Saint Lucia enjoys political stability. However, the introduction of foreign values through foreign content on television, the extent of consumerism, and the increase in urbanization have eroded traditional cultural values. Social integration has been difficult to accomplish in the absence of clear policies and the presence of 'disintegrating' factors (crime, substance abuse, stigmatization/discrimination/marginalization of socio-economic groups and disintegration of the family unit.) The provision of basic services and facilities, effective participation, and the reorientation of the value system need to be enhanced to support the process of social integration. The Ministry of Planning has the central role in coordinating intersectoral collaboration. The political structure is based on central control with little decentralization of planning and services. Efforts towards decentralization in the 1980s have not progressed significantly. The government does not have a formal policy on community action. The role of women in national development has been defined and is documented in a 1994 report 'Putting Gender on the Agenda'. A plan of action to address the needs of women has been developed and is presently being implemented.

Saint Lucia had continued economic growth from 1990 to 1995. The growth rate has been slower than in the period prior to 1990, ranging between 2.14% to 7.2%. In 1995 the growth rate was 4.1%. The major sectors of the economy are agriculture, tourism, construction and manufacturing. The major fluctuation in sectoral growth has occurred in the agricultural sector and in particular, the banana industry which accounted for 69% of agricultural earnings in 1990. It has been plagued with shortages of inputs, global liberalization of trade policies and the reduction in the price on the European market, and in 1994, the Tropical Storm Debbie damaged 58% of the crop. The industry recorded an increase in production of 13.6% in 1995.

The tourism sector plays an increasing role in the economy, due to an increase in the total visitor arrivals and stay-over visit arrivals. Hotel occupancy rates averaged 68% for the period 1990-1995. Growth in the construction industry has been influenced by the implementation of major public sector projects. The manufacturing sector experienced a significant decline in growth rate to 1% in 1990. Since 1990, the performance of this sector has only shown moderate improvement due to competition from regional and international low cost suppliers, decreased demands from the country's major markets and the state of the domestic economy. The effects of these factors reached their peak in 1994 when the sector contracted by 12%. In 1995, this sector grew 14%. The public sector investments have remained at over 13% of the GDP.

Between 1992 and 1994 the labor force grew 6.8% to 62,034. The percentaje of females in the labor force increased from 46% in 1992 to 53% in 1994. Youth in the age group 15-19 years made up 10.7% of the labor force in 1994. Labor participation rates increased from 64.9% in 1992 to 67% in 1994. There was an increase in female participation rates from 54.7% to 60% and a decrease in male participation rates from 77.3% to 74%. Unemployment rates increased from 16.7% in 1992 to 19.2% in 1994. This increase was observed in all age groups, but was greatest (from 37% to 47%) in the 15-19 years. The working poor are concentrated in the agriculture and manufacturing sectors There is little information on income distribution.

The estimated population of Saint Lucia increased 8.2% since 1990 and was 145,213 in 1995. There has been little change in the age-sex structure of the population during the period 1990-1995.The birth rate had a small decline from 27.6 in 1991 to 25.2 in 1995. Total fertility rates fell from 3.0 in 1990 to 2.5 in 1995. Teenage fertility rates fell from 104 in 1990 to 80 in 1995, yet teenagers still account for 20% of all births. In 1995, the under-5 population constituted 11.8% of the population, children 0-14 years 34.8%, and 64% is under 30 years of age. Adolescents make up 10.9% of the population. Twenty-six percent of the population are women in the reproductive age group, 15-49 years. Persons 65 years and over account for only 6.1%. The economically active adults (15-64 years) comprise 59% of the population and the age dependency ratio was 0.69 in 1995. Thirty percent of the population lives in urban areas. There is limited data on migration. According to the 1991 population census 25% of the population had moved from their place of birth, 30% of whom were residing in the capital city at the time. The 1995 Poverty Assessment survey revealed that 20% of households had reported recent migration.

Enrollment at the primary school level is high with equal opportunities for boys and girls. The percentage of students going to secondary schools rose from 31.9% in 1990 to 43.8% in 1994. More females got acceptance to secondary school with the enrollment ratio averaging 1:1.13. The number of school places has increased by 34% between 1990/91 and 1993/94.

