At the time of writing this report, there has been a volcanic emergency in Monserrat, the 106Km², pear-shaped, mountainous, Eastern Caribbean island, since July 1995. The whole southern-third of the island is classified as a danger zone and the population has been relocated to shelters and other accomodation in the northern 'safe-zone'. The island is one of five British Dependent Territories in the Caribbean. Monserrat has internal self-government in the shape of an elected Legislative Council. The government of the day forms an Executive Council. The Governor, the Queen's representative, exercises reserve powers for the Crown. The government consist of a Chief Minister, and three other Ministers. There is no local government machinery. The capital and main town is Plymouth and, since the emergency, Salem is the defacto capital.

2.1 Economic trends. Traditionally, Monserrat has been an agricultural country. In the late 1970s an offshore financial sector was developed; new legislation has been introduced to strengthen Monserrat's position as an offshore centre, specially in the sphere of company formation and trusts, which must now be licensed and be approved by the Governor. In recent years economic activity has broadened, with tourism, light industry and construction being economically significant. In 1996, domestic exports stood at EC$ 63.5 million, being more than double the EC$ 30.8 million recorded for 1995. Rice processing and electronic assembly accounted for over 99% of the island's export during 1996. Country's rebuilding subsequent to the direct hit from hurricane Hugo in 1989, gave a tremendous boost to the construction industry. The government relies on locally generated revenue for its recurrent budget, but depends on the United Kingdom and on loans for capital investment. Up until the volcanic crisis, the government was running a small surplus on its current account; however, in early 1996 it moved into a deficit. Tax revenues fell due to the decline in business activity and a lower level of imports. The shortfall in revenue required a budgetary supplement from the UK of EC$ 21.4 million to meet the rising recurrent expenditures. As a result of the volcanic crisis the operations of many private business have been disrupted, with rising operational costs caused by relocation; also farming has been adversely affected as most of the best farmlands are located in the designated unsafe zone.

2.2 Demographic trends. Even before the volcanic emergency, Monserrat had experienced negative population growth. At its peak, the population stood at just over 17,000 in the early 1970s. The last 1991 Census gave a population of 10,444. The bulk of emigrants have been primer age adults who have migrated to the UK, the USA and to other Caribbean countries; there is also a significant expatriate community, mainly comprised of retirees from North America, who bought land and build houses from the early 1960s onwards. In 1997, assessed population was 6,000-7,000 persons.

2.3 Social trends. The standard of living in Monserrat is relatively high. Adult literacy is high at around 98% for both men and women; all children aged 5 to 15 attend school. The Technical College has premises adjacent to the Monserrat Secondary School in Plymouth and undertakes a range of vocational studies at post-school level. The number of people on public assistance has been low, with 350 in 1995, the vast majority of those being the elderly (defined as those aged 60+ years). There has been a low level of unemployment, typically around 2-3%. Female participation rate is high and many persons do two or more jobs. Health services are one of the main employer of migrant labour, particularly nurses.

2.4 Food supply and nutritional status. Farming is still an important economic activity, but the bulk of foodstuffs are imported. There is no one in Monserrat who has inadequate access to food to meet their basic needs. However, it has been found cases of anaemia in children and in women. The Women=s Obesity Survey, conducted in 1991, also found that 46% of all women were obese. Over 1990-93 there was a marked reduction in obesity in children, dropping from 10% to 4% of those aged 11 and from 6.1% to 2.3% of those aged 15 years. However, obesity in those aged 5 years had increased from 2.8% to 8.3%.

2.5 Lifestyle. Lifestyle shifted and Monserrat became more of a consumer society; this is reflected in higher alcohol consumption, greater levels of car ownership and changing patterns of diet. People are now eating more imported processed foods, confectionery and carbonated drinks with a high sugar content. Over time, the consumption of traditional ground provisions and root vegetables have been declined. These changes partly account for hte high level of obesity, as does the low level of participation in organised games and individual exercise. The incidence of smoking is negligible in Monserrat, so for both sexes and all age groups. However, alcohol abuse is serious and widespread; among adults it is frequently associated with domestic violence, injuries and, also, mental illness. In fact, mental illness remains among the principal causes of hospital admissions in Monserrat, although they have now declined principally because of a more effective community pshychiatric service provided by nurses, who are very involved in public health education programmes. Use of illegal drugs is a small but significant problem.

