Dominica is the largest and most northerly of the Caribbean's four Windward Islands. The country covers an area of 750 km2, with the highest point being Morne Diablotins, which stands at 1,447 meters. Like many of its Caribbean neighbors, the island is volcanic and it boasts many waterfalls, springs and rivers, lush vegetation, and a variety of rare flora and fauna.
The Commonwealth of Dominica attained political independence from the United Kingdom in 1978. It is a multi–party democracy, with a president as the head of state; executive power rests with the cabinet, which is headed by a prime minister.
The 2001 census indicated that approximately 86.8% of the population is of African descent; 8.9% is racially mixed; 0.8% is white; and 2.9% is Carib or Kalinago, the indigenous population. The official language is English, but most of the population speaks a patois, a blend of African and French linguistic structures. The population is predominantly Roman Catholic.
Dominica is divided into 10 parishes; Roseau is the capital, located in the parish of Saint George. Communication systems are quite good on the island, and the country has a network of seaports, airports, and roads.
The population increased from 71,727 in 2001 to 72,862 in 2010, representing a 0.04% increase. This is in contrast to the 2.2% increase seen in the previous decade. In 2010, the male to female ratio was 1:1 (see Figure 1) (1).
Total births decreased annually from 2006 to 2010. As shown in Table 1, the total number of births was 941 in 2010 (12.8 per 1,000 population), declining from 1,054 (15.0 per 1,000) in 2006. Births to teenagers (15–19 years old) increased from 15.1% of total births in 2006 to 15.3% in 2010, with a peak of 17.7% in 2009. The fertility rate decreased from 2.1 children per woman in 2006 to 1.8 in 2010. The crude death rate in 2006 was 7.5 per 1,000 population and increased to 8.1 in 2010 (2).
In 2005, life expectancy was 74.7 years (71.7 years for males and 77.7 years for females). The life expectancy at birth in 2010 was 76 years, with females expected to live longer (78 years) than males (74 years) (2).
The Dominican economy showed both positive and negative growth between 2005 and 2010. It experienced 4.76% growth in gross domestic product (GDP) in 2006, which was attributed to improvements in tourism, construction, offshore services, and a boost in the banana industry. Economic growth declined in 2007 to 2.51% due to decreased revenues from tourism and agriculture. Tourism suffered a 9.9% contraction, and agriculture a reduction of 12%, mainly from the decline in banana exports. Economic growth further declined in 2009/2010, with −0.3% growth in GDP, following two years of unstable global economic conditions. Tourism receipts fell by about 16% and family remittances from overseas fell by about 51%.
In 2009, the main drivers of the GDP were government services (19.2%), followed by agriculture (17.3%), financial services (15.5%), and wholesale and retail trade (14.3%). The GDP in 2007 was US$ 329.36 million and in 2010 was US$ 353.52 million. Dominica's debt to GDP ratio was extremely high: in 2007 it was 90.9% and in 2010 was 95.5% (US$ 248.8 million). Despite setbacks in the economy, per capita income increased from US$ 5,133 in 2006 to US$ 5,664 in 2010 (3).
Dominica has maintained its focus on health care and has introduced several strategic health care interventions. In November 2006, a four–bed intensive care unit was opened at the Princess Margaret Hospital, with the support of the Government of Cuba. The presence of this facility has reduced the need for patients to travel to countries such as Martinique and Guadeloupe for critical care. Since its inauguration, 270 persons have received care in this unit by professionally trained staff. The costs are heavily subsidized by the Government, and while not yet quantified, it is apparent that the facility has greatly reduced the social and financial burdens of referring patients to foreign facilities (4). Also with support from the Government of Cuba, a diagnostic center was established within the primary health care delivery service in August 2006.
Health Determinants and Inequalities
Poverty remained a leading developmental challenge in Dominica, especially considering the past reliance on the weakened banana industry. In 2008/2009 the country conducted a Country Poverty Assessment (CPA) which indicated that 28.8% of the population was deemed to be poor (living on US$ 6.20/day), representing 22.8% of households; this compares to 39% in 2003. The indigent population (living on US$ 2.40/day) was calculated at 3.1% (down from 15% in 2003); the vulnerable population (living on US$ 7.90) was calculated at 11.5%. Overall, these figures indicate that 43.4% of Dominicans found it challenging to meet their basic needs (5).
