Anguilla is the most northerly of the Caribbean's Leeward Islands. Anguilla's 91 km2 are mostly flat. The territory has few natural resources, mainly salt, fish, and lobsters. The capital is The Valley.
The British colonized Anguilla in 1650; it became a separate British dependency on 19 December 1980. Anguilla's executive authority is vested in Her Majesty, the Queen. The Government of the United Kingdom is responsible for Anguilla's external relations, defense, and internal security. The territory is governed as a Westminster–style parliamentary democracy. There is a unicameral legislature, with seven popularly–elected members of the House of Assembly. Elections are scheduled every five years, with the most recent having been held in 2010.
Anguilla participates in subregional, regional, and international organizations and forums. The country is an associate member of the Caribbean Community (CARICOM) and of the Organization of Eastern Caribbean States (OECS).
Its currency, the Eastern Caribbean dollar, is pegged to the United States dollar, at US$ 1.00 = EC$ 2.6882. The country's economy is service–based, with tourism, offshore banking, and remittances being the mainstays.
In 2006–2007, the economy was vibrant, growing by 10.9% in 2006 and 12.0% in 2007; this growth was attributed to expansion of the tourism and the construction sectors. However, in 2008, growth was only 4.5% due to the global economic downturn. The economy further declined by 13.6% in 2009, and provisional results for 2010 indicate that the real gross domestic product (GDP) fell by 3.8% (1).
The 2001 census population was 11,561, with 5,705 males and 5,856 females. The estimated population for 2010 was 16,373. In 2006, life expectancy at birth was 77.3 years (74.4 for males and 80.3 for females). In 2010, life expectancy at birth was estimated to be 80.2 years (78.2 for males and 83.4 for females). Figure 1 shows Anguilla's population structure, by gender and sex, for 1992 and 2010.
Over the reporting period there were 900 births, 472 males and 428 females. The birth rate fluctuated, from 12.8 per 1,000 population in 2006, to 9.9 in 2008, and to 11.4 in 2010. There were 325 deaths during the period, and the death rate was 4.1 per 1,000 population in 2006 and 4.9 per 1,000 population in 2010 (see Table 1). Variations in the birth and death rates over the reporting period may be due to Anguilla's small population base, where slight increases or decreases in the absolute number can produce big shifts in the rate.
Migration is an important demographic factor in the territory. The boom in Anguilla's construction and tourism sectors in 2006 and 2007 increased the demand for labor, creating a magnet for workers from elsewhere seeking employment in Anguilla. It was estimated that, in 2009, migration inflows were 14.06 per 1,000 population (2). Persons naturalized or registered came mainly from the Dominican Republic, Jamaica, Saint Kitts and Nevis, the United States of America, and other Caribbean countries.
The use of information and communication technology increased between 2006 and 2010. Cell–phone subscriptions rose from 96.72 per 100 population in 2006 to 128.07 in 2010; fixed telephone lines, on the other hand, decreased from 41.58 per 100 population in 2006 to 41.02 in 2010. Internet users, too, increased, from 36 per 100 population in 2006 to 48 in 2009 (3).
The territory has made a number of advances in health over the years, including improving sanitation, maintaining vaccination coverage above 95% for targeted diseases, eradicating smallpox, and the measles; it has also continued partnerships in combating the HIV epidemic and improved water quality and food safety. There is an effective regulatory system in place to ensure continued food safety (such as mandatory food handlers' education and certification programs, and monitoring water quality through periodic testing/sampling); development of a primary health care system; provision of dialysis services; provision of free antiretroviral drugs; and effective and relatively low–cost dental services.
Health Determinants and Inequalities
School is compulsory for children aged 5–17 and education is free in all public schools. In 2008, overall primary school enrollment stood at 92.9%, with girls' enrollment (93.0%) being slightly higher than that of boys (92.7%). The Anguilla Community College was established in 2009 to provide in–country access to postsecondary and tertiary education. In addition, Anguilla participates in the University of the West Indies–Open, which offers multi–mode teaching and learning services through virtual– and physical–site locations across the Caribbean. In 2010, adult literacy was 97.7%, with males being at 97.4% and females at 98.1%.
There were 8,736 work permits issued between 2007 and 2009, which allowed non–Anguillans to work in the territory; 6,979 (79.9%) were issued to males. Data shows a decreasing trend for the issuance of work permits—3,458 in 2007, 2,979 in 2008, and 2,299 in 2009.
