Pan American Health Organization

Anguilla

  • Introduction
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of AnguillaAnguilla is a self-governing, Overseas Territory of the United Kingdom. It is one of the northernmost of the Leeward Islands in the Lesser Antilles group of islands in the Caribbean, and covers an area of 91 km2. It has a parliamentary system of representative government. The territory is divided into 14 administrative districts. There is no formal urban and rural delineation and the population is classified as 100% urban. The country is an associate member of the Caribbean Community (CARICOM) and the Organization of Eastern Caribbean States (OECS) and participates in subregional, regional, and international organizations and forums.

According to the 2011 census, Anguilla has a population of 13,572 persons, an increase of 16.4% since the 2001 census. The census reported 6,707 (49.4%) males and 6,865 (50.6%) females giving a male-to-female ratio of 1:1.02. The population of Anguilla is largely homogenous with the majority (85.3%) identifying as black, followed by Hispanics (4.9%) (). Immigrants who have been naturalized or registered came mainly from the Dominican Republic, Jamaica, Saint Kitts and Nevis, other Caribbean countries, and the United States of America (). Children under 5 years old made up 7.8% of the population and those 65 years and over comprised 7.5% of the population. The total dependency ratio for 2011 was 45%, with a child dependency ratio of 34% and old-age dependency ratio of 10.9% (). Figure 1 shows the changes in Anguilla’s population structure between 1990 and 2015. The population is an aging one, and estimated life expectancy has seen a steady increase. In 2015, overall life expectancy was estimated at 81.3 years, with 78.7 years for males and 83.9 years for females ().

Figure 1. Population structure, by age and sex, Anguilla, 1990 and 2015

Anguilla’s population increased 95.2% between 1990 and 2015. In 1990, the population structure had an expansive shape, increasing more quickly in ages older than 30 years and more slowly below that age. By 2015, the expansive shape shifted to ages older than 50 years with stationary growth under that age, as a result of aging and decreases in fertility and mortality over the last five decades.

Source: Pan American Health Organization, based on the U.S. Census Bureau. International Data Base. Last Updated: August 2016.

Annual population growth has shown a downward trend: growth was 2.2% in 2009 and 2.0% in 2014. The crude birth rate was estimated to be 12.8 births per 1,000 population and total fertility rate was 1.7 children per woman.

The economy is heavily dependent upon tourism. In 2014, estimated GDP was US$ 310.79 million and per capita GDP was US$ 21,493 (). The gross national income per capita for the same year was US$ 21,188, placing Anguilla’s economy in the high-income category. However, Anguilla has experienced a boom-bust cycle related to the 2008 global crisis, which accentuated weaknesses in the financial sector and undermined its fiscal position ().

According to the Anguilla Education Act of 2012, school enrollment is mandatory for children aged 5 to 17 years old, and education is free in all public schools. Functional literacy in Anguilla is 93%. Net enrollment in primary school is universal, with 100% completing the last grade. For the 2014/2015 school year, the student-to-teacher ratio was 17:1 for public primary schools and 11:1 for secondary schools (). The male-to-female ratio of enrolled students was 1.1:1 at the primary level and 1:1 at the secondary level.

The most recent country poverty assessment (CPA) (2007/2009) indicated a decrease in the proportion of indigent persons to 0% (from 2% in 2002) and a decrease in the Poverty Headcount Index to 5.8% from 23% over the same period ().

The Anguilla Population and Housing Census of 2011 surveyed the quality of housing and access to sanitation (). Most residents (61.5%) live in undivided, private houses and 96% of construction is of concrete block. Electricity is the source of lighting in 98% of homes. On average, there are 2.75 persons per household. Almost all households (99.2%) use the government trash collection system.

The Royal Anguilla Police Force has identified burglary, theft, and robbery, sexual violence, and firearm-related offences as the top crimes in the territory, noting that perpetrators are mainly males. There has been an increase in male youth gang violence, but the gangs tend to be disorganized, lacking significant drug connections or networking capacity ().

Between 2011 and 2012, there were 68 motor vehicle accidents resulting in 46 hospital admissions and 2 deaths.

In 2014, the Government created a position for Gender Development Coordinator, and a gender policy is in the process of being developed. The Government of the United Kingdom extended the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) to Anguilla in 2016.

Women have succeeded in attaining high positions within the public service. As of April 2015 two of Anguilla’s nine parliamentarians were female. Of the seven Permanent Secretaries, four are women, and in the Judiciary and its administrative branch, three of the four officials are female, including one female Head of Department ().

