Grenada has had a relatively consistent health policy, whereby the goal is to ensure the entire population has access to quality health services based on need, which would allow them to lead socially and economically productive lives. The goals and targets established through the Caribbean Co-operation in Health (CCH) iniciative has been adopted as the priority areas of the Grenada Health Service, and Primary Health Care (PHC) is still the main strategy used for improving the health status of the population and to accomplish the goal of Health for All by the year 2000. The new government, in mid 1995, has indicated its commitment to the establishment of a statutory body to manage the entire public health care system. Work has started on the statutorisation of the General Hospital -the major hospital in the country, and this would result in the creation of a Board of Directors to manage the facility; a second significant policy development is the implementation of a National Health Insurance (NHI) programme; it is envisioned that this would create an equitable way of injecting some new resources into the health sector, and contribute to the improvement in the quality of care delivered to the population, as well as of reducing the dependance on central government for the financing of the health sector. The Ministry of Health (MOH) is about to undertake a health needs assessment in conjunction with the Central Statistical Office (CSO). These strategies and initiatives are considered essential to achieving the objective of improved efficiency in the management and financing of the health system, and PHC will also be strenghthened and revitalized.

2.1 Economic trends. After a negative growth of 1.2% in GDP in 1993, there was a 2.6% and 2.8% growth in 1994 and 1995; GDP per capita was US$ 1,970 in 1995. The combined production of traditional agricultural crops of cocoa, nutmegs and bananas fell by 26.1% in 1996 when compared to 1995. The inflation rate has been relatively stable in recent years and increased slightly from 2.1% in 1995 to 3.1% in 1996. In 1994, unemployment rate was estimated at 26.7%. Grenada implemented a structural adjustment programme between 1992-94, focused upon reducing sector expenditure, stimulating private sector growth, providing incentives for projects related to manufacturing, tourism and informatics, and the privatization of government assets; during those years, the value of government services declined by about 5% per year. Total public sector recurrent expenditure in 1996 was US$ 68.1 million, 7.5% higher than 1992; however, health expenditure in 1996 was US$ 9.6 million, 17.2% higher than 1992.

2.2 Demographic trends. The estimated population in 1995 was 98,000; 48.3% below the age of twenty and 10.8% above the age of 60. Total live births have been declining over the last decade; the crude birth rate decreased by about 31,5% , from 34.0 per 1000 population in 1985 to 23.3 in 1995, and with the crude death rate remarkably stable, standing at 8.2 in 1995. Total fertility rate averaged 3.2 during the period 1992-95. In 1995, 26.1% of births were born to women in the 20-24 eyars age group, while teenage mothers account for 16.9% of all births; this moved from 28.6% and 18.3% respectively in 1992. The pace of development in the southern part of St. George=s, in particular within the tourism and manufacturing sector, has resulted in an increase in the number of persons migrating therre from other parts of the country to take up employment.

2.3 Social trends. The overall literacy rate is estimated at about 85%. The education system is structured in a manner which prevents about half of the children taking the 11+ common entrance examination from going into secondary school, primarily due to lack of adequate space in those schools. Communities are countinuously being challenged to address issues such as the breakdown in families, growing levels of truancy, increased neglect and abandoning of children, and teenage pregnancy. These issues intensify when employment opportunities are limited. Domestic violence, incest and teenage conflict with the law are continuing areas of concern. One of the major constraints faced by the country in addressing most national issues, and in particular social problems, is the level of documented information on the status of the population.

2.4 Food supply and nutritional status. Presently the country does not actively monitor the prevalence of iodine or vitamin A deficiencies. According to the Grenada Food and Nutrition Council, about 30% of pregnant women had iron deficiency (Hb<10g/dL) as well as 55% of one year old children and 39% 4-5 year age group (Hb<11g/dL). Low birthweight prevalence was about 10% in the 1992-95 period. Less than 2% of children under 5 years were found to be of abnormal weight for age; over 50% of those less than one year old were found to be overweight. Greater attention will be paid to intersectoral approach to improving the nutritional status of the population.

