approved funding for a three-year evaluation and dissemination project.

The aim of this paper is to provide an overview of the evaluation's objectives and the methods used, and to summarize some of its core findings. Other papers in this supplement of this journal present detailed analyses from several of the evaluation's specific objectives (Box 1) (16–25).

Determining the extent to which the 15 mandates (monitored by 26 indicators) in the Port-of-Spain Declaration are reported to have been implemented and the national and other characteristics associated with high levels of implementation within the 20 CARICOM countries and territories

Paper: Validating the self-reported annual monitoring grid for the 2007 Caribbean Community Declaration of Port-of-Spain on noncommunicable diseases, by Samuels et al. (16)

Describing, within the limitations of currently available data, trends in NCD mortality and risk factors from the year 2000 to 2013, in the 20 CARICOM countries and territories

Paper: Premature mortality from cardiovascular disease and diabetes in the Caribbean and associations with health care expenditure, 2001–2011, by Razavi et al. (17)

Paper: An updated systematic review and meta-analysis on the social determinants of diabetes and related risk factors in the Caribbean, by Guariguata et al. (18)

Undertaking in-depth case studies within 7 countries and territories in order to determine:

The agreement between reported implementation of the mandates and substantive change (effective implementation)

The degree of use of multisectoral approaches including the engagement of civil society, the private sector and Government ministries and agencies in addition to the Ministry of Health

Factors associated with success and those associated with difficulties in achieving (a) and (b), including the political impact nationally

What evidence exists on the impact of the implementation on risk factors and health outcomes

Paper: Evaluating policy responses to noncommunicable diseases in seven Caribbean countries: challenges to addressing unhealthy diets and physical inactivity, by Murphy et al. (19)

Undertaking in-depth analyses of the success of policy development and implementation on the following selected major themes:

Documenting tobacco control measures within all CARICOM countries and investigating factors associated with their successful implementation

Estimating the potential for revenue generation for NCD prevention and control from taxes on tobacco and alcohol

Paper: The potential for using alcohol and tobacco taxes to fund prevention and control of noncommunicable diseases in Caribbean Community, by La Foucade et al. (20)

Undertaking an evaluation of the development, implementation, and potential impact of Caribbean Wellness Day.

Paper: Caribbean Wellness Day: promoting a region-wide day of action, by Bartholomew et al. (21)

Determining the degree to which regional and international bodies have met their POS NCD Declaration mandates;

Assessing the impact of the POS NCD Declaration regionally and internationally, including its role in instigating and shaping the UNHLM.

Paper: Regional and global impacts of the 2007 Port-of-Spain Declaration on noncommunicable diseases, by Kirton et al. (22)

Using the lessons learnt from this evaluation to detail an action plan and implementation strategy that:

Fills gaps identified in the implementation of the POS NCD Declaration

Paper: The Community Food and Health Project. Health and other impacts of community food production in Small Island Developing States: a systematic scoping review, by Haynes et al. (23)

Takes account of multisectorality and opposed interests

Paper: Regulatory measures to fight obesity in Small Island Developing States of the Caribbean and Pacific, by Foster et al. (24)

Improves upon the monitoring of POS NCD mandates, monitors the WHO NCD targets, and includes the development of an indicator of investment in prevention and health promotion.

Disseminating the lessons learnt from this evaluation nationally and regionally to enhance implementation of POS NCD Declaration and globally to inform the attainment of commitments from the UNHLM on NCDs.

Paper: Communication strategy to disseminate the results of the evaluation of the Port-of-Spain declaration (POSDEVAL) across multiple audiences in the Caribbean, by Greaves et al. (25)

The abbreviations used in Box 1 are: CARICOM = Caribbean Community; NCD = noncommunicable disease; POS = Port-of-Spain; UNHLM = United Nations High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases; WHO = World Health Organization.