The highest incidence of poverty (49.8%) was in St. David among the Kalinago or Carib peoples, who reside on the east of the island. However, this was a steep reduction from the 2003 poverty level of 70% in this population, owing to government interventions through targeted public expenditure. Other parishes with poverty rates higher than the national average were St. Joseph (47.2%), St. Paul (32.6%), St. Patrick (42.7%), St. David (40.4%), and St. Andrew (38.1%). These parishes comprise the entire eastern section of the island and are all banana–producing areas. St. John, the second largest town in Dominica, had the lowest incidence of poverty at 10.2%. This town is home to the local branch of Ross University, an offshore American university catering mainly to medical training, which provides jobs and revenue generating opportunities for nearby communities (5).
In 2009 there were 32,093 persons in the labor market, with 86% employed and 14% unemployed; 16.6% had been unemployed for over a year. The male unemployment rate was 11.1% and the female rate was 17.6%. However, unemployment among the poor was 25.9%; female unemployment (33.9%) among the poor was higher than for males (20%). This situation has implications for achieving Millennium Development Goals (numbers 1 and 3) (5).
Dominica Social Security (DSS) is the main safety net for the population and receives contributions from Dominican nationals in the employed labor force who are 16–60 years of age. The DSS provides sickness, maternity, invalidity, employment injury, funeral expense, and survivor benefits to contributors. A total of 7,981 persons registered with DSS between 2006 and 2010, of whom 4,037 were male and 3,944 were female. The DSS received 811 claims for work–related injuries over the 2006 to 2010 period and has paid out US$ 774,815 in benefits (6).
National programs targeting poverty alleviation were implemented through the Government's Growth and Social Protection Strategy. This strategy was delivered through the Basic Needs Trust Fund (BNTF) and the Dominica Social Investment Fund (DSIF). In 2009, the BNTF, which employs 97 people, delivered several programs targeting 12,783 beneficiaries at a cost of US$ 1,255,738. Initiatives were for public welfare assistance, including access to medical services, an education trust fund, a school feeding program, a school supplies and textbook program, and small business development, as well as areas within the Public Sector Investment Program (3). The DSIF, a three–year program funded by the European Union in the amount of US$ 5.76 million, began in 2009. It aims at reducing inequalities and targeting vulnerable groups, namely, youth at risk, children at risk, the elderly, the disabled, women at risk, vulnerable persons living with HIV and AIDS, and the Carib community (3).
The Government of Dominica has embraced the policy of universal access to primary and secondary education. Schools have been rebuilt and refurbished, and the Ministry of Education has undertaken initiatives to improve the quality of education. In 2010, 78 early childhood education facilities were licensed and a national curriculum was implemented in the primary school system. The Government also supported children's education by providing textbooks, uniforms, and transportation, as well as by implementing the school feeding program at a cost of approximately US$ 701,000 annually (3).
During 2005–2009, gross enrollment for primary schools was 79.0% for males and 84.0% for females with a net enrollment for males at 69.0% and for females at 76.0%. Secondary schools had a gross enrollment of males at 109.0% and females 101.0%, while the net enrollment for males was 62.0% and for females, 74.0% (7).
Between 2001 and 2008, 15,491 students were enrolled in primary and secondary schools; of these 54% (8,329) were in primary schools and 46% (7,162) in secondary schools. In 2009–2010, gross enrollment for primary schools was 112.3% and the net enrollment was 97.0%. Gross secondary school enrollment was 98.2%, with a net enrollment of 80.0% (8). In 2008, Dominica's overall literacy rate was 86.0%. The highest percentage of illiteracy was in those 60 years old and older (5).
The Environment and Human Security
ACCESS TO CLEAN WATER AND SANITATION
In 2009, 95.8% of Dominicans had access to potable drinking water. The proportion of households with water piped to the house in 2009 was 61.2%, piped to the yard was 10.5%, to a public standpipe was 19.4%, and private catchment was 4.7%. The remaining 4.2% collected water from other sources such as rivers, streams, water trucks, and from neighbors (5).
With respect to sewage facilities, in 2008, 14.6% of the households had water closets linked to sewer lines and 50.6% used septic tanks. The proportion of Dominican households using pit latrines was 24.3%; 51.4% of the poor used pit latrines (5).
Monitoring Aedes aegypti populations for dengue virus transmission using the house, container, and Breteau indices was ongoing by the Ministry of Health. Between 2006 and 2010 the house index (percentage of houses infested with larvae or pupae) ranged from 11% to 16%, the container index (percentage of containers infested) ranged from 7% to 15%, and the Breteau index (the number of positive containers per 100 houses) ranged from 17% to 25%. Efforts continued to reduce these indices (9).