The United Nations Development Program identified gender issues as an area in need of attention in Anguilla. Problems included wage differences between men and women across all occupation categories, as well as domestic violence (4). Data revealed that in 2006 there were no female ministers of government; of the seven permanent secretaries that year, one was a female, increasing to four by 2010. Among the heads of departments in the public service, in 2006 there were 9 females and 24 males with an increase to 13 females in 2010.
The Environment and Human Security
The National Environmental Management Strategy and Action Plan for 2005–2009 emphasizes the need for governmental agencies to collaborate with one another and with nongovernmental agencies. The Department of Health Protection 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.
ACCESS TO CLEAN WATER AND SANITATION
Anguilla has no rivers and is dependent on rain, wells, and desalination for its water supply. WHO figures for 2000 indicate that 60.0% of the population had access to safe water and 99.0% to improved sanitation. In 2006–2010, measures were instituted to improve the water supply: polyvinyl chloride (PVC) pipelines were installed to replace galvanized piping and a desalination plant was established. The Water Corporation of Anguilla was established in 2008, and is responsible for the supply and distribution of potable water for public consumption through the piped water system in Anguilla.
The total metric tonnage of solid waste increased from 10,452.85 in 2006 to 13,442.36 in 2010. Household waste increased from 3,429.98 metric tons in 2006 to 6,031.24 in 2010. Industrial waste also increased, from 523.74 metric tons in 2006 to 1,059 in 2010.
DEFORESTATION AND SOIL DEGRADATION
Erosion is a problem on the coast due to sand mining. Anguilla's dry scrub forest continues to suffer from invasive plant species and inadequate zoning/planning legislation and regulations.
The major disasters faced by Anguilla are hurricanes, tropical storms, and flooding. The low–lying topography of Anguilla increases the risks of flooding. In 2008, the territory was buffeted by Hurricane Omar, which caused substantial beach erosion. The country is also subject to earthquakes, but no major ones occurred during the period under review.
As a small island developing state, Anguilla is vulnerable to climate change and its sequelae. Challenges identified include increasing extreme weather events, especially hurricanes and droughts, increasing sea surface temperatures, sea level rise, coral reef degradation, and species and habitat destruction. Challenges for the fishing industry include the encroachment of the Sargasso weed which reduced the lobster and crayfish quantities; in addition, insects and other pests such as the pink mealy bug and the black sooty mole decreased agricultural production.
There was one reported case of salmonellosis in the period 2006–2007.
Health Conditions and Trends
HEALTH PROBLEMS OF SPECIFIC POPULATION GROUPS
Maternal and Reproductive Health
There has been progress towards achievement of Millennium Development Goal (MDG) 5 (improving maternal health). All pregnant women received antenatal care from, and were delivered by, trained health care workers. A prevention of mother–to–child transmission of HIV program was in place, and there were no HIV–positive mothers in the reporting period. Maternal deaths were rare, with only two in the decade: one in 2002 (amniotic fluid embolism) and another in 2010 (ectopic pregnancy). The cesarean section rate was 30.8% in 2008 and 42.9% in 2007. This was higher than WHO's recommended rate of 15.0%. Abortions or miscarriages were the main cause of obstetric admissions. In 2008–2010, there were 25 admissions for missed abortion, 34 for incomplete abortion, and 20 for threatened abortion (5). No data on contraceptive prevalence were available for the review period.
Children (up to 9 years old)
There was a very successful immunization program and coverage for DPT3 was 100%. The incidence of low birthweight (under 5½ lbs. or 2.5 gm) ranged from 8.0% in 2007 to 16.1% in 2009. In 2010, there was one suspected case of hand–foot–and–mouth disease.
The population under 5 years of age represented 7.2% of the total population in 2006. There were 8 deaths in this age group in 2006–2010. Coverage in the 1–year–old population against measles, mumps, and rubella (MMR) was 100%.
Caribbean Food and Nutrition Institute anthropometric data for 2010, collected among Anguillan children aged 0–5, showed that 1.3% of males were severely overweight and 2.6% were underweight. Among the girls in this age group, none were severely overweight, but 5.0% were underweight. In 2010, there were 341 reported cases of acute respiratory infection in the under–5–year–old population. Gastroenteritis was also a significant cause of morbidity with 326 cases in the latter age group. There were also 33 suspected cases of hand–foot–and–mouth disease in 2010.
Children 5–9 years old made up 6.6% of the population. In 2010, acute respiratory infections and gastroenteritis were the major causes of morbidity in the over–5 population with 54 cases of gastroenteritis and 669 cases of acute respiratory infections.
