HEALTH FOR ALL 2000: CAYMAN ISLANDS

1. TRENDS IN POLICY DEVELOPMENT

The Government of the Cayman Islands decided to develop a five-year strategic Health Plan in 1994. Consequently, with the participation of Health Care professionals and community involvement, eight strategies and various action plans were developed in 1995 and tabled in the Parliament in 1997. Many components of the plan are already in the implementation phase.

It is the Government's policy to provide community-based health care services with central support. The development of health centers in all districts initiated in 1993 and will be in operation by August 1997. An 18-bed hospital was commissioned in Cayman Brac in 1993 and a 128-bed hospital construction project in Grand Cayman was initiated in 1994 and will be completed in 1998.

The main constraint has always been financing of health care services. It is the general policy to enable the community to pay for their health care. To this end the Government consolidated the efforts since 1994 in the development of a National Health Insurance Law which was approved in June 1997. This will enable all employees and their dependents to have health insurance. The public health programs will continue to be funded by the government.

2. TRENDS IN SOCIOECONOMIC DEVELOPMENT

2.1. Economic trends

The Gross Domestic Product (GDP) steadily increased from $317 million (adjusted for purchase power) in 1987 to $514 million in 1994, although the annual rate of GDP growth varied from a 14.1% peak in 1988 to a low of 1.4% in 1991. The economy continued to prosper in 1995 with a 5.3% growth, an inflation of 2.3% (the lowest in 10 years), while the 4% unemployment rate recorded in October was the lowest since the 1989 Census of Population and Housing. Economic growth was fuelled by successes in finance and tourism, the two main sectors of the economy.

Estimates of government expenditure for 1995 indicate a total of $171.9 million, which is 3.4% less than the budgeted figure. This reflects the Government's efforts to control public expenditure. Percentages of poor populations are not available.

2.2. Demographic trends

According to the 1989 census, 40% of the 25355 population is less than 15 years of age. The crude birth rate, the death rate and the total fertility rate have been stable during the last decade at about 18 births per 1,000 population, 4.5 deaths per 1,000 population and 335 births per 1,000 women. The annual population growth varied from 4-6% during the period. This was due to a rapid increase in more than 10,000 work permit holders and their dependents. This has also produced changes in the population structure of adults and elderly in comparison to 1989, placing a demand on health services. Plans are underway for expansion of geriatric care services.

2.3. Social trends

Adult male and female literacy rates are 98%. It is compulsory for all children above 4 years and nine months and below 16 years to attend school. Introduction of cable television provided an opportunity for the public to be better informed of health matters.

2.4 Food supply and nutritional status.

The percentage of newborns weighing less than 2500 g at birth decreased from 11.2% in 1990 to 4.5% in 1995. There is no evidence of significant numbers of children with moderate or severe protein-energy malnutrition, while there is obesity among children and adults. There have been no significant changes in the proportion of women or children showing evidence of iron deficiency. No cases showing evidence of iodine deficiency disorders or of vitamin A deficiency among women and children have been found. Vitamin supplements are provided to pregnant women and pre-school children as a routine.

The majority of foods are imported from the USA. The Agriculture Department's efforts promote the local food production. The promotion of nutrition guidelines for good health is underway.

2.5 Lifestyle

Government has placed emphasis in the development of sports and recreational facilities during 1993-1995 and the efforts are continuing. Health education efforts in schools for promoting healthy lifestyles among school children will be strengthened, while the Health Services Department has promoted them through mass media. A Young Parents Program has been initiated to support young mothers, the issue of promoting family planning services for teenagers (<16 years) still remaining. Police has established a surveillance system on domestic violence. The National Drug Strategy Plan addresses the issues of abuse of drugs, legal substances and rehabilitation.

3. HEALTH AND ENVIRONMENT

3.1. General protection of the environment

Development has proceeded rapidly in the last two decades with attendant effects on the environment. Growth in the urban and suburban population has been greater than the infrastructure can comfortably support. This resulted in increased traffic with attendant air pollution, increased demand for potable water, increased demand for sewage treatment and disposal, pollution of groundwater (now unfit for human consumption in most urban areas) and increased noise pollution.

A major priority of the new Environmental Health department is the drafting of legislation, standards and guidelines related to environmental health to complement the existing Public Health Law, which is insufficient to cope with environmental issues having impact on human health and welfare. In addition, the department promotes public awareness of environmental issues.