The entire Dominican population used the services of the Fond Cole Sanitary Landfill, which was commissioned in 2007 at a cost of US$ 3,680,665. According to the Ministry of Health's Environmental Division, an average of 21,000 tons of waste have been disposed of annually. Specialized equipment was used to collect medical waste from health centers and hospitals around the island. Household and commercial waste was collected once or twice weekly and land–filled, with the exception of lead–acid batteries, glass, tires, scrap metal, cardboard, and used engine and cooking oil, all of which were recycled (9).
The age group 15–24 years accounted for the highest number of land transport accidents with 17.4 deaths per 1,000 in 2009. This is a decrease from a peak in 2006 when the rate was 56.5 deaths per 1,000 (2).
Eleven females were victims of homicide, four of them children, during the 2006–2010 period. The number of crimes against women increased in this period: there were 90 incidents of rape in 2006–2010 compared to 61 in 2001–2005; sexual offenses increased by 125% (from 89 to 201 cases), while incest increased from 6 cases to 7 in the same period. A total of 472 cases of child abuse were reported for 2006–2010, compared to 337 in the previous five years. There were 180 (2006) and 155 (2007) detected incidents of child abuse, most of them being sexual abuse (210, 62.6%), followed by physical abuse (70, 20.8%), emotional abuse (52, 15.5%), and unidentified (3, 1.1%). Reports were not broken down by sex or age (10).
Cases of domestic violence are being reported more frequently than before in Dominica because increased outreach programs and campaigns are making the public more aware and sensitive to these issues. Between 2006 and 2009, 1,697 cases of domestic violence were reported to the Bureau of Gender Affairs; 911 (53.7%) reports were made by females and 786 (46.3%) by males (10).
An estimated 90% of the Dominican population lives within 5 km of an active volcano. The country is also prone to hurricanes and landslides. In 2007, Hurricane Dean, a Category 2 storm, caused two deaths on the island and damage in excess of US$ 59.6 million, or 24% of GDP. That same year, an earthquake measuring 6.2 on the Richter scale damaged some buildings, primarily churches. In 2008, Hurricane Omar, a Category 3 storm, damaged property along the coast. Some fishermen's boats sustained extensive damage, which for some represented their only source of revenue. The Government subsequently acquired a loan of US$ 9.16 million to enhance coastal areas. In 2009, a landslide in San Sauveur, Saint David Parish, caused the death of one child and two adults (11).
Principal institutional responsibilities for issues related to climate change in Dominica rest with the Ministry of Agriculture and the Environment's Environmental Coordinating Unit (ECU). Dominica successfully completed the first and second National Communications on Climate Change reports, as required by the UN Framework Convention on Climate Change. During 2006–2010, there was no data collection or monitoring of critical variables such as sea level rise and greenhouse gas emissions (including carbon dioxide and methane). Most of the data collected related to atmospheric surface variables, but the collection was not comprehensive.
Erosion along Dominica's 148 km of coastline was a continuous threat to property and communications networks. Anticipated sea level rise increased the country's vulnerability to beach erosion, loss of habitat for marine life, loss of fresh water aquifers, and damage to coastal infrastructure. This poses a hazard for human settlements and land transportation, as most of Dominica's communities (81%) are located on the coast (9).
FOOD AND NUTRITIONAL SECURITY
Agriculture and food security remained a driving force in Dominica's economic development. In 2006 the outlay for food imports was approximately US$ 25.9 million; in 2010 this amount rose to US$ 36.6 million (the increase was attributed primarily to inflation) (3). Policies and priorities focused on diversification of crops from a banana monoculture to fresh produce, livestock, cocoa, coffee, and citrus. Production of these items is incipient and was fraught with problems including adverse weather conditions. Subsistence farming was encouraged and funded through the BNTF (3). Food safety was monitored through meat inspections at the abattoir, sampling and testing of imported canned goods at ports of entry, and inspections of food establishments (9).
Health Conditions and Trends
HEALTH PROBLEMS OF SPECIFIC POPULATION GROUPS
Maternal and Reproductive Health
Maternal and child health services were offered at all health centers in Dominica. There were 941 live births in 2010, a 10.8% decrease from 2006. Beginning in 2000 all pregnant women have been seen by trained health personnel. In 2009, 96.8% of women visited public health facilities and 3.4% visited private medical practitioners for prenatal care (2). Nearly all (99%) births took place in a hospital. Approximately 26.0% of babies were breast–fed exclusively for six months. Teenage births increased in 2009 (17.7%), compared to the figure in 2006 (15.1%). There was one maternal death each year in 2007, 2008, and 2009; there were two maternal deaths in 2010 due to complications of pregnancy (2).