The Health System

Health care is the responsibility of the Ministry of Health and Social Development. In 2004 the Health Authority of Anguilla Act No. 1 was enacted, creating the Health Authority of Anguilla (HAA). Under this act the Ministry of Health assumed the role of purchaser of primary and secondary health services from the HAA as the sole service provider in the public sector. The Ministry of Health is responsible for governance and regulation of the entire health care system, which includes both public and private sectors.

The island is divided into three health districts that have one polyclinic, four health centers, and the 32-bed Princess Alexandra Hospital, all operated by the HAA. The hospital is the only admitting facility and all births occur there. There are four private health facilities that provide a range of non-emergency services. Tertiary care services are not available in Anguilla and must be accessed overseas. The national public health laboratory, located at the hospital, is also operated by the HAA. Laboratory services are largely dependent on the subregional laboratory at the Caribbean Public Health Agency (CARPHA) in Trinidad and Tobago. Anguilla utilizes the Pan American Health Organization (PAHO) Revolving Fund and the OECS procurement mechanism to attain specified essential medicines for the population.

Health care services are provided on a co-payment basis and the entire population is not insured, which poses financial barriers to access. The government, through the Ministry of Social Development, provides financial assistance, based on means testing, for persons who cannot afford to pay for services. Furthermore, there may be cultural and language barriers to access for immigrant populations.

Secondary and tertiary levels of health care, which generally must be sought overseas, pose an unsustainable financial burden to Anguilla. The government covers these costs in many cases through the Ministry of Social Development’s Medical Treatment Overseas Program. In 2015, almost US$ 1 million was spent on overseas medical treatment of 49 persons, 25% of whom were trauma cases.

Leading Health Challenges

Critical Health Problems

Communicable Diseases

Mosquito-borne diseases remain the major communicable diseases affecting Anguilla. Chikungunya virus was first detected in 2014; there were 55 confirmed cases in 2014 and 3 in 2015. Local transmission of the Zika virus was confirmed in June 2016 and as of the end of September 2016 five cases had been laboratory-confirmed. One imported case of malaria (P. falciparum) was confirmed in 2014. Dengue is endemic, and between 2010 and 2015, the highest annual number of cases reported was in 2014, with eight cases.

Anguilla has low prevalence of HIV and AIDS: a total of eight cases (two females) were identified between 2010 and 2015 and no new cases were identified in 2014 or 2015. No tuberculosis infection was reported between 2010 and 2015. In 2016, the country completed the validation exercise for the elimination of mother-to-child transmission of HIV and syphilis.

Chronic Conditions

Noncommunicable diseases figure prominently in Anguilla’s disease burden: cardiovascular disease, cancer, and diabetes collectively account for approximately one-half of deaths annually. In any given year, the local treatment cost for the major NCDs exceeds 50% of total local health care costs. In 2012, US$ 478,148, which was 52% of the total expenditure on local medical treatment for that year, was spent to treat 11 clients on dialysis. This represented a 66% cost increase compared to 2011. In 2013 this figure almost doubled to US$ 888,888 for 17 clients.

The STEPS Noncommunicable Disease Risk Factor Survey was launched in 2016, which should remedy the current lack of information on NCD risk factors in Anguilla, especially for the adult population.

Human Resources

The Health Authority of Anguilla is the primary employer of health personnel. Planning for training, recruitment, and retention of health personnel is an area of weakness, and a draft human resources plan was completed in 2013. There are 12.5 public sector physicians, 26.3 nurses, and 1.3 dentists per 10,000 population, a ratio that is adequate according to international standards (). The system is supplemented by visiting health professionals in both the public and private sectors. Although some continuing education is provided locally, training of health professionals at the tertiary level has to be accessed outside of Anguilla.

Health Knowledge, Technology, and Information

The Health Information Unit manages information from the health facilities under the Health Authority of Anguilla (HAA), including from the laboratory. This unit manages the medical records of the hospital (including all birth records) and administrative and surveillance data from all facilities. The surveillance system is based on the Caribbean Public Health Agency model, which covers surveillance of communicable diseases, noncommunicable diseases, and mortality. The Health Information Unit collects information from approximately 67% of the communicable disease reporting sites and manages all birth and death records. Death registration is mandatory prior to burial and relevant staff receives training on death certification. Reporting is largely paper-based with subsequent collation using Excel software. No formal assessment has been conducted regarding the quality of data.

The Environment and Human Security

An assessment done in 2012 concluded that Anguilla is already experiencing some effects of climate variability and change (). Projections are for an increase in average atmospheric temperature, reduced average annual rainfall, increased sea surface temperatures, and the potential for increased intensity of tropical storms. Most infrastructure and settlements are located on or near coastal areas that face pressure from natural forces (wind, waves, tides, currents) and human activity (beach sand removal and inappropriate construction of shoreline structures). These vulnerabilities could be magnified by climate change, particularly sea level rise and accelerated coastal erosion.

