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Country Health Profile.
Data updated for 2001Anguilla Health Situation Analysis and Trends Summary Country Chapter Summary from Health in the Americas, 1998. ANGUILLAGENERAL SITUATION AND TRENDSSocioeconomic, Political, and Demographic Overview Anguilla, the northernmost of the Leeward Islands, lies to the north of the island of St. Maarten, and covers an area of 71.3 km2. The island is coral limestone formation, with a generally undulating surface; its highest elevation is 738 m above sea level. The climate is tropical, and average annual rainfall is low, ranging from 20 to 50 inches. It is difficult to distinguish urban from rural settlements in Anguilla. All major settlements are easily accessible by the main road network, which consists of paved and unpaved roads. The island is accessible by sea and air. There are two seaports that accommodate cargo and passenger ferries servicing the St. Maarten/Anguilla route. In December 1980, Her Majesty Queen Elizabeth signed the "Anguilla Act, 1980," which formally decreed the separation of Anguilla from Saint Kitts and Nevis. The island is a British Dependent Territory. The Governor presides over the Executive Council, which is composed of the Chief Minister, a Cabinet of Ministers, and the Deputy Governor. The Deputy Governor and Governor are representatives of the United Kingdom. The Administration reports to the Legislative Council. General elections are held every five years; the present coalition government was elected in March 1994. A 1992 review of the Anguilla economy led to the development of the National Development Plan, 1994–1998. The primary goal of the Plan is to ensure sustained and stable economic growth, while minimizing environmental and social losses. Several of the objectives in the Plan have implications for the health sector. These include a planned annual increase in recurrent government revenue of 4.5%; maintained annual growth in recurrent expenditure of 2%; investment of EC$ 22.2 million in the public sector; and promotion of human resource development through the expansion of education, health, and other sectors. The Anguillan economy registered an annual average growth rate of 7.2% (in constant prices) from 1992 to 1994, but a negative growth rate of 4.4% in 1995 as a result of the devastation caused by Hurricane Luis in September 1995. Gross domestic product in 1990 constant prices was US$ 52.4 million in 1995, compared with US$54.8 million in 1994. Hotels and restaurants, agriculture, and transportation were the sectors that suffered the greatest loss in 1995. Conversely, wholesale and retail, mining and quarrying, and construction, registered significant growth. Measured in 1990 constant prices, per capita GDP showed steady growth, from US$ 5,128 in 1992 to US$ 5,517 in 1994, declining in 1995 to US$ 5,085. The tourism industry is the mainstay of the economy, and Government policy advocates investment in large tourism infrastructure projects. According to the 1992 census, the tourism sector employed 21% of the labor force. The offshore financial services sector is being developed as a means of strengthening and diversifying the overall economic base. New legislation governing this sector was passed in 1995. Anguilla has no direct taxes, personal or corporate, and no currency exchange controls. The 1992 census reported a 7% unemployment rate. The male-female ratio for the employed was 1.2:1, a change from the 1984 ratio of 1.8:1. Increased female employment is related to growth in the tourism sector and increased opportunities for women in the service industries. According to the 1992 census, the distribution of the labor force by occupation group was: 32.3% in production, construction, and transportation; 25.1% in service industries; 20.6% in clerical and sales; 12.5% in professional and technical occupations; 5.6% in agriculture: 3.0% in administration and management; and 0.8% in unspecified occupations. The 1992 census revealed that there were 2,619 housing units in Anguilla in 1992. However, a survey carried out by the Lands and Survey Department in the same year found 4,048 dwelling units, including houses and apartments. This apparent discrepancy exists because the 1992 census only recorded occupied dwellings. The Land and Survey Department study describes 91% of houses as "constructed from concrete," with 42% of all houses judged to be in good structural condition. Fourteen percent were under construction at the time of the survey. Sixty-four percent of households have telephones installed, 75% have access to electricity and sewerage, and 90% have water available in their houses. Most households have access to radio and television. Average occupancy is three persons per household. Anguilla’s 71.3 km2 territory is divided into 7,394 parcels, 66% of which are under 1 acre in size. Approximately 95% of the land is privately owned, in small family plots. Education is compulsory through age 15 in Anguilla. Student enrollment in primary schools from 1992 to 1995 ranged from 1,370 in 1992 to 1,484 in 1995. The teacher-student ratio at this level is 1:20. Secondary school enrollment was 