Dominica

HFA - 2000

 

1. TRENDS IN POLICY DEVELOPMENT

In the budget of 1995 of the first change of Government in 15 years, policies were established for sustained and balanced growth in Agriculture, Industry, Tourism and the Services Sectors. The declared emphasis was on stimulating a faltering national economy and is largely consistent with the economic policies of the previous administration. At the same time, there was a definite renewal of a political commitment towards a further strengthening of the social services network, notwithstanding the tenuous economic climate.

A National Socio-economic Development Reform Strategy is being designed to stimulate future economic and social development. The Reform Strategy proposes to take action in the following target areas, inter alia: Macro-economic framework; Human Resource Development; Job Creation; Capital Mobilization; Productivity and Efficiency; and Incentives Framework. If the vision behind this strategy were achieved, positive impact will be experienced in the areas of poverty reduction, employment creation especially among women, and the quality of the social fabric.

Another significant area of policy development is a resolution to reform the health care delivery system. Specifically, the policy decision has been taken to introduce a National Health Insurance Scheme and to increase the level of user charges for services provided. The goal is to improve the quantity and quality of locally available health care services as well to engender a culture of efficiency within the system, without discriminating against anyone because of their inability to contribute financially. Finally, the Government has been directing its energies towards the institutionalization of the strategic and operational planning processes at both the national and sector levels.

2. TRENDS IN SOCIO-ECONOMIC DEVELOPMENT

2.1 Economic Trends

The economy has been described as small, open and especially vulnerable to external shocks. The Gross Domestic Product (GDP) grew in real terms at an average annual rate of 2.1% in 1991-1995 compared to that 5.6% in 1986-1990. The lack of buoyancy in the economy was due largely to the poor performance of the banana industry which dominates agricultural output. The communication sector is the fastest growing sector of the economy, registering real growth of 12% and contributing 8.8% to the GDP in 1995. This sector is followed closely by gains in the banking and insurance sector and construction sector. In terms of overall contribution to the GDP, however, the dominant sectors have been agriculture (despite negative growth in each of the last three years), government services, wholesale and retail trade and banking and insurance. The real per capita GDP rose from EC$5,286 in 1991 to EC$5,527 in 1995 - a mere 4.5% increase over the period. This is in stark contrast to 1986-1990 when per capita GDP climbed by 22.3%. With an average annual increase of less than 1% in per capita income, the population has had to contend with a period of stagnation in general living standards. In current prices, the per capita GDP rose from EC$5,707 in 1991 to EC$6,830 in 1995 - an increase of 19.7%. However, this is not considered to be the most sensitive index of measuring real growth and cannot be used, by itself, to analyze living standards. Having no readily available sources of data which disaggregate income levels within the population, the best indicators of this phenomenon are derived from recent studies of employment status and poverty. According to the 1991 Population and Housing Survey, only 67.8% of males and 35.3% of females were employed. This represents an 11.6% and 0.7% decrease in gainful employment among males and females respectively since 1980. Among the employed, 30.8% were engaged in agriculture-related pursuits, 11.9% in the wholesale and retail trade, 11.8% in construction and 10.1% in commerce as principal areas of economic activity. About 15% of the employed were insurance and real estate, public administration, manufacturing and hotels and restaurants. The Poverty Assessment Survey in 1995 showed that 27% of households live in poverty. The assessment concluded that despite considerable improvements in specific living conditions such as access to water, sanitation, electricity, health, education and television, "there was a great deal of poverty and an intensifying of poverty and vulnerability". The Government has sought to establish and strengthen safety nets for the poor. These include public assistance programmes, school feeding programmes, income-generating projects, exemptions or rebates on user charges for the health services and community care programmes for the elderly. Other actions earmarked include the establishment of small businesses in the poorest communities, implementing targeted credit schemes, initiation of a community service for youth and strengthening intersectoral linkages.