The island’s heavily degraded, infertile soils (low in organic matter) and poor agricultural land management practices were identified as exacerbating factors threatening agriculture and food security. The tourism industry was cited as the main contributor to high levels of per capita CO2 emissions.

Anguilla, similar to other countries and territories in the Caribbean Basin, is vulnerable to hydro-meteorological disasters such as floods and storms. Major flooding was caused by Hurricane Gonzalo in October 2014, but there were no major injuries and no deaths. Anguilla purchases tropical cyclone and excess rainfall coverage policies from the Caribbean Catastrophe Risk Insurance Facility. In 2014, the five-year comprehensive disaster management policy and strategic plan were revised, and espoused a proactive rather than reactive approach to disaster management.

Water scarcity is a major issue for Anguilla and the island is heavily dependent on rain and water storage for water supply. The freshwater resources are subterranean, and the water is brackish and unfit to drink. In addition, the groundwater yield has been deemed insufficient to meet the long-term needs of the island ().

In 2011, 95% of the population had access to improved water sources, compared to 59% in 1995. According to the 2011 Population and Housing Census (), most households (73%) obtained water from a cistern that piped water into the dwelling, 15% used the public water piped into the dwelling, and 4% used a public stand pipe, well, or tank. Three of every five households (61%) indicated that their main source of drinking water was bottled water. Additionally, 98% of the population reported they had access to improved sanitation facilities compared to 57% in 1995, and flush toilets accounted for 98% of those facilities.

Aging

Policies and plans to address the increasing elderly population in Anguilla have been put in place, including the National Policy for Older Persons (2009), and standards for operating care facilities included in the National Policy on Residential Care Facilities for Older Persons (2012).

There are four private sector and one public care institutions for the elderly that house 60 persons, with a female-to-male ratio of approximately 1.3:1.

Monitoring the Health System’s Organization, Provision of Care, and Performance

In 2013, the Government of Anguilla adopted the Framework for Fiscal Responsibility, which supports a commitment to continued open and transparent management of public finances consistent with the highest standards of governance and democracy. This should bode well for sustainable development. The National Policy and Strategic Plan for Health (2015-2020) was also developed and is in use.

A Chronic Disease Unit was created in 2015, replacing the National HIV/AIDS Program, and restoring the National Chronic Disease Commission. The focus of the new unit is sexual and reproductive health (including sexually transmitted infections and HIV/AIDS) as well as the major chronic, noncommunicable diseases. A National Noncommunicable Disease Action Plan for 2016-2025 was also developed. Tobacco control legislation has not been introduced in Anguilla.

A United Kingdom progress report on implementation of International Health Regulations (IHR) (2005) and other commitments made during the 2013 Joint Ministerial Council meeting stated that UK Overseas Territories were “considered broadly compliant with IHR … although surveillance and response systems could be further strengthened” (). The report was consistent with conclusions of the assessment commissioned by the Organization of Eastern Caribbean States in 2016 (). The requirement that countries and territories be able to respond to chemical, biological, and radionuclear emergencies was identified as an area of major weakness for Caribbean territories.

Membership with the International Atomic Energy Agency (IAEA) is considered strategic and beneficial, but Anguilla is ineligible due to its Overseas Territory status.

Prospects

Anguilla is politically and socially stable and the tourism industry provides its high-income status. The Sustainable Development Goals in the areas of quality education and clean water and sanitation appear to be on track. The extension by the United Kingdom of the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) to Anguilla and the increase in women’s parliamentary participation are steps in the right direction for gender equality and the empowerment of women and girls. The introduction of the Fiscal Sustainability Framework bodes well from a sustainable development perspective and should foster institutional strengthening and justice.

Anguilla has been successful in many areas of health, including the reductions in diseases preventable by immunization, maternal mortality, and deaths from communicable diseases. However, major issues that must be addressed are the burden of noncommunicable disease, the sustainability of health care financing, and universal access to health care services. These challenges may be exacerbated by the aging population and the health system must adequately prepare for these realities. Box 1 highlights some of Anguilla’s accomplishments in health.

Box 1. Highlights in Health, Anguilla

  • Major health advances include the reduction in maternal mortality and maintaining zero mortality from vaccine-preventable diseases. Anguilla successfully participated in the global switch from trivalent to bivalent polio vaccine in 2016. The territory completed the validation exercise for the elimination of mother-to-child transmission of HIV and syphilis in 2016.
  • The prevention of noncommunicable diseases has been elevated to the highest priority by the government as evidenced by the approval of the national plan of action and the development of a Chronic Disease Unit. The latter represents a concerted effort to move away from vertical approaches to programming and a better use of resources in addressing priority public health problems.