METHODS

Evaluation objectives

The overarching objective of the evaluation was to assess seven years on, the implementation of the 2007 Port-of-Spain Declaration in order to learn lessons that will support and accelerate its further implementation and will inform the attainment of the commitments of United Nations' 2011 High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. This overarching objective was elaborated into eight detailed project objectives (Box 1). The first six of these are research objectives, which essentially cover the following themes: 1) trends in risk factors, morbidity, and mortality; 2) national and Caribbean-wide policy responses, and factors associated with policy successes and difficulties; 3) the international impact of the Declaration; and 4) the potential for raising revenue from tobacco and alcohol taxation in order to support NCD prevention and control. Objectives 7 and 8 are to disseminate and use the research findings to strengthen the multisectoral response in the Caribbean towards the prevention and control of the NCD epidemic.

Evaluation leadership and partners

The evaluation was led and coordinated by the Faculty of Medical Sciences Public Health Group and the George Alleyne Chronic Disease Research Centre at the University of the West Indies (UWI), in Barbados. Partners who contributed to meeting one or more of the research objectives included: the HEU Centre for Health Economics and the Institute of International Relations, UWI St. Augustine campus (Trinidad and Tobago); Department of Community Health and Psychiatry, UWI Mona campus (Jamaica); the Caribbean Public Health Agency (CARPHA); the Global Health Diplomacy Programme at the University of Toronto; and the Pan American Health Organization Eastern Caribbean Office. The key partner in the dissemination phase of the project was the Healthy Caribbean Coalition, which provided support for the development of the project website, policy briefs, videos, and other associated materials.

All partners were members of the project steering group, which met monthly throughout the lifetime of project. They were supported by a project advisory committee, which included experienced international leaders in public health. The advisory committee provided feedback on draft protocols for the specific objectives. (All the partners and advisory committee members are listed in the acknowledgments section of this article.)

Overview of the research methods

There are eight research objectives. Objectives 1 to 6 are research objectives; Objectives 7 and 8 are to disseminate and use the research findings.

Detailed protocols were developed for each of the six research objectives, using as appropriate a mixture of quantitative and qualitative data collection and analytical methods. The detailed protocols can be found as part of the evaluation's main technical report (26), which is available on the project's website (https://onecaribbeanhealth.org/wp-content/uploads/2018/01/POSDEVAL_The-Investigators-report_FINAL.pdf). In addition, several papers published in this supplement issue of the journal describe findings from the research objectives, and provide details on the relevant methodologies; these papers are listed under the relevant objectives in Box 1.

The methods for each of the six research objectives (as described in Box 1) are summarized briefly below.

For Objective 1: Use of routinely available data on national characteristics, such as population size, per capita income, educational attainment, and female participation in the work force and representation in parliament, as potential predictors of the policy response as assessed by the monitoring grid.

For Objective 2: New analyses of routinely available data sources, including trends and disparities in NCD mortality using the World Health Organization (WHO) Mortality Database and United Nations (UN) population data. This was only possible for those countries that have provided data to the WHO Mortality Database and for those with populations over 90 000 (as population estimates for smaller countries (including 8 of the 20 CARICOM members) are not available from the United Nations Development Program). New systematic reviews and meta-analyses were also undertaken as part of meeting this objective.

For Objective 3: In-depth, semistructured interviews with a broad range of stakeholders in seven countries.

For Objective 4(a): Data collected from countries and territories using the Framework Convention on Tobacco Control monitoring protocol. This protocol was adapted for use in the CARICOM territories that are overseas territories of the United Kingdom.

For Objective 4(b): New data collection on imports, production, prices, and current tax levels of tobacco and alcohol products in three CARICOM countries, and modeling the potential effects of tax rises on sales and tax revenue.

For Objective 4(c): In-depth, semistructured, qualitative interviews with regional and national stakeholders involved in organizing and implementing Caribbean Wellness Day, and analysis of media penetration.