2.2 Demographic Trends

The 1991 Population and Housing Census returned a count of 71,373, a decline of 2,420 persons (3.3%) from the 1981 Census. This decline has been largely due to emigration, a characteristic demographic feature since 1960. The projected population at the end of 1995 is 74,707, with slightly more males (52.3%) than females (47.7%). The relative youthfulness of the population is evidenced by the fact that 18.6% are in the 0-4 years age group, while fully 50% fall into the under 20 years cohort.

In 1991, the total fertility rate was reported at 3.0, down from 4.2 in 1981. This figure was projected to be 2.9 in 1995. The most reproductive age-group falls in the 25-29 years range with an age-specific fertility rate of 141.4, followed by the 20-24 years age-group (129.7) and the teenage group (114.6). The mean age at child-bearing is 26.8 years. The crude birth rate declined from 24.0 in 1991 to 20.2 in 1995, with an average annual rate of 23.1 over that period. The average annual crude death rate during 1991-1995 was 7.5, slightly higher than the 6.5 annual average rate recorded 1986-1990. The most significant increases were observed among those 80 years and above. Infant mortality rates fluctuated between 14.2 and 16.4 during 1991-1995, although an unexplained high of 22.5 was recorded in 1994.

2.3. Social Trends

Dominica does not have a compulsory education system but a relatively high level of school enrollment has been maintained traditionally, without prejudice to any of the sexes. In 1993, the last year with complete data available, 91.6% of the 5-19 age-group was registered within the school system. This level of attendance has been more or less consistent for the past decade. The highest level of education attained by most Dominicans is primary school (67.1%). A further 15% have completed their secondary and post-secondary education, while 1.7% attained university or advanced level education and training. The 1991 Census reported that 10.5% of the adult population had no formal education and could therefore be regarded as functionally illiterate. Illiteracy is evenly distributed among the sexes with 10.5% for males and 10.3% for females.

The unemployment rate has been put officially at 9.9% using the 1991 Census as the base of analysis. This represents a significant improvement over the 18.6% reported in 1981. It is to be noted, however, that 24.2% of the productive population were engaged in "home duties" as their main economic activity – a category occupied overwhelmingly by females. Although declining, a number of disparities still exist between males and females. For example, females outperform males at the secondary school level, but males are almost twice as likely to go on to University. Even with comparable or better education, only 35.3% of females find employment outside the home as compared to 67.8% of males. The Government has spearheaded moves to redress the imbalance given the vital role that women can play in development. A Ministry of Women's Affairs has been commissioned and an increasing number of programmes have targeted skills training and job creation for women.

The total number of households increased by 16.5% from 1981-1991 (the last two census years). Most of the households were owner-occupied (72.0%), with 19.2% private-rented. The average number of rooms per household was 3.4 in 1991, up from 2.8 in 1981, while the average household size decreased from 4.3 to 3.5 persons over the same period. More than 6,000 residential units are connected with telephones. It is estimated that upwards of 80% of households have access to radios and television sets. The radio station is used extensively as a means of public health information and education. The use of television for such purposes is still very under-developed.

2.4 Food Supply and Nutritional Status

The major agricultural crops produced since 1991 have been bananas, citrus, coconuts and ground provision. There is also significant production of livestock, while fishing remains an important occupation. Dominica is close to self-sufficiency in the production of the staple foods but is lagging badly in the production of protein-type foods. An excess of EC$20 million worth of meat and meat preparation, milk and cheese, and fish and fish preparation are imported annually. It is an area that is targeted for attention under the national agricultural diversification thrust.

The level of undernutrition among young children (0 -59 months) has been very marginal since 1991, hovering at an annual average of 1.4%. No severe cases of undernutrition were reported in 1995. On the other hand, obesity has been as high as 8.7% and may indicate a cause for concern in the future. Data on other forms of nutritional disorders such as iron, iodine and vitamin A deficiencies are not readily available.

The overwhelming majority of newborns weigh at least 2,500 grams at birth. Still, an annual average of 7% of newborns exhibit some level of below normal weight at birth. No discernible progress has been demonstrated in this area since 1991.