Infants (under 5 years old)
In 2010, infants and children under 5 years oldcomprised 8.9% of the total population (6,462), with males and females roughly evenly distributed (1). There were no cases of vaccine–preventable diseases in children between 2006 and 2010. Immunization coverage in 2009 remained at 100% for MMR, 99.4% for polio, and 98.6% for BCG. The pentavalent vaccine (with vaccines for diphtheria, pertussis, tetanus, Haemophilus influenzae type b, and hepatitis B) was introduced in 2006; coverage in 2009 was 99.6% (4).
During the 2006–2009 period, 8% of live–born infants weighed less than 2,500 g (low birthweight). The majority (88.8%) of children under age 5 were within normal weight for their age. In 2009, growth monitoring revealed a rising trend of obesity in children under age 5 with districts showing variations between 5.2% and 15.2% (2).
The neonatal mortality rate fluctuated over 2006–2010. The peaks and valleys evident in the infant mortality rate in the same period may be attributable to outbreaks of septicemia that occurred in the neonatal nursery of the Princess Margaret Hospital (2). This is illustrated in Table 2.
There were 99 deaths among infants and children under 5 years old between 2006 and 2010. The three leading causes of death were respiratory disorders specific to the perinatal period (21 deaths), congenital malformations (19 deaths), and bacterial sepsis of the newborn (17 deaths). There were 10 deaths in the 1–4–year age group (6 males and 4 females) in 2006–2010 (12).
Children (5–9 years old) and Adolescents (10–19 years old)
In 2010, children from 5 to 9 years old comprised 10.6% of the population (7,735), 10–14–year–olds comprised 10% (7,268), and 15–19–year–olds made up 9.6% of the population (6,974). Together, these three age groups accounted for 31.2% of the population, representing 51% males and 49% females (1).
There were six deaths (four males and two females) among 5–9–year–olds in 2007–2010. In the age group 10–14 years old, there were seven deaths-all from noncommunicable diseases (five males and two females)-during the same period. In the 15–19–year age group, there were seven deaths-all males. The main causes of death in the latter age group were attributed to noncommunicable diseases, including one death from drowning and one from homicide (12).
Adults (20–59 years old)
Adults between 20 and 59 years old comprised 48.1% of the total population (34,681 persons), with males accounting for 51% and females for 49% (1). There were 296 deaths in this age group during 2007–2009; 203 were males (68.5%) and 93 were females (31.8%).
Between 2005 and 2009 there were 40 deaths in the 15–24–year age group (70% were males). External causes, including road accidents and homicides, accounted for exactly half (50.0%) of these deaths. Road accidents accounted for 32.5% of these deaths. Rates of land transport accidents are highest in the 15–24 and 25–55 age groups; there was a peak in these deaths in 2002 and 2006 for the 15–24–year age group. Homicides accounted for 17.5% of all deaths among 15–24–year–olds, with a male–to–female ratio of 2.5:1. The number of homicides was down from a high of 10 in 2002; there were no homicides reported in 2005 and 2008 (2).
The Elderly (60 years old and older)
The elderly population increased in 2010, accounting for 13.4% of the total population (9,750), showing a very slight increase over the 2003 figure of 9,610. In 2010, females accounted for 55.5% (5,413) and males for 44.5% (4,337) (1). In 2009, the Government launched a program called "Yes We Care," a major social initiative designed to provide relief to the most vulnerable of the elderly population. Through this program the Government approved income–tax–free pensions, free hospitalization, and a minimum pension for all non–pensionable persons retiring from the public service. The Government continued to meet the operating costs of the Council for the Aging, the Dominica Infirmary and Grange Home (residences for the elderly), and the Grotto Home (residence for the homeless) (3).
During 2007–2009 there were 1,296 deaths in this age group; 625 were males (48.2%) and 671 were females (51.8%). This represented 75.5% of all deaths. Noncommunicable diseases accounted for 88.3% of deaths in this age group; cerebrovascular disease (20.5%) and diabetes (14.2%) were the leading causes of death (12).
Clinical cards were maintained at the primary health care level reflecting health data by households in Dominica. A total of 2,828 households were identified as "high risk" and were monitored by public health nurses. Of these, 80 were referred to the District Environmental Health Officer for violations of public health laws, mainly with regard to sanitation on their premises (2).