For Objective 5 and Objective 6: In-depth semistructured interviews with stakeholders in key regional and international organizations, including PAHO, CARPHA, UWI, and WHO.

Ethical considerations

The evaluation received approval from the Institutional Review Board of the University of the West Indies, Cave Hill Campus (Barbados), plus appropriate approval from each of the countries in which new data collection took place.

RESULTS

The subsections below highlight three broad areas of findings and provide an introduction to the more detailed papers in the rest of this supplement.

Disparities in trends in mortality

There are marked disparities in NCD mortality and in trends in NCD mortality over time among the CARICOM members. Major contributors to these disparities are trends in cardiovascular disease (CVD) (stroke and ischemic heart disease) and diabetes mellitus (DM) mortality (combined as CVD-DM mortality). Table 2 shows the marked differences in premature (< 70 years) CVD-DM mortality trends among CARICOM countries with available data from the WHO Mortality Database and UN population figures. Further detail is given in the paper by Razavi et al. (17) in this supplement.

TABLE 2

Percentage decline in age-adjusted premature (< 70 years old) cardiovascular disease and diabetes mellitus mortality for women and men in Caribbean Community countries with available data for 2001–2005 and 2006–2011a

2001–2005			2006–2011
Women			Women
	Trinidad & Tobago	24.1		Saint Lucia	27.1
	Jamaica	15.5		Barbados	24.5
	Bahamas	15.2		Suriname	15.9
	Guyana	14.6		St. Vincent & Grenadines	14.8
	Suriname	13.5		Belize	13.9
	Saint Lucia	6.8		Trinidad & Tobago	13.0
	St. Vincent & Grenadines	4.3		Bahamas	9.5
	Grenada	0.6		Guyana	6.9
	Antigua & Barbuda	-3.1		Jamaica	6.0
	Barbados	-4.9		Antigua & Barbuda	2.6
	Belize	-6.1		Grenada	-4.3
Men			Men
	Belize	26.0		Barbados	23.8
	Trinidad & Tobago	20.2		Saint Lucia	20.9
	Antigua & Barbuda	11.1		Trinidad & Tobago	12.0
	St. Vincent & Grenadines	6.3		Bahamas	9.7
	Bahamas	5.3		Suriname	9.1
	Suriname	2.7		Belize	3.1
	Jamaica	1.8		Guyana	2.3
	Guyana	0.5		Jamaica	-2.3
	Grenada	-6.0		Grenada	-3.6
	Barbados	-6.1		Antigua & Barbuda	-8.5
	Saint Lucia	-27.1		St. Vincent & Grenadines	-9.4

In the respective cells, dark green shading indicates a decline in mortality > 20%; light green shading indicates a decline in mortality of 10%–20%; pink shading indicates an increase in mortality of 0%–20%; and red shading indicates an increase in mortality > 20%.

Barriers and facilitators to country implementation of the 2007 Port-of-Spain Declaration

Among the CARICOM members, there are widely differing levels of policy development and implementation in response to the 2007 Port-of-Spain Declaration. The number of indicators met, as reported by each CARICOM member in 2014 in the monitoring grid, is shown in Table 3.

TABLE 3

Caribbean Community (CARICOM) members by gross domestic product per capita, population, and number of CARICOM 2007 Port-of-Spain Declaration indicators met in 2014

Level of compliance/Member		GDP per capita PPP $a	Population (thousand)b	Number of indicators met (out of 26)
Highest compliers
	Barbados	17 235	283	20
	Trinidad and Tobago	33 284	1 354	19
	Jamaica	8 482	2 862	18
	Bahamas	23 191	382	17
Middle compliers
	Grenada	12 682	106	15
	Cayman Islands	43 800c(2004 est.)	59	15
	Guyana	7 280	763	15
	Saint Lucia	12 398	176	15
	Suriname	16 125	548	14
	Antigua	20 620	99	14
	Bermuda	85 700c(2013 est.)	64d	12
	British Virgin Islands	42 300c(2010 est.)	30	11
	Dominica	10 803	73	11
	Belize	8 433	352	9
	Saint Kitts and Nevis	24 738	54	8
	Saint Vincent and the Grenadines	10 867	109	7
Lowest compliers
	Anguilla	12 200c(2008 est.)	14	5
	Turks and Caicos	29 100c(2007 est.)	34	2
	Montserrat	8 500c(2006 est.)	5	2
	Haiti	1 741	10 572	1

