Socioeconomic, Political, and Demographic Overview
Saint Vincent and the Grenadines is located at the southern end of the Windward Islands, between Saint Lucia and Grenada. The country comprises the island of Saint Vincent and seven smaller inhabited islands and islets that together constitute the Grenadines; altogether, the islands cover 388 km2.
The Medium-Term Development Strategy Paper (19961999) sets out the Governments policies and policy implementation arrangements designed to bring sustainable economic growth and social development to the nation. The guiding principles have been defined as equity, the provision of essential services to all citizens, the maintenance of an environment in which all citizens can realize their full potential, and the promotion of employment.
The medium-term strategy emphasizes improving banana production and diversifying agriculture, supporting private sector development, expanding tourism, improving fiscal management and budget reform, making public sector delivery more efficient and effective, pursuing human resources development, and managing environmental problems more intensively.
Real GDP grew at an average annual rate of 3.5% during 19921995, with most of the increase occurring in 1992 and 1995. The decline in economic performance during 1993 and 1994 has been attributed to disruptions in the banana export market and to a drop in production caused by drought; during these years, tourism gathered importance, and its revenues exceeded those from bananas. Per capita GDP in 1995 was US$ 1,987, representing a recovery from the period of stagnation in the growth of per capita GDP during 1993 and 1994.
The 1996 Poverty Assessment Report for Saint Vincent and the Grenadines examined the nature, extent, geographic concentration, severity, and causes of poverty in 13 selected communities. It concluded that 41.9% of the studied population were poor. Moreover, 30.5% of households and 36.2 % of the population were considered to be indigent. Three out of every ten workers were engaged in the informal sector where work was irregular and economic returns unstable.
The 1991 Population and Housing Census Report estimated the unemployment rate at 19.8%. Just prior to the 1991 Population and Housing Census, 22.8% of the employed population was engaged in the agricultural sector, 15.5% in wholesale and retail trade, 10.8% in construction work, and 8.4% in manufacturing. Unemployment levels were highest among persons engaged in construction (32.2%), wholesale and retail trade (10.9%), and agriculture (10.8%).
Although education is not compulsory, almost all of the population aged 515 years old attends school (95.3%). The country has 65 primary schools and 23 secondary schools. Most nationals had not studied beyond the primary or basic school level (66.9%), 18.5% had progressed to the secondary level, and 2.4% had reached post-secondary vocational training and university education; the remainder of the population (about 10%) had no formal education and must be deemed to be functionally illiterate.
The 1991 Population and Housing Census Report showed 27,002 households in the country, compared to 20,090 in 1980, a 34.4% increase during the period. The 1996 Poverty Assessment Report revealed that housing conditions were poor in some communities, but it also showed that most households were privately owned.
The 1991 Population and Housing Census Report returned a final count of 106,499 persons, indicating an average annual growth rate of 0.8% since the previous 1980 census. Since then, mid-year population estimates have been set at 108,965 for 1992 and 110,723 for 1995, representing an average annual growth rate of 0.4% between 1992 and 1995, or about 50% of the rate recorded for the previous decade. One-quarter of the population (25.7%) lives in the capital city of Kingstown and its suburbs and may be considered urban; more than 90% of the population resides on Saint Vincent.
The annual average net emigration between 1992 and 1995 has been established as 947. The population is relatively young: in 1995, 37.2% of the population was younger than 15 years old. Only 6.5% of the population falls into the age group 65 years old and older. Together, these two groups account for 43% of the population, suggesting a somewhat steep dependency ratio. The sex distribution is even. Life expectancy at birth has been set at 70 years, disaggregated as 65 years for males and 72 years for women.
The crude birth rate has shown only marginal decline in recent years, moving from 24.7 per 1,000 population in 1992 to 23.6 in 1995. No change in the total fertility has been observed, having been reported as 2.8 children per woman in both 1992 and 1995. There is no underregistration of births.
The crude death rate for the 19921995 period was 6.5 per 1,000 population, with slight variations from year to year.
Infant deaths averaged 42 over the 19921995 period, while the infant mortality rate varied slightly from 14 to 18 per 1,000 live births. It is noteworthy that in 1995, 35, or 83% of infant deaths, occurred in infants under 1 day old.