In 1991, the National Policy Statement on Women was adopted and in 1994, the Ministry of Women's Affairs was created under the direction of the Attorney General. Women have equal opportunities for education and are in the majority for participation in secondary and tertiary education programs, and adult literacy classes. Women have always participated in public and political life but their involvement in political life has been lowkeyed and at the grass roots level. Women have not contested in the last three general elections.

The radio is the most widely used method of mass communication in the country, and has been used for health education in both Creole and English. Access to television has increased.

The 1995 Poverty Assessment Survey found that 5.3% of households and 7.1% of the population were indigent, in that their expenditures were inadequate to cover their dietary requirements. Severe malnutrition is now almost non-existent. Pockets of undernutrition exists in certain areas. The number of reported cases of malnutrition in the under-5 population ranged between 1 and 6 cases per year for the period 1990-1995. Children in preschools and primary schools benefit from the School Feeding Programme which is funded by World Food Programme. The majority of preschools are privately owned. Multiple micronutrient deficiencies are not a public health problem in Saint Lucia. Iron deficiency anemia is a persistent problem but the extent of the problem, particularly in the vulnerable groups of women and children has not been assessed. Iron deficiency anemia in children and non-pregnant women is not reported. Analysis of antenatal records in 1990 showed that 20% of pregnant women had hemoglobin levels of less than 10gm/dl. There is routine hemoglobin screening and administration of iron supplements to pregnant women. Fortification of wheat flour with absorbed iron is practiced by regional producers. Food imports averaged 19.87% of the total imports for the period 1990-1994. The Consumer Price Index for food items has shown a steady increase from 126.0 in 1990 to 160.5 in 1995, an increase of 27 percent.

The use of the electronic media in nutrition education has increased and has focussed on using locally available food items. Health education is conducted in schools, health facilities, work places and via the media. Sexual health is still a taboo subject which is not adequately addressed. Sexual health is included in the Family Life Education curriculum in primary and secondary schools.

From 1990 to 1995, there has been an increase in the number of reported cases of domestic violence and abuse to the Social Services department. It is not clear whether this represents an actual increase in number of incidents or increased awareness and willingness of persons to report. Victims of domestic violence receive support and counselling from the Social Services department and the Crisis Center. The Ministry of Womens' Affairs has prepared booklets and leaflets which provide victims and providers of care with information on the rights of victims, and available support services.

The Bureau of Health Education and the Cancer Society have been the main advocates against the use of tobacco. In 1994, all Ministry of Health buildings were declared as smoke free areas and this was extended to include all government buildings in 1995. The sale of tobacco and alcohol to minors is prohibited by law. Information on tobacco consumption is not available. There have been no assessments in the trends in alcohol use. Alcohol abuse is the most common drug abuse admitted to the Drug Rehabilitation and Treatment center. In 1995 6% of all deaths in persons 15-64 years, were alcohol related. The value of production of alcoholic beverages and tobacco has increased by 18.6% between 1990 and 1993. The use of psychoactive substances has increased especially among young males. There is an inpatient service for drug rehabilitation. The majority of clients are self referred and receive a complete physical examination and screening for STD=s. An after care service is available on an outpatient basis. Polyabusers accounted for 60-76% of admissions during the period 1992-1994.

Several agencies are involved in health and the environment sometimes leading to difficulties in coordinating the planning and implementation of activities. The government has several initiatives to ensure sustainable development, including the establishment of a National Environmental Commission, review of legislation which impact on environment and health, the construction of the Roseau Dam, the Solid Waste Management project, an Integrated Coastal Zone Management Plan, and an Action Plan for Integrating Health and the Environment. The Ministry of Planning has responsibility for the monitoring and control of air quality. Standards for air quality are available but have not been translated into policy. The contribution of traffic to air pollution, especially in the capital city, is increasing. Unleaded petroleum is available, but it is more expensive than the leaded variety. Water quality is the combined responsibility of the Water and Sewerage Authority and the Ministry of Health (MOH). There are mechanisms for the surveillance and control of biological and chemical contamination of water. Land use has been zoned for agricultural, industrial and for human settlement. However, problems arise in the monitoring and enforcement due to attitudes and practices of the population with regards use of chemicals and protection of the water supplies. The reponsibility for solid waste management is shared by the Ministry of Planning, the Environmental Health Branch of the Ministry of Health, the Castries City Council and the Ministry of Community Development. Approximately 60% of collection in Castires is contracted out privately. The disposal of solid waste is through the use of open dumps and its management is unsatisfactory. Waste generated by public health care institutions is incinerated on the premises of these health facilities. There is no assessment of the adequacy of this practice or the manner of disposal of wastes generated in the private health sector.