Adolescents (10–14 and 15–19 years old)
The Global School–based Student Health Survey, which was conducted in Anguilla in 2009 among children aged 13–15 years, showed that 30.0% of them had sexual intercourse and 76.5% of them indicated that they had sexual intercourse for the first time before age 14 years. Approximately 69.0% used a condom the last time they had sexual intercourse. Approximately 19.0% had seriously considered attempting suicide, and 8.2% reported that they had no close friends (6). There were 2 suspected cases of hand–foot–and–mouth disease in the age group in 2010.
Data from the Department of Social Development showed that in the reporting period there had been 58 cases of child neglect, 40 cases of physical abuse, and 32 cases of sexual abuse in persons under the age of 18 years.
Between 2006 and 2009, no person in the 15–19 age group was found to be positive for HIV. In 2006, there were 21 births to teenagers in the age group 13–19 years accounting for 11.2% of all (187) births in that year, while in 2010 there were 19 births in that same age group which accounted for 10.0% of all (190) births (5).
Adults (20–64 years old)
Adults 20–44 years old accounted for 4.0% of the population in 2006.
Chronic diseases were the leading cause of morbidity in the adult and elderly population. During the period of 1996 to 2010, there were 7 HIV/AIDS cases in the 20–29 age group, 18 in the 30–39 age group, and 2 in the 44–64 age group.
The Elderly (65 years old and older)
Persons 65 and over made up 19.2% of the population in 2006. There were no HIV cases in the age group over 60 years old during 1996–2010.
During 2006–2010, there were 325 deaths. The death rate fluctuated from 4.1 per 1,000 population in 2006 to 2.9 in 2009 and 4.9 in 2010. In the same period, there was 2 maternal deaths, 1 neonatal death, 1 infant death, and 11 stillbirths. In 2010, there was 1 death in the under–1–year–old population (due to respiratory distress); 1 in the 15–24–year age group; 7 in the 25–44–year age group; 10 in the 45–64–year age group; and 47 in the 65 and older age group.
In 2006, chronic diseases were among the leading causes of mortality (see Table 2). That year, deaths due to homicide were the second leading cause of death, and transport accidents ranked third. Data for 2010 showed diabetes mellitus as the leading cause of death, accounting for six deaths (two males and four females), followed by malignant neoplasm of the prostate, with five deaths; and by Alzheimer's disease, also with five deaths (three males and two females) (see Table 3). Chronic, noncommunicable diseases dominated the five leading causes of death in 2010; notably, homicides and malignant neoplasm of the female breast did not rank among the top five causes.
The most important vector–borne disease for Anguilla is dengue fever. In 2008, there were seven cases of dengue fever, none in 2009, and one in 2010. There were no cases of malaria in 2006–2010.
There were no cases of vaccine–preventable diseases covered under the Expanded Program on Immunization (EPI) schedule. Chickenpox cases reached their peak in 2008 and 2009, with 57 and 55 cases, respectively. There is a vaccine available against chickenpox, but it was not included in the EPI schedule.
One person died from leptospirosis in 2010.
HIV/AIDS and Other Sexually–transmitted Infections
In 2009–2010, four persons tested positive for HIV. The AIDS incidence was 23.7 per 100,000. The male:female ratio was 1.3:1. Heterosexual sex was the main mode of transmission. Antiretroviral treatment is provided free in cases where a person is unable to afford treatment. There were four cases of herpes and one case of syphilis in 2010.
There was one case of imported tuberculosis during the 2006–2010 review period.
Fourteen cases of influenza A(H1N1) were laboratory–confirmed by the Caribbean Epidemiology Center in 2009.
Chronic, Noncommunicable Diseases
Chronic, noncommunicable diseases were the major causes of mortality and the leading causes of hospital admissions in Anguilla. During 2008–2010, diseases of the circulatory system accounted for 186 admissions. Of these, the three leading causes were: cerebrovascular disease (66), primary essential hypertension (34), and congestive heart failure (25). Endocrine, nutritional, and metabolic diseases accounted for 80 admissions; of these 32 were for diabetes mellitus type 2. There were 28 admissions for malignant neoplasms of which 9 were cancer of the prostate. Uterine fibroids accounted for 37 admissions. There were five deaths due to malignant neoplasm of the prostate in 2010 and one death due to cancer of the cervix uteri. There were no deaths from breast cancer in 2010.