Current strategies for air quality involve developing legislation and standards for air quality with regards to particulate matter, sulfur dioxide, and other airborne pollutants, but constraints are a lack of baseline data and of instruments and analytical equipment. In the case of solid waste, strategies include landfills as the method of disposal, monitoring of leachate movement at landfills, legislation for proper handling and transport of infectious waste, drafting of legislation and guidelines for the treatment of hazardous household and industrial waste.

Strategies for food safety aim for the control and monitoring by training of food inspectors in HACCP methods, upgrading of the Laboratory to carry out monitoring, licensing food vendors and premises, inspecting foods at port of entry, inspecting locally slaughtered meat and reviewing planning applications for commercial food establishments with requirements of sanitation, hygiene, process control and waste disposal.

3.2. Water supply and sanitation

The percentage of the population with safe drinking water available in the home, or with reasonable access is 100, while the percentage of population with adequate excreta disposal facilities available is 99.5. The piped water (desalinated) system has been extended to 70% of the population. It is envisioned that within 3-5 years, the entire population will have access to piped water supply.

Current strategies for drinking water quality include developing legislation and standards, routine monitoring for quality with emphasis on public supplies and facilities, regulation and monitoring of public water suppliers, sponsoring training programs for operators of non-municipal supplies, establishing of a ground water monitoring program and upgrading of existing laboratory facilities.

4. HEALTH RESOURCES

4.1 Human resources for health

In 1995, there were 14.3 physicians per 10,000 population, 4.5 midwives per 10,000 population, 38.4 nurses per 10,000 population, 3.9 pharmacists per 10,000 population, 3.6 dentists per 10,000 population and 18.2 other health care providers (including community health workers) per 10,000 population. While there has been an absolute increase in health professionals during the last decade, the rapid population overcame the increase. There has been a decline in nursing ratio to population.

Approximately 95% of the physicians and 70% of other health care professionals (nurses, pharmacists, etc.) are contracted officers from overseas. Although the Government supports the training of nationals as health professionals, there are not enough personnel available to be trained.

4.2 Financial resources for health

There has been a steady increase in the Government Budget to Health Care Services, almost three times in 1995 ($178 million) over 1985; however the percentage of recurrent health expenditure out of total Government recurrent expenditure has dropped from 12.5 to 9.5 during the same period. The total government health expenditure per capita in 1995 was US$623. The percentage of recurrent government health expenditure going to salaries was 75%.

4.3 Physical infrastructure

Government operated two hospitals (59 and 18 beds), 4 Health Centers, a Dental and an Eye clinic offering curative services on a fee for service basis. School children, pregnant women, civil servants with their dependents, indigents and veterans are offered free health care, with limits applying in some categories. There are also private outpatient health care facilities in the islands. Many employers provide Health Insurance for their staff and their dependents. A recently enacted Health Insurance Law will allow employers and their dependents to have health insurance. No one is deprived of health care due to lack of funds and the services are accessible to everyone.

4.4 Essential drugs and other supplies

A 100% of essential drugs are available at government health care facilities. There are no "remote facilities" as per W.H.O. definition. All formulary drugs, essential and non-essential, can be requisitioned from the central pharmacy storeroom by any appropriate section of the health services department. The formulary contains all drugs deemed essential by W.H.O. guidelines in addition to many other pharmaceuticals. The primary action being taken to ensure access of all to essential drugs is the expansion of our district clinics into health centers. The considerable increase in size and quality of the facilities as well as the extended hours has been of significant benefit to patients resident in the districts.

4.5 International partnership for health

There is no financial aid received from International Agencies except for technical assistance from PAHO/CAREC in the form of fellowships, workshops, etc., which amounts to approximately US$25,000, which is considered negligible in comparison to about US$20 million (1995) budget for Government Health Services.

5. DEVELOPMENT OF THE HEALTH SYSTEM

5.1 Health policies and strategies

A planning committee of 25 members, drawn from health professionals, community at large, Members of Parliament and non-governmental organizations, was established in 1994 for the development of the Strategic Plan for the Health Services. The committee developed the Mission Statement, which indicates that the Health Service, the provider of comprehensive health care, aims to ensure the wellness of people through a community-based system characterized by professional leadership, technologically advanced support, and collaboration with local and overseas providers.

The parameters utilized in the development of the plan are that: no one will be denied access to the Health Service; only the highest ethical standards will be accepted; excellence of the service will not be compromised; and participative decision-making will take place at all levels of the Health Service. Action plans were developed for implementation of the strategies and validated the development of primary and secondary level health care facilities.