The Food Unit of the Environmental Health Department is responsible for all aspects of Food Protection, Control and Safety. A ten year plan has been developed addressing major issues that impact on food quality and safety. The functions of the unit have been reviewed. A proposal has been developed for the establishment of a Food Quality and Control Unit. There has been extensive training of food handlers. Hotel staff have received training and have refresher courses every two years. There is great under reporting and incomplete and inconclusive investigations of food borne illness. In the hotel and restaurant industry, food samples are not kept and there is no routine system for testing food samples; there are delays in reporting and guests may have left the premises or the country by the time a report is submitted to the Food Unit.

The Occupational Health and Safety Unit of the Ministry of Education, Culture, Labor and Broadcasting, is responsible for monitoring, investigation and enforcement of worker=s health legislation. The working population is not adequately covered by occupational health services as there is only one Occupational Safety officer. The legislation on occupational health needs to be updated and made more comprehensive. The law makes provision for reporting of occupational diseases but there is no compliance or enforcement of the law. There is no national institution for health promotion. The Pesticide Control Board was established in 1975 and The Pesticides Control and Labelling of Pesticides Regulations were introduced in 1987. There is no national chemical poison prevention and treatment centre.

The 1991 Census indicated that 100% of the population had water supply available in the home or within a reasonable access. 75% of the population were connected to the municipal water supply and 48% had pipe borne water in the home. There are 37 water sources supplying water to 31 treatment facilities. The problems of water quality which were aggravated by the damage sustained to water treatment and storage facilities as a result of Tropical Storm Debbie. The improper disposal of chemicals used in the agriculture and manufacturing sector near raw water sources and the unrestricted access to raw water sources with possible contamination by humans and animals affect water quality. A study in 1995/96 on the existing pipe borne water supply in the island reported that approximately 46% of the population are served by water treatment facilities which lack the basic process of chemical sedimentation. Despite the recent completion of the Roseau dam, the water supply to consumers in the Castries/Gros Islet basin has been frequently interrupted due to damage in the old water distribution system.

The main forms of sewerage disposal are the pit latrine (49%) and septic tanks (29%). Only 6% of the population were linked to the sewerage system. Eleven percent of households had no excreta disposal facilities and were concentrated in rural areas. Government still operates some 50 public toilet facilities throughout the island and still provides household items such as toilet paper and soap to these facilities. The maintenance of these facilities is costly and accounts for 30-35% of the annual recurrent budget of the Environmental Health Department.

The number of reported cases of diarrheal disease and parasitic infestation have been decreasing but still are major causes of morbidity in the general population and in the under-five population. Under-reporting of these diseases is extensive with negligible data from the private sector. The reported number of typhoid cases was 6 in 1990 and 1 in 1995, dysentery (all) fell from 89 to 33 and gastroenteritis in infnats below 5 years of age from 878 in 1990 to 168 in 1995. The number of cases of schistosomiasis reported to health authorities fell to between one and three per year from 1991 to 1995. Nine cases had been reported in 1990.

The majority of health personnel are employed in the public sector. There has been a shift of health professionals especially laboratory staff, from the public to the private sector. An increasing number of physicians and dentists are entering the private sector because of limited opportunities for employment in the public sector. The number of other categories of health professionals in the private sector will increase when the private hospital begins operateion in 1997. The deficiency in the numbers of nurses experienced from 1989 to 1991 has been offset by the employment of foreign trained nurses and the recommencement of local training of nurses.

The Sir Arthur Lewis Community College is the only local institution that trains health professionals. In 1994 it conducted a Community Nutrition Diploma Course for Field Nutrition Officers and short courses on family planning, sexually transmitted diseases, women's health and adolescent health. Its nursing division was established in 1988. The University of the West Indies trained teachers, nurses and family life educators in Family Life Education in 1990, 91 and 92.

The number of public health professionals/specialists is inadequate for the country. Public health training is not available locally and nurses. Community Health Aides have been used in the public health sector since 1980. They are recruited from their area of residence, are trained locally and receive in-service training. There were 67 CHAs on staff with no change in numbers over the period 1990-1995.