840 in 1992 and 962 in 1995. Females accounted for 51% of students in primary school, and 54% of total enrollment. Over 80% of the labor force received a secondary school education. A further 6% were educated at a technical college, and 7.6% received university education. The adult literacy rate is 92% (1994), with no reported differential rate by sex. The estimated population in 1995 was 10,302. The last census, conducted in 1992, established the population as 8,960, of which 49.9% were males. Average annual population growth rate has been 1%. The average annual rate of natural increase for the last 10 years (1986–1995) was 11.4. The crude birth rate was 16.7 per 1,000 population for the period 1992–1995. It has shown a decline in the period, with 141 live births registered in 1992, 171 in 1993, 163 in 1994, and 167 in 1995. The percentage of births to teenage mothers also declined. Nineteen of the 141 live births in 1992, and 18 of the 163 live births in 1994 were to teenage mothers. The general fertility rate in 1995 was 74.2 per 1,000 women 15–44 years of age. Migration into Anguilla has been increasing, particularly from neighboring Caribbean islands. In the 1992 census, non-Anguillans accounted for 16% of the population, evenly distributed by sex. No significant trend in migration to urban areas has been observed. During the 1992–1995 period, 237 deaths (124 females and 113 males) were reported. The number of deaths by year was 68 in 1992, 63 in 1993, 52 in 1994, and 54 in 1995. During this period, 64.6% of all deaths were in the 70 and older age group (153 deaths), 12.7% were 60–69 years old (30 deaths), 11.6% were 40–59 years old (25 deaths), 4.2 % were 20–39 years old (10 deaths), and 5.1% were less than one year old (12 deaths). Seven deaths occurred in the 1–19-year age group. The infant mortality rate for the 1992–1995 period was 18.7 per 1,000 live births. There were 12 infant deaths in this period: 4 in 1992, 2 in 1993, 1 in 1994, and 5 in 1995. Infant deaths occurred mostly in the neonatal period. During the 1992–1995 period, 671 deliveries and 8 stillbirths were recorded. One maternal death occurred in the entire 1992–1995 period. SPECIFIC HEALTH PROBLEMSAnalysis by Population Group Perinatal and Child Health Because many Anguillans seek health services in neighboring islands, these data are not complete. Over the 1992–1995 period, there were 9 neonatal deaths and 16 perinatal deaths reported. An analysis of perinatal deaths revealed that 67% were due to asphyxia and hypoxia, and occurred during the neonatal period. Twelve deaths under age 1 were recorded in 1992–1995. There were 76 low-birthweight infants registered from 1992 to 1995. Three deaths in the 1–4-year age group were recorded during 1992–1995. Acute respiratory tract infection is the leading cause of morbidity in this age group. Gastroenteritis is not reportedly a serious problem. Cases are generally managed in the clinics by district nurses, using oral rehydration salts and referring them to another level as appropriate. There is no defined prevention and control program for diarrheal diseases. Growth monitoring of all children under 5 years old is performed at district clinics. An informal descriptive study was conducted in 1997, reviewing a sample of infants registered and monitored at the Valley Clinic. Results indicate that obesity in this group (estimated at 10%) is emerging as a problem. Breast-feeding is declining; only 3 % of infants were observed to be breast-fed at three months, and 50% of infants were "eating from the family pot" at 6 months of age. Immunization coverage during the 1992–1996 period was 100% for BCG, MMR, polio, and DTP. Two suspected cases of flaccid paralysis were investigated in 1995, but neither was confirmed as polio. All pregnant women are immunized against tetanus. The school health service provides screening for children in the 5–9-year age group, including physical examinations and dental, hearing, and vision screening. Worm infestation was reported in 4% of 5–6 year olds. Health of Adolescents The number of births to teenage mothers is declining. During the 1992–1995 period, births to mothers under 19 years old averaged 13.5% of total births. Family planning services are available to adolescents, and a family life education program, which includes peer counseling and skills training, has been implemented in schools. An increasing number of cases of abuse in children under 16 years old have been referred to the Social Welfare Department. Between 1991 and 1994 there were 122 cases, compared with 51 cases in the 1987–1990 period. Most of the cases were female. Health of Adults Prenatal care is provided by midwives in district clinics and by the resident obstetrician/gynecologist. Approximately 80 % of pregnant women attending prenatal clinics enroll before the 16th week of pregnancy. Routine supplements of iron, folic acid, and vitamins are distributed. A review of laboratory reports of hemoglobin estimates for pregnant mothers for the period January to June 1995 revealed that 15.6% of these women had hemoglobin levels below 11 mg/dl. Prenatal referrals to the hospital for complications of pregnancy and