The predominant causes of death relate to those diseases that are grouped under the category "diseases of the circulatory system," and accounted for a cumulative total of 1,058 deaths (38.8% of deaths from defined causes) during the period 19921995. Within this cause group, 423 deaths resulted from heart diseases (ICD-9, 410429), 289 deaths from hypertensive disease (401405), and 264 deaths from cerebrovascular disease (430438). The second leading cause of death was neoplasms, with 418 deaths (15.4%); followed by external causes, with 196 (7.2%) deaths; and conditions originating in the perinatal period, with 147 deaths (5.4%). There was a cumulative total of 132 deaths, representing 4.6% of all deaths, that was assigned to "deaths from ill-defined causes" (780799). Full registration of all deaths is reported.
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
Health of Children and Adolescents
Children have been listed in the 19911995 National Health Sector Plan as one of the countrys vulnerable groups deserving special attention. As a result, several specialized programs for young children have become institutionalized within the health care delivery system, including prenatal care of women following set protocols, special child health clinics that provide complete assessment and immunization, ongoing education of parents and guardians, and community follow-up care.
Immunization coverage against common childhood illnesses has neared 100% for many years; as a result, there were no confirmed cases of tetanus, diphtheria, or tuberculosis among the age group under 5 years old between 1992 and 1995. Most of the deaths occurring in children aged 09 years old are confined to the first year of life. In 1995, 47 deaths occurred among children under 1 year old. The main causes have been conditions originating in the perinatal period (ICD-9, 760779) (24 deaths) and congenital anomalies (740759) (18 deaths). Most newborns weigh at least 2,500 g at birth, but an annual average of 2.1% of newborns exhibit some level of below-normal weight at birth.
Approximately 90% of all children under 5 years old enjoy a satisfactory nutritional status in terms of weight-for-age as set out in the growth chart recommended by the Caribbean Food and Nutrition Institute (CFNI). An annual average of 5.7 % suffer from undernutrition, however, with most falling into the category of moderate undernutrition. Although improvements in this index have been observed between 1992 and 1995, the level of undernutrition remains unacceptably high. Moreover, obesity has shown a gradual but steady rise, from 3.8% in 1992 to 4.7% in 1995.
Health of Women
From 1992 to 1995, 22% of all births, on average, occurred in teenage women, while 9% occurred in women 3549 years of age. Because high-risk pregnancies comprise nearly 30% of all births, a health and family life education program has been put in place in primary and secondary schools and youth guidance centers and skills training programs have been established.
Women of childbearing age (1544 years old) are one of the priority groups targeted for special attention by the Government. A range of programs providing prenatal and postnatal care, family planning services, and general medical care has been established for women.
The protocol governing the delivery of maternal and child health services stipulates a minimum of six prenatal checks. Records show that 82% of all pregnant women now satisfy this criterion. Virtually all mothers and children receive the minimum of three postnatal checks within the first ten days of delivery. In 1995, 7.0% of all pregnant women making their first prenatal visit displayed hemoglobin levels under 10 g. Identical levels were seen among women at 32 weeks and over their pregnancies on repeat visits. Indeed, anemia in pregnancy has been listed as one of the main concerns among obstetrical patients admitted to the Kingstown General Hospital: 2.0% of 12,290 total admissions to the maternity ward in the 19921995 period were seen for this problem. Other major problems were abortion (3.6% of total admissions), premature labor (1.8%), pre-eclampsia (1.5%), and postpartum hemorrhage (1.4%).
The National Health Sector Plan (19911995) is committed
to increase the number of deliveries occurring at the
district level, outside of Kingstown General Hospital. To
this end, Barrouallie Health Centre was upgraded to a
maternity unit in 1993, as a means of encouraging district
deliveries. In 1992, only 20% of total births occurred at the
district level, however, and the number barely increased to
Records show that in 1995 there were 10,458 women, or 39.4 % of women of childbearing age, who were using family planning methods.
Four of the seven deaths attributed to maternal causes occurred in 1994.
The 1991 Population and Housing Census Report showed that 9,040 (33.5%) of all single-parent households with one or more children were headed by women. Almost 90% of these women were never married, while 36.3% of them had responsibility for four or more children.