3.1 General protection of the environment. Responsibility for environmental matters is shared between the Ministry of Agriculture, Trade and Environment and the Ministry of Health and Community Services. The 1995 Medium Term Development Plan, which laid out objectives and plans for all areas, meets the requeriments of Agenda 21. Three main sources of biological hazards in Monserrat are: fuel storage compounds, agro chemicals, and used car and boat batteries and lubricants. There has been long term problems with solid waste collection and storage points. This contributed to an explosion in the rat population in early 1990s. The three deaths from leptospirosis in 1993-94 are perhaps a reflection of this problem. Solid waste disposal was achieved through landfilling and limited open burning at a site at White=s. This site was not well managed and unsuitable for its purpose; however, it is in the unsafe zone, and has had to be abandoned. There is now a temporary dump-site at Little Bay, which is rather more unsuitable than White=s. Food safety measures are adequate, particularly through food handlers workshops, inspection of premises, and prosecution and seize of adulterated or spoiled goods, but could be improved by means of specific national policies as well as legislation.

3.2 Water supply and sanitation. 100% of households received piped water and had adequate sewage disposal, through septic tanks. Water quality is monitored on a weekly basis by both the Environmental Health Department and the Monserrat Water Authority. There have been no infant deaths from diarrhoeal diseases. However, the volcanic crisis poses an obvious threat to these services. Technical assistance and funds have been provided by the British Government to identify other water sources.

4.1 Human resources for health. Monserrat has a nursing school organised by a Nursing Tutor that prepares candidates for regional examinations in nursing, midwifery and nursing assistants. An offshore medical school with some 500 students, the American University of the Caribbean (AUC), was located in Monserrat until volcanic activity and hurricanes forced it off Monserrat in 1995. The AUC offered a number of fee-paid annual scholarships to Monserratians via the Ministry of Education. Apart from this, Monserrat relies on regional institutions for the basic and post-basic training of health professionals. Many attend in-service events throughout the regional and some avail themselves of the programmes provided via the UWIDITE network. Health staffing per 10,000 population in 1993 included 9 physicians, 1 dentist, 4 dental nurses, 15 student nurses, 32 registered nurses/midwives, 23 nursing assistants, 1 nurse anaesthetist and 17 other health providers.

4.2 Financial resources for health. Health services in Monserrat are financed by the government. Allocations have risen progressively over the review years. In 1992 health expenditure was EC$ 5.7 million, comprising exactly 5.7% of government spending. Since 1990, health has been the second highest spending department, after education. Some 75% of the health budget goes for wages and personal emoluments. The budgetary system does not distinguish between hospital and primary health care allocations; however, there is no doubt that the hospital consumes between 45% and 60% of the health budget. User fees are levied for government health services; however, fee collection arrangements are not good and in 1995 some EC$ 0.18 million was owned, just 2.5% of the health budget, letting the level of subsidy at 97.5%. A large number of users are either exempt from fees or pay it ar a reduced rate; these include all school children and students, those on public assistance, police and prison officers, prisoners, the mentally ill, expectant and nursing mothers, and for the diagnosis and treatment of hypertension and diabetes. Throughout this period spending on capital formation in the health sector has been high: the main item of expenditure has been on the continued refurbishment (EC$ 24M) and equipping (EC$ 1M) of Glendon Hospital by the British Government. A study done in 1993 estimated that 50% of all outpatient attendances, 70% of antenatal care, 70% of family medicine consultations and 60% of dental care was in the private sector; it also estimated that off-island treatment accounted for 10% of the overall health workload for Monserra;.the estimated cost of these private health care was EC$ 2.9M. Another hidden area of health expenditure was spending on health insurance premiums by the government, businesses and individuals. It was estimated that in 1993 about EC$ 1.1M was paid for health insurance coverage by employers. The claim and premium experience of known schemes was reviewed in 1993: it was found that for every dollar collected in premiums, only 25 cents was paid out in claims; therefore, a net capital outflow from Monserrat.

4.3 Physical infrastructure. Before the volcanic emergency, Monserrat had 12 district clinics and one hospital, located in Plymouth. The clinics were in fair condition, apart from one or two exceptions. Glendon Hospital had been damaged by hurricane Hugo in 1989 and was in the process of extensive refurbishment and re-equipping, as mentioned. After several reviews of these health facilities, under the Health Sector Adjustment Project, the overall conclusion was that Glendon Hospital was larger than merited by the needs of the population (hospital occupancy hovers around 63%) and that there were far too many district clinics. As a result of the volcanic emergency, the hospital and 50% of district clinics are now closed. There is a temporary hospital facility at St. John's in a former school and the remaining clinics have been upgraded by the addition of more rooms, additional diagnostic equipment and the staff from the closed clinics.

