Vol.5, No.11B, 12-18 (2013) Health
http://dx.doi.org/10.4236/health.2013.511A2003
The challenge of combatting non-communicable
diseases in Trinidad: Access to hospital care
Patricia J. Boda
Department of Geosciences, Middle Tennessee State University, Murfreesboro, USA;
Received 4 September 2013; revised 4 October 2013; accepted 17 October 2013
Copyright © 2013 Patricia J. Boda. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Chronic illnesses, or non-communicable dis-
eases (NCDs), account for a growing number of
deaths worldwide. The English-speaking Carib-
bean has the highest per capita burden of NCDs
in the region of the Americas [1]. This paper
presents an overview of hospital availability on
the island of Trinidad in the West Indies and
examines rates of NCDs as reported in hospital
discharge summaries. The project integrates a
Geographic Information System (GIS) with epi-
demiologic and bio-statistical data to provide
essential spatial analysis not otherwise possible.
It examines the island’s ability to effectively de-
liver treatment to residents with NCDs by pro-
viding a geographic perspective to public data
published on the internet by the Trinidad-Tobago
Ministry of Health and the Central Statistical Of-
fice. The study reveals a significant variability in
several dimensions of access to health care.
Keywords: Access; Health Care; Caribb ean;
Trinidad; Non -Communicable Di s ease
1. INTRODUCTION
Communicable or infectious illnesses such as HIV/
AIDS, malaria and tuberculosis continue to consume
massive amounts of time, energy and financial resources
of many health departments world-wide. However, non-
communicable diseases (NCDs) account for a growing
share of total deaths. In fact, heart disease, cancer,
chronic respiratory diseases and diabetes are by far the
leading causes of mortality in the world, and account for
63% of all deaths [2]. NCDs tend to be of slow progres-
sion and long duration and therefore are very expensive
for insurance companies, for health care systems, and for
patients. Although the p erception is that NCDs primarily
affect wealthy nations, nearly 80% of NCD deaths occur
in low- and middle-income countries [1,2].
The English-speaking Caribbean has the highest per
capita burden of chronic non-communicable diseases
(CNCDs) in the region of the Americas [1]. Cardiovas-
cular disease, cancer, diabetes, and chronic respiratory
disease account for 71% of all deaths in Latin America
and the Caribbean in 2008 and that rate is expected to
rise from 10% to 81% by 2030 [2]. For the most part,
these countries have passed through the demographic and
epidemiological transition which has resulted in rapidly
aging populations who are more prone to chronic illness.
Leaders of several Caribbean nations were convened
in Port of Spain, Trinidad in 2007 to discuss the crisis of
NCDs in the Caribbean. They developed a decisive plan
of action for the reduction of NCDs that became known
as the Port of Spain Declaration. The fifteen point com-
mitment plan included a commitment to support initia-
tives, establish comprehensive plans, establish programs
for research, address smoking, address food security, and
promote physical activity. The leaders further agreed to
have these initiatives in place by 2008.
At a 2011 High Level meeting of the United Nations
General Assembly, the organization assessed the capacity
of countries to address NCDs, in particular, challenges
facing the Small Island Developing States (SIDS). Due
to their small size, and typically remote locations, they
face a variety of additional challenges associated with
limited resources. The small size limits the diversity and
volume of natural resources. This results in limited eco-
nomic resources, limited employment opportunities, and
inadequate social services such as health care.
Research regarding health in the Caribbean region of-
ten has been linked with health and health care in Latin
America with little attention given to the Caribbean as a
distinct region with distinct issues and challenges [3-5].
A limited volume of work has been produced on NCDs
in the Caribbean that called for increased awareness and
prioritization of combatting NCDs [6,7] and strategies to
be incorporated into public policy [8].

P. J. Boda / Health 5 (20 13) 12-18 13
More recently, literature regarding NCDs in the Car-
ibbean has focused on disease-specific studies, in par-
ticular, diabetes and hypertension in individual countries
[9,10]. Others have reported on socioeconomic determi-
nants of health and identified that the elderly and the
poor have increased risks for NCDs [9,11]. A consider-
able amount of attention has been given to patient’s per-
ceptions on the quality of care they have received and
self-reported incidence of disease [11,14]. In these stud-
ies, patients reported varied levels of satisfaction with
their clinic and hospital visits. Many reported excessive
wait times and too little time with providers. Little, if any
attention has been given to the network of hospitals and
providers, to variations within one country or to a spatial
or geographic approach.