5.2 Intersectoral cooperation

Intersectoral cooperation is essential for health care delivery, both within and outside the Government. Depending on the nature of the subject, various committees are involved to achieve this. In the development of health care facilities, Steering Committees included Public Works Department personnel. In planning and implementing Health Promotion Programs in schools and community, Health, Education, Cancer Society and Medical Societies are involved. An Emergency Medical Relief Plan is an integral part of the National Hurricane Preparedness Plan.

5.3 Organization of the health systems

The Primary Health Care System is well defined, providing the primary care services through the District Health Centers. The completion of a hospital in 1998 will mainly provide emergency care, specialist services and inpatient care. While the referral system is in place, specialist services are directly sought. Presently, the organizational chart is being reviewed to eliminate any ambiguities.

5.4 Managerial process

While significant strides have been made in decentralization of responsibility, constraints being addressed in relation to financial and administrative authorities, as the Health Services Department being a Government Agency, had been locked into the Central Government's rules and regulations.

5.5 Health information System

The Health Information System is set up to have an early warning system to detect defined communicable diseases of public health importance. The hospital laboratory acts as Public Health Laboratory and is equipped to diagnose common diseases in the country. There is a referral system (overseas) for specialized diagnosis. Staff is available to investigate unusual disease occurrences. Presently data on hospital admissions and mortality is computerized, allowing to study trends.

5.6 Community action

Community involvement in the development of the strategic plan has empowered it to be behind the programs and projects. The Red Cross has been an integral part of the Disaster Preparedness activities. Lions Club has been lending its support for the sight conservation program and was responsible for constructing and equipping the Eye Clinic.

5.7 Emergency preparedness

The last natural disaster that threatened the Cayman Islands was Hurricane Gilbert in 1988. An Emergency Medical Relief Plan is in place in the event of a hurricane or any other natural disaster. A National Health Coordinator is responsible to ensure that the plan is updated yearly, essential supplies are available and staff is allocated. An Intersectional Committee overseas the Emergency Medical Relief Plan which is part of the National Hurricane Plan.

6.0 HEALTH SERVICES

6.1 Health education and promotion

The Strategic Plan for Health provides for empowering the community to accept responsibility to contribute to maintain personal and community health. Recognizing the importance of lifestyle, the Government created a full time position of Health Promotion Officer in 1994. Health promotion activities are organized with intersectoral cooperation. Public education programs are organized through mass media: radio, television and newspaper. Churches and business places are other conduits for public awareness programs. Health promotion activities are targeted in promoting disease prevention (immunization, STD/AIDS, colon cancer, heart disease), healthy lifestyle (breast-feeding, diet, tobacco, drugs), health skills and healthy environment.

6.2 Maternal and child health/family planning (family and reproductive health)

In 1995, the percentage of pregnant women attended by trained personnel during pregnancy was 99.8%, while trained personnel also attended 99.2% of deliveries.

The availability of maternal and child health services has improved, through increase in staffing and a better supply system. Two obstetricians were engaged in offering quality time with 'high risk cases'. Clients have a wider choice of safe and effective contraceptive methods, including IUCD, and oral contraceptives. Colposcopies and cryotherapy have greatly influenced early diagnosis and prompt management of various gynecological conditions.

The Government is making a provision of minimum $500 coverage for antenatal care in the Health Insurance scheme, which will have a positive influence upon maternal and child health.

6.3 Immunization

The percentage of infants reaching their first birthday fully immunized, according to national policies, against poliomyelitis, diphtheria, tetanus and whooping cough was 98% in 1995. Also, 95% were fully immunized against measles (MMR vaccine also is given at 15 months). Only 76% of infants were immunized against tuberculosis. Around 90-95% of women had been immunized with tetanus toxoid (TT) during pregnancy. Only high-risk groups such as health care workers, police, prison officers and fire service officers are immunized with hepatitis B vaccine. Hemophilus influenza B vaccine was introduced into the national immunization schedule in 1992.

There had been no cases of poliomyelitis for decades, but the AFP surveillance is 100% complete and effective. Similarly, there had been no cases of adult tetanus or neonatal tetanus during the past ten years. There had been no reported cases of measles since 1991.

6.4 Prevention and control of locally endemic diseases

There has been no major change in the control measures for locally endemic diseases. Vector borne diseases such as dengue, yellow fever and malaria are not endemic in the Cayman Islands. However there had been 2-4 cases of imported malaria cases per year. Whenever a malaria case or any other vector borne illness is detected, the Mosquito Research and Control unit is notified for action.

Appropriate drugs and treatment facilities are available for managing all diseases prevalent. All blood transfusions are screened for various conditions. Laboratory facilities exist for effective diagnosis, either locally or by a reference laboratory in Miami and other jurisdictions.