2.5 Lifestyle. The general trend in mortality shows that the prevalent conditions of diabetes and hypertension can be linked to the lifestyle of the individuals and, accordingly, the Health Education Department of the MOH places particular emphasis on programmes wich provides information pertaining to these chronic diseases and advise on actions wich would have a positive impact on lifestyles. Despite the development of a family life education curriculum for secondary schools, the programme is not fully integrated, and the teaching is left up to the discretion of the teacher; many parents also strongly object to their children being taught sex education. These were considered some of the major constraints in the efforts to positively impact on lifestyle habits in the school system. The national Drug Avoidance Committee has worked assiduously in fullfilling its mandate to shape policies and oversee the implementation of action programmes aimed at reducing the demand for drugs and alcohol. Health promotion activities will continue to be the primary mechanism used to generate improvements in the habits that create lifestyle problems, focusing on the importance of diet and exercise.

3.1 General protection of the environment. The objectives of the Environmental Health Department in the MOH includes the improvement of waste water treatment and water pollution control; to ensure that adequate quantities of safe potable water is readily accessible to the population; to improve arrangements for the disposal of excreta and other substances detrimental to human, animal and plant life; and to improve the level of food hygiene in the country. The introduction of the 1995 Solid Waste Act established the Solid Waste Management Authority, a statutory body intended to accomplish a more efficient removal and disposal of garbage, hence reducing pollution and litter in the environment; these functions are carried out through private contractors, while the MOH continue its regulatory role. Grenada does not have any national policies nor organised programmes to combat coastal pollution, but is cognizant of the various international agreements protecting the Caribbean sea from pollution.

3.2 Water supply and sanitation. About 85% of the population have access to potable water. The National Water and Sewerage Authority conducts tests to monitor the water quality levels; treatment plants are strategically located throughout the island, and they are regularly monitored to ensure tue adequacy of the quality. There is usually a scarcity of water, especially in the dry season, and an almost continuous water rationing is in place in the southern part of the country; there is an emergency program which focuses on the replacement of mains to reduce the level of wastage, and the installation of water meters to facilitate a rate policy based on utilization. According to the 1991 Census, 59% of households use pit latrine, 33% use septic tanks and 3% linked to a sewerage system. 3.9% of households had no toilet facilities, and this represents over 850 households. The St. George=s Sewerage System was upgraded in 1992-93, and the number of households linked to the sewerage system has now increased to 7% of the population.

4.1 Human resources for health. In 1996, the public sector employed 50 physicians, of whom 10 were District Medical Officers, conducting clinics at the community level; 232 nurses, of whom 173 nurses-midwives worked in the three hospitals; 50 in the district and 9 in the mental and geriatric facilities; 26 pharmacists, based in the community, the procurement division and at the hospitals; 7 dentists; and 5 dental auxiliaries. There were, also, 15 physicians -mostly general practitioners, 21 pharmacists and 7 dentists working exclusively in the private sector. The MOH implemented a performance appraisal system in 1996 to have a more objective approach to personnel management, and has recognized the need to focus internally to satisfy some of the demand for training among its staff. It has developed an internal training programme, which will target staff at all levels of the system in areas considered a priority: management, public and interpersonal relationship, and a promotion of a better understanding of the public service.

4.2 Financial resources for health. The health sector has been consistently receiving over 12% of the annual government recurrent budget, and public health recurrent expenditure is estimated to have represented about 4.5% of GDP over the period 1992 to 1996. The main hospital spends about 40% of the total health expenditure, while the district health services, which includes the programmes representing community health services, environmental health and the dental department, uses around 26%. Wages and salaries in the sector accounts for approximately 70% of the total health expenditure. The health sector in Grenada is underfinanced, in that the demand for resources to satisfy the population needs is growing faster than the resources available for the sector. A major constraint in the financial reform of the health sector is the limited understanding of the level of health expenditure in the private sector. The Government is presently reviewing the way in which the health sector is financed, and has told the public thath the introduction of a National Health Insurance (NHI) programme is an approach that is being considered: NHI is intended to create an environment of Social Solidarity among the population, and be the source of a new injection of funds into the health sector.