Health of Adults and the Elderly
In 1995, 23.6% of all deaths occurred among the age group 2059 years old, a level that held throughout the 19921995 period. Of the 179 deaths attributed to this age group, the leading causes were neoplasms, endocrine and metabolic diseases, and immune disorders.
In 1995, 8.9% of the population fell into the age group 60 years old and older. Persons in this cohort have been shown to be at greatest risk from chronic noncommunicable diseases. The major causes of illness and death among this age group have been hypertensive diseases, malignant neoplasms, and cerebrovascular accidents.
The Government operates a 120-bed home for the aged that mainly provides general care. Current policy encourages noninstitutional care of the elderly within the community, and a task force has been set up to determine the scope of problems among the elderly, indicate appropriate responses, and adopt holistic approaches to care.
There are no specialized health services for the elderly, although legal provisions have been made to exempt them from user fees. The elderly also are the main beneficiaries of the routine diabetic clinics that are conducted at all health centers.
Everyone has access to health care through the general health services delivery system that includes maternal and child health and diagnostic services at the primary level and any available secondary care services. By law, prenatal, postnatal, and family planning services are provided free of cost, and children under 17 years old are exempt from charges.
Two institutions provide services for the disabled in Saint Vincent and the Grenadinesthe School for Children with Special Needs, which has campuses in Kingstown and Georgetown, and the Sunshine School for the Disabled in Bequia. As a way to streamline programs, for the past five years the disabilities of children attending these institutions have been continually assessed according to international criteria. In 1995, of a total enrollment of 94 children, 18 were hearing-impaired, 3 were visually impaired, 32 were mentally retarded, 7 were physically challenged, 6 were autistic, and 28 were learning-disabled. All students attending these institutions must, by law, be fully immunized against common childhood illnesses. Routine medical checks also are provided to all students, in collaboration with the public health service delivery system.
Analysis by Type of Disease
Infectious diseases rates have decreased. Infectious diseases ranked eighth among the ten leading causes of death between 1992 and 1995, and only skin infections featured among the main reasons for visits to public sector clinics. Gastroenteritis, once a scourge among young children, accounted for just 1.2% of medical visits 677 in 1995.
Vector-Borne Diseases. Dengue fever and leptospirosis have been the two vector-borne diseases of public health significance. There were 224 reported cases of dengue in 1995, of which 115 were confirmed by laboratory diagnosis.
The relatively high prevalence of the Aedes aegypti mosquito illustrates the severity of the problem: the household index for the mosquito was reported at 16.5% in 1995, up from 14. 8% in 1992. Moreover, the Breteau Index averaged 27.7 over the 19921995 period. Both indices are much higher than the safety zone of 1% infestation that has been established by PAHO/WHO.
Leptospirosis has made a comeback in Saint Vincent and the Grenadines within a very short time. The disease was insignificant at the beginning of the decade, but by 1995 there were 42 suspected cases, with 13 confirmed and 3 deaths.
Tuberculosis. New cases of tuberculosis averaged seven between 1992 and 1995, peaking in 1993 with 13 new diagnosed cases, the highest number of cases recorded in any one year for more than a decade. An annual average of two deaths from this disease were recorded over the period. The incidence of tuberculosis has been highest among those aged 40 to 54 years old.
AIDS and Other Sexually Transmitted Diseases. By the end of 1995, a total of 182 HIV-infected cases had been confirmed by laboratory since the first case in 1984; of these, 73 had developed full-blown AIDS and 71 had died. Sixteen new cases of HIV infection were confirmed in 1992, 27 in 1993, and 26 each in 1994 and 1995. In 1992 there were 7 new AIDS cases, 8 in 1993, 15 in 1994, and 6 in 1995. In Saint Vincent and the Grenadines, the case fatality rate among AIDS patients is 94%; about 75% of infected persons fall into the age group 2544 years old, with the 2529-year-old age group being most affected (25.4%); heterosexual transmission (59%) is the main mode of spread, and only 1.9% has been by vertical transmission; and HIV transmission through intravenous drug use and blood transfusion is unknown.