The health sector is the second highest recipient of government funds. The approved budget averaged 12-13% of total recurrent expenditure from 1992 to 1995. The major source of funding comes from the consolidated fund.

The National Insurance Scheme (NIS) makes an annual contribution towards the medical expenses of persons who are members of the insurance. This contribution is not based on the actual cost of health service provided to its members. The amount was EC$ 1 million until 1994 and was increased to EC$ 3 million in 1994/95. Before 1994 the amount disbursed contributed between 34-70% to the total health revenue and accounted for 50% in the financial years 1994/95 and 1995/96.The contributions by International donors have dwindled; they play a more significant role in capital expenditure in the health sector (78% of the funds for capital works completed in 1989-1994). In 1992 the user fees for the public sector were reviewed; they accounted for 29.5% of total health revenue in 1989/90 and 49% in 1992/93. Revenue collection is inefficient. Only 30% of hospital billings and less than 25% of confinement fees are collected. The government has identified groups which are exempt from user charges based on level of income, as well as certain public servants such as nurses, police and fire officers. Numerous problems exist in evaluating the ability of persons to pay for services. The expenditure on drugs and medical supplies (excluding vaccines) averaged 4% of the total recurrent health expenditure for the financial years 1991/92 to 1995/96.

The role played by the public and private sectors in the provision of services depends on the type of service. Antenatal care is provided by both sectors, whereas immunization, casualty/ emergency services, and the care of persons with cancer and those requiring renal dialysis, has been the responsibility mainly of the public sector. In 1993 the Ministry of Health commenced discussion for the development of a National Health Insurance (NHI). The NHI benefits will cover medical expenses incurred for inpatient, outpatient, drugs, diagnostic and ambulance services to individuals using the public hospitals. The NHI will not cover dental and vision care, services obtained at health centres and private clinics, and overseas medical care.

There are two general hospitals (193 and 107 beds), two district hospitals (28 and 21 beds), a psychiatric hospital, a Drug and Rehabilitation center and 34 health centers. Seventy percent of the health centers are in a good condition. During the period 1992-1995, major repairs have been completed on 14 health centers. A five year plan for the development of the physical infrastructure has been prepared. A 1994 feasibility study on the rehabilitation of Victoria Hospital analyzed national demographic and socioeconomic trends, morbidity patterns and the human, physical and financial resources as a basis for recommendations for the development of the health services throughout the country. The 10 year Health Sector Plan:1993-2003, also addresses the development of physical infrastructure. The procurement of equipment is not coordinated and as a result a variety of brands of particular items are procured by different departments. This adds to the problem of maintenance of equipment and the purchasing of spare parts. The absence of preventative maintenance has adversely affected the lifetime of equipment.

The Regional Formulary and Therapeutics Manual of the Eastern Caribbean Drug Service is used. The manual contains a national essential drugs list. These drugs are the only ones available in the public health service with the exception of drugs which do not qualify for ECDS purchasing and specially authorized drugs. During the period 1990-1995, the drug budget of the Ministry of Health has ranged between EC$ 1.1 - 1.8 million. It represented 6.23% of the total health budget in 1990/91, and has averaged 3.95% for the financial years 1991/92 to 1995/95. The Government took over the purchase of contraceptive supplies in 1994 and drugs for the leprosy programme in 1995. The availability of pharmaceutical supplies has improved, with fewer and shorter periods of drug shortages. A study on rational drug use in hypertension and diabetes was conducted during 1992-1995. Practices were fairly rational and deficiencies were communicated to health professionals through Drug Utilization Review seminars. There is no national drug regulatory authority. CARICOM is planning the establishment of a Regional Advisory Body on Drugs and Therapeutics which will serve as a Regional Drug Regulation Authority. There is no legislation related to the importation of drugs. The Chief Pharmacist prepares the import licenses for controlled drugs being imported by private pharmacies, and monitors the type and utilization of this category of drug in the country.

The St. Lucia Blood Bank Service commenced screening for HIV and HBsAg in 1986 and for HTLV-1 in 1989. All prospective donors are screened by a questionnaire to exclude persons at high risk of having a blood transmitted disease. Donors that are accepted are screened for HIV, HTLV-1, HBsAg and VDRL and ALT. During the period 1988-1995, 6 of the 9645 blood donors tested were positive for HIV infection.