6.5 Treatment of common diseases and injuries

Mortality

In 1996 an internal audit revealed that heart disease, cancer, stroke, accidents and pneumonia (in that order) were the leading causes of death. Mortality from cardiovascular disease/stroke increased 24% between 1985 and 1994. Accidents are the leading cause of death in the 15-44 years of age group. Motor vehicle accidents accounted for 58% of all accidental deaths and 16% are drownings.

Morbidity

The prime causes of morbidity (central arterial pathology and trauma) are reflected in mortality with the exception of cancer. It is strongly suspected that cancer (being the second main cause of mortality) is under-diagnosed as a cause of morbidity.

7. TRENDS IN HEALTH STATUS

7.1 Life expectancy

Estimated overall life expectancy at birth was 77.5 years in 1996, with 75.0 for males and 79.0 for females. The mean age at death (excluding infants) was 70 with 68 for males and 73 for females.

7.2 Mortality

Infant mortality rate was 6.2 deaths per thousand live births in 1995, infant deaths varying from 1-7 per annum during the past ten years. The probability of dying before the fifth birthday was 6.2 per thousand live births. There were two maternal deaths during the past decade, but none in 1995. There were no deaths due to acute respiratory infections or diarrheal diseases in children under 5 years of age. No deaths from tuberculosis were recorded. The number of deaths from cardiovascular diseases (all types), cancer (all types) and traffic accidents were 42, 23 and 5. Mortality due to communicable disease is negligible. Deaths due to AIDS vary 1-3 per year. Acute respiratory tract infections such as pneumonia are responsible for a few deaths among the elderly.

7.3 Morbidity

Surveillance data of notifiable diseases from 1995 indicated that there were 8 cases of imported malaria and 2 cases of tuberculosis. There were no cases of leprosy, measles, neonatal tetanus, or polio. Sexually transmitted diseases (including AIDS) and upper respiratory tract infections (influenza and other viral infections) are prevalent. As of 1995, the number of HIV positives was 18, there were 19 AIDS cases and 16 deaths related to AIDS.

Limited data on morbidity for chronic conditions and non-notifiable disorders is available. The leading causes for admissions in 1995 were disorders of the circulatory system and injuries. The commonest among diseases of the circulatory system were: ischemic heart disease, disorder of pulmonary circulation, atherosclerosis and cerebrovascular disorders. The majority of the injuries were due to involvement in motor vehicle accidents; the leading injuries were: fractures, followed by intracranial and internal injuries. Health promotion, screening programs and provision of state of the art facilities are the steps taken to prevent, treat and control these conditions.

In 1981, 28% of children in primary schools, (39%) in middle school and 46% in high schools were decay free. In 1995 the figures had significantly improved with 66.8% of five year olds, 60% of twelve-year olds and 60% of sixteen-year-olds being decay free. A 1990 survey indicated a D.M.F index of 4.6 for twelve-year olds. The 1995 D.M.F for the same age group was 1.7.

7.4 Disability

Data on blindness is not available. Special education facilities are available for handicapped and impaired children. Data on mental health indicates that the prevalence of mental illness is 5.5%. Schizophrenia, depression, manic disorders and mental retardation were the most important causes of disability. Rapid modernization together with the increase in drug use has led to the break up of the extended family units. The absence of facilities for the rehabilitation of the mentally ill has been significant. Patients who are withdrawn, lacking in drive, volition, apathy and social skills are mainly managed by medication maintenance, frequent home visits especially for the high-risk group and creative attempts to improve their situations.

8. OUTLOOK FOR THE FUTURE

Recognizing the need for state of the art facilities for secondary care, a $26M new hospital is under construction in phases, with the expected date of full completion being the later part of 1998. Based on the need to provide primary care services in the community, the Government is also constructing new Health Centers in all the four districts with facilities to meet the needs for the next 10-15 years, with potential for development to meet the needs beyond.

There will always be the problem of financing health care as the costs are escalating day by day. The issue arises as to how much should be provided by the Government. Considering the escalation of health care costs and in order to relieve the burden at the time of need, the Government decided that health insurance is essential. A law to ensure that all employers provide health insurance for their employees and dependents was enacted in June 1997. Also, recognizing that it is neither cost effective nor efficient to provide tertiary care in the Cayman Islands, this is sought through a formal contract with the Baptist Hospital in Miami, along with other relationships with the University of the West Indies in Jamaica, and other institutions in Miami.

With the full implementation of the Strategic Health Plan, it is envisioned that the good quality of life can continue to be enjoyed by the residents of and visitors