Noncommunicable Diseases and Other Health-Related Problems
Of the total 56,131 visits for medical consultation at all 38 health centers in 1995, the leading noncommunicable disease diagnoses were musculoskeletal problems (11.4%), hypertension (10.5%), arthritis (6.2%), and diabetes (6.0%). Thus, chronic diseases predominate even among the leading causes of morbidity.
Diabetes and Hypertension. Prevalence rates for diabetes and hypertension are unknown. However, records show that in 1995 there were a combined total of 5,863 persons suffering from these conditions who were registered at health centers. Of these, 1,280 (21.8%) were diabetics, 3,589 (61.2%) were hypertensives, and 994 (17%) suffered from both. Special clinics for persons suffering from these conditions are held weekly at all health centers.
Malignant Tumors. Malignant neoplasms are among the leading causes of death in Saint Vincent and the Grenadines, causing 411 deaths in the 19921995 period (103 in 1992, 99 in 1993, 103 in 1994, and 106 in 1995). The main cancer sites were the digestive organs and peritoneum (127 deaths in the period); genitourinary organs (114 deaths in the period); lymphatic and hemopoietic tissue (47 deaths); bone, connective tissue, skin, and breast (43 deaths); and respiratory and intrathoracic organs (31 deaths).
Cervical cancer screening services are available to all women in both the public and private sectors. Screening programs seek the early detection and treatment of cervical carcinoma. As a matter of policy, all women who are registered in the Governments family planning program are screened routinely for this condition. A total of 12,612 Pap smears were analyzed during the 19921995 period, with the following results: invasive cancer, 15; cancer in-situ III, 48; cancer in-situ II, 84; and cancer in-situ I, 180; the remainder were normal.
Behavioral Disorders. Activity statistics of the Mental Health Centre, the countrys only psychiatric hospital that also functions as a residential drug abuse treatment facility, indicate that substance abuse (48.9%), drug-induced psychosis (21.3%), and schizophrenia (20.8%) were the main causes of admission between 1992 and 1995, accounting for 91% of the 1,199 admissions during the 19921995 period; mental retardation, epilepsy, and manic depression accounted for 2.4%, 2.2%, and 1.3 % respectively.
In terms of community mental health, an annual average of 1,040 follow-up home visits were made to outpatients, and attendances at outpatient sessions averaged 3,029 per year; the purpose of the visits was to conduct ongoing psychiatric assessment of all discharges, refill or change medication as necessary, and provide consultation to community-based staff. These community assessments are conducted by a core team on a monthly basis. In 1995, there were 1,241 active patients on the community mental health register.
Mental Health Centre admission records for the 19921995 period indicate that of the 587 admissions due to substance abuse, 47.5% were for marijuana, followed by 27.7% for cocaine, and 24.8% for alcohol. About 91% of all admissions for substance abuse were males, while the most vulnerable age group has been shown to be 1529 years, with 63% of all admissions falling into this category.
Accidents and Violence. There were 196 deaths resulting from external causes (accidents and violence) during 19921995: transportation accidents accounted for 30 of them (15.3%), homicide and injury purposefully inflicted by others for 35 (17.8%), suicide and self-inflicted injury for 22 (11.2%), and other violence for 55 (28.1%). The last group includes deaths due to injury unknown whether accidentally or purposely inflicted.
In 1994, a National Committee Against Violence was established to educate the public on all forms of violence, especially domestic violence; provide social and psychological support to victims of violence and their families; and maintain a data base on all aspects of violence.
Oral Health. Government-run oral health services are directed toward providing qualitative and affordable oral health care to the population, particularly school-age children. The number of appointments at the main Kingstown Dental Clinic and the three satellite centers increased 11.9% from 69,124 in 1992 to 77,381 in 1995. On average, 35% of these visits were for extractions, decreasing by 6% over the period, while the number of restorations increased by 8%.
In 1993, a survey on the status of dental health among schoolchildren was completed with PAHOs assistance. The survey revealed that 69% of all schoolchildren (515 years old) were affected with dental caries, a known major cause of tooth loss that helps to explain the high demand for extractions. The other major problem was calculus, with 20 % of the surveyed population being affected.
The introduction of fluoride treatment at the primary-school level has been achieved. Currently, all children under 16 years of age attending dental clinics are treated with topical fluoride gel. There is no fluoridation of the communal water supply system.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
The Governments overall strategy for economic growth, as articulated in the 19911995 National Development Plan, centers on increasing output and improving productivity primarily in the agriculture, tourism, education, and health sectors.