In 2010, there was an average of 12 patients per month on dialysis. Of these, four patients were hypertensive, and seven were both diabetic and hypertensive.
Accidents and Violence
During the reporting period, there were 8 fatal and 40 serious road traffic accidents. Between 2008 and 2010, there were 200 violent crimes. However, there was a decrease from 2008 (104) to 2010 (33). There were 51 drug offenses: 34 in 2008, 12 in 2009, and 5 in 2010.
The results of the Global School–based Student Health Survey, conducted in 2009, showed that 35.7% of students (42.6% of males and 28.4% of females) had been in a physical fight one or more times during the year prior to the survey. In addition, 28.0% of students stated that they had been bullied during the 30 days prior to the survey.
The World Health Organization Assessment Instrument for Mental Health Systems (WHO– AIMS) was applied in Anguilla in 2009; the data were based on information from 2007. The results showed that Anguilla has a mental health policy, that the Mental Health Act was approved in 2006, but that the territory has no mental health plan (7).
Mental health care is provided in the primary health care setting. In 2007, a 10–bed psychiatric unit was commissioned at the Princess Alexandra Hospital. In that year, 128 clients were assessed, treated, and counseled in three of the country's four community health centers; 60 of them (47%) were female. Data for 2007 also show that 65 clients (51%) had schizophrenia and other related disorders; 19 (15%) had neurotic, stress–related, and somatoform disorders; and 15 (12%) had mood affective disorders. In addition, 8 of the clients (6%) had mental and behavioral disorders due to psychoactive–substance use, 1 (1%) had a disorder of adult personality and behavior, and 20 (16%) had other mental illnesses.
In 2007, 28 clients (20 males and 8 females) with mental disorders were admitted to the Princess Alexandra Hospital. Their total length of stay was 89 days, with an average of 3.2 days per discharge.
Other Health Problems
There were no reports of occupational diseases during the review period.
There was a steady decrease in both fillings and extractions over the review period. Extractions decreased from 1,824 in 2006 to 1,559 in 2010. Fillings decreased from 6,669 to 2,600.
Risk and Protection Factors
The Global School–based Student Health Survey (GSHS) showed that 6.1% of students aged 13–15 years old had smoked cigarettes in the 30 days prior to the survey (7.5% males and 4.3% females). Of those who smoked 87.8% had first tried a cigarette before age 14. The same study also showed that 45.8% of the students had drunk at least one alcoholic drink on one or more days in the 30 days prior to the survey.
Health Policies, The Health System, and Social Protection
In 2004, the Government established the Health Authority of Anguilla (HAA), a semi–autonomous statutory body that is responsible for the delivery of health care services. This devolution of authority enabled the Ministry of Health and Social Development to assume its steering role of policy formulation, strategic planning, standard–setting, regulation of the sector, and monitoring and evaluation.
A strategic health plan is in place, covering the 2008–2014 period. Strategic priorities identified include: health systems development; health services; human resource development and management; family health; food and nutrition and physical activity; chronic, noncommunicable diseases; communicable diseases; environmental health; and mental health and substance abuse (8).
THE HEALTH SYSTEM'S PERFORMANCE
An assessment of the Anguilla health system's Essential Public Health Functions was carried out in 2010 as a follow–up to the assessment done in 2001/2002. The final report is pending at the time of writing.
There is no national health insurance system, but the Social Security System provides benefits such as for sickness, maternity, and disability. At the end of 2006, 13,364 persons were registered with the Social Security System (7,537 males and 5,827 females).
Some of the health–related legislation is outdated. Legislation enacted during the reporting period included the Mental Health Act (2006) and the National Health Fund Act (2008). The objective of the National Health Fund Act is to ensure that all Anguillans and residents have access to good quality care when clinically needed and in an equitable manner. The operation of the fund was still delayed at the time of writing.
HEALTH EXPENDITURES AND FINANCING
Funding for the health sector comes from the Ministry of Health, which provides a subvention to the Health Authority of Anguilla (HAA) based on an annual service agreement and the territory's annual program budget. Funds are also received from fees for service.
HUMAN RESOURCE DEVELOPMENT POLICIES
Human resource policy is guided by several documents such as the Constitution, the General Orders (established rules, procedures, and obligations that govern the public service), the HAA human resources policy, and the Public Service Commission Act and its regulations—all emanating from the Government of Anguilla. The immigration policy indicates that non–Anguillans, also called non–belongers, will not be placed on the Permanent Establishment. Permanent Establishment refers to security of tenure and this applies to persons who are belongers whether through birth or citizenship. Persons recruited from overseas are given multiple contracts of two– and three–year duration. Non–belongers, recruited on the island, are placed on month–to–month appointments of one year duration. Contracts are awarded by the Government of Anguilla statutory bodies such as the HAA and the private–sector organizations.
