Data updated for 2001

GRENADA

GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

Grenada lies at the southern end of the Windward Islands and comprises three sister islands: Grenada, Carriacou, and Petit Martinique. The country’s total land area extends for 133 mi².

The gross domestic product (GDP) at factor cost in constant 1990 prices was US$ 195.1 million in 1995 (about US$ 1,980 per capita), which represents a 5.3% increase from the 1992 figure. Annual inflation between 1992 and 1995 averaged 2.6%. Tourism was the most vibrant sector between 1992 and 1995—its percentage contribution to the GDP increased by 23.3%, moving from 7.3% to 9.0%.

Agricultural production of traditional crops such as cocoa, nutmeg, and bananas had mixed success between 1992 and 1995. Cocoa production increased by 17%, nutmeg’s decreased by 24%, and bananas’s decreased by 32%. Other agricultural crops had fairly stable production during the period.

Telecommunications were significantly enhanced between 1992 and 1995, with the most modern services and communication technologies available by the end of that period. The single electricity generating plant was privatized in 1994, and there are plans for expanding its capacity.

The rate of inflation has remained relatively unchanged, increasing slightly from 2.1% in 1995 to 3.1% in 1996. In 1996 the unemployment rate (between ages of 15 and 60 years old) was 13.6%.

Total public sector recurrent expenditure in 1996 was US$ 68.1 million. Health expenditures went from US$ 8.2 million in 1992 to US$ 9.6 million in 1996 In 1996, per capita recurrent health expenditure was US$ 97.10.

Grenada’s estimated population in mid-1995 was 98,500, 50.8% female and 49.2% male with 47,313 persons (or 48.3% of the total population) below the age of 20 years. The capital, St. George’s has an approximate population of 31,994 (33% of the total population).

Life expectancy currently is estimated at 68 years for men and 72 years for women.

The total fertility rate over the 1992-1995 period averaged 3.2 children per woman of childbearing age.

The adult literacy rate was estimated at 85% in 1996.

Mortality and Morbility Profile

In 1992 and 1995, leading causes of death included diseases of pulmonary circulation and other forms of heart disease, with 131 deaths and 119 deaths, respectively. Other leading causes of death were cerebrovascular disease, with 94 and 114 deaths, respectively; malignant neoplasms with 72 and 95 deaths; ischemic heart disease, with 30 and 51 deaths; diseases of the urinary system, with 22 and 33 deaths; endocrine and metabolic diseases, with 25 and 32 deaths; certain conditions originating in the perinatal period, with 21 and 38 deaths.

During 1992–1995, there were 31,440 admissions to the General Hospital, with a bed occupancy rate of 60%. Admissions and discharges from the General Hospital are categorized by service and diagnosis, but only data on service are regularly compiled into a report.

Data on morbidity—which is limited to information about persons seeking treatment in the public primary health care system and reflects only notifiable diseases—show that the main causes of infant morbidity continue to be respiratory tract infections, gastroenteritis, and diarrhea.

SPECIFIC HEALTH PROBLEMS

Analysis by Population Group

Health of Children: Between 1992 and 1995, there were 119 deaths in children under 1 year of age, with 48% of these deaths occurring within the first day of life. In the same period, 27 children aged 1–4 years old died and in the age group 5–9 years old, 16 children died.

The proportion of low-birthweight babies ranged between 9.7 % and 10.6% of total births in 1992–1995. The infant mortality rate in 1992 was 10.5 per 1,000 live births and 12.7 per 1,000 live births in 1995. The neonatal mortality rate was 9.9, and 7.4 per 1,000 live births for the years 1993 and 1995, respectively.

According to data on the estimated population of children under 5 years old and the number of first visits to well-baby clinics, more than 80% of this age group is seen by trained personnel in the public sector. In 1995, the Ministry of Health instituted a campaign to encourage more breast-feeding. A total of 1,154 infants were seen at age 3 months, and of these, 397, or 34.4%, had been solely breast-fed for the first three months of life.

Health of Adolescents: In 1995, the country had an estimated 21,000 persons between the ages of 10 and 19 years old. Fertility rates among teenage women have continued to decline, dropping from 92.9 per 1,000 to 82.4 between 1992 and 1995. Teenage pregnancies decreased by 9.7%, from 433 to 391 births, representing 18.3% and 17.1% of total births in those years.