The Governments social development policy focuses on the need to promote self-sufficiency for disadvantaged groups; for example, by encouraging the community to work together to solve its own problems. In this regard, efforts have been carried out in the agriculture, health, education, housing, and community development sector.
According to the 19911995 Health Sector Plan, the Government views access to health care as a basic human right and an integral part of national development and acknowledges that all citizens have the right and duty to participate individually and collectively in the planning, implementation, and evaluation of their health care services at all levels; that health cannot be achieved through the efforts of the health sector alone, but must involve close collaboration with all other sectors; and that the fullest and best use must always be made of national resources to promote health and development. To this end, the Government is committed to provide comprehensive and affordable health care services at primary, secondary, and tertiary levels; facilitate intrasectoral and intersectoral collaboration in providing health care to the population; strengthen links with the community, the private sector, and nongovernmental organizations; institute necessary regulatory mechanisms to ensure the availability of quality health care; and establish dynamic management systems that facilitate the delivery of effective and efficient health care.
The key development areas in health that the Government pursued during the 19911995 period were health education and health promotion; disease prevention and control; maternal and child health, including family planning; strengthening of environmental health services; continued development of community and hospital care services; strengthening of pharmaceutical supplies management; drug abuse prevention and control; strengthening of health information systems; and reform of health legislation.
As part of its effort to attain universal access to health care, the Government has identified mothers and children, the poor, and the aged as vulnerable groups requiring special attention. As a result, various services are targeted toward women and children, and the poor, aged, and unemployed are granted concessions in accessing health care services.
Since 1991, the Government has pursued a policy of health sector reforms as a way to increase efficiency in the use of resources and improve cost recovery within the system. Reforms have involved the establishment of new management structures and the streamlining of systems to encourage greater accountability; legislative initiatives also were undertaken to adjust user charges. A review of the health sectors management systems was completed in 1994, leading to changes in organizational structure and functional relationships. The process resulted in the creation of a Senior Management Committee and the adoption of protocols to guide the delivery of services and new forms and schedules for reporting.
Organization of the Health Sector
Health services in Saint Vincent and the Grenadines are basically offered at the primary and secondary levels; at least two major institutions provide social support as well as health care. At the primary care level, 38 health centers spread over 9 health districts provide services. Each health center is staffed by a full-time district nurse/midwife, a nursing assistant, and a community health aide. Other district health team members such as the district medical officer, pharmacist, and environmental health officers provide support.
On average, each health center covers a population of 2,900 and no one is required to travel more than three miles to access care. Available primary care services include emergency care; medical care; prenatal care and postnatal care; midwifery services; child health services, including immunization; family planning services; and communicable and noncommunicable disease control.
At the secondary level, the 209-bed Kingstown General Hospital is the countrys only government acute care referral hospital that provides specialist care in most major areas. Five rural hospitals, with a combined 58-bed capacity, provide a minimum level of secondary care services for which specialist intervention is not indicated. In addition, there are three small, privately owned and operated acute care hospitals with a total capacity of 24 beds. The Government also operates the 120-bed Mental Health Centre, which provides care to acute and chronic psychiatric patients, and the Home for the Aged, which caters to the indigent elderly population and functions as a refuge for abandoned persons with disabilities.
Health Services and Resources
Organization of Services for Care of the Population
Health Promotion and Community Participation. The Health Education Unit has grown into an active unit within the Ministry of Health and the Environment; its main program involves information, education and communication, health promotion, and community outreach activities. To date, there are ongoing training programs in health and family life education for parents, students, out-of-school youth, and community members; daily radio and television programs; and continuous production of a range of audiovisual and graphic materials. The Health Education Unit also coordinates health promotion activities.
There is an ongoing experiment to stimulate community participation in health by promoting the active involvement of community members in the planning, implementation, and evaluation of health programs. Community action is facilitated at the health committee or health center level and at the higher district health team level. It is hoped that this initiative will further involve the community in efforts to modify lifestyles and alleviate health problems. Although some success from this effort has been recorded over time, performance has been irregular.