Information on the resources allocated was not available as some funds are not disbursed directly to the country and information on funds for capital projects was not presented on a yearly basis. International institutions have operated in various capacities as health advisors, donor agencies, trainers and facilitators in the implementation and financing of projects. The impact of international cooperation and partnerships has been to stimulate and pioneer new techniques and developments, and assisting in the transfer of technology.

The government has concentrated its efforts on ensuring a minimum level of health services through the development of a National Health Insurance which will cover hospitalized care for the employed and their families, while the government will be responsible for the care of persons who are socially dependent. New legislation for solid waste management has recently been passed. Most of the legislation pertaining to health is presently under review, in particular laws pertaining to workers' health, emergency preparedness, and food quality and control. The revision of the user fees which are prescribed in the Hospital Regulation in 1992 has had a beneficial effect on the health revenue collection for the Ministry of Health. The National Policy for the Ministry of Health 1993-2002 is included in the National Ten Year Health Sector Plan - St. Lucia, June 1993-July 2003. The plan with the policy has not been circulated to the different health departments. There are no policies which provide support for research for PHC. There is no specific plan of Action for HFA. However the goals and strategies are reflected in the health plans of the different departments and the Ministry of Health.

Intersectoral cooperation has improved significantly but relies on informal relationships between individuals. It has always been best at the lower levels of the health sector, but is occurring more frequently at the central. Community involvement in the health sector has mainly been limited to the development and implementation of specific health projects.The increase in the level of intersectoral cooperation has occurred because of a need to make maximum use of the scarce resources available to the different government sectors. Government has also acknowledged that the health sector must be included in all aspects of national development.

The community health nurses form the backbone of primary health care is service and are trained to deliver the services, receive regular in-service training and are guided by written procedure manuals. Training in public health community participation, and the team approach and management, is not adequate. Utilization rates of primary health facilities are not routinely studied. Diagnostic equipment and other resources are adequate. The referral system within and from the primary health care system is well developed. The referral from the secondary and tertiary level is inefficient. Data is not collected on the number of referrals to district and general hospitals, which come from the PHC services.

The preventative health care services are utilized appropriately. Analysis of the use of other levels of care is not performed. The majority of health centres offer medical services only once a week, therefore clients have to seek care at other health care facilities in the public or private sector. The Accident and Emergency Department at Victoria hospital and St Jude hospital bear the brunt of the work after hours and on public holidays. District hospitals control their own budget but they receive all supplies for the primary health services from the budget of the Community Nursing Service. The budget for health centres is controlled at the central level.

There is a significant move towards the privatization of services. Sixty percent of the garbage disposal services have been privatized. Other areas that are being considered are transportation for support medical staff on on-call duty, and the laundry and food catering services at the main hospital.

The management at the district level has improved. The costing of plans is often based on previous experience but the need to justify budget requests has encouraged Heads of Departments to provide more detailed and accurate plans. Structures are not always in place for the routine monitoring of national plans and strategies except for certain programmes which require this process in reporting to international donors. Mechanisms for dissemination of information and decision are present but do not always function effectively.

Health information is not adequate or when available is not used extensively in decision making. The Health Information System has undergone much reorganization during the period 1990-1995. The system remains fragmented, especially in the area of data storage and analysis and continues to focus on morbidity and mortality data with little expansion to include information required for improved planning and management like physical infrastructure, inventory of biomedical equipment, human resources and others. The Health Information system for communicable diseases receives reports from routine and sentinel sites, laboratories, hospitals and special programs (EPI, leprosy, HIV/AIDS and STD=s). Surveillance is in place for dengue, diarrhoea, rash, acute flaccid paralysis and acute respiratory tract infections in children. Recently a monthly newsletter was prepared to provide information to health workers on the communicable disease patterns in the country. The collection and analysis of data on births and deaths is well developed. Analysis of morbidity data on chronic non-communicable diseases is not performed. The Epidemiological unit collects information data on antenatal, postnatal, and family planning services from reports of the Community Nursing Service.

Health professionals working in the community have received basic training in surveillance. At the district level, Public Health Nurse Supervisors and Environmental Health Officers are responsible for disease investigation and control. The laboratory at the main general hospital processes specimens for bacteriological and certain viral investigation. Other viral studies have to be sent to CAREC for analysis. There are no public health laboratories.