4.3 Physical infrastructure. Hospital facilities in the public health sector include a 240 bed General Hospital, and two rural hospitals, Princess Alice with 60 beds and Princess Royal with 40 beds. The General Hospital is in a poor physical condition, and active planning to redevelop it commenced in early 1997. At the community level, there are 6 health centers and 30 medical stations scattered throughout the tri-island state; all facilities are within easy access to the entire population, and most are in satisfactory physical condition. One of the major constraints is the limited financial resources allocated towards maintenance of equipment and facilities in the health sector. MOH intends to conduct a rationalisation study of all the physical facilities, to analyse their levels of utilization and determine if it is necessary to have fewer, better equipped, and better staffed facilities.

4.4 Essential drugs and other supplies. Grenada has been procuring most of its medical and pharmaceutical supplies through a sub-regional programme managed by the Eastern Caribbean Drug Service. The annual procurement cycle ensures that the regional formulary is reviewed annually and revised periodically, and that all essential drugs will be available throughout the country in a regular and timely manner. The prices obtained through this service are extremely lower than those obtained in the private sector, and the quality is monitored consistently and shows to be of a high level. The government has a very liberal policy on the provision of essential drugs to the population. The fees in place for drugs in the public sector is extremely low, and this needs to be reviewed and adjusted. All persons, whether seen by a doctor in a public or private facility, can procure their medication at a public pharmacy for this highly subsidized fee: in a lot of cases, the patient do not pay the prescribed fee if the doctor writes "free" on the prescription, indicating an inability to pay.

4.5 International partnership for health. Apart from capital projects, most of the international assistance provided to Grenada is not costed and included as a component of the budget of the MOH. As a member of the Organisation of Eastern Caribbean States, Grenada participated in a USAID funded Health Care Policy, Planning and Management Project between 1994-96. That project facilitated close interaction and dialogue among officials of the Ministries of Health and Finance, and Social Security institutions in the member states, through regional meetings and training programmes. A major component of the international partnership since 1991 has been the annual visit by a group of medical personnel from Florida, USA, to provide medical attention to Grenadian children; also, teams of medical personnel from the US military have assisted in the refurbishing of medical facilities, and provided medical and dental treatment to the public.

5.1 Health policies and strategies. Health is considered a basic human right, and all Grenadians have access to health services at both the primary and secondary level regardless of their ability to pay. District health services are primarily free, with a small fee in place for pharmaceuticals; hospital fees are also way below cost and most beds provide free service. The government has indicated that they intend to provide more autonomy to the management of the health services, and reduce the role of the state in the direct running of the sector. In an effort to develop an adequate understanding of the sector, the MOH is working with the Central Statistical Office to conduct a national health needs assessment. Also, the MOH will focus on streghtening the co-ordination of global and regional policies and strategies adopted, to ensure that they are internalized within the relevant departments in the Ministry. While priority is attached to creating an autonomous General Hospital, more detailed analysis must be done on the financial implications of the reform, as well as other management issues which can impact positively on the process. The MOH intends to revive the district health services to have more vibrant Primary Health Care teams wit full community participation by using an intersectoral approach that, if successful, should contribute to the provision of a better service to the population.

5.2 Intersectoral cooperation. There has not been much organized effort to facilitate an intersectoral approach towards health policy development, and health program planning and implementation. The Ministry has representation on the Board of Directors of several organizations and, also, established several committees with intersectoral representation; however, there is much room for improving the co-operation and working relationship with other government ministries and departments, non-governmental organizations, the private sector and the wider community.