2.5 Lifestyle

Teenage pregnancy is neither a new nor deteriorating phenomenon. The number of births to teenage women declined sharply from 27.4% of total births in 1986 to 14.2% in 1995. Still, there is room for considerable downward movement in the rate of teenage pregnancy given its wide range of inhibiting social and economic implications. The introduction of health and family life education in schools and at the community level, and the widespread availability of family planning services has led to the decline in fertility rates. Family planning services are offered through government-run clinics, doctors' offices and the privately-run Dominica Planned Parenthood Association. Based on records from these services, 40% of the women of the child-bearing age-group were active female contraceptive users. However, the level of contraceptive prevalence is likely to be much higher given the current general fertility rate. The most popular forms of contraceptives among women have been oral pills (62.1%) and injectables (30.6%), while significant increases in the use of condoms has also been recorded apparently to serve the additional role of prophylactic.

The number of indictable offences in Dominica involving violence is on the increase. The main forms include burglary (often with aggravation), grievous bodily harm, unlawful carnal knowledge and arson. The fastest growing offences were grievous bodily harm with almost a five-fold increase between 1991-1994 and burglary which increased by 57% over the same period. As yet, there are no specific programmes designed to stem the tide of criminal offences, although some public debate has been initiated. It has been reported that in 1995, 8.7% of all admissions to a hospital psychiatric unit presented with a diagnosis of alcoholism, 7.6% with cannabis psychosis and 2% categorized as cocaine abuse. More work needs to be done to determine the size and scope of this problem. Iinformation could not be found on tobacco use, but the general sense is that the prevalence of smoking is low and declining.

3. HEALTH AND ENVIRONMENT

3.1 Environmental Protection

The Government has expressed a commitment to "preserve the environment in its most pristine form". The strategies to accomplish this have been promoted as follows: controlled land use practices, including the protection of forest reserves ; application of environmental impact assessments and hydro-geological studies to all physical development projects; protection of waterways from chemical pollution -- especially to the use of chemicals in agriculture; restriction of sand mining from beaches; and proper management of solid and liquid wastes. An improved solid waste disposal system will shortly be implemented. No significant health problems are linked to environmental issues with perhaps the exception of an endemic problem of typhoid fever. A total of 44 confirmed cases of typhoid have been reported during 1991-1995, an annual average of nine cases. The main source of contamination has been traced to food handling practices in conjunction with inadequate sewage disposal methods.

3.2 Water Supply and Sanitation

More than three-quarters (77.5%) of the households have direct access to the national water supply system. The system is treated routinely to maintain bacteriological quality. Importantly, neither springs nor rivers were mentioned as sources of domestic water supply.

Many serious concerns persist over the state of sewage disposal. One-quarter of the households (25.5%) have no approved form of sewage disposal. Although this represents an improvement from 1981 when the figure was 40%, it still remains unacceptably high. The situation is more grave in some West Coast Villages where up to 60% of households have no sewage disposal facilities. The predominant means of sewage disposal is the water closet (36.8%), followed by the pit latrine 35.4%. It is not surprising that gastroenteritis was the foremost notifiable infectious disease (18.6/10,000) in 1994. About 55% of the population are served with a communal solid waste collection and disposal service. The serviced area runs from Portsmouth in the North to Scottshead in the South, including the capital city of Roseau. This service is expected to be extended nation-wide by 1998 under a new solid waste management initiative. A new landfill site at Fond Cole has been earmarked for development with a projected life span of 15 years.

4. HEALTH RESOURCES

4.1 Human Resources

Human resources for health care delivery have remained constant since the turn of the decade. No significant change has been observed in either the categories or numbers of health personnel available, although some emphasis has been placed on deployment of staff in favour of strengthening the primary health care services. The evolution of the Primary Care Nurse and Community Health Aide, and the institutionalization of a framework within which Family Nurse Practitioners can function speak to this orientation. There are two training institutions for health care professionals in Dominica - the government-run School of Nursing and the private off-shore Ross University Medical School. The School of Nursing has a training programme tailored to the specific needs of the national health service, while the latter’s curriculum is not informed by local needs since the market is exclusively foreign. One of the most important factors limiting the expansion of human resources for health in recent history has been the controls placed on public sector spending. Even with the availability of adequate financing, however, targeted human resource expansion and development may prove difficult since the optimum needs of the health sector in terms of number, mix and deployment are yet to be defined. This remains one of the important challenges of the future. All of the traditional categories of health personnel are reflected on the establishment with nurses, nursing assistants and doctors appearing in the highest ratios. It has been suggested that the area of health/project planning is sufficiently pivotal to the management and operation of the health sector to be added to the establishment.