Health of Women: It is estimated that approximately 78% of pregnant women attended prenatal clinics held in community health facilities and were seen primarily by a nurse. Only 5 % to 7% of these women, however, registered their first visit before the 12th week of pregnancy, while 80% of those who attended did so by the 16th week of pregnancy or later.

Health of the Elderly:Mid-year data indicate that persons 60 years old and older represent 10.8% of the total population (10,648 persons). Data also showed that 31% of households were headed by persons 60 years old and older, 53% of them by women and 47% by males. Among the elderly, 30% live alone. In 1996, 8.9% of the labor force (38,078 persons) were 60 years old and older, of which 59% were men and 41%, women. There are 13 homes that care for the elderly (1 public and 12 private), and a nongovernmental organization also works specifically with this age group. The older population is primarily affected by diabetes, hypertension, and coronary or cardiovascular diseases and their complications. For persons screened in the district health services over 1992–1995, between 8.5% and 14.1% were diagnosed with diabetes mellitus and between 10.5% and 11.7%, with hypertension.

Analysis by Type of Disease

Communicable Diseases

After having had no cases of dengue fever in 1992 and an average of fewer than 10 in the following three years, there were 21 cases in 1996.

In 1996, immunization coverage of children under 1 year old was lower than the expected standard for the country, showing an overall decline compared to previous years—80% were immunized against diphtheria, tetanus, whooping cough, and poliomyelitis and 85% were immunized against measles.

Legislation enacted in 1980, and currently being reviewed and updated, mandates that all children under 13 years old must be immunized against diphtheria, whooping cough, tetanus, measles, and poliomyelitis. There have been no reported cases of neonatal tetanus in the last two decades; immunization coverage of women attending the public prenatal services in 1995 exceeded 80%.

The AIDS epidemic continues to progress slowly in Grenada. The cumulative total of reported HIV-infected persons stood at 141 at the end of 1996, with a male-to-female ratio of 2:1. Of these, 7 were pediatric cases. In 1996, 19 new HIV-infected cases have been reported with 3 pediatric cases. This is the first year in which more than one case has been reported. In 1996, 17 cases of AIDS were reported, resulting in a cumulative total of 96 cases—70 men and 26 women—of which 71 died.

The number of cases of syphilis reported to the Ministry of Health dropped from 127 in 1992 to 54 in 1996, a reduction of more than 57%. In 1996 there were 112 gonorrhea cases, more than double that of the previous year. These figures may understate the true numbers, since most persons tend to seek a private physician to treat these diseases.

Noncommunicable Diseases and Other Health-Related Problems

Nutritional Diseases. There is no active monitoring of the prevalence of iodine or vitamin A deficiencies in Grenada.In 1996, the Council launched a project to monitor iron deficiency anemia in the population. The project will develop a protocol for the treatment of anemia and investigate the causes of the high prevalence of anemia in different population segments. Preliminary results show that between April and September 1996, 30% of pregnant women attending prenatal clinics for the first time during their pregnancies had hemoglobin levels under 10 g/dl, and that 34% of those attended clinics in the rural parish of St. Andrew. Of the total 626 children under age 1 year who were screened, 55 % showed hemoglobin concentrations under 11g/dl, indicating that iron deficiency anemia in children of this age group was a problem throughout the island. Of the 2,667 children aged between 4 and 5 years old who were checked, 39% had hemoglobin concentrations under 11g/dl. Staff in the maternal and child health program check the hemoglobin levels in infants to estimate the incidence of anemia in that population. In 1995 and 1996, the program was improved so that every health center could conduct the screening. Of the 2,680 infants who made their first visit to the maternal and child health service in 1996, 629, or 23.5%, had hemoglobin levels under 11g/dl.

RESPONSE OF THE HEALTH SYSTEM

National Health Plans and Policies

Grenada’s health policy aims at ensuring that every Grenadian has access to quality health services. The Government has embraced primary health care as the main strategy for improving the population’s health status and attaining "health for all by the year 2000"; it also has adopted the goals and targets established through the Caribbean Cooperation in Health initiative as the priorities for its health services.

The country has undergone an epidemiological transition that has moved chronic diseases ahead of communicable diseases as causes of morbidity and mortality. This change is placing greater demand on the health sector’s limited resources. It should be said, however, that despite the demand, everyone in Grenada has access to public health services, regardless of their ability to pay.