Ethnic or Racial Groups
The indigenous peoples of Dominica, known as the Carib or Kalinago, account for 5% of the country's population and reside primarily in the Carib Territory in the parish of Saint David. The health status of the Kalinago mirrors that of the general population. Considerable improvement was achieved on Millennium Development Goal 1 (poverty alleviation) during 2005–2010 through the efforts of the government, partnerships, and the Kalinago community. This population is on track to achieve Millennium Development Goals 2, 3, 4, and 5. Residents of the Carib Territory have access to three health centers at Castle Bruce, Marigot, and Salybia. Visits to health centers have increased, health promotion sessions occur monthly, and prevention measures, including rapid testing for HIV and Mantoux screening for tuberculosis, are ongoing. Antenatal visits have decreased. Problems of concern to the Kalinago are unemployment, teenage pregnancy, substance abuse, and chronic, noncommunicable diseases.
Over the review period there was a 9.7% increase in the total number of deaths, from 536 (in 2006) to 588 (in 2010), with a corresponding increase in the crude death rate, from 7.5 to 8.1 per 1,000 population. There were 1,671 deaths in the 2007–2009 period, of which 870 (52%) were males and 801 (48%) were females (2). The age–specific death rates ranged from 0.3 per 1,000 in children 5–14 years old to 54.3 in persons 65 and older. The age–specific death rate per 1,000 population for males 65 and older was 56.8 per 1,000 in 2005 and 54.0 in 2009. For females 65 years and older, the death rate increased from 37.8 per 1,000 in 2005 to 54.4 per 1,000 in 2009 (2).
The 10 leading causes of death represented 60.4% (1,688) of all deaths in 2006–2010 (see Table 3). In looking at the trend over 2006–2010, the leading causes of mortality were cerebrovascular disease, followed by diabetes and ischemic heart disease. Malignant neoplasms accounted for 306, or 10.9%, of all deaths. Of the 10 leading causes of deaths, cancer of the prostate, the main type among males, accounted for 6.6% of all deaths; among females, the main type was breast cancer, accounting for 1.8% of all deaths (2).
In 2010, the leading causes of death followed the same trend, with the three leading causes being cerebrovascular diseases (49 deaths), diabetes mellitus (39 deaths), and ischemic heart disease (37 deaths).
In 2007/2008 Dominica experienced outbreaks of dengue, with 122 reported cases. Of these, 45 (22 males and 23 females) were confirmed by the Caribbean Epidemiology Centre (CAREC) and 38 required hospitalization. In 2010 there was another outbreak with 631 clinical cases (279 males and 352 females); 75 of these were laboratory confirmed, and there was 1 death. The most affected age group was 15–49–year–olds (47%). From June to December 2010, 11 cases of leptospirosis were diagnosed. All were male and there was one death (4).
There were no cases of vaccine–preventable disease in children between 2006 and 2010. In 2009 there was one case of tetanus which resulted in death (4).
There were no cases of zoonoses during the review period.
HIV/AIDS and Other Sexually–transmitted Infections
There were 77 certified deaths due to AIDS between 1997 and 2009. In the 2006–2009 period, 10,099 persons were tested for HIV. Of the 4,602 persons tested between 2006 and 2007, 862 were male and 3,474 were female (266 were unspecified). In the 2006–2009 period, 20 males and 8 females tested positive for HIV. In 2009, 997 blood donors were screened, all with negative results. The Preventing Mother–to–Child Transmission of HIV (PMTCT) program commenced in 2001 and has had a 100% success rate. During 2008 and 2009 there were four mothers whose infants were at risk for contracting HIV, but after appropriate management the infants tested negative. In 2010, 43 persons were receiving antiretroviral therapy. In 2010, two females in the 20–24–year age group and four males in the 20–49–year age group tested positive for HIV, bringing to 34 the number of persons living with HIV and AIDS. The 35–39–year age group had the greatest concentration of HIV/AIDS cases, with 25 cases. There were two diagnosed cases of AIDS in 2010; both were male. There were seven deaths due to AIDS in the reporting period (six males and one female). Dominica offered voluntary counseling services for HIV/AIDS in all health centers, and three testing sites have been established in district clinics (2).
Between 2007 and 2009 there were 454 cases of sexually–transmitted infections (STIs) in Dominica. Non–symptomatic syphilis (laboratory–confirmed only) accounted for 82.4% of the total number of STIs. Women accounted for the majority of syphilis cases (56.7%), but men accounted for 91% of gonorrhea cases. There were no reported cases of chlamydia in the period 2007–2009, but this may reflect the absence of testing on the island. Two cases of congenital syphilis were reported in children under 10 years old in 2009 (2).