4.2 Financial Resources

The actual government expenditure in the health sector has averaged 13.2% of total recurrent budget during 1991-1995. This ranks health as the third largest consumer of government's resources, behind administration (21.3%) and education (16.4%). In 1995, 39.2% of the total recurrent expenditure on social and community services was allocated to health. Expenditure in the health sector relative to the GDP hovered round the 4.5% mark, somewhat less than the 5% recommended minimum level of expenditure on health. In terms of the GDP per capita on health, an increase was recorded from EC$245.37 in 1991 to $312.73 in 1995. Expenditure in the health sector is still skewed in the direction of secondary care with hospital and laboratory services consuming about 50% of the financial resources for health. Primary health care allocation has shown only a marginal increase from 22.5% in 1991 to 22.9% in 1995. It must also be noted that environmental health services account for 7.7% of the health expenditure, thus increasing overall expenditure on primary health care services. Almost three-quarters (72.9%) of the total expenditure on health is directed towards personal emoluments, with the remainder applied towards all other operating costs.

4.3 Physical Infrastructure

Concrete actions have been taken over the past decade to improve the quality and quantity of the components of the physical health infrastructure. The improvement has been most obvious at the only secondary care referral centre on the island. The rate of progress in this area has been hampered by inadequate financing and because many buildings which house these facilities are privately owned. The Government’s Health Sector Plan commits it to completing the process of retrofitting and to the construction of six new primary care facilities so as to greatly reduce the reliance on privately owned buildings. Currently, there are no protocols to govern the procurement of medical equipment for use in the health service, whether by direct purchase or by donor contribution. However, this need has been fully recognized and plans documented to develop a comprehensive set of guidelines to direct this process. Overall, the physical infrastructure is adequate and highly accessible. The main deficiency lies in its upkeep and maintenance and this is being systematically addressed.

4.4 Essential Drugs and Supplies

Dominica is a full participant in a regional pooled procurement for pharmaceutical and medical supplies. This has generated an average of 25% savings on items purchased, while at the same time enhancing quality, reliability and availability of essential drugs and supplies. About 10% of the health budget is allocated to the purchase of drugs and medical supplies. Legislation relating to issues such as prescription drugs, drug registration and license to dispense drugs is dated and in urgent need of review. Also, there is no drug inspector with responsibility for enforcing the provisions of the relevant legislation.

4.5 International Partnership for Health

Prospects for bi-lateral international partnership for health have receded far into the background. Most international partnerships over the past decade have been multi-lateral in character involving other Caribbean countries, with the possible exception of French Cooperation which has maintained strong bi-lateral links. In response, the Government has infused health and environment considerations into its economic and social development initiatives and strengthened the ties of regionalism. For example, the World Bank funded regional OECS Solid Waste Management Project has been promoted as an intersectoral project with implications for tourism, health and the environment. Dominica continues to subscribe to the Caribbean Cooperation in Health (CCH) which offers a platform for a regional approach to health services delivery, including shared services with CARICOM and PAHO/WHO indispensable collaborators.