An essential consideration when attempting to reduce
NCDs has been conspicuously absent from published
research—access to services. This study attempts to fill
this void by examining the level of available hospital
care based on established health districts. It presents an
overview of hospital services on the island of Trinidad.
Data were entered into ArcMap and distances and popu-
lations to provider ratios were calculated. The process re-
vealed that there were significant differences in access to
hospital services among four health di st rict s.
In order to effectively reduce the rate of NCDs, there
must be a threefold approach that includes surveillance,
preventio n, and treatment. Surveillance consists of moni-
toring expo sures ( r isk f actors) , monito r ing outco mes, and
assessing health system capacity and response. Preven-
tion includes addressing exposures (risk factors), educa-
tion and intervention and treatment examines levels and
availability of and access to services.
Access can be a difficult term to define and represents
different models to different people. It is a multi-dimen-
sional concept that evaluates the ability of a population
to use medical services. Lee 1998 defined access as a
product of four variables: 1) availability of services, 2)
the possession of the means to access the services such
as transportation, insurance or money, 3) non-discrimi-
natory attitudes of providers, and 4) the failure of the ill
themselves to cope with the situation via lack of com-
munication, recogn ition of symptoms and ability to navi-
gate the health system in place [15].
Penchansky and Thomas identified five dimensions that
encompassed five specific barriers: availability, acces-
sibility, accommodation, affordability, and acceptability.
Availability defines numbers of providers such as physi-
cians, dentists, nurses and other health care workers in
relation to the demand for their services. It also includes
numbers of hospital beds and services that facilities pro-
vide. Accessibility generally describes geographic acces-
sibility and identifies the geographic barriers to receiving
such services such as distance, transportation, and travel
time to the facility. Accommodation refers to the degree
that services meet the needs of patients and include hours
of service, waiting times, appointments and scheduling.
Affordability discusses the cost of services and accept-
ability describes how the provider interacts with the pa-
tient on a personal level. Acceptability in cludes potential
barriers such as gender, ethnicity, language and sexual
orientation and also encompasses patient satisfaction [16].
Each dimension can obstruct access by creating barriers
that limit utilization of services. These five dimensions
of the Penchansky’s model were employed in this study.
2. DATA SOURCES
Primary data source for the number of physicians was
the Annual Statistical Report compiled by the Trinidad-
Tobago Ministry of Health (Mo H) f or 2004- 200 5 [1 7]. In
that report data for four hospitals was contained: Port of
Spain General Hospital, San Fernando General Hospital,
Sangre Grande and Point Fortin. Due to these limitation s,
only these four facilities are incorporated in this research.
Community shapefiles containing population figures,
hospital locations and number of physicians were made
available through the Univ ersity of the West Indies (UWI)
in St. Augustine. This file did not include communities
on the sister island of Tobago and as a result, it was ex-
cluded from analysis.
Data files were entered and analyzed in ArcMap 10.1.
3. ACCESS IN TRINIDAD
Trinidad-Tobago is considered to be a high-income
country by the World Bank [18]. The burden of NCDs on
small island countries is enormous. In comparing rates of
NCD deaths between the United States and Trinidad-To-
bago for example, the percentage of total deaths is very
similar between the two countries (Table 1).
While the burden may be similar, the capacity to treat
these illnesses is not. In Trinidad-Tobago, there are 8 phy -
sicians for every 10,000 people, while in the U.S. the
number is 26 per 10,000 people. In other words, the U.S.
has more than 3 times the medical doctors p er 1 0,0 00 t han
Table 1. Comparison of NCD burden between the U.S. and
Trinidad-Tobago, 2010 [1].
Trinidad-Tobago United States
Total NCD 78% 87%
CVD 34% 35%
Diabetes 14% 3%
Cancer 13% 23%
Respiratory 3% 7%
All other NCDs 14% 19%
MDs/10,000 8% 26%

P. J. Boda / Health 5 (20 13) 12-18
14
Port of Spain G eneral Hospital has the lar gest number of
physicians with 219, followed by San Fernando with 136,
Sangre Grande with 19 and Point Fortin with 9 practicing
physicians. Additional facilities not mentioned in the Sta-
tistical Report include 4 facilities with a combined number
of physicians of 36, three hospitals with 1 physician each.
In addition, there is one maternity hospital as well as a
mental health facility that were not included in the ph ysi-
cian counts for thi s st udy.
Trinidad-Tobago despite the fact the disease burden is
similar [1].