THE HEALTH SERVICES
Primary health care is used as the model of care. At the community level, the public–sector health facilities include one polyclinic and four health centers. These provide a range of services, including maternal and child health, family planning, medical clinics, and health promotion. The 32–bed Princess Alexandra Hospital offers the main specialties such as internal medicine, obstetrics and gynecology, pediatrics, and radiology. There is one private hospital, the Hughes Medical Centre, and a private clinic, the Hotel de Health.
There is good access to the health facilities. However, for those migrants who only speak Spanish, the language barrier posed difficulties in communication to access health care. Many Anguillans choose to go overseas: proximity to other islands such as Puerto Rico, Saint Martin, and Saint Thomas; confidentiality; and the fact that persons who seek care outside Anguilla can afford it account for the practice. Transfers from the health care system to other countries averaged 35 in the period 2006–2010. In 2010, the four countries receiving referrals were Barbados (nine), Puerto Rico (five), and Antigua and Saint Martin (three each). An arrangement with the United Kingdom allows for an annual quota of patients to receive care there.
Anguilla participates in the Organization of Eastern Caribbean States' Pharmaceutical Procurement Service (OECS/PPS), and is able to benefit from bulk purchasing. The drugs are available for a subsidized cost at the health facilities.
Knowledge, Technology, Information, and Human Resource Management
SCIENTIFIC PRODUCTION IN HEALTH
There is no formal health research agenda but research activities take place on an ad hoc basis. For example, the Global School–based Student Health Survey was undertaken in 2009.
Anguilla had 122 public–sector health care workers. The numbers and density are shown in Table 4. There were 13 (11.0%) medical doctors; 37 (30.0%) nurses and midwives; and 6 (5.0%) public health practitioners. Health care providers aggregated by gender showed that women accounted for 77% (94 out of 122) of all health care providers. Gender disparity was seen mainly in nursing (35 women and 3 men) and ancillary staff (32 women and 3 men) (9).
The country is reliant on health staff from other countries. All the doctors and at least 20% of the nurses are foreign–recruited contract workers. In 2004–2006, the density per 10,000 population for physicians, nurses, and dentists was 8.5, 24.2, and 2.0, respectively. In 2010, the ratio was 12 doctors and 18 nurses per 10,000 population.
Most of the training for the health professions must be accessed abroad. For example, nursing assistants complete one or two years of training in Grenada. Continuing education takes place both locally and abroad. The Saint James School of Medicine was established in 2009 as a private, off–shore medical school. The school offers two scholarships annually to Anguillans. Graduates can practice in Canada and the United States of America.
The Princess Alexandra Hospital is the largest employer of health care workers in Anguilla, employing 66.0% of the entire public–sector human resources in health workforce. Primary care services employ another 23.0% of the health workforce. There were no primary care physicians, but two general practitioners were allocated to the community health services for primary care services. There are specialists in the areas of anesthesia, gynecology, internal medicine, pediatrics, and surgery.
Health and International Cooperation
The country benefits from the United Kingdom's Department for International Development (DFID)–funded regional Overseas Territories projects and emergency aid in the event of natural or man–made disasters. Technical cooperation programs for health are those funded by the Pan American Health Organization. Anguilla also received grant money for HIV/AIDS from a European Union project that is managed by the PAHO HIV Office in Trinidad.
Synthesis and Prospects
Anguilla has been successful in many areas of health. These include the reduction in diseases preventable by immunization. There are some aspects where there is an unfinished agenda and new challenges to be addressed. Two of the issues are the economic cost associated with the treatment of infectious diseases such as tuberculosis and HIV and the management of noncommunicable diseases.
In terms of the health system, some of the areas that will need to be addressed include the limited number of trained health care professionals at the national level and the strategies that will have to be developed for training, recruitment, and retention. The health information system and the national surveillance system need to be strengthened to provide timely and accurate information. More emphasis will be placed on the response capacity for health–related emergencies associated with natural disasters. Of critical concern for Anguilla and other small island developing states is the effect of climate change on weather patterns and the likely health impact such as the increase of mosquito–borne diseases such as malaria, yellow fever, and dengue. The health sector in Anguilla is committed to meeting these challenges.
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