The Government is decentralizing the health services and placing them under the management of a board of directors established by law. As part of an effort to introduce a national health insurance program, the financing of the health services also is being reviewed. The insurance program would create an equitable way of injecting new resources into the health sector, contribute to improve the quality of care, and help to reduce the dependence on the central government for health sector financing. The proposal for implementing the health insurance program is being reviewed to ensure that it responds to Grenada’s needs and that both health care providers and the public understand it fully.

Organization of the Health Sector

The health sector’s basic organization has remained unchanged in recent years. Most program heads are based at Ministry of Health headquarters, as are those for administrative, planning, health promotion, and budget and expenditure.

In 1992, the budgets for Carriacou and Petit Martinique health services were consolidated under one program, which has led to better monitoring of resources and a more integrated management and delivery of health care services in the two sister islands. An administrator for the consolidated program was appointed in 1996.

A Medical Board chaired by the Chief Medical Officer is responsible for granting medical licenses to practice medicine in Grenada. Nurses must register with the Nursing Council. A pharmacy council monitors the importation and distribution of pharmaceuticals to the public and private sectors and registers pharmacists and pharmacies on an annual basis.

The Ministry of Health’s Environmental Health Department is responsible for controlling water pollution; improving wastewater treatment; ensuring that the population has access to an adequate supply of safe drinking water; improving systems for the disposal of excreta and other substances harmful to human, animal, and plant life; and improving the country’s food hygiene. The department is staffed by 14 environmental health officers.

The Ministry of Health is responsible for monitoring water quality, but its resources are insufficient to do so. The National Water and Sewerage Authority currently handles the monitoring, and submits periodic reports to the Ministry through the Chief Medical Officer. The Ministry is working to acquire its own quality monitoring capabilities through the Caribbean Environmental Health Institute (CEHI) and in conjunction with resource personnel provided by the Produce Chemist Laboratory.

The introduction of the 1995 Solid Waste Act established the Solid Waste Management Authority, a statutory body intended to accomplish a more efficient system of removal and disposal of garbage. These functions previously carried out by the MOH are now privatized and contractors have the responsibility to keep the country clean. The MOH will continue its regulatory role in its monitoring of solid waste management in the country.

Grenada has no national policies or organized programs to combat coastal pollution, but is cognizant of the various international agreements protecting the Caribbean Sea from pollution. Legislation pertaining to environmental health is being revised, and the anti-litter act is currently being processed.

Health Services and Resources

The Ministry of Health relies on health promotion as one of its main approaches for improving the overall health of the public. The Health Education Department, a well-established unit within the Ministry, has been working toward improving the health sector’s links with other sectors. Several workshops have been held for health workers, teachers, religious and community leaders, and NGO members to ensure as well as has involved the community in the planning of health activities, including participating in the health needs assessment, the organization of community health fairs, and the participation discussions about issues such as AIDS and chronic diseases. A health education curriculum is being developed with the Ministry of Education.

Several NGOs are involved in health promotion programs in the community. For example, the Grenada Planned Parenthood Association conducts a youth outreach program through which counselors visit schools and community groups to speak on family life and sex education issues.

The 1991 Census of Population and Housing indicates that 50.2% of Grenadians had their water supply piped into their dwellings, another 13.4% had water piped into their yards, 7.5% had private catchments, and 21.1% used public standpipes. The National Water and Sewerage Authority estimates that in January 1994, the percentage of households with pipe connections was about 59%, which means that about 85% of the population has access to potable water—96.4 % in St. George’s and 76.1% in the rest of the country. 59% of households used pit latrines, 33% used septic tanks, 3% were linked to a sewerage system, and 3.9% (more than 850 households) had no toilet facilities. The St. George’s Sewerage system was upgraded in 1992, and in 1993, the Grand Anse Sewerage project was put in place.

The Ministry of Health continues to upgrade the food handling and processing situation with the objective of reducing foodborne diseases. Several workshops have been held and will continue to be held for itinerant vendors to provide information and support for better food-handling practices.

Since its establishment in 1986, the National Drug Avoidance Committee has worked to "shape policies and oversee the implementation of action programs aimed at reducing the demand for drugs and alcohol." A national master plan for the 1997–2001 period has been completed.

Grenada is divided into seven health districts. Six of the districts have a health center, which is the major primary care facility, and an additional 30 medical stations distributed throughout the country are usually the first point of contact within the health system.

Each health district is assigned a District Medical Officer; several categories of nurses, including family nurse practitioners, public health nurses, district nurses, and community health aides; dentists and dental auxiliaries; pharmacists; and environmental health officers.