Unless indicated otherwise, these data on gross domestic product (GDP) per capita (at purchasing power parity (PPP)) are from the World Bank.

Unless indicated otherwise, these data on population size are from United Nations Population Division.

These GDP data are from the U.S. Central Intelligence Agency (www.cia.gov/library/publications/the-world-factbook/fields/2004.html).

The population figure for Bermuda is from the country's 2010 census.

No CARICOM member had implemented all the mandates from the 2007 Declaration, as monitored by the 26 indicators, and with 10 members implementing fewer than half of the mandates. There was a clear relationship between country population size and the number of mandates implemented (Figure 1), with the main outlier in this relationship being Haiti, the poorest country in CARICOM. Barbados and the Cayman Islands performed better than would be predicted by their population size.

FIGURE 1

Country percentage of compliance with Caribbean Community 2007 Port-of-Spain Declaration mandates in 2014 vs. country population size (log scale)

Across the 20 CARICOM countries, those mandates that had the best implementation tended to be those for which there was support from regional organizations. These included Caribbean Wellness Day, risk factor surveillance, and ratification of the Framework Convention on Tobacco Control (FCTC). For Caribbean Wellness Day, this assistance included planning supports, provision of branding materials, and a tool kit from PAHO (27). Risk factor surveillance was reinforced by technical support from CARPHA personnel. FCTC support came through the clear road map provided by the FCTC and help from PAHO.

Table 4 lists the indicators by level of implementation (percent of the indicator fully or partially met) among the 20 CARICOM members, alongside the regional and international organizations that provide support for their implementation. The least well implemented indicators tended to be those with the least support from regional and international organizations, and include some of the macro-determinants of diet and physical activity. While 15 of the CARICOM countries and territories reported that they had convened an NCD Commission (which is recommended as the mechanism for engaging all of society in addressing the multifactorial upstream determinants of health), these commissions or analogous bodies were reported to be functioning in only 10 of those 15, according to a report prepared by the Healthy Caribbean Coalition (https://www.healthycaribbean.org/wp-content/uploads/2016/04/A-Civil-Society-Report-on-National-NCD-Commissions-in-the-Caribbean-Towards-a-more-Effective-Multisectoral-Response-to-NCDs-Part-1.pdf).

TABLE 4

Percentage of Caribbean Community (CARICOM) 2007 Port-of-Spain Declaration grid indicator compliance among the 20 CARICOM members, with associated regional and international organizational support, based on grid reports received by the University of the West Indies in 2015a