4.4 Essential drugs and other supplies. Monserrat is a full member of the Eastern Caribbean Drug Service. In excess of the 80% of drugs and medicines used in government health services are supplied through this agency. Two commercial pharmacies and private medical practitioners also import drugs for dispensing. There are occasional shortages caused by poor stock-keeping or other administrative problems, but these are rarely prolonged.

4.5 International partnership for health. Monserrat is a CARICOM member and collaborates with all relevent regional and international health initiatives, including epidemiological surveillance. There have been long standing arrangements with Guadaloupe for visiting medical specialist and some twining arrangements have been arranged via 'Partners of the Americas' who have an office in Monserrat. Family Life Services enjoys a high level of support from International Planned Parenthood Federation and there is an active branch of the Red Cross, which receives support from the British Red Cross.

5.1 Health policies and strategies. Sucessive governments of Monserrat have all given health care and the health sector a high priority in their development and expenditure plans. Government policy has been elaborated in many national and sectoral planning documents. Their basic thrust has been on ensuring the provision of high quality and accesible services to all Monserratians. Specific health policies are as follows: to develop and maintain appropriate health care facilities; to ensure that both public and private health care systems are developed and maintained to the required standards; to license and regulate medical organisations and personnel to ensure that the health practices are conducted to the required standards; to ensure that government policies relating to the Ministry's sphere of activities are effectively implemented; to promote the development of the people of Monserrat through community based programmes; and, to promote a stable working environment through the introduction and maintenance of appropriate labour legislation and practices. As a result of previous technical assistance the government of Monserrat had a draft health plan that identified some key priorities and programmes: the strengthening of environmental health services; improving the scope of services provided by the hospital and distric clinics; and, reviewing the number and functions of District Clinics.

5.2 Intersectoral cooperation. While there are a number of intersectoral meeting points, the bulk of collaborative work between government departments and agencies occur on an informal basis. The small size and intimate relationship in Monserrat make this possible and effective where it works well.

5.3 Organization of the health system. The Ministry of Health and Community Services are responsible for health and social services in Monserrat. The Permanent Secretary is responsible for the day to day administration of the Ministry. The Director of Health Services is charged with the day to day management of hospital and primary health care services. The first level of care provided by government services is the Distric Clinic. Each clinic has a nurse and some are resident within the district; doctors visited the clinics on a regular basis and held medical or family practice clinics. Private practitioners, concentrated in Plymouth, also provide family medicine. Secondary care is provided from the 44 bedded Glendon Hospital. Private practitioners also provided ambulatory care. The Glendon Hospital offered medical, surgical, peadiatric, obstetric, gynecological, ophthalmology and psychiatric care. These services are further extended by the use of Visiting Specialist from other parts of the Caribbean, the USA and Canada. Clinical support services include a laboratory, pharmacy and x-ray. Tertiary care is provided through referral to institutions overseas and by Visiting Specialists. The bulk of referrals are within the Caribbean; to Barbados, Antigua and Guadeloupe. Many Monserratians travels overseas as private referrals.

5.4 Managerial process. During the review period there have been two major initiatives directed at improving health care management in Monserrat: the Health Sector Adjustment Project (HSAP), and the Public Sector Reform (PSR); the former was sector specific and the latter was public sector wide. The work of HSAP focused on improving the management and policy making within the health system; the overall thrust was to produce a more decentralised and accountable management structure. The PSR project was to lead to an elaboration of objectives for the health sector. However, management structures and processes remain a problem: there has been no fundamental or significant changes in the organisation or management of health care in Monserrat. The health management and budget system remains highly centralised. While centralised, mangement has been weak in the sense that it has been difficult to achieve major shifts in policy or to deliver the planning and policy objectives that have been stated in successive documents.