other medical reasons comprised 43% of prenatal clinic attendance in 1993, 57% in 1994, and 55% in 1995. Virtually all deliveries (>99%) are performed at the hospital and attended by trained health personnel. No home deliveries are performed. There are no available data on abortions. Immediate postpartum care begins in the hospital and continued through home visits by district midwives. The communication between hospital and the districts in this area requires strengthening. Family planning services are delivered at the health centers. Registered clients totaled 560 in 1993, 747 in 1994, and 601 in 1995. New acceptors constituted 10%–15% of current users, but a decrease in the number of new acceptors has been reported (83 in 1993, 86 in 1994, and 63 in 1995). Oral contraceptives and injectables were used by 54% and 31% of clients, respectively, in 1995. No intrauterine device insertions were recorded between 1993 and 1995. Pap tests are available in the private and public sectors. Coverage is low, with 279 examinations conducted in 1993, 189 in 1994, and 261 in 1995. Of these, abnormalities were reported in 53% of specimens in 1993, 68% in 1994, and 47% in 1995. Two cases of cancer in 1993 and 1994, and 19 in 1995. Three deaths from cervical cancer were reported during the 1992–1995 period. Chronic noncommunicable diseases, mainly diabetes and hypertension, contribute significantly to the morbidity and mortality in this group Health of the Elderly The elderly (60 years and over) constitute 12% of the total population as outlined in the 1992 census report. Females comprise 55% of age group. Most elderly persons live at home with extended family, but a growing number live alone. Health care providers, mainly nurses, make periodic home visits to the housebound elderly for routine monitoring and medical care, averaging 329 visits annually (1993–1995). Chronic noncommunicable diseases are the main contributors to mortality and morbidity in this age group. In 1995, 70% of diabetic admissions to the hospital and 57% of hypertensive admissions were over 60 years old. Other problems affecting the care of this group include social isolation, lack of occupational and recreational facilities, and disabilities. Family Health The 1992 census revealed that 25% of households housed single persons; 42%, nuclear families; 12%, extended families; and 2%, composite living arrangements. Statistics compiled by the Social Welfare Department indicate that during the 1991–1994 period, the average annual number of reported cases concerning child support was 133; child abuse cases averaged 31; an average of 9 cases concerned divorce; 69 related to domestic disputes; and 72 concerned juvenile delinquency. Family members have access to public and private health services. Public health services at primary and secondary care levels are very accessible, and include maternal and child health services and general medical care. Families can seek exemptions from the nominal charges at the hospital through the Social Welfare Department. Workers Health There is no specific program that addresses occupational health. Both the Environmental Health Department and Labor Division are proposing surveillance and promotion activities in this area. Analysis by Type of Disease Communicable Diseases Vector-Borne Diseases. No cases of malaria or yellow fever were reported on the island during the 1992–1995 period. Cases of dengue fever occur in Anguilla, but no known case of dengue hemorrhagic fever was identified during the reporting period. The Aedes aegypti mosquito is highly prevalent on the island, but no reliable estimate of the household or Breteau index is available. Vaccine-Preventable Diseases. There were no confirmed cases of poliomyelitis, tetanus, measles, tuberculosis, rubella, or diphtheria reported from 1992 to 1996. Acute Respiratory Infections. Acute respiratory infections cause significant morbidity in children and adults. Eight deaths in 1995, mainly in the 65 and older age group, were attributed to acute respiratory infections. Sexually Transmitted Diseases. Sexually transmitted diseases (STDs) are prevalent, but no data are available because many persons go to St. Maarten for treatment. Pap tests from 1993 to 1995 indicated the presence of STDs. There were 312 blood donors for the 1993–1995 period, all of whom were screened. None tested positive for HIV or syphilis, nine were positive for hepatitis B (3 % prevalence). Noncommunicable Diseases and Other Health-Related Problems Nutritional Diseases and Diseases of Metabolism. Obesity, particularly among women and children, is cited as one of the major health problems facing Anguilla. This is related to lack of physical activity and over-consumption of processed or refined foods. Most of the food eaten in Anguilla is imported. Anemia was found in an estimated 22% of 5- and 6-year-olds and 7% of 11-year-olds in 1996. In 1992, an estimated 14% of women were anemic. Accidents and Violence. Data on accidents and violence are inadequate, as are data on morbidity due to domestic violence. From 1992 to 1995, two deaths due to accidents and one from violence were recorded. Police statistics for 1992 