5. DEVELOPMENT OF THE HEALTH SECTOR

5.1 Health Policies

The National Health Sector Plan (1995-1999) reaffirms the commitment of Dominica to the tenet that "all citizens have the right to attain the highest possible level of health in order to be able to work and live in accordance with acceptable standards of human dignity at an affordable cost". The emphasis continues to be on a shared responsibility between the Government and the community to achieving lasting improvement in the quality of life. The gains achieved in health status from sustained public health interventions are well recognized and documented. Now, the strategy is to deepen the orientation towards preventive health care, while at the same time pursuing the following programme priorities: application of the principles of health promotion to programme planning, implementation and evaluation; reform of the health sector to meet the special challenges related to institutional strengthening, mobilization and efficient use of resources and human resource development; improvement of the health infrastructure through an on-going process of retro-fitting and maintenance; and strengthening community participation and intersectoral linkages. The priority groups served are defined as: children 0 - 5 years old; pregnant and lactating mothers; women in the reproductive age-group; adolescents; the elderly; and underserved population in urban and rural areas (e.g. indigenous population).

5.2 Intersectoral Cooperation

Intersectoral cooperation has been promoted as a central strategy in national development planning and programme execution. But, the consensus is that practical application has not been as consistent as required to give maximum effort. One of the deficiencies has been the absence of functional mechanisms to stimulate and manage the process in an organized fashion Perhaps the most celebrated example of success in this area in recent times has been the evolution of a National Socio-economic Reform Strategy using the multi-sectoral and community participatory approach. Emphasis has been placed in the health sector to develop linkages with all sectors and, in recent times, with macro-economic analysts and planners within the central government system. It is a direction that will be pursued further.

5.3 Organization of the Health System

In 1979, a model primary health care system was fashioned. The main thrust of the re-organization of health system was the division of the island into seven (7) health districts, each with its own management team responsible for organizing the delivery of health services at that level. A Central Technical Committee provided policy, advisory and technical support services to the District Health Teams. Under this arrangement, primary health care now has its own discrete budget which has been disaggregated by district based on programming needs and priorities. In effect, there has been a devolution of a measure of authority and responsibility to District Health Teams with the goal of enhancing programme delivery. The main benefits have been greater synergy of efforts among the various programme areas, a dedicated budget for primary health care and the implementation of more goal-directed activities. Also, this process encourages greater community input. The system continues to prosper and has been endorsed again in the National Health Sector Plan .

5.4 Managerial Process

The re-organization of the health system stimulated changes in the managerial process. The position of Director was created with responsibility for the management and technical supervision of the community health services. District Medical Officers were assigned the responsibility of functional coordinators of the District Health Teams. The Director of Primary Health Care Services reported to and received directions from a Central Technical Committee. This Committee functioned under the chairmanship of the Chief Medical Officer and included the chief technical experts in the major disciplines. In many respects, it was the senior management committee of the health sector advising on policies, planning programmes and directing the monitoring and evaluation processes. This Committee has lapsed into a state of dormancy and a vacuum currently exists in the exercise of its functions. A revival appears to be highly indicated.

A measure of re-framing of the management structure at the secondary care level has also occurred in the last five years. This involved the creation of the post of Hospital Services Coordinator with responsibility for the general administration of the Princess Margaret Hospital. Coupled with this initiative, accommodation was made to the job responsibilities of the Hospital Medical Director. Clearer distinctions between general administrative responsibilities and technical supervisory functions in the hierarchy of the hospital management structure were made.

5.5 Health Information System

The Health Information System is still a fledgling entity. Although significant technological and other improvements have occurred since 1991, a number of outstanding issues remain to be addressed. The system is equipped with a range of data collection instruments and software programmes for generating various reports. Only very few reports are produced in any scheduled or systematic way. The crux of the problem appears to be the lack of timeliness in the input of data. This is a function of inconsistent submission of data from the service delivery points coupled with incomplete data entry into the system at the central level. The system will benefit immensely from the services of a computer analyst and may benefit from an on-going in-service training programme for health workers in all aspects of information management.

5.6 Community Action

It is a national dictate that communities and individuals should be integrally involved in the process of development. The involvement of the community in the drafting of a National Socio-economic Development Strategy, the public debate that was encouraged on the new initiatives for health sector financing, as well as the active role which community members play in the life and work of District Health Teams have all been hailed as success stories in community participation. Nonetheless, there is a view that in Dominica vibrant community action coalesce around national issues and local needs and not as a perennial orientation.