The number of cases of tuberculosis varied from 9 in 2006 to 2 in 2007, 4 each in 2008 and 2009, and 8 in 2010. The tuberculosis incidence rate in 2010 was 11.0 per 100,000 population.
The first two cases of influenza A(H1N1) were identified in Dominica in June 2009; both cases were introduced by persons traveling from the United States. Between June 2009 and the end of the reporting period there were 498 suspected cases of H1N1 (251 males and 247 females) but only 49 cases were confirmed. The most affected age group was 5–14–year–olds, with 31% (2).
Other Communicable Diseases
The incidence of acute respiratory infections (ARIs) increased in 2007, and at the height of transmission, ARIs accounted for 42% of admissions to medical wards. The age group most affected was 5–14–year–olds. In 2008 there was an outbreak of rotavirus gastroenteritis which affected 203 persons (80 males and 123 females). The hardest hit were children between 1 and 4 years old, with 85 reported cases. In 2010, 30 persons were hospitalized due to a norovirus outbreak (12).
Chronic, Noncommunicable Diseases
Noncommunicable diseases were the 10 leading causes of death between 2006 and 2010, representing 56% of deaths in that period. In that same period, cerebrovascular disease was the leading cause of death with 317 (11.3%) deaths. In 2009, noncommunicable diseases comprised 55% of all defined causes of mortality in Dominica with malignant neoplasms accounting for 21% of the 10 leading causes, followed by cerebrovascular disease with 19.7%. For males, malignant neoplasm of the prostate accounted for 46 deaths (19.7%), followed by pulmonary heart disease with 25 deaths (10.7%). For females the leading cause of death in 2009 was cerebrovascular disease (44 cases or 18.3%), followed by hypertensive disease (27 cases or 11.3%). Diseases of the circulatory system and cancers were the leading causes of death among Dominicans from 2001 to 2010, a reflection of lifestyle behaviors such as unhealthy diets, physical inactivity, increased tobacco use, and alcohol abuse (2).
Dominica's 40–bed psychiatric unit is located adjacent to the Princess Margaret Hospital, the island's public secondary care institution. The Mental Health Act was enacted in 1987; there is a Mental Health Review Board, but no national mental health policy or plan. In 2007 national expenditures on mental health were approximately 3% of the total national health budget (US$ 404,873). Health regulations allow primary health care physicians and family nurse practitioners to prescribe psychotropic medicines, which were widely used (13).
In 2010, there were 382 admissions to the psychiatric unit; males accounted for 268 (70%) admissions and females 114 (30%). Twenty–six of those admissions were under 17 years old (19 males and 7 females). On discharge, approximately 61% of these admissions carried a diagnosis of schizophrenia or related disorders; substance abuse accounted for 26%. On average, patients spent 14.7 days in the psychiatric unit. Scheduled mental health clinics are held in primary health care facilities throughout the island. No data were available on the sex, age, and diagnoses of persons seen in the 13 outpatient mental health clinics (13).
Other Health Problems
The government dental services saw a total of 8,277 persons in 2010, including 4,614 adults and 2,499 children. A total of 9,701 procedures were performed, of which 4,419 were preventive, 2,346 were curative, and 2,936 were surgical (12).
In 2010 there were 323 severely mentally challenged children identified on Dominica, 48 of whom attended the two special needs schools on the island. Most children with special needs are cared for by relatives and do not attend school (8).
Other Health Issues
Data for 2006–2008 suggested that skin infections (6,497 cases; males 38.7% and females 61.3%), colds (2,799 cases; males 43.1% and females 56.9%), and eye infections (737 cases; males 40% and females 60%) were conditions of concern (2).
Risk and Protection Factors
In April 2006 the National Drug Abuse Prevention Unit, in conjunction with the Inter–American Drug Abuse Control Commission (CICAD), conducted a survey of substance abuse among secondary school students in Dominica. A total of 52.36% of students reported consuming alcoholic drinks, 7.7% reported smoking cigarettes, and 2.5% reported inhaling substances (2).
The STEPS survey of chronic disease risk factors in Dominica (based on the WHO STEP wise Framework for Surveillance) was carried out from November 2007 to May 2008. Dominica completed steps 1, 2, and 3 of the protocol. The results indicated that 48.3% of Dominicans were at high risk for noncommunicable diseases, 27.9% at increased risk, and 2.9% at low risk. The STEPS survey also revealed a high prevalence of overweight and obesity in 15–64–year–old adults; 15.7% of this population smoked tobacco and 33.3% of males reported having had four or more alcoholic drinks in the week prior to the survey (2).