The high dependence on tourism and that market’s sensitivity to natural disasters and communicable disease threats, within the context of Anguilla’s vulnerability to natural disasters and climate change, remain major challenges. The effects of climate change on weather patterns and the likely health impacts, such as the increase of mosquito-borne diseases and the emergence of new threats such as the chikungunya and Zika viruses, are of critical concern. Emphasis continues to be placed on the response capacity for natural disasters and health-related emergencies.

The limited number of health care professionals and strategies for their training, recruitment, and retention need to be addressed. The existing rudimentary health information system must be modernized to improve accuracy and efficiency.

References

1. Ministry of Economic Development, Statistics Department (Anguilla). Anguilla population and housing census 2011: preliminary findings #5 [news release]. The Valley: Ministry of Economic Development; 2014. Available from: http://gov.ai/statistics/images/Press Release Census Findings no5 – Preliminary Results – Nov 2014.pdf.

2. Pan American Health Organization. Health in the Americas: 2012 edition. Washington, D.C.: PAHO; 2012.

3. Ministry of Economic Development, Statistics Department (Anguilla). Anguilla population and housing census 2011: preliminary findings #7 [news release]. The Valley: Ministry of Economic Development; 2014. Available from: http://gov.ai/statistics/images/Press%20Release%20Census%20Findings%20no7%20Preliminary%20Results%20-%20Dec%202014.pdf.

4. Pan American Health Organization. PLISA: Health Information Platform for the Americas. Demographic-socioeconomic indicators: life expectancy at birth for countries and territories of the Americas, 2015 [Internet]. Washington, D.C.: PAHO; 2015 [updated September 2016]. Available from: https://www.paho.org/data/index.php/en/indicators/demographics-core/343-life-expectancy-en.html.

5. United Nations Statistics Division. National Accounts Main Aggregates Database. [GDP/GNI:]All countries and regions/subregions (totals) for all years—sorted by region/subregion [Internet]. New York: UN; 2016. Available from: http://unstats.un.org/unsd/snaama/dnllist.asp.

6. International Monetary Fund. United Kingdom—Anguilla—British Overseas Territory: 2011. Article IV consultation discussions. Country report no. 12/8. Washington, D.C.: IMF; 2012. Available from: http://www.commercialregistry.ai/news/IMF%20Report%20on%20Anguilla.pdf.

7. Department of Education (Anguilla). End of year report 20142015. The Valley: Government of Anguilla; 2016. Available from: http://www.gov.ai/documents/education/doe_report_2014_2015.pdf.

8. Kairi Consultants Limited. Anguilla country poverty assessment 2007/2009. Vol. 1. The Valley: Government of Anguilla; 2009. Available from: http://www.gov.ai/documents/statistics/Anguilla_CPA_-_Main_Report_Final_(Submitted).pdf.

9. Ministry of Economic Development, Statistics Department (Anguilla). Anguilla population and housing census 2011: selected housing and household indicators—analytical brief. The Valley: Ministry of Economic Development; 2011. Available from: http://unstats.un.org/unsd/demographic/sources/census/wphc/anguilla/AIA-2015-05-22.pdf.

10. Caribbean Development Bank. Country gender assessment (CGA), Anguilla. St. Michael, Barbados: CDB; 2016. Available from: http://www.caribank.org/wp-content/uploads/2016/05/CountryGenderAssessmentAnguilla.pdf.

11. Pan American Health Organization. Health situation in the Americas: health indicators 2014. Washington, D.C.: PAHO; 2014.

12. Simpson MC, Clarke JF, Scott DJ, New M, Karmalkar A, Day OJ, et al. CARIBSAVE climate change risk atlas (CCCRA)—Anguilla. St. Michael, Barbados: UK Department for International Development, Australian Agency for International Development, and The CARIBSAVE Partnership; 2012. Available from: http://www.caribbeanclimate.bz/closed-projects/2009-2011-the-caribsave-climate-change-risk-atlas-cccra.html.

13. Foreign & Commonwealth Office (United Kingdom). Joint Ministerial Council 2013UK progress report. London: FCO; 2014. Available from: https://www.gov.uk/government/publications/joint-ministerial-council-2013-uk-progress-report.

14. Organization for Eastern Caribbean States. Roadmap for implementation of IHR 2005 Requirementsrequirements in OECS Member States. Castries, St. Lucia: OECS; 2016.

15. Ministry of Health and Social Development, Health Information Unit (Anguilla). Chief Medical Officer’s report, 2015. The Valley; Ministry of Health and Social Development, Health Information Unit. Chief Medical Officer’s Report, 2015; 2015.

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Reference/Note:

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