The National Health Sector Plan (1995-1999) keeps faith with the practice of community participation in health and commits itself to "fostering a co-partnership with the community" in the delivery of health services. However, full cognizance is given to the fact that "new strategies must be sought to achieve meaningful social mobilization".

5.7 Emergency Preparedness

Dominica has felt that the brunt of at least three destructive hurricanes in recent history with phenomenal damage done to the economic, physical and social infrastructure. As such, there is universal awareness within the country of the critical importance of emergency preparedness. A National Disaster Preparedness Committee has coordinated the development of a National Disaster Plan and holds responsibility for its periodic update. The health sector produced a Health Disaster Plan which details actions to be taken at every level in the event of any emergency situation. Consequently, emergency preparedness planning is well entrenched. However, very little has happened in terms of simulation exercises to practice and sharpen responses. This is one of the objectives that the health sector has committed itself to pursuing on an annual basis. New emphasis is also being placed on mass casualty management at the pre-hospital and casualty stages.

5.8 Health Research and Technology

There are no specific policies on research and technology. Neither are there any on-going research efforts in place. A great deal of work is required in this area.

6. HEALTH SERVICES

6.1 Health Education and Promotion

There is a fully established Health Education Unit within the Ministry of Health which has responsibility for public information and education on issues of health. It performs this function through the training of other categories of staff in the principles and practice of health education; planning and implementing health education programmes and activities with community groups; producing and presenting mass media programmes on relevant health and health-related topics, and the production of graphic arts materials. Dominica has also endorsed the Caribbean Charter on Health Promotion launched in 1994 and is seeking to apply its components to the planning process at all levels. One of the priorities identified in the National Health Sector Plan (1995-1999) is the application of the principles of Health Promotion to programme planning, implementation and evaluation. It is recognized as one of the most cost-effective strategies in challenging health problems and promoting healthy lifestyles. The main constraints to the application of this approach is the somewhat low level of existing inter-sectoral cooperation and the temperamental nature of community participation. A high level of awareness and interest of the media to become involved has been reported.

6.2 Maternal and Child Health/Family Planning

Specialized programmes relating to ante-natal and post-natal care and family planning services have become institutionalized. There is universal coverage for pregnant women available through clinics and health centres. However, at variance with the maternal and child health protocol, only 30% of pregnant women receive their initial check-up by the 16th week of pregnancy. This statistic must be interpreted with caution since, a significant though unknown number of pregnant women make their first ante-natal visit to a private physician rather than to the public system. About 70% of all births occur at the Princess Margaret Hospital, with the remainder attended by trained nurse/midwives. All deliveries are attended by trained health personnel.

The number of women in the child-bearing age group on family planning methods increased from 5,255 (34.6%) in 1991 to 5,739 (43.9%) in 1995. These are the consolidated figures provided by the government health centres and the Dominica Planned Parenthood Association. The most popular methods used in 1995 were oral contraceptives (58.4%), injectables (33.7%) and the intra-uterine device (0.6%). An organized cervical cancer screening programme has been in place since 1988 with an aim of early detection and treatment of cervical cancer – the second most commonly diagnosed cancer in Dominica.

6.3 Immunization

Immunization coverage of the most vulnerable population under one year of age has now attained complete coverage. This has been accomplished through an aggressive expanded programme of immunization delivered through both public and private health care facilities. There are no routine immunization programmes against Tetanus for pregnant women or with respect to Hepatitis B.

6.4 Prevention and Control of Endemic Diseases

Typhoid fever, tuberculosis and dengue fever are the three endemic communicable diseases of concern. Typhoid incidence rates have ranged from 11.4/100,000 in 1989 to 17.3/100,000 in 1993. The localities most affected have been Marigot, Portsmouth and Grand Bay. Although the incidence of tuberculosis has declined from an annual average of 9.8/100,000 between 1986 and 1990 to 5.4 over the past five years, its continuing appearance has evoked specific strategic action. The response to the typhoid fever problem has been directed towards health education of the public and improvement in sewage disposal practices; while case finding, contact tracing and examination of sputum by direct microscopy of persons presenting with respiratory symptoms are being employed in the surveillance programme for tuberculosis. The aedes aegypti eradication programme has been operational for almost two decades with the aim to control, if not eradicate, the vector of dengue fever. Methods of control in use have been source reduction, treatment with chemicals and biological intervention. Even so, there was still a high household index of 15.4%. The acceptable level is 3 - 5%.