5.3 Organization of the health system. The basic organizational structure of the health sector has remained primarily the same in recent years, despite the absence of an approved Organogram showing lines of communication and assigned areas of responsibility. District Health Services continues to be the primary focus of the MOH in the delivery of health services with full complement of professionally trained and competent staff. Pediatrics, Ear, Nose & Throat and Mental Health consultants are the only specialists who conduct clinics at the district level. Individuals who are seen by the DMO in the community, and for whom specialist care is required, are referred to the General Hospital. The waiting time to see the consultant can take several weeks based on the number of appointments already booked, but the patient can make an appointment to see the same consultant in his private office within a day or two. When a patient is discharged from the hospital and returns to the community, there is no smooth functional referral system in place to inform the district medical team on the need for follow up patient care. The Community Health Services Administrator and Health Planner posts were abolished in 1994 and subsequently removed from the budget; in 1996, a MOH Senior Planning Officer position was introduced.

5.4 Managerial process. There had been a lack of continuity within the MOH senior management levels despite staff in middle management positions -who are primarily responsible for the preparation and implementation of the programme plans and budget for their departments- have worked with the MOH for several years. The MOH prepares an annual budget for recurrent and capital expenditure; the way in which the budget estimated are prepared makes it difficult to monitor and cost the various activities undertaken, since the government use line item rather than programme budgeting. Despite sound justification to the Ministry of Finance, financial allocations made are usually less than requested; also, there is no guarantee that the MOH will recieve the entire amount allocated, since the expenditure pattern is heavily dependant on the revenue flows. This constraint generally results in the inescapable commitments being met, and reductions in other areas such as maintenance and procurement.

5.5 Health information system. Government have always advocated the need to improve the health information system, to provide timely and accurate information on what is happening in the district and hospital services. Despite attempts made in 1992 to improve the quality and use of community health information, at present the systems are not functioning as planned. Several actions can be taken to improve the efficiency of the health information unit and the usefulness and quality of information produced; in 1993, the format for presenting the data was drastically improved but the content of the report has to be addressed to confirm its accuracy. The French Government has continued to assist the MOH by providing the services of an Epidemiologist; closer collaboration between the epidemiologist and the generators and collectors of information would facilitate a better team approach and consequently improve the quality of data produced; also, a more organised referral system between the district and the hospital and vice-versa, can improve the accuracy of information generated. Programme managers must be trained and encouraged to use data more frequently in the implementation and monitoring of their activities; training in the analysis and interpretation of data would facilitate that process.

5.6 Community action. There is minimal community involvement in the planning and implementation of national health activities, health workers playing the dominant role in these matters. Some departments within the MOH, v.g. Health Education, takes a pro active approach to community involvement and therefore has a high level o community contact. The outreach programmes are not structured and uniform throughout the country, and this will feature prominently in the revival of the Primary Health Care teams. Several NGOs are involved in community programs, with the focus being on health promotion activities.

5.7 Emergency preparedness. Grenada has been fortunate not to have been affected by any major natural disaster which claimed lives or sustained severe economic losses since 1992. There is a functional National Emergency Relief Organisation which opened a full time office in 1996; before that time the office was only opened during the hurricane season from June to December. MOH has a disaster preparedness plan which identifies the health command post and health personnel who should be active during a disaster. Disaster simulation exercises for hurricanes were held in 1992 and 1996 and were considered successful. Training in mass casualty management was also conducted for health staff and persons form other related sectors.

5.8 Health research and technology. The MOH does not have a planned research agenda, but several bits of research has been done on recent years. Under a USAID funded sub-regional project, Grenada benefitted from three areas of research: a hospital cost study done at the General Hospital; a feasibility study on the potential of introducing National Health Insurance; and a case study looking at an approach to identifying and costing a basic package of health services. The main area which has been identified for detailed research pertains to the level of expenditure on the private sector, and also the health information produced through that sector.