Health Policies, The Health System, and Social Protection
Health services in Dominica are operated and financed primarily through the Ministry of Health. The Ministry's key responsibilities include health policy and planning, regulation and monitoring, development and implementation of health programs, and the provision of environmental health services. In November 2010, the Ministry launched the country's National Strategic Plan for Health 2010–2019, which identified key health priority areas. They include: training and development of staff in critical clinical and administrative areas; reorienting delivery models to achieve greater efficiency and effectiveness; improving capacity for planning, monitoring, and evaluation; and developing an efficient, automated health information system (14).
THE HEALTH SYSTEM'S PERFORMANCE
Dominica's performance in essential public health Functions was assessed in 2010. The country performed within the "optimal" range in health promotion. Performance was "above average" for monitoring, evaluation, and analysis of health status; surveillance, research, and control of risks and threats to public health; social participation in health; development of policies and institutional capacity for planning and management in public health; and reducing the impact of emergencies and disasters on health. Two functions achieved "average" range: strengthening institutional capacity for regulation and enforcement in public health and evaluation and promotion of equitable access to necessary health services. Performance was within the "minimum" range for three functions: human resources development and training in public health, quality assurance in personal and population–based health services, and research in public health (15). Figure 2 shows a comparison of performance in 2001 and 2010 (16).
The Health Information System headed by the national epidemiologist continued to provide relevant and timely data. In 2006, Dominica installed an electronic patient–admission system with links to the Ministry's Health Information Unit. In 2007, through a partnership with the Pan American Health Organization, the Ministry of Health began a process of systematic collection and analysis of human resources data. Multiple databases also have been developed for collection and analysis of information in order to facilitate surveillance of communicable and noncommunicable diseases and HIV/AIDS. Epidemiological data are collected on a continual basis. Dominica experienced problems with the collection of data on morbidity: since most of this data are collected manually, accuracy and timeliness are of concern.
Legislation was revised or enacted to affect public health practices in the review period. In 2006 the Public Health Embalmers and Funeral Directors regulation was amended. The Environmental Health Services Rodent Control Regulations and the Control of Mosquito Regulations were enacted in 2007.
HEALTH EXPENDITURES AND FINANCING
The total Government budget in 2006 was US$ 120.02 million, with the health budget accounting for 10.6% or US$ 12.7 million. The health budget decreased to 9% of the total budget for 2007–2009, then increased to 10%, or US$ 19.68 million, in 2010. In 2008, the total annual expenditure on health was US$ 22.5 million or 8.2% of the total budget, representing 6.3% of GDP. The total annual per capita expenditure on health was US$ 333.91. Private health expenditure was 37.5% of total health expenditures in 2008. The total spent on pharmaceuticals in 2009 was US$ 1.81 million, allowing for US$ 24.98 per capita (17).
THE HEALTH SERVICES
The Ministry of Health is divided into several departments. The Administration Department is responsible for central policy formulation and health administration. Primary health care services are provided through a network of 52 health centers and 2 district hospitals located across the country. The Princess Margaret Hospital provides diagnostic, curative, and some rehabilitation services. Tertiary services are accessed outside of Dominica, mainly on the neighboring islands of Martinique, Guadeloupe, and Barbados, and financed jointly through public and private out–of–pocket expenditure. The Environmental Health Department monitors the environment and carries out intervention measures to promote public health. The Drug Abuse Prevention Unit coordinates all activities to reduce illicit drug use among the populace. The National AIDS Response Programs are responsible for the coordination of HIV/AIDS activities in the country in collaboration with other agencies (14).
For delivering primary health care, Dominica is divided into seven health districts grouped into two administrative regions. Each health district has four to seven Type I clinics and one Type II health facility. Type I clinics serve a population of 600–3,000 persons within a radius of about 6 km and are staffed by a district nurse/midwife. Services include medical care, home visits, family planning, maternity services, and child health, including immunization, nutrition, health education, school health, mental health, and dental care. Specialist staff also conduct clinics in the districts. Private health care services are limited in Dominica, consisting mainly of outpatient care provided by private practitioners who are based in the capital. Privately owned health facilities include a 28–bed hospital, a medical laboratory, and several pharmacies (14).