5.5 Health information system. Monserrat was an enthusiastic participant in PAHO's Community Health Information Systems project. On the technical side, Monserrat has a well constructed system: health data is regularly entered onto a computer based system and recent data are easily accessible. However, this data collection process is not al all integrated into the management and decision-making process and does not form a critical part of decision-making. Epidemiological surveillance in under-developed organisationally and information tends not to be acted upon unless there is a crisis. The main constraints are managerial asthe technical support side is pretty well advanced.

5.6 Community action. There are a small number of active NGOs in the health field; these include Family Life Services, the Red Cross and the Old People's Association. these have been logn established organisation and no new ones have arisen. The Health Department has attempted to get individuals and communities involved in health promoting activities of a variety of kinds. However, this has not resulted in any mass movements or community health organisations.

5.7 Emergency preparedness. Emergency/disaster preparedness arrangements in Monserrat are well honed as a result of suffering a direct hit from hurricane Hugo in 1989, and the more recent volcanic emergency, the most significant threat to the health of the population. The threat here is indirect and direct. The former relates to the constant ash emissions that the population has learned to live with; the indirect is the effect of relocation, cramped and over-crowded accommodation in shelters and private homes and the stresses associated with living in a major disaster area. The best scientific advice is that the volcanic emergency will continue for the foreseeable future.

5.8 Health research and technology. Health research and technology are relatively under-developed in Monserrat. Small scale surveys are frequent, but no long term research takes place. The constraints here are more organisational an personal. There is a wealth of potential research material available. However, the management and orientation of the health system means that these opportunities are not seized.

6.1 Health education and promotion. The staffing of the Division comprised: one health promotion officer, one nutrition officer, and one AIDS/STD Programme co-ordinator. Health promotion with respect to family planning and family life education was undertaken by the NGO Family Life Services, which also provided a full range of clinical services from their premises in Plymouth. Health promotion only had a budget of EC$ 1,000, but drew financial support form other programme areas. Nutrition and AIDS had separate budgets. The main health promotion priorities were: vector control, AIDS, food safety and disaster management. The Division undertook all public relations activities for the Ministry. In addition it hosted a radio programme concerned with health matters. This reflected its priority to educate and inform the public about health matters and how to effectively use health services.

6.2 Maternal and child health-family planning (family and reproductive health). Child health prenatal care was offered at the 12 district clinics by a nurse midwife. Pregnant women were encouraged to attend clinics by their 12^th week. All pregnant women attending district clinics were evaluated at least once during pregnancy by the doctor in charge of obstetric services at Glendon Hospital. All on-island deliveries were at Glendon Hospital. It appears that the number who were delivered at Glendon receiving private care had increased from 40% to over 50%. Mothers were discharged on the third day, if were no complications. Discharge summaries were given to aid the district nurse who does the follow up on mother and infant for 10 days after delivery. Mothers returned to the postnatal clinic at 6 weeks for an examination by the nurse. High risk mothers are referred to a medical officer. Family planning are offered by district clinics, Family Life Services (FLS), and private practitioners. A full range of services is provided, including counselling health education, physical examination, supply of contraceptive methods/devices, pap smears, and pregnancy testing. In 1993 FLS had 452 acceptors, 355 in 1994 and 355 in 1995. This service catered for approximately 40% of the demand; the other portion being catered for by district clinics (40%) and private practitioners (20%). Oral contraceptives are the method of choice followed by injectibles, IUDs and condoms.

6.3 Immunization. Between 1992 and 1995 childhood immunization coverage was 100%.

6.4 Prevention and control of locally endemic diseases. There were two vector control programmes; the first was aimed at the Aedes aegypti mosquito and had four cycles of three months duration each, focusing on source reduction-removing physical breeding places; oiling and fogging were only used sparingly. The house index was an average of 10 throughout the review period. The second programme concentrated on rodent control. The rise in the rodent population was said to have been associated with poor solid waste arrangements. These had been improved after privatisation in 1995 and rats had moved on and farmers became the main complainants. Bait was mixed and old to the public.

6.5 Treatment of common diseases and injuries. Among children, respiratory infections are the major common illness. Among adults it is non-communicable chronic diseases, such as diabetes, heart disease and mental illness which are the main problems. Access to treatment has been facilitated by low or zero user fees. District clinic work with adults is also devoted to the care of chronic conditions and their complications. One nurse practitioner specialises in eye care, particularly of diabetics. a visiting ophthalmologist comes on a frequent basis to review cases and undertake surgical procedures. There are protocols in place for the treatment of diabetes and hypertension.