6.1 Health education and promotion. Health promotion is one of the main approaches being used by the MOH to upgrade the general health standards of the public on exhibiting a healthy lifestyle. The Health Education Department (HED), a well stablished unit within the Ministry, has been involving the community in the planning of health activities such as the health needs assessment and in the holding of health fairs. They also took part in forums organised to discuss issues such as AIDS and chronic diseases. A health education curriculum is now being developed in conjunction with the Ministry of Education, and this would institutionalise Health and Family Life Education in schools in a structured manner. The lack of a health education policy, and the absence of a clearly articulated health policy is considered a major constraint in implementing a comprehensive programme. Also there is a shortage of personnel and inadequate transportation arrangements for staff to carry out the requiered duties in the community, and fulfill the demand for health promotion activities. The existing salary structure is inconsistent with other departments and this demotivated the staff and results in resignations and persons not functioning at their full potential. Some mechanism for evaluating the impact of health education programmes has to be developed to determine the effectiveness of the programmes delivered.

6.2 Maternal and child health. This MCH programme is well stablished, and is a major component of the district health services. The MCH Manual, approved in 1992, outlines the goals and objectives of the programme and lists all the services provided to mothers, infants, and pre-school children in the country. It is estimated that over 75% of pregnant women attend ante-natal clinics in the public sector; although the MCH manual recommends that all pregnant women recieve services by the 12^th week of pregnancy, only about 5% to 7% doing so in recent years. Over 80% of children under 5 years old are seen by trained personnel in the public sector. Grenada Planned Parenthood Association -GPPA provides family planning services; the MOH intends to improve the monitoring of family planning services and collaborate more closely with GPPA in order to enhance the quality of services funded. During 1995-96 the MOH instituted a campaign for improved breast feeding among mothers: 34,4% of infants had been breastfeeding solely for 3 months.

6.3 Immunization. 1996 immunization levels were lower than the expected standard for the country, and shows a general decline as compared to the levels of previous years. A more thorough approach is being introduced for monitoring the program: visits have been made to all health centers to review the methodology used in identifying target population and guided staff on areas which can be enhanced. There is increased surveillance of fever and rash, and flaccid paralysis to ensure that measles and polio are effectively kept under control; the cold chain is also closely monitored and maintained to guarantee vaccines’ effectiveness. People’s Law #41 of 1980 requires immunization of children under 13 from diphtheria, pertussis, tetanus, measles and poliomyelitis; immunization against mumps and rubella is also provided by MOH. Consideration is being given to the re-introduction of the vaccine for tuberculosis. Although there has not been a case of neonatal tetanus in over two decades, the MOH continues to ensure that pregnant women are immunized against tetanus; its coverage being over 80%.

6.4 Prevention and control of locally endemic diseases. MOH continues to upgrade the food handling and processing situation with the objective of reducing food borne diseases. Several workshops have been held and will continue for itinerant vendors to provide information and support for better food handling practices; this should have a positive impact on the quality of food sold to the public. The Aedes aegypti erradication program is conducted on an annual basis to reduce the mosquito population, thus reducing the possibility of dengue fever while monitoring the potential of malaria. The main methods used are chemical control throughout the country, focusing on high risk areas, and continued health education programmes encouraging the public to maintain a clean and healthy environment; this focus has been changing to source reduction and biological control with a heavy emphasis on community participation. The environmental health department continued to work towards reducing the incidence of rabies through the annual vaccination of domestic animals throughout the island, hence breaking the link between the transmission of the rabies virus from the mongoose to man.

7.1 Life expectancy. Life expectancy in Grenada is estimated at 68 years for men and 72 years for women.

7.2 Mortality. The infant mortality rate in 1992 was 10.5 per 1,000 live births, and move up to 12.7 in 1995; its major contributor continues to be perinatal mortality: congenital anomalies of the heart and circulatory system; hypoxia, birth asphyxia and other conditions of the respiratory system; and slow fetal growth, fetal malnutrition and immaturity. Maternal mortality is extremely low in Grenada; almost all deliveries are done by a qualified midwife or physician, and this could be a contributing factor in this low rate. In the general population, the top three causes of death in 1995 were diseases of pulmonary circulation and other forms of heart diseases, cerebrovascular diseases, and malignant neoplasms. According to the MOH, the fourth cause of death in the general population corresponds to signs, symptoms and ill-defined conditions.