On the island of Trinidad, there are four health districts
and seven hospitals. The locations of the seven hospitals
are shown on the following map (Figure 1), along with
numbers of physicians and community population con-
centrations. Communities with higher populations are
shown in the darker shades and those with the least popu-
lation are in the lightest shade. The district with the highest population is the Southwest
district with a population of 500,300, followed by the
Northwest distri ct wi t h a popu l a ti on of 41 4,482, the North
Central with 201,549 people, and the eastern district has
contains the least number of residents (101,55 7).
As mentioned previously, 2005 is the most recent data
available on the Ministry of Health (MoH) website and
hospital data in that report included only four facilities.
They are the public facilities in Port of Spain, San Fer-
nando, Sangre Gran de, and Point Forti n [1 7] .
Figure 1. Health districts, providers and community populations.
OPEN AC CESS

P. J. Boda / Health 5 (20 13) 12-18 15
3.1. Availability of Hospitals in Trinidad
A key question in public health, and included in the
Penchansky Model of access is availability of services.
One method to determine this is to examine population to
provider ratios. According to the Bureau of Primary
Health Care (BPHC) in the US, an acceptable level of
people per provider is 3500 to 1, that is, one physician
per 3500 people, or potential patients [19]. Population
figures and numbers of physicians were compiled by
health district and the population to provider ratio for
each district was calculated (Figure 2).
As Figure 2 indicates, the lowest ratio is the North-
west, or the Port of Spain district, where there are the
most physicians. The highest population to provider ratio
is the North Central District with a ratio of over 8000:1.
This is somewhat deceptive however because there is a
major medical complex located within the boundary, but
no hospital. It is interesting to note that the eastern dis-
trict, with the lowest population, also has a high popula-
tion to provider ratio at over 5000:1.
3.2. Geographic Accessibility of Hospitals
The second dimension of access described by Pen-
chansky is geographic accessibility [16]. The BPHC
states that if a population center is within 30 miles or 30
minutes travel time of a provider, that population has
satisfactory access to care [19]. Buffer zones of 10, 15
and 20 miles were applied around the four hospitals
(Figure 3). At first glance it appears that nearly the entire
island is included within the 20 mile zone and therefore
has access according to the BPHC definition.
This is misleading however. Although 20 miles is a
reasonable distance, the time required to travel the 20
miles on Trinidad roads is considerably more than 30
minutes, which is commonly accepted as the standard
[19]. As seen in Figure 3, which disp lays first class roads
on the island, there are a great many sharp turns and
twists due to mountainous terrain. Turns and changes in
elevation necessitate reducing speed considerably and
increases travel time. For example, the community of
Tableland, shown in Figure 3 as a cross, is located on the
15 mile buffer line from San Fernando Hospital and
therefore has a straight-line distance to the facility of 15
miles. The driving distance between these two points was
calculated by summing the segments of the primary road
between the centroid of the community to the hospital.
The actual distance is approximately 29 miles on the first
class road of Naparima. This is still within the 30 mile
limits set by the BPHC. However, the average speed is
approximately 45 miles per hour through the mountain-
ous terrain. At that speed, the trip require approximately
38.6 minutes driving time, which exceeds the BPHC
limit for adequate access to health care.
Figure 2. Health districts, providers and community popula-
tions.
The total population of communities outside the 15
mile buffer zone was calculated to be approximately 71,
500 residents. Assuming all residents outside the 15 mile
zone have immediate access to a first class road, and
assuming driving times are similar th roughout the island,
a minimum of 71,500 residents of the communities out-
side the 15 mile buffer zone do not have adequate access
to a hospital.
3.3. NCD Cases by Hospital
The Annual Statistical Report contains hospital dis-
charge information by department and the International
Classification of Disease codes (ICD). The nine leading
causes for hospital admission were the same for all four
facilities; Port of Spain (PoS), San Fernando (SF), San-
gre Grande (SG) and Point Fortin (PF). The tenth illness
appeared in some facilities but not others so it was not
incorporated into this project. Comparing rates among
the nine illnesses among the four main hospitals, the
burden of NCDs is evident (Figure 4).
The four leading causes of NCD deaths worldwide,
heart disease (also known as cardiovascular disease (CVD),
cancer, respiratory disease and diabetes, account for
22.6% of all hospital discharges at the Port of Spain
General Hospital, 28.9% of discharges at San Fernando
General Hospital, 44.2% at the Sangre Grande facility,
and 52.6% of all discha rges at the Port Fortin Hospital.