to 1994 register 24 reported cases of rape and indecent assault, 3 cases of murder and manslaughter, and 76 serious assaults and wounding. These figures show a moderate increase compared with the 1989–1991 period. Oral Health. Oral health screening and treatment take place at the Dental Clinic. The ratio of tooth extractions to fillings, while declining, is approximately 1:2, an unacceptably high level. No dental epidemiological survey has been conducted in the last five years, so scores for decayed, missing, and filled teeth (DMFT) are not available. The number of visits to the dental clinic steadily increased from 5,670 visits in 1992, to 6,156 in 1993, and 6,564 in 1994. Visits decreased to 6,009 in 1995. Tooth extractions have consistently declined in this period, from 2,526 in 1992, to 1,788 in 1993, 1,614 in 1994, and 1,508 in 1995. No clear trend is seen in the number of fillings: there were 2,347 in 1992, 3,733 in 1993, 2,935 in 1994, and 3,323 in 1995. Natural Disasters. Anguilla lies in the tropical storm belt and is at risk from hurricanes and storm surges. In September 1995, the island’s infrastructure was damaged by Hurricane Luis, adversely affecting Anguilla’s main sources of national and personal income. Thirty-five percent of houses were damaged, and direct damages to the health sector’s infrastructure, equipment, and supplies totaled US$ 218,000. There is a national disaster plan, and a national emergency relief committee coordinates mitigation and response activities. There is a need for operational plans at village and departmental levels. Risk Factors. There is evidence of degradation of coastal and marine environment due to pollution caused by discharge of sewerage from hotels and restaurants, and discharge of sewerage and oil from visiting yachts and ships. No coastal pollution-monitoring program has been implemented. There are no rivers in Anguilla, and a significant portion of the water supply is derived from wells. The groundwater is at risk of contamination from direct discharges of effluents, chemicals, and pesticides in areas near the aquifer; intrusion of salt water; and uncontrolled disposal of solid waste. The Environmental Health Department does not monitor water quality. The septic tank is the most common method of liquid waste disposal in Anguilla (81% of households). Poor design frequently results in malfunction and the release of partially treated effluent into the underground water system, from which the public supply is drawn. The Environmental Health Department lacks expertise in regular monitoring of effluent from package treatment plants. The high prevalence of the Aedes aegypti mosquito, which breeds in water cisterns and rock holes, poses a constant threat for dengue and dengue hemorrhagic fever outbreaks. No estimate of the Aedes aegypti index is available. RESPONSE OF THE HEALTH SYSTEMNational Health Plans and Policies In September 1995, the Minister of Social Services outlined the key policies and priorities for health development. The stated aim of the Government’s health policy is to provide high-quality, accessible primary and secondary health care services to the population of Anguilla and to include provisions for the transfer of patients overseas. The health policy advocates a partnership of private and public health care providers. The Government’s top priorities involve improvements in the following areas: quality care; performance of environmental health services; access to health care; and the scope, accessibility, and performance of primary health care services. The policy promotes good physical and mental health and greater service efficiency and cost-effectiveness. The policy statement acknowledged that the achievement of these priorities is dependent on improved performance in the private and public sector through more consumer-oriented service, better management, improved public/private sector collaboration, and a more proactive approach to planning. Organization of the Health Sector Institutional Organization The Ministry of Social Services is responsible for the management of health services. The Director of Health Services bears responsibility for the effective functioning of all departments, and delegates responsibility through the Senior Medical Officer of the Hospital, the Primary Health Care Manager, Health Services Administrator, and Principal Nursing Officer. The post of Primary Health Care Coordinator was recently created. In 1995, a new management structure for health services, which utilizes four teams, was approved by the Executive Council with the objective of making demonstrable and expeditious improvements to health care management. The four teams are described below. The Health Services Strategy group is responsible to the Ministry of Social Services for health planning, advice on policy issues, financial and budgetary review, and quality assurance in the public and private sector. This group comprises senior technical and administrative staff and a representative of the Ministry of Finance. The Senior Management group is responsible for the overall management and coordination of publicly provided health services. It is chaired by the