Environmental Protection. The Government of Saint Vincent and the Grenadines has declared the 1990s as the "Decade of the Environment." To that end, the portfolio of the Ministry of Health was extended to include the environment, and the Ministry became known as the Ministry of Health and the Environment; a new Environmental Services Coordinator post was created in 1995, with responsibility for coordinating all national plans and activities related to environmental protection and preservation; and a National Environmental Advisory Board was appointed by the Cabinet in 1995 to advise the Minister on policies and programs aimed at the environmental protection.
The main environmental issues that have been targeted for attention are the protection of the nations flora and fauna; the protection of beaches from pollution and sand mining; controlled use of chemicals and pesticides, especially in agriculture; and the proper management of solid and liquid wastes.
Water Supply, Sewerage Systems, and Solid Waste Disposal. The 1991 Population and Housing Census Report indicates that almost one-half of all households (47.6%) have water from the communal supply system piped into their premises (yard and house), and an additional 29.4 % receive their water from a public standpipe. This means that more than three-quarters of all households (77%) benefit from a reliable potable water supply. It should be noted, however, that 10.8% of households still receive their domestic water supply from suspect sources such as springs, rivers, streams, and other communal water sources.
The pit latrine remains the most prevalent means of sewage disposal among households (62.3%), followed by the septic tank (30.1%). It should be noted, however, that the number of households without any approved form of sewage disposal has declined from 8% in 1980 to 3.7% in 1991. Some parts of the capital, Kingstown, are linked by a commercial sewage system that encompasses 3.1% of premises.
In 1995, approximately 64% of all households were provided with a once-weekly refuse collection service, representing a 16% increase in coverage between 1992 and 1995. This service is also augmented by a widespread distribution of community refuse collection bins that are emptied as necessary.
Saint Vincent and the Grenadines is a participant in the Organization of Eastern Caribbean States (OECS)/World Bank Solid Waste Management Project. The project will establish four sanitary landfill sites, two on mainland Saint Vincent and two in the Grenadines, and will extend collection service nationwide.
Food Safety. Broad promotional campaigns have been launched to develop positive attitudes and practices in the handling, preparation, storage, and sale of food that is sold for human consumption. For example, all health districts now routinely conduct clinics for food handlers that provide information and education, demonstrations, medical examination, and, where necessary, treatment. In 1995, there were 2,733 food handling establishments and 3,655 food handlers registered with the public health authority. There are also itinerant vendors, however, who operate without basic sanitary facilities and outside of the reach of public health regulations.
Workers Health. The Accidents and Occupational Diseases Act No. 24 of 1952 mandates employers to notify the Department of Labour about any accident arising out of and in the course of the employment of any worker that causes loss of life or disability. In 1995, 11 cases of injury on the job were reported. In strict interpretation of and compliance with the law only very serious accidents are reported, and the consensus is that the legislation should be expanded to enforce the notification of all occupational health and safety problems.
Factory Act No. 5 of 1955 regulates employment conditions in factories and other workplaces regarding the health, safety, and welfare of persons employed therein and allows for the inspection of the plant, machinery, and any inputs. This Act is enforced by Environmental Health Officers, who work closely with the Department of Labour, the Trade Union Congress, and the Employers Federation.
Disaster Preparedness. Saint Vincent and the Grenadines is the home of the La Soufriere volcano, which last erupted in 1979. The islands also are vulnerable to tropical storms and hurricanes, although no major disasters have occurred recently. However, there is a national consciousness of this vulnerability and the need for continuous disaster preparedness and vigilance.
The Central Disaster Preparedness Committee, which operates under the chairmanship of the Prime Minister, encompasses five subcommittees responsible for disaster management, relief operations, disaster assessment, health conditions, and public information and education. All of these aspects are addressed in the National Disaster Plan. The health component establishes responses in the event of various disasters; the main considerations are mass casualty management, environmental sanitation, food protection, and the potable water supply. The plan also spells out necessary equipment and supplies that must be available at health facilities at the peripheral and central levels in response to disasters.