7.1 Life expectancy. Life expectancy at birth for men is 70.3 years and 73.7 years for women. No data is available on life expectancy at 65 years for men and women.

7.2 Mortality. There were 127 deaths in 1992, 103 in 1993, 97 in 1994 and 125 in 1995. In 1992 the main causes of death among females was: cerebrovascular disease (13 cases), diabetes (13 cases), heart disease (12 cases), and malignant neoplasm (9 cases). The majority (76%) of these cases were aged 70 years or more. Among men, the main causes of death were: cerebrovascular disease (12 cases), heart disease (12 cases), and malignant neoplasm (8 cases). 73% of deaths were men aged 60 years or more, with 55% being aged 70 years or more. For women, this pattern of death was continued in 1993. However, deaths due to diseases of the respiratory system claimed 7 cases -just double that if 1992. among men, heart disease continued to be the main cause of death. Male deaths from diabetes mellitus (5 cases), cerebrovascular disease (3 cases) and malignant neoplasm (5 cases) declined considerably over the 1992 figures.

7.3 Morbidity. Glendon Hospital in Plymouth, with 44 beds was the island's sole in patient facility. In 1992 there were 1,991 admisions, in 1993 there were 1,382 admissions (598 male and 779 female). In 1994 beds were reduced to 39 and there were 1,294 admissions and 1,181 for 1995 (part year). Occupancy varied between 50%-60% between 1992 and 1995. Throughout this period, the main causes of hospital admissions were for common conditions: gynaecological disorders, diabetes, asthma, prostate conditions, fractures, soft tissue injuries, hypertension, head injuries, pneumonia, and mental illness. Men predominated by a factor of 3:1 among all injuries and alcoholism; females predominated among medical conditions by an average ratio of 2:1, with the exception of pneumonia. Casualty attendances in 1992 was 6,980 and 6,969 in 1993. Out patient attendances in 1992 were around 2,300. The largest single speciality was surgery. Among the under 5s the main causes of admission were phimosis, gastro-enteritis, and respiratory infections -viral and syndrome.

7.4 Disability. There are two main groups of the disabled in Monserrat. Firstly, there are children born with a physical impairment or learning disability. At the other end of the extreme, there are elderly or mature persons who are disabled by the effects of ageing or chronic conditions, such as diabetes. In the late 1980s and early 1990s, Children's Research International attempted to set up a register and a surveillance system for disabled children in Monserrat and other British Dependent Territories. This was not successful because of the lack of interest and dedicated professional staff. The Monserrat Red Cross school for handicapped children is the only provision on the island for children with special educational needs. The school was badly damaged by hurricane Hugo and was refurbished with donations from British Charities. At the moment the school had been relocated in the northern safe zone.

8.1 Overall assessment and strategic issues. Health care and health services in Monserrat are very much dominated by the volcanic emergency. At this time it is not clear if and when Plymouth can be safely resettled. As a consequence of the emergency, the population has dwindled to 6/7,000. The indications are that more people are leaving. These tend to be prime age adults with professional, technical or vocational skills and experience. This is particularly evident in the health sector: the volcanic emergency has not made recruitment easy and will continue to be a constraint. Leaving this aside, Monserratians enjoy good standards of health care. This clearly is a result of high standards of nutrition, water supply, sanitation and primary health care. Hospital services are adequate, and could be improved in standard and scope of services provided to the population. Future health policies in Monserrat must clearly focus on non-communicable chronic diseases, better environmental health services and environmental management. However, there is a lack of effective management at all levels of the health system. A considerable proportion of the health expenditure goes into health insurance premiums and give the population no direct benefits. clearly, some kind of national health insurance would allow for a better retention of health dollars and the ability to invest in recurrent and capital developments in local health services. If the country is to make a shift to an insurance based system in which the user pays more there will have to be changes. If the perceived quality and efficiency of services do not get better there will be public resistance and political reluctance to take such a major policy step acceptable. The volcanic emergency has forced the country to make improvements in primary health care and it is to be hope that these will be sustained once the emergency is over. A considerable amount of consultancy and analysis is being done in Monserrat as a consequence of the emergency. However, there are few in the health sector and the little that has been done has not been written up. It will be of benefit to long term health policy and planning for this to be done. this would be an obvious point for international support and co-operation for Monserrat. The short and medium prospects for Monserrat will be determined by the course of the volcanic emergency.