Indicator	Regional/international organizations supporting	2015 score
FCTC ratified	WHO FCTC, PAHO	95%
CWD multi-sectoral, multi-focal celebrations	PAHO/WHO, CARICOM, CARPHA, HCC	93%
NCD plan	PAHO/WHO, CARICOM, HCC	85%
Global Youth Tobacco Survey	PAHO/WHO, CDC	83%
Global School Health Survey	PAHO/WHO, CDC	83%
Ongoing, mass physical activity (PA) or new public PA spaces	…	80%
STEPS or equivalent survey	PAHO/WHO, CARPHA	75%
Minimum Data Set reporting	PAHO/WHO, CARPHA	75%
National NCD Commission convened	…	73%
Smoke-free indoor public places	WHO FCTC, PAHO, Bloomberg philanthropies project	65%
Multi-sector food & nutrition plan implemented	PAHO/WHO	65%
QOC CVD or diabetes demonstration project	PAHO/WHO	65%
Multi-sectoral NCD Commission appointed and functional	CARICOM, HCC	63%
Mandatory physical activity in all grades in schools	…	63%
NCD budget	…	58%
Policy & standards promoting healthy eating in schools implemented	…	58%
NCD communications plan	…	58%
Chronic Care Model/NCD treatment protocols in . 50% PHC facilities	PAHO/WHO, CDC	58%
≥ 30 days per year media broadcasts on NCD control (risk factors, treatment)	…	55%
Tobacco taxes > 50% sale price	WHO FCTC, PAHO	45%
Advertising, promotion, & sponsorship bans on tobacco	WHO FCTC, PAHO	38%
≥ 50% of public and private institutions with physical activity and healthy eating programs	…	33%
Mandatory provision for PA in new housing developments	…	23%
Mandatory labeling of packaged foods for nutrition content	…	18%
Trade agreements utilized to meet national food security & health goals	…	13%
Trans fat free food supply	…	8%

The abbreviations and the symbol used in the table are: CARPHA = Caribbean Public Health Agency; CDC = (U.S.) Lefts for Disease Control and Prevention; CVD = cardiovascular disease; CWD = Caribbean Wellness Day; FCTC = Framework Convention on Tobacco Control; HCC = Healthy Caribbean Coalition; NCD = noncommunicable disease; PA = physical activity; PAHO = Pan American Health Organization; PHC = primary health care; QOC = quality of care; WHO = World Health Organization; … = no support from regional organizations.

Investing in NCD prevention and control: potential role of tobacco and alcohol taxes

Revenue generated from further increasing taxes on tobacco and alcohol could exceed US$ 37 million in Grenada, Jamaica, and Trinidad and Tobago (20). That amount is three times the estimated US$ 12.6 million cost of World Health Organization “best buy” NCD interventions for these populations. With increased taxes on tobacco and alcohol, consumption will fall (28, 29) since the price elasticity assumptions used are all negative. The methods and findings from those three CARICOM countries are reported in detail in the paper by La Foucade et al. (20) in this supplement.

DISCUSSION

The overall objective of the evaluation of 2007 Port-of-Spain Declaration on NCDs was to assess implementation of its mandates, learn lessons, and, through the dissemination of the findings, help accelerate further implementation. This paper provides an introduction to the detailed objectives, the methods used, and some of the main findings. Other papers in this supplement provide details on the methods and findings for specific objectives (Box 1).

From our introduction to the evaluation, there are four noteworthy, broad conclusions. The first is that there are marked disparities in both rates and trends in premature NCD mortality among CARICOM members (30–33). This is summarized in Table 2 and discussed in greater detail in the paper by Razavi et al. (17) in this supplement. There is no clear-cut relationship between the degree of implementation in the Port-of-Spain commitments as assessed by the monitoring grid and in the change in CVD-DM mortality. Two of the countries that performed best on implementation (Barbados and Trinidad and Tobago) did have large declines in mortality after 2007. However, Saint Lucia and Saint Vincent and the Grenadines also had large decreases in mortality, but they performed much less well, according to the monitoring grid results. The grid scores provide a high-level assessment of implementation, and they also indicate the need for more specific hypothesis-driven investigation into what underlies these differences. One such investigation has been conducted in Barbados for trends in coronary heart disease mortality, and it found that improved coverage of effective medical treatments could largely explain the decline in mortality, despite a background of worsening risk factors (34).

A weakness of the mortality analyses presented here is that they only run to 2011, and trends beyond this time point may be different. A further weakness is that the analyses do not include countries with populations of fewer than 90 000 (true for 8 of the 20 CARICOM members), as population denominator data for them was not readily available. The Global Burden of Disease Study does provide estimates of mortality rates for these 8 countries, but as others have done elsewhere (30, 31), we have chosen to focus on original rather than modeled data.