7.3 Morbidity. As far as AIDS is concerned, the cummulative total of reported HIV cases stands at 141, plus 96 AIDS cases at the end of 1996, 71 of whom have already died. The overall male to female ratio is 1.9 meaning one woman infected by every two men. Three pediatric cases were reported in 1996, the first year in which more than one case has been reported, rising up to seven the count for HIV/AIDS pediatric cases, all linked to vertical transmission. Reported data has shown an alarming increase in gastroenteritis in children between 1992 and 1996, increasing by 60% in those under 5 years old and by 73.5% in those above five years old; however, the clinics have been under reporting the cases and, with improved monitoring, the levels of 1996 is more in line with what is happening in this area. There were 21 cases of dengue fever in 1996, after having none in 1992 and an average of under 10 for the following three years; there was better statistical reporting after an epidemic in the region in 1995, and prior to that, there was a high percentage of non compliance. The number of cases of syphilis moved from 127 in 1992 to 54 in 1996, a reduction of over 57%; the 112 gonorrhoea cases in 1996 were more than doubled that of the previous year, but was slightly lower than the 116 cases recorded in 1992. This may not be a true reflection of the number of cases in the country, since most persons would go to a private physicians to treat these diseases.

7.4 Disability. The National Council for the Disabled is the organization primarily responsible for activities pertaining to disabled persons and has a mandate to support individuals and the parents of persons with disability, both physical and mental; they are presently conducting research on disabilities prevalence in the country. Some districts have a register of disabled persons in the community, but the council is of the opinion that more outreach programmes should be conducted to provide support to those disabled persons who have difficulty in going to the health center. The council indicates that training for disabled persons should be a priority in order to allow them to engage in productive activities. They also advocate greater team work with MOH, social services, to strenghten the coordination and implementation of programs relevant to their development.

8.1 Overall assessment and strategic issues. The epidemiological transition in Grenada, whereby the prevalent diseases moved from the communicable diseases to the chronic non-communicables, is creating a greater demand on the limited resources available to the health sector. Despite this, the entire population has access to health services in the public sector, regardless of their ability to pay, but there have been compliants about the quality of care delivered. One of the major challenges facing the MOH is the creation of a more harmonious working relationship among the staff. Most persons are putting tremendous effort into their work, and wants to see improvement in the health status of the population, but therre is little synergy within the Ministry thus retarding the true potential of the combined efforts. Political commitment to health reform is strong, and public consultation has been taking place in the community pertaining to the reform measures being introduced and specifically about the statutorization of the hospitals. Better planning of the consultation process has to be done to get more persons to participate.

8.2 Futures vision. The vision of the health sector will be looked at from the aspects of the delivery of services, and the management and financing of those services. The major objective of the MOH is to provide a reliable and efficient health service of an acceptable quality at both the primary and secondary levels at a cost the country can afford. The financing of health services will be structured to ensure that there is a balanced mix of financing options between central government, national health insurance, and out-of-pocket payments. Persons who are employed contributes on a regular basis towards the functioning of the health sector with this being done within the context of a NHI programme. NHI will be administered in conjunction with the national insurance scheme, and professionally managed by an NHI agency to create a synergy within the health sector and create improvements in the quality of health care provided. The central government will continue to ensure that those persons who cannot afford to pay for health services are not denied care. In this way, the Ministry of Finance will continue to contribute significantly to the financing of health services, and the Ministry of Social Services will identify persons who need to be given support from the government.

8.3 Proposed strategies. Infornation on persons residing within each health district will be enhanced to have a clearer understanding of the health profile of the population. All health workers are health educators, and this philosophy will be developend through training of staff and organizing forum to reach the community in an effective manners. Community participation and intersectoral coordination will be an integral part of the health promotion process, and a vital link in the revitalization of the Primary Health Care programme. The National Health Plan will be the primary tool to chart the direction of the health sector. In conclusion, the strategy to be employed in improving the health status of the population will be through community participation and intersectoral collaboration; enhanced health promotion activities; a more sustainable health financing mechanism; more reliable and effective hospital service; and a comfortable working environment for health care providers.