The process of community involvement is not formalized and has inadequate financial resources. Community health and environmental health exist since 1980. The community is not involved in the selection process. The most successful examples of community involvement are the Schistosomiasis Prevention and Control project, the St Lawrence Excreta Disposal and Water Supply Improvement project and Dengue Fever Prevention. The community has also participated in surveillance of certain communicable disease, health education and promotion activities, strategies to reduce teenage fertility and HIV/AIDS/STD control. NGO’s are few in number. The Cancer Society was responsible for the introduction of screening for cervical cancer and has now shifted its focus from screening activities to cancer education and support. The Sickle Cell Association and the Diabetic and Hypertensive Association have also made contributions to health development.

The management structure for emergency preparedness has been reorganized, and is the responsibility of the new National Emergency Management Organization. Subcommittees have been formed to manage the areas of health and welfare, transportation, telecommunications, supplies management, damage assessment, rehabilitation. Training and education has been ongoing and included disaster simulation exercises in 1991 and 1994. The awareness of the public has been raised. There is an emergency plan for the Ministry of Health which includes plans for the hospitals and health centres. A health emergency information system is in place and has been put into operation during the recent flooding.

The country experienced a series of earth tremors in 1990 and an oil spill n 1995. No major damage was reported as a result of these incidents. Over the past two years, the country has been subject to severe flooding which have been caused in part by the indiscriminate cutting of forest areas and the improper garbage disposal. In 1994 the passage of Tropical storm Debbie resulted in 3 deaths and caused major damage to the agriculture sector and to the physical infrastructure. Damage to health facilities was estimated at EC$ 1.9 million and the total damage estimated at EC$230 million.

The Caribbean Charter for Health Promotion was adopted by the government in 1994 but has not been translated into a national policy. The Bureau of Health Education (BHE) is responsible for health education and promotion within the Ministry of Health.education and promotion does not exist in the country. The budget of the BHE is inadequate for health education and promotion activities of the Ministry of Health. The level of intersectoral cooperation is high. The BHE is represented on various governmental intersectoral bodies and collaborates with other ministries, NGO=s and community groups. Formal training in health education is not available locally and has to be pursued at regional and international institutions. In-service training on health education and promotion is ongoing for health workers.

The use of the mass media, especially the radio and television, has increased but is limited because of the costs. Use of the print mass media and the preparation of articles, flyers and printed T-shirts is restricted to the observance of International Days for specific health issues. The popular theatre as a vehicle for health education and promotion has been used in the HIV/AIDS/STD and immunization programmes. The AIDS/HIV/STD programme has also used a carnival band and calypso to disseminate information to the general public.

There are no clear policies on reproductive health. Reproductive health care services, available at all health centers, include antenatal, postnatal, family planning, and treatment of medical problems including sexually transmitted diseases. The community health nurse is the main provider of the preventive reproductive health services. Family planning services are offered at all health centers with more flexible hours than other MCH services to accommodate working clients. The St. Lucia Planned Parenthood Association provides family planning services at a clinic in the capital city, at some work places, and through Community-Based Distribution outlets throughout the island. The last contraceptive prevalence survey was conducted in 1988 and showed that 54.8% of fecund non-pregnant and in-union women were using a contraceptive method. After the 1991 study on adolescent fertility strategies have been developed at local and regional levels to reduce teenage pregnancy.

Antenatal, postnatal and family planning services are offered at least once a week at all health centers. The number of trained health professionals providing MCH services is adequate. Only 50% of women use the public health clinics for antenatal care and of these 10-15% register before 16 weeks. All pregnant women have at least one consultation with a trained health worker. All pregnant women are screened for sickle cell anemia and cervical cancer. Intranatal care is provided mainly at the general and district hospitals. Between 95-99% of deliveries occur in hospitals. The monitoring of mothers in the early postnatal period is not timely or adequate. Only 44% of women who have delivered, seek care in the public sector for the six-week postnatal examination. In 1993 a Community Paediatric Program was implemented with a pediatrician visiting health centers throughout the island at least on a six-weekly basis. Developmental screening of children by community health nurses commenced in 1994. There is no organized school health programme. Family nurse practitioners, community health nurses and dental staff conduct physical and dental assessments of primary school children.