It is clear that Trinidad experien ces substantial rates of
NCDs in all areas; however the burden appears signifi-
cantly higher at the Sangre Grande facility. This health
istrict had a population to provider ratio of 5077:1, and d

P. J. Boda / Health 5 (20 13) 12-18
16
Figure 3. Areas of geographic accessibility.
Figure 4. Percentage of hospital discharges for NCDs by
facility.
is therefore medically underserved according to the def-
nition used by the BPHC. With only 19 physicians ser-
vicing a population of over 96,000 who live in the dis-
trict, the provider shortage problem is evident.
There also appears to be significant regional variations
in reported hospital use. Circulatory illness (CVD) was
dominant (22%) in Point Fortin and only 13% in Port of
Spain. Diabetes appears to also be significant in Point
Fortin and much less in San Fernando and Port of Spain.
It is curious to encounter such regional variations. As-
suming that people go to the nearest facility when the
seek hospital care, there are significant regional varia-
tions of NCDs on Trinidad. There are several possible
explanations: there is possibly more elderly in the region,
perhaps more obesity, or a different ethnic group near
that particular facility. It also could be a case of miscod-

P. J. Boda / Health 5 (20 13) 12-18 17
ing by the hospital or any number of other possibilities.
Likewise, in the Sangre Grande facility, digestive and
respiratory illness accounted for the majority of hospital
stays but represented a much smaller volume at the other
facilities. Again, while likely explanation may exist, it
appears that different NCDs prevail in different areas.
This warrants further investigation
4. SUMMARY
The disease burden of Trinidad is equal to the burden
of higher income countries. The small size limits natural,
economic, human and infrastructure resources and there-
fore limits the ability of SIDS to effectively combat
NCDs. Although there are a number of medical schools
throughout the re gion, ther e remains a shor tag e of trained
medical doctors on many islands, including Trinidad.
This shortage impacts access hospital services for tens of
thousands on the island.
Penchansky’s five dimensions of access are all chal-
lenging on the island. The first, availability, defines
numbers of providers such as physicians and hospital
facilities in relation to the demand for their services. On
Trinidad, the availability b arrier is rooted in the shortage
of physicians. This study revealed that the population to
provider ratio was excessive in many areas. The second
dimension, geographic accessibility, is a barrier for ap-
proximate 71,500 people who live outside the 15 mile
zone from each of the four hospitals and experience ex-
cessive time and excessive distances to receive hospital
care.
Accommodation, the degree that services meet the
needs of patients and include hours of service, waiting
times, appointments and scheduling, is also a barrier on
Trinidad, again due to provider shortages. Research has
documented that patient satisfaction is low [11-14].
Acceptability impedes access on the island due to
mixed ethnicity, language and culture differences. Ap-
proximately 45% of the population are Indian, 45% Af-
rican, and 10% other ethnicities. It is often difficult, for
example, for an African to locate a physician that under-
stands the African cu lture.
Affordability is a person’s ability to pay for services
and includes insurance coverage. Due to limited re-
sources, there are also limited employments, insurance
and affordability that become barriers.
In other words, all five barriers as outlined by Pen-
chansky and Thomas are operating on the island of
Trinidad and impact the ability of health care officials to
effectively reduce the burden of NCDs [16]. Although
Trinidad has made progress toward its commitment to
the Port of Spain Declaration, th ere is additional work to
complete to reach the country’s goals in combatting the
increase of NCD deaths.
Additional research is needed to evaluate access to
clinics in the health districts with updated figures. How-
ever, many government agencies that collect and manage
the data are reluctant to share that information for a va-
riety of reasons. With more cooperation and access to
information, the human resource shortage in the region
would be greatly abetted by others. Many researchers in
the region have requested that organizations make spatial
data available. Unfortunately, to date, many Caribbean
SIDS often are not willing or able to provide these nec-
essary items due to limited size, as well as limited human,
economic and technology resources.
Further research is also needed regarding the regional
variations in illnesses reported by the hospital discharge
summaries. Are these variations indeed representative of
the populations living near these facilities? If so, addi-
tional clinic hours and educational programs would be
valuable interven tions for maintaining healthy communi-
ties and minimizing hospital use.
5. ACKNOWLEDGEMENTS
A special note of acknowledgement is due to the University of the
West Indies, St. Augustine Campus and Dr. Bheshem Ramlal for shape-
files, physician and community data.
6. FUNDING ACKNOWLEDGE MENTS
This study was significantly aided financially by a grant from Middle
Tennessee State University and the Faculty Research and Creative
Activity Committee grant. The grant provided travel expenses to Trini-
dad-Tobago in 2011 and 2012.
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