6.5 Treatment of Diseases and Injuries

Dominica has maintained a well-organized health system for the treatment of common diseases and injuries. The primary care services available at clinics and health centres provide the first level of care, while secondary care services are available at Princess Margaret Hospital. The policy is to strengthen these services, especially in the area of emergency care.

7. TRENDS IN HEALTH STATUS

7.1 Life Expectancy

Life expectancy at birth for the combined sexes has been projected at 67.8 years for 1995 – an increase of 1.1 years over the 1990 projection. Women now survive their male counterparts by 7.3 years. Life expectancy for females has been reported at 71.4 in 1995 as opposed to 64.1 for males.

7.2 Mortality

The crude death rate has increased marginally between 1991-1995, moving from 7.2 to 7.9. Most of the deaths (62.5%) occurred among the population 65 years. Chronic diseases are now entrenched as the dominant causes of mortality with neoplasms, hypertensive diseases, heart diseases, endocrine and metabolic diseases and diseases of the circulatory system being foremost. The three most fatal diseases accounted for 43.2% of all deaths occurring between 1991-1995. This trend is expected to continue into the future. The infant mortality rate has averaged 16.6 per year during 1991-1995 -- an increase compared to 14.9 in the preceding five year period. Maternal mortality rates have been reported at between 0-1 per thousand during the last ten years.

7.3 Morbidity

Morbidity data are very incomplete due in large measure to the deficiencies in the data collection and retrievable system and are therefore inconclusive. The best statistics suggest that diabetes and hypertension are the most common causes of morbidity with an estimated 4% of diabetics and 18% of hypertensives in the general population. They account for the highest number of visits to clinics and health centres. From the limited data available, the main communicable diseases reported in 1994 have been gastro-enteritis, sexually transmitted diseases, chicken pox and mumps. With respect to morbidity from malignancies, the main categories have been breast, cervix, stomach and skin, in that order. A continuous cancer screening programme is in effect especially for cancer of the breast and cervix.

7.4 Disability

In the absence of a specific census or study, the status of physical and mental disability in the society is not known. Yet, many social workers feel that the problem has enough significance to warrant investigation. The Mental Health Report, 1995 estimates the age-adjusted prevalence of schizophrenia at 0.9%, while the prevalence of alcoholism among medical out-patients was reported as 29%. These appear to be the major mental health challenges. A total of 2,166 mental health out-patients were monitored in 1995 compared with 2,148 in the previous year. A Draft Mental Health Policy has been formulated and is awaiting ratification.

8. OUTLOOK FOR THE FUTURE

8.1 Assessment and Strategic Issues

Since the turn of the decade, considerable progress has been made in health care and in most of the sensitive indicators. Still, there are many outstanding issues to be resolved and a variety of strategic options are available. An analysis of the strategic issues is now discussed .

Health Status The greatest challenge to the health of the population is the incidence and prevalence of chronic diseases, notably diabetes, hypertension and cancers. Life style is a major risk factor in the development and outcome of these conditions and this indicates an area for strategic action. The infant mortality rate has increased over the past five years -- a trend attributed to increases in deaths during the neonatal period. Awareness of disability as a health and social development issue is emerging slowly. Targeted action here can only be predicated on a full knowledge and analysis of the various dimensions of the problem.

Health Policy The commitment to health as a prerequisite to social and national development is well documented. The National Health Sector Plan (1995-1999) has established the priorities of the government -- health promotion, re-organization of the health sector, development of health infrastructure and programme development.