Saint Lucia offers immunization with BCG, DPT, OPV and MMR vaccines to children under five years of age. The public sector is the main provider of childhood immunization services. The Ministry of Health provides vaccines to private practitioners and receives immunization given by this sector. Immunization coverage rates have been 90% or greater for BCG, DPT and OPV for the period 1990-1995. MMR coverage rates have remained above 90% since 1993 but there are important regional fluctuatuions In 1995, two health regions, which account for 17% of the target population, recorded coverage rates of 74% and 83%.. Saint Lucia recorded its last case of poliomyelitis in 1970. The surveillance system was started in 1992 and has had great difficulty in receiving regular and timely reports on acute flaccid paralysis from hospitals. Neonatal tetanus was last reported in Saint Lucia in 1985. During the "Big Bang" campaign of 1991, 96% of children below 15 years received measles vaccine. There was a mop-up campaign for children under-5 in 1996. A surveillance system for rash and fever was introduced in October 1991 with 4 reporting sites that increased to 38 in 1995.

Saint Lucia experienced an outbreak of Congenital Rubella Syndrome during March-April 1983 in which approximately 20 cases were reported. In response to this outbreak, rubella vaccine was introduced into the immunization programme in 1983. Antenatal screening for rubella antibodies is not routine. Immunization of women in the postpartum period commenced in 1987. In 1992-1993 six cases of rubella were laboratory confirmed through the rash and fever surveillance for measles elimination. Hepatitis B is not included in the national immunization schedule. In 1989-1990 two hundred health staff including doctors, dentists, nurses, laboratory and dental staff were offered immunization with Hepatitis B vaccine.

Surveillance is conducted on communicable diseases of international, regional and national interest. Active surveillance is in place for dengue, diarrhoeal diseases, measles, poliomyelitis and HIV/AIDS/STD. During the period 1992-1994, 25 cases of measles were reported to the Epidemiology unit compared with 75 to the measles surveillance system. This is due to the fact that the measles surveillance system relies more on reports from nurses than from the doctors. The community is not actively involved in disease surveillance. Vector control programmes are in place with an emphasis on health education and the reduction of risk factors. Health workers have been trained in the diagnosis and surveillance of dengue fever, measles and poliomyelitis and mechanisms have been put in place to facilitate the transport of laboratory specimens to the main hospital and to CAREC. Laboratory facilities for bacterial, parasitic and certain viral infections are available locally. The laboratory investigation of other viral disease such as dengue, measles, poliovirus, leptospirosis is conducted at CAREC. All blood for transfusion is screened for HIV, HTLV1, VDRL and ALT.

The entire population has reasonable access to primary health facilities. Women and children make greater use of preventive health services but there are no national standard treatment guidelines for the treatment of common communicable and noncommunicable diseases. During 1990-1995, training in the management of common diseases has not been done on an organized basis..

Life expectancy improved significantly over the previous three decades from 55 years in 1960 to 72 in 1991, and has shown no significant change for the period 1990 to 1995. The 1991 Population Census gave the life expectancy at birth as 69.2 years for males and 73.9 for females.

In 1995 the crude death rate was 7.3/1000, a significant decline from 14.6 in 1960. Between 1990 and 1995 the infant mortality rate oscilated between 12 and 18 per thousand live births. The IMR is underestimated due to under reporting. In 1995 ten infant deaths that had not been previously registered were retrieved from hospital records. Conditions originating in the perinatal period accounted for 63% of the registed infant deaths during the period 1990-1995. Rougly 50% of these are prematurity, birth asphyxia and respiratory problems. The under-5 mortality rate averaged close to 7.5% of all deaths during the period 1990-1995.

In the period 1991-1995, heart disease and cerebrovascular diseases were the major causes of death in persons over 65 years, tumors for 45-64 years and accidents for 15-44 years. In 1995 11% of deaths were due to Diabetes Mellitus (an increase from 8% for 1990-1994). In 1995 only three percent of the 966 reported deaths were due to infections. Infectious enterocolitis, septicemia and tuberculosis were the leading causes. For 1990-1994 the patern was similar and there were 2 deaths from tetanus and 1 from dengue hemorrhagic fever. In 1995, 1 death was due to leptospirosis, and 2 from shigellosis and none registered from dengue hemorrhagic fever.. The number of deaths due to AIDS increased from 23 to 71 from 1990 to 1995. In 1996 only 1death was registered as due to AIDS whereas the AIDS/HIV surveillance system reported 10 deaths.