The acute care facilities in the public sector include a 240-bed at St. George’s General Hospital and two rural hospitals, Princess Alice, with 60 beds and the Princess Royal, with 40. A 20-bed acute psychiatric unit is located on the grounds of the General Hospital, and it serves as the entry point for those seeking psychiatric care and support. There also is an 80-bed psychiatric hospital (Mt. Gay), which handles chronic patients, and a geriatric facility with 120 beds; occupancy rates usually exceed 100% at both. Carlton House provides support and assistance to substance abuse patients.

Consultants conduct specialist clinics in pediatrics; ears, nose, and throat; and mental health at the district level. The District Medical Officer refers persons seeking care in other specialties to the General Hospital, but there are long delays before receiving services. Referrals for admission to the General Hospital also are made through the Accident and Emergency Department. No established follow-up system is in place to inform the district medical team when a discharged patient returns to the community, and this is an area that also will be given high priority in the future.

Grenada procures most of its pharmaceuticals and medical supplies through the subregional program managed by the Eastern Caribbean Drug Service. The procurement cycle ensures that regional standards are reviewed annually and revised periodically, and that essential drugs are available on a timely basis.

In 1996, there were 50 physicians employed in the public health sector, and most of them also worked in private practice; 10 were District Medical Officers who conduct clinics at the community level. There are 36 doctors who work primarily in a hospital setting, 16 of whom are consultants and the rest, junior doctors. Fifteen doctors work exclusively in the private sector, most of them as general practitioners. There are 6 physicians per 10,000 population.

Several categories of nurses work in the public health system—173 nurse/midwives work in the three hospitals; 50 work at the district level, including public health nurses, family nurse practitioners and district nurses; and 9 work in the mental and geriatric facilities. There are 24 nurses per 10,000 population.

The public sector employs 26 pharmacists, most of whom are based in the community, the procurement division, and at the hospitals. There are 18 private pharmacies staffed with 21 pharmacists. Grenada has 4.8 pharmacists per 10,000 population. Seven dentists are employed in the public sector, but they all have private practices as well; another seven work exclusively in private practice. The country has 1.4 dentists per 10,000 population. Five dental auxiliaries work with the dentist in the public sector, mainly with the school population.

Human Resources

St. George’s University School of Medicine provides annual scholarships to Grenadian nationals, but caters primarily to non-nationals. In 1997, Grenada was among four countries whose medical schools met eligibility criteria to participate in the United States of America’s Federal Family Education Loan Program. In 1996, the school added a Faculty of Arts and Sciences, which offers undergraduate training in several disciplines, including pharmacy and nursing and physician’s assistants.

Research and Technology

The Windward Island Research and Educational Foundation was created in 1994 and registered in Grenada as a nonprofit organization in November 1996. The Foundation’s programs are designed to conduct collaborative research projects with scientists from local and international institutes on the epidemiology and control of communicable diseases, particularly zoonotic infections, noncommunicable diseases, and on health systems and conservation ecology.

Expenditures and Sectoral Financing

The health sector has consistently received more than 12% of the annual Government recurrent budget, and public health recurrent expenditure is estimated to have represented about 4.5% of GDP over the 1992–1996 period. The main hospital accounted for 40% of all health expenditures, and district health services—including community health services, environmental health, and dental department programs—accounted for approximately 26%. Wages and salaries in the sector accounted for approximately 70% of health expenditures on human resources.

The health sector in Grenada is underfinanced—the population’s demand for resources is growing faster than the resources available for the sector. In order to advance reforms, a financial model will have to be developed, showing current financing sources and the effect of the new funds generated by the proposed health insurance program. A major constraint in carrying out a financial reform of the health sector is the limited understanding of the level of health expenditure in the private sector, which has grown in terms of numbers of physicians, pharmacies, and small hospitals.

External Technical and Financial Cooperation

Most international assistance provided to Grenada, excluding capital projects, is included as a component of the Ministry of Health’s budget. During 1994–1996, however, some international assistance to the Ministry was not included in the total expenditure component. For example, Grenada participated in a USAID-funded health care policy, planning, and management project, which facilitated dialogue among officials of the Ministries of Health and of Finance and the social institutions in the member states of the Organization of Eastern Caribbean States. In addition, medical personnel from various organizations and groups from the United States and Canada have worked with local personnel to provide attention, and personnel teams from the United States military have assisted with refurbishing medical facilities and providing medical and dental care.