Organization and Operation of Personal Health Care Services
The occupancy level at the Kingstown General Hospital has averaged 71% per year between 1992 and 1995, a 2% increase over the immediately preceding period. The most active wards have been maternity, surgery, and medicine, in descending order. After a consistent level of activity between 1992 and 1994, hospital admissions fell by 6.2% in 1995. This drop was observed mainly in the maternity ward and may indicate a small measure of success in the efforts to encourage more deliveries at the community level. General hospital utilization is also reflected in the periods average length of stay of 6 days.
All rural hospitals report occupancy levels below 35%, suggesting a high degree of underutilization; reasons given for this low activity include the absence of diagnostic facilities (laboratory and radiography) and of specialist care; the situation is under review. The leading causes of admission to these institutions have been gastroenteritis and maternity cases.
The Mental Health Centre, by contrast, operates at a 120 % occupancy level, and the Home for the Aged never falls below maximum capacity. A recent evaluation of the psychiatric services in Saint Vincent and the Grenadines emphasized the need for strengthening the community outreach program as a way to divert the emphasis from institutional care.
Community services are the cornerstone of the health care delivery system. Every year, more than 90,000 visits are made to health centers for the full range of services offered, and almost 48,000 household visits are made by various health staff categories.
Inputs for Health
Essential Drugs and Medications. Saint Vincent and the Grenadines is a founding member of the Eastern Caribbean Drug Service (ECDS), and, as such, benefits from an average 25% savings on the pooled procurement of pharmaceuticals and medical supplies. In recent years, the range of items covered by the service has been expanded to include contraceptive supplies, resulting in even greater economy. About 11.8% of the total recurrent health budget is allocated to the purchase of pharmaceuticals and medical supplies.
The range of drugs available within the public health system is dictated by the National Formulary committee, which is responsible for formulating and updating National Formulary. The National Formulary is closely linked to the Regional Formulary that has been established by ECDS.
A new drug inspector post was created in 1995, designed to monitor the implementation of the legal provisions regarding the dispensing of prescription drugs, drug registration, and drug importation. Relevant legislation is currently being reviewed to facilitate the work of this officer.
All traditional categories of health personnel are available, with nurses, nursing assistants, and doctors representing the highest proportions. There were 574 health personnel posts in 1995, of which 53 were physicians (48 per 100,000 population) and 231 trained nurses of all categories (141 per 100,000 population). As of 1995, upward of 90% of all permanent positions provided for under the budgetary estimates were filled. In 1996, there were only limited shortages in the areas of physiotherapy, pharmacy, and medical technology.
Training of Human Resources.
Saint Vincent and the Grenadines has two training institutions for health care professionals: the Government-run School of Nursing and the private offshore Kingstown Medical College, an affiliate of the St. Georges Medical School headquartered in Grenada. Health care professionals also receive training at regional and international institutions. Moreover, the emphasis on efficiency and productivity has led to strengthening of managerial and supervisory functions.
Expenditures and Sectoral Financing
From 1992 through 1995, actual Government expenditure on health averaged just under 15% of the total recurrent expenditure. The actual recurrent expenditure on health for the four years was US$ 37.46 million, out of a total recurrent expenditure of US$ 250.90 million, and 4.6% of GDP was spent on health; in the previous four-year period the recurrent expenditure on health averaged 15.4% of total recurrent expenditure. Health now ranks as the third largest consumer of Governments recurrent expenditure, behind the servicing of public debt and education, in that order. Even so, health still attracts 40% of all recurrent expenditure in the social sector.
In 1995, Kingstown General Hospital received 33.7% of all expenditure, and this pattern has held over the period under review. Although the way that the services are organized and the manner in which the budget is presented preclude a precise quantification of expenditure on primary health care, it is known that community health centers and associated services and environmental health services together are allocated 29.2% of the recurrent health budget. Personnel salaries across programs account for 58% of health expenditure.
In January 1995, the Government enacted legislation to revise the user-fee schedule within the public sector, which led to increase revenue collection from 2% to 6% of actual Government expenditure in the public health sector. In a related initiative, in 1995 Parliament agreed to introduce a National Insurance Programme. A Cabinet-appointed Steering Committee is currently in the process of undertaking all of the background work required to establish this program. Finally, a reform package for the sector seeks to strengthen general and supplies management systems, introduce cost tracking mechanisms, revise admission and billing procedures, and launch a consumer education program.
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