From 1990 to 1994, 5 maternal deaths were reported giving an average maternal mortality rate for that period of 2.8/1000 livebirths. In 1995, no deaths were reported. There has always been a concern of under reporting of matrenal deaths.

Morbidity data is collected mainly from the public sector clinics. Diagnostic confirmation is not always sought due to problems of transport of specimens. From 1990 to 1995 120 cases of tuberculosis (all respiratory) were reported. The reported cases of leprosy have decreased from 15 in 1991 to 5 in 1995. The leprosy programme had 24 cases on treatment in 1996, a decrease of almost 50% compared to 1989. A total of 15 cases of dengue were reported in 1990-1995. The country is at high risk for an epidemic as the virus is circulating in the country and the aedes aegypti indices are high. The surveillance system for dengue fever was strengthened by intensive staff training starting in 1995. Following this training, the number of suspected cases rose sharply in 1996 to 59 with only 7 cases confirmed by laboratory investigation. The last case of poliomyelitis was in 1970. Since 1985 no cases of neonatal tetanus have been reported. There have been no confirmed cases of measles since surveillance commenced. There were 3 cases of malaria reported during the period 1990-1995. The 2 cases reported in 1995 were imported.

As of March 31st 1996, 143 cases of HIV had been reported to the AIDS/ HIV surveillance system of which 7 were in children. In adults, the number of females infected is increasing and the male:female ratio is 1:1.27. Eighty five cases of AIDS were reported between 1985 and 1995. The incidence rate for AIDS has shown a steady increase, 71% of male cases and 57% of female cases at age 20-44 years. The main route of transmission is heterosexual. In 1994, 1010 pregnant women were tested for HIV. There was only one positive result. In 1995, 800 cord blood samples were tested for HIV. There were no positive results.

There are no national registers for chronic diseases.

The 1991 Population census recorded 9449 persons with disabilities which represents close to 7% of the total population; 58.2% were females. The cause of the disability was not recorded. Locomotor disability was the most common type of disability reported, followed by vision and mental problems. These three groups represented 45.8%, 21.7% and 14.2% of reported disabilities for males and 47.8%, 25.8% and 9.5% for females. There is a program of Community Based Rehabilitation, with the Community Health Aides as the main providers of the service. At the end of 1995, the CBR register had a record of 591 persons with disabilities.

Saint Lucia has maintained a relatively good state of health with improvements in life expectancy and low mortality rates, especially in the under-5 population. The improvements in housing, water supply, sanitation and general nutrition have reduced the incidence of communicable disease and malnutrition. However, the adoption of unhealthy lifestyles has contributed to the increased morbidity and mortality from chronic diseases which will require a redefining of the role of PHC. The increase in accidents and substance abuse, especially among the young population, further contributes to morbidity with long term disability and even death. The number of health professionals for the delivery of PHC services is adequate. The present economic climate does not allow for much expansion of physical and financial resources. Cost-containment measures will need to be strengthened and implemented. The implementation of the NHI is seen as a major factor in increasing health revenue. Partnerships need to be developed with the private sector especially with regard to the provisions of drugs and pharmaceuticals.

The importance of health information as a basic tool for planning and management has already been stated but must be emphasized. Health professionals need to be given the necessary authority, responsibility and appropriate training to manage the health programs more efficiently. Improvements in the management of common diseases has been limited by inadequate morbidity data and standard treatment and management guidelines. The decentralization of health planning and management, and the promotion of intersectoral collaboration and community participation are necessary processes in order to lessen the adverse effects of the current socioeconomic climate on health. In the face of limited financial resources, a shift in focus of disease programs and the changing role of the health professional, international partnerships cannot be ignored. The role of international institutions as advisors, and in the transfer of technology, the training of health professionals and the coordination of regional programs in health must be strengthened to ensure that the country is successful in addressing these new challenges.

The national health policy to ‘maintain and upgrade the present and future stock of human resources' will be achieved through the provision of health services which focus on the promotion and protection of health.

These objectives will be addressed through strengthening in the areas of health education and promotion; provision of health services; management of health programs; partnerships in health; and cost-containment and cost recovery mechanisms.

The mechanisms employed for resource mobilization are based on the principle that the pursuit of good health is a basic human right, that other sectors impact on and have a responsibility for the health of the population, and that individual must assume responsibility for personal and community health.