Secondary health services are delivered through the Princess Margaret Hospital. Visits to the accident and emergency department averaged 32,333 annually between 2006 and 2009. The specialist clinics in the hospital's outpatient department saw an annual average of 3,000 persons over the reporting period. Admissions to the Princess Margaret Hospital increased from 6,626 in 2006 to 6,923 in 2010, of which 21% were admitted to the surgery department, 20% to maternal and child health, and 59% to the medicine and psychiatry units (2).
In 2009, the radiology department at Princess Margaret Hospital began to operate a semi–digital X–ray system. The hospital's CT scan machine has a single slice system with the capacity to save CT images digitally on compact discs. A new hyperbaric chamber was also commissioned at the hospital for treatment of diving accident victims and patients with diabetes and other medical conditions. The Princess Margaret Hospital commissioned a plant to produce oxygen in 2009, and expanded the number of kidney dialysis machines available (12).
Knowledge, Technology, Information, and Human Resource Management
SCIENTIFIC PRODUCTION IN HEALTH
The Ministry of Health engaged in research including the following: a burden of illness study, a study of HIV in men who have sex with men (MSM), and a study on the nutritional status of children aged 5–14 years (2). Workload and financial constraints have prevented the Ministry from publishing these studies.
HUMAN RESOURCE DEVELOPMENT POLICIES
In 2007, through a partnership with the Pan American Health Organization, the Ministry of Health began a process of systematic collection and analysis of human resources data. The Princess Margaret Hospital employs most health workers, with 483 employees who constitute 58.6% of workers in the health sector (2). Over the 2005–2009 period, nurses represented the largest proportion of health care workers in the public sector (45%); nursing assistants accounted for 8.3% of health workers. Medical doctors represented 15% (124) of the health workforce (2). The density of health workers by occupation is shown in Table 4.
Most persons pursuing a career in health traveled to Cuba for medical training; some attended the University of the West Indies. A few attended Ross University, an American medical school with an on–island campus. General nursing and midwifery training were available in Dominica and education for health personnel was ongoing.
Health and International Cooperation
Dominica is a member of the Commonwealth of Nations, the Caribbean Community (CARICOM), and the Organization of Eastern Caribbean States (OECS); it also has established alliances with other regional and international organizations. Donor support during the reporting period included assistance from the European Community for a water supply project for indigenous communities in the Carib Territory totaling US$ 2.2 million in 2008/2009 (17). The Government of the People's Republic of China has committed to the full rehabilitation of the Princess Margaret Hospital, and the Cuban Government assisted with the refurbishment of the Nursing School and Hostel at a cost of US$ 441,679 (17). In 2007, also with assistance from Cuba, a diagnostic center was established at the Reginald Fitzgerald Armour Hospital in Portsmouth, which is now able to perform various tests that were previously unavailable in the north of the island. The Caribbean Environmental Health Institute provided scholarships and fellowships for environmental health officers, in order to enhance the Environmental Health Department's capabilities. The Caribbean Food and Nutrition Institute continued its technical assistance program in Dominica. The Caribbean Regional Drug Testing Laboratory provided an efficient, well–equipped facility to ensure that the pharmaceutical products used in the country are fully reliable. CAREC provided epidemiological and other specialist services in–country when requested, to assist with urgent situations (such as gastroenteritis outbreaks and natural disasters). CAREC also assisted in developing country–specific and regional systems to address specific health issues such as HIV/AIDS.
Synthesis and Prospects
Dominica's population showed negligible growth-0.04%-between 2001 and 2010. Despite the effects of the global economic crisis, the country tackled poverty alleviation, particularly among the indigent poor, and improved quality and access to primary and secondary education. And the population's health status continued to improve: the fertility rate has fallen, life expectancy has increased, access to clean water supply and sanitation continues to improve, and provisions for the disposal of solid waste also advanced. Efforts are being made to improve the health infrastructure and health information system, and several patient care initiatives have been introduced to advance the health agenda.
That said, Dominica still faces many health issues. Communicable diseases are still a problem, births to adolescents continue to be a matter of concern, and substance abuse is on the rise, particularly among the country's youth. The incidence of noncommunicable diseases is extremely high, affecting Dominicans from very young ages and placing a considerable financial burden on families and the State. The population needs to be educated regarding the risks of noncommunicable diseases and efforts must be made to inculcate positive lifestyle practices among the younger population. Beginning in the schools, health promotion must be further incorporated into all programs, thus cementing positive attitudes and behaviors. Prevention efforts and the targeting of at–risk populations are key to the control of noncommunicable diseases. The country must engage all sectors in this undertaking, if the rising tide of noncommunicable diseases is to be reversed.
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