- Leading Health Challenges
- Health Situation and Trends
- Full Article
Anguilla 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
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.
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.
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.
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.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
Antenatal care coverage and skilled attendance at birth have remained at 100% for pregnant women in Anguilla for the 2010-2015 period. There was one maternal death in 2010. More than 52% of pregnancy-related hospital admissions in 2014 were for delivery. Hypertensive disorders of pregnancy such as preeclampsia and eclampsia accounted for eight admissions. There were no admissions due to postpartum hemorrhage and one admission for complications related to the puerperium. Since 2002, the annual percentage of births by caesarean section has been consistently above 30%, and between 2011 and 2014 was above 40%. In 2014, the stillbirth rate was 13.2 per 1,000 births; 8% of newborns were preterm and 23% were low birthweight.
In 2014 the infant mortality rate was 13.3 per 1,000 live births, which was lower than the subregional and regional averages for the corresponding year. Between 2001 and 2014 it ranged from 0 to 18.3 deaths per 1,000 live births, with a maximum of 3 deaths in any given year.
In 2014, mild anemia among 5 year olds attending kindergarten was well under the 40% international threshold of public health significance. Between 2011 and 2015, severe anemia in this 5-year-old cohort never exceeded 1%. The School Health Report for 2014-2015 showed that based on body mass index (BMI) calculations for kindergarten students, 5% were overweight and 21% were obese. Among Grade 6 students, 14% were overweight and 23% were obese ().
Vaccination coverage is typically over 95% annually for diphtheria/pertussis/tetanus (DPT), hepatitis B, Haemophilus influenza type b, poliomyelitis, BCG, varicella, and the first measles/mumps/rubella (MMR1) immunization. The switch from trivalent oral polio vaccine (tOPV) to bivalent (bOPV) and inactivated polio vaccine (IPV) was completed in 2016. In 2015, human papillomavirus (HPV) vaccination was introduced for 9-13 year old girls and as a part of the school health program. The National School Health Policy was finalized in 2015.
Health of Adolescents
The estimated adolescent fertility rate was 67.2 and 46.7 per 1,000 women ages 15-19 in 2001 and 2011, respectively. In 2014, of the reported 152 births, 10 (6.6%) were to adolescents. Since 2001, births to adolescents in Anguilla have consistently accounted for less than 20% of births annually, and show a decreasing trend (see Figure 2).
Figure 2. Proportion of births to adolescents, Anguilla, 2010-2015
For the period 2010 to 2014, of a total of 341 deaths, 178 (52%) were due to noncommunicable diseases (). These include 70 deaths (21%) due to cardiovascular diseases: 29 deaths (9%) from cerebrovascular disease, 23 (7%) from ischemic heart disease, and 18 (5%) from hypertensive disease. There were 73 (21%) deaths due to malignant neoplasms and 29 (16%) due to diabetes. Additionally, three deaths (<1%) were attributed to alcohol-related liver disease and three to chronic respiratory disease (see Figure 3). Of the 73 reported cancer deaths, 49 deaths were in males (67%) and 24 (33%) in females. Prostate cancer was the leading cause of death overall with 21 deaths (29%) and also the leading cause of death for men (43%). Cancer of the cervix accounted for the highest proportion (21%) of cancer deaths in females (5 deaths). Cancers of the digestive organs, including colorectal and stomach, accounted for a total of 14 deaths (19%). Figure 3. Proportion of deaths, by cause, Anguilla, 2010-2014
Of the deaths caused by noncommunicable diseases, 49 (28%) were premature, i.e., in persons under 70 years of age. The male-to-female ratio of premature NCD deaths was almost 3:1, with 36 premature male deaths and 13 premature female deaths. Cancers (mainly prostate) and deaths due to external causes appear to be significant drivers of mortality and premature mortality in men relative to women.
In 2014, the syndrome of fever and respiratory symptoms (814 cases or 42.3%) was the most commonly reported communicable illness for both sexes and for all ages. Gastroenteritis accounted for 17% of reports. There were two confirmed cases each of Hepatitis B and C infection in 2014.
In 2014, mental and behavioral conditions accounted for 43, or 5% of all admissions to Princess Alexandra Hospital, with 28 (65%) males and 15 (35%) females. Psychotic disorders dominated with 21 (49%) admissions and were also responsible for the highest average length of stay (14.3 days) of all mental and behavioral conditions. Psychotic disorders also dominated in patients seen in outpatient services, accounting for 69% of clientele. More patients visited for abuse of cannabis than alcohol but there were more clients seen for mixed substance abuse than for cannabis and alcohol combined.
Suicides are relatively rare in Anguilla: there was one suicide reported in 2013, and none reported in 2014.
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.
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