Director of Health Services, and is composed of senior technical heads of departments. The Primary Health Care Management team and the Hospital Management team are each responsible for day-to-day management of services in their respective departments. A Department of Primary Health Care supervises the delivery of services at the community level. The private health sector in Anguilla is small, limited to primary and selected tertiary care. Anguillans frequently go to Saint Kitts, Puerto Rico, St. Maarten, and elsewhere for medical services, even those available in Anguilla. The Government proposes strengthening the private sector through greater sharing of facilities, information, and joint training. By enhancing the role of the private sector, the Government aims to retain a portion of the scarce private and public funds spent overseas. The Medical Council certifies and monitors medical practices. There is no mechanism for regulating the practice of other health professionals. Organization of Services for Care of the Population Health Promotion and Community Participation. The Department of Primary Health Care works to empower communities to take decisions concerning their own health. Health committees have been formed in two health districts. While no formal structure exists presently in support of intersectoral collaboration, several informal intersectoral programs have been established, including programs on water monitoring and solid waste management, a dental mobile unit, and a health/education liaison committee. Two health educators deliver education programs that focus on the promotion of health and wellness, and emphasize behavior modification and lifestyle changes, targeting schoolchildren, young adults, and community groups. Alliances have been formed with the media, and a weekly radio program disseminates health information. Epidemiological Surveillance. An epidemiologist was appointed in 1995. The health information system is being improved through the Community Health Information System and Health Sector Adjustment projects. The Environmental Health Department is responsible for waste management, food hygiene, vector control, liquid waste management, the monitoring of drinking water, environmental sanitation, beach and roadside cleaning, building better hygiene practices, occupational health and safety, and the provision of low-cost sanitation services. The Department retains responsibility for collection of refuse from government institutions, public roads, and beaches. Domestic solid waste is collected twice weekly. No provision is made for the removal of construction waste, old appliances, and derelict vehicles. Hotels and other commercial establishments are required to make their own arrangements for collection of waste. An estimated 12 tons of garbage are disposed of daily at the 10-acre landfill, where waste is placed in pre-excavated trenches and covered with fill. Potable water supplies encompass rainwater collected in cisterns, groundwater extraction from wells, and reverse osmosis treatment of salt water: 41% of households receive their water from rainwater collected in cisterns, and 32 % from both cisterns and a private piped source. All homes have access to piped water within the home or in the yard. The two main aquifers supplying water are located in the Valley, and contain 70% of the groundwater resources of the island. Over 70% of local demand is supplied by the public water system, 28% comes from rainwater collected in cisterns. The commercial sector (restaurants, bars, shops, and some hotels) is allegedly the largest consumer of public water. The Government received funding from the British Government and the European Union for a water development project. The Anguilla Water Authority is responsible for the planning, construction, operation, and maintenance of water supply works. Treatment and testing of groundwater is the responsibility of the Anguilla Water Authority, while the Environmental Health Department carries out inspection and treatment of cisterns. The Environmental Health Department does not conduct water quality surveillance, and monitoring by the Water Authority is not continuous. There is no sewerage system in Anguilla. All wastewater/sewerage is treated and disposed of on-site by means of septic tanks (81% of households), soakways, pit latrines (13%), and package treatment plants, which are used primarily by hotels, some commercial establishments, and government institutions. Environmental conditions in schools, health facilities, and public buildings are monitored. Routine vector control activities are performed at these compounds. The 1978 Food Hygiene regulation empowers the health department to conduct periodic inspections of premises where food, drink, and other commodities are sold. The food handlers’ program involves the examination, certification, and registration of all food handlers and premises. Education of food handlers is an integral component of the program. Vector control activities concentrate on the control of the Aedes aegypti mosquito and rodents. Organization and Operation of Personal Health Care Services The health care delivery system consists