Health Resources In the absence of recent study/ report, the present establishment of numbers and categories of staff appears satisfactory. Even so, the lack of provision for a health planner has limited the strategic and operational planning processes within the health sector. Also, the deployment of staff in a proportionate and equitable fashion is vital to the development of all sections of the sector. In excess of 70% of the recurrent health budget is allocated to personal emoluments and must be a matter for concern. This is especially so given the fact that almost 5% of the GDP is already spent on health, with no realistic expectation for any significant increase in real terms in the foreseeable future. This situation poses two challenges; one is to improve the level of efficiency within the sector, while the other relates to generating alternative financing to supplement government input.

Development of Health System Precise actions have been taken over the past ten years to re-organize the health system to give optimum effect to the primary health care approach. Efforts at intersectoral cooperation and community involvement have not been as successful as anticipated. Innovations have also been made to the managerial process at both the primary and secondary care levels. One of the current programme priorities envisage a further re-structuring of the health system in response to the present and emerging realities. The Health Information System is still an area of considerable weakness.

Health Services The availability and accessibility of the health services are good. A three-tier system ensures that all aspects of essential health care are available to the entire population within acceptable limits. Maternal and child health/family planning services, immunization, control of communicable diseases, treatment of common diseases and injuries, and health information and education are all offered routinely within the system. One area of under-utilization of the health services is ante-natal care of women Also, visits during the last trimester of pregnancy may not be as regular as needed, with negative implications for the outcome. These are areas to be addressed in the future.

Socio-economic, Socio-political Environment The real growth in the national economy during 1991-1995 declined by more than one-half over the preceding corresponding period of time. This has precipitated a measure of financial stringency by the Government. Meanwhile, per capita GDP increased by a mere 4.5% over the five-year period creating a negative impact on personal disposable income. The level of unemployment and poverty in the society remain issues of serious concern. Nearly one-half of all women are not employed outside of the home, while 27% of population is said to exist below the poverty line. The issues of stimulating the economy, increasing employment opportunities and reducing the impact of poverty are foremost national considerations.

International Partnership for Health Decreasing international assistance for the social sector, including health, has reduced the level of extra-budgetary resources hitherto available. The recent approach has been by way of strengthening multi-lateral linkages among Caribbean countries to vie for grants or concessionary loans.

Under the Caribbean Cooperation in Health Initiative, mechanisms are being developed for the sharing of services and expertise within the region. It is seen as a very viable option for the future.

8.2 Futures Vision

The broad objectives for the development of health and health-related services are set out in the National Health Sector Plan (1995-1999). They involve the strengthening local health systems to meet the specific needs of communities. This includes prioritization of programmes and more efficient allocation and distribution of resources. Exploring new avenues for generating resources to sustain the sector. Careful management of information within the sector. Improving the quality of secondary care by instituting structural changes, infrastructural improvements, improving human resources and enhancing quality of care. Streamlining functional relationships between main administration and peripheral services in terms of personnel and financial and supplies management. It is anticipated that these objectives will be accomplished through the careful harnessing of all available resources at all levels - national, regional and international. Very close links will be maintained with regional governments and with organizations such as PAHO/WHO and CARICOM in order to access required technical and other forms of assistance.

8.3 Proposed Strategies

Considerable efforts have been made in defining the most feasible strategies for achieving the goals set as articulated in the National Health Sector Plan (1995 - 1999).

Equity for Health Applying the risk approach, the most vulnerable groups within the society have been targeted for priority attention -- women and children, adolescents, the elderly and urban and rural poor.

Health Promotion and Protection will become an integral component of health care at both primary and secondary levels. All programmes and activities will seek to include communities and individuals in the decision-making processes. Efforts will be made to empower people to improve their living conditions, nutrition, hygiene and general life style.

Strengthening the Health Sector The main strategy will involve the continued re-organization of the sector with emphasis being placed on deconcentration and decentralization. Managerial processes will be reviewed and adjusted consistent with the needs of the sector.

Specific Health Programmes Chronic diseases have been underlined for special attention given their prominent place among the morbidity and mortality statistics. Other major health components will receive attention in one form or another.

International Partnership in Health The main thrust will be on strengthening links with regional partners in seeking international assistance. At the same time, shared experiences and expertise among CARICOM partners will be paramount.