A second broad conclusion is that countries with additional capacity, as indicated by greater population size, were able to implement more of the Declaration's mandates. The major exception to this was Haiti, the largest country in CARICOM but the one with the lowest level of implementation. In Haiti, lack of capacity is undoubtedly also related to its extreme poverty, being the poorest country in the Americas and the only one in which the burden of disease and mortality from infectious causes is still greater than from NCDs (1, 2).

A third conclusion is that in addition to national capacity, support to national governments from regional and international organizations has played a very important role in enhancing the implementation of some mandates (35). Those mandates for which there exists guidance and support appear to have been the best implemented. This type of support is likely to be particularly important for those smaller countries with the least capacity for developing and implementing policy. This relationship is explored further in two papers in this supplement, by Murphy et al. (19) and by Kirton et al. (22).

Fourth, there is much room to improve “all of society” and “all of government” responses to NCDs, both at the national and regional levels, taking into account the Health in All Policies model (35–38). The mandate in the 2007 Port-of-Spain Declaration intended to promote an “all of society” response was the establishment of national NCD Commissions or analogous bodies. However, these commissions were reported as being functional in only half the CARICOM countries. In smaller countries, with limited human resources, having one NCD Commission that supports multisectorality for health and wellness can be more feasible than one focused on specific disease groups. However, NCD Commissions do not address the need for “all of government” responses, which require the establishment of mechanisms to facilitate cross-sectoral working within government in order to achieve the oft-stated public health goal of Health in All Policies. One recommendation has been for an interministerial task force on NCDs. However, there would still be the need for political capital to be invested in convincing government ministers other than the health minister that priority for actions in their ministries should include addressing NCD risk factors. Health in All Policies remains a concept that has yet to be institutionalized. These issues are addressed in the paper in this supplement by Murphy et al. (19).

In conclusion, the evaluation of the 2007 CARICOM Port-of-Spain Declaration on NCDs was intended to learn lessons and inform further implementation. Approaches to dissemination are reviewed in the paper in this supplement by Greaves et al. (25). A major vehicle for dissemination has been the construction of a custom-built website (www.onecaribbeanhealth.org) and the use of social media.

The main results of the evaluation were considered at a multisectoral stakeholder workshop held in Port-of-Spain in February 2016. At this workshop, multisectoral and multidisciplinary groups were established to draft recommendations for action. Detailed recommendations from these groups are available on the evaluation project's website (https://onecaribbeanhealth.org/).

A core set of recommendations were presented to the regular CARICOM Heads of Government meeting in July 2016 (the 37th regular meeting) and July 2017 (the 38th regular meeting). The recommendations emphasized the relative lack of multisectoral action on the upstream determinants of NCDs, particularly ones related to diet and physical activity. The recommendations also reflected the fact that although 13 out of the 14 independent CARICOM countries had ratified the Framework Convention on Tobacco Control, there was much less evidence that its articles (including banning smoking in public places) had been fully implemented.

In response to these recommendations, the CARICOM Heads of Government meetings issued a communique on NCDs in 2016 and again in 2017. The full text of the two communiques is available on the CARICOM website (https://caricom.org/media-center/communications/communiques/). In brief, the communiques reinforce the commitments of the CARICOM Heads of Government to taking multisectoral action to address the determinants of NCDs. Actions referred to include banning smoking in public places; supporting increased domestic food production; using fiscal and legislative measures to promote the consumption of nutritious foods and decrease the consumption of those high in added sugar, salt, and trans fats; and banning advertising to children of highly processed foods.

Based on the evidence from this evaluation, the major challenge and opportunity for accelerating action on NCDs is to take advantage of the political momentum represented by the mandates from the 2016 and 2017 CARICOM Heads of Government communiques. Further development and collaborative deployment of regional public goods (such as tool kits and model legislation) for NCD policies and programs will be essential.