of a public and private sector. The private sector services include primary and secondary care. The public sector delivers primary care services from five district health centers. Secondary care is delivered at the Princess Alexandra Hospital. A nurse or doctor makes referrals to services at the hospital from the primary care level. For primary health care delivery, the island has been divided into five health districts each with a health center and defined boundaries. Two levels of care—Level III and Level II. Level III comprises the smallest four health clinics, which are staffed by a public health nurse, clinic aide, and environmental health officer. These clinics provide basic core services. Level II care is provided from the Valley Health Clinic, which serves as a referral center for Level III, and offers daily medical clinics as well as basic primary care services to its defined catchment population. Referrals are made from Level II to the hospital. Except for puerperal mothers, there is no systematic mechanism for referral of patients from the hospital back to the primary level of care. Public dental services are located at the central unit in the Valley, and supported by a mobile unit that provides care to the primary schools. A 10-bed geriatric care unit provides institutional care for the elderly. A psychiatric nurse provides community mental health services, and is responsible for maintenance care of all mentally ill patients. Emergencies can be referred to a district medical officer. There is no mental health facility. Violent cases are detained at Her Majesty’s Prison, and patients requiring specialized hospital care can be referred to neighboring Caribbean islands, at the Government’s expense. The island has no facilities for tertiary care, which is sought from the United Kingdom, St. Maarten, Puerto Rico, and other Caribbean islands. Inputs for Health Anguilla has become an active member of the Eastern Caribbean Drug Service (ECDS), a regional procurement scheme for pharmaceutical and medical supplies. The ECDS also gives support in the areas of inventory control and organization. The situation has vastly improved as a result of ECDS cooperation. There is no national drug formulary and purchases are guided by the regional Eastern Caribbean Formulary. Similarly, there is no stipulated list of essential drugs. Vaccines are obtained from the Expanded Program on Immunization (EPI). Inventory control is good, and a reliable service is maintained. Drug expenditure has remained constant in the 1992–1995 period. During that period, a total of US$ 658,145 was spent. The highest annual expenditure in this period was US$ 168,552 in 1993. Human Resources There are no training institutions for health personnel in Anguilla. Depending on health staffing needs, personnel are sent to various Caribbean islands. Increasingly, local training workshops, particularly in primary health care issues, are organized. It is the Government’s policy to support training for health personnel in the public and private sectors, and to open all locally organized training to participation by the private sector. In 1995, there were 9 doctors, 37 trained nurses, 2 dentists, 4 pharmacists, 2 dental auxiliaries, 3 laboratory technicians, 2 radiographers, 4 environmental health officers, 1 nutritionist, and 3 health educators. New categories of workers have been trained to enhance delivery of services at the primary health care level in the fields of nutrition and dietetics, health information, epidemiology, environmental health, and public health nursing. Nursing personnel were redistributed in the primary care sector for improved island coverage. Expenditures and Sectoral Financing The Government is the major provider of health services in Anguilla. Recurrent expenditure on health in 1995 was 18% of total Government expenditure, which ranks second after education, and represents 4.5% of the gross domestic product. Approximately 12% of the total recurrent expenditure for health is collected in users’ fees for dental, hospital, and pharmacy services. Some 90% of the cost of health services is subsidized through exemption of persons from charges and unrealistic user fees. The level of private expenditure is not known. However, it was estimated that in 1993, nationals spent at least US$ 1.48 million for private doctor fees and for accessing treatment outside of Anguilla. The country’s decision in 1995 to restructure its health care process has led to greater definition in the health budget, and a separate budget line for primary health care with delegated financial control for expenditure and monitoring. External Technical and Financial Cooperation The health services received assistance for capital expenditure from the Dependent Territories Regional Secretariat of the British Foreign Office, totaling US$ 1.3 million from 1992–1995. The Overseas Development Agency of the United Kingdom funded the health sector adjustment project, which examined restructuring of the health services with a particular focus on equity, efficiency, effectiveness, quality, and strengthening primary health care.
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