Pan American Health Organization

Belize

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

Flag of BelizeAlthough geographically it is part of the Central American Isthmus, Belize has historical ties with the Anglophone Caribbean; as such, it is the only English-speaking country in Central America. In 2016, Belize’s estimated population was 375,900 (). The country’s multi-ethnic population includes a majority Mestizo (52.9%), followed by Afro-descendant Creoles (26%), Garifuna (6.1%), and indigenous Maya (11.3%). Belize stretches for 22,966 km2 and has a low population density of 16.4 persons per km2. An estimated 31% of the population lives along the coast, with the remainder scattered widely throughout the country’s interior. These characteristics make it difficult and expensive to provide health care services.

Belize’s population is young and growing rapidly. According to the 2010 census, 46% of the population was under 19 years old and 6.5% was 60 years old and older (Figure 1 shows the country’s population structure in 1990 and 2015). The country’s population increased roughly 40% between 2000 and 2010 (); at this rate, the population will double by 2036. Life expectancy is estimated at 73.7 years, with the male/female rate breakdown being 71.1/76.6 years, respectively.

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

Belize’s population size increased 91.6% between 1990 and 2015. In 1990, the population structure showed a rapidly expansive structure. By 2015, the pyramidal structure had shifted to age groups older than 20 years and groups younger than that beginning a period of stationary growth. These changes were a result of the aging of the population and decreases in fertility and mortality in the last two decades.

Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 2015.

Officially, 45% of the population resides in urban areas (). But such urban-rural designation is subjective, however, since “urban” is regarded as any city or district town, while everywhere else is considered “rural.” Moreover, the population’s distribution is very fluid, with many suburban communities growing rapidly and haphazardly outside the main district towns and cities. Further, unplanned urbanization, coupled with the ongoing rural-to-urban flight in search of employment, fuels the expansion of the cities and main district towns. For example, in Belize City, the largest population center and the commercial capital, surrounding wetlands and mangrove areas are being encroached upon for housing. This practice further degrades the environment, increasing associated health related risks.

The 2010 census also showed that 14.2% of the country’s population is foreign born, with the single largest majority being from neighbouring Guatemala (). The country’s porous borders facilitate the unregulated cross-border movement of undocumented migrants. In under five years, a migrant village, Bella Vista, expanded from a marginal settlement to being one of the largest villages in the country (). Rapid population growth imposes undue burdens on the public health infrastructure.

Belize is considered to be a small, upper middle-income developing country with a GDP per capita of US$ 4,829 (), a Human Development Index (HDI) rank of 101 among 188 countries, and an HDI Index of 0.715 (). The national unemployment rate of 8% for 2016 () masks substantial age and gender differences, with unemployment among youth and women being more than three times the national average. The economy is overly dependent on a narrow range of mostly agricultural-based exports to a few preferential markets. To varying degrees, these export industries employ seasonal, mostly migrant labor from neighboring republics. And while there is a work permit system in place to regulate the inflow of seasonal laborers, monitoring procedures are weak, and many laborers remain in the country.

Tourism is gaining importance in the national economy: in 2015, overnight tourist and cruise arrivals were 341,145 (an increase of 6.2% compared to 2014) and 957,975, respectively ().

The literacy rate among the adult population is marginally less than 80%, with females having a higher literacy rate than males at 84.1% compare to 75.2% (). No comprehensive study on poverty has been undertaken in the recent past, but the last study, in 2009, found that 41.3% of the population was at or below the poverty line, a percentage that included 15.8% regarded as indigent or extremely poor ().

Among vulnerable populations are those living in poverty, including children and the elderly, as well as indigenous and Afro-descendant peoples and the LGBT population. Belize’s 2009 Country Poverty Assessment found a child poverty rate of 50%, which exceeded the national average of 41.3%. The report noted that children are more prone to poverty, and that their poverty rate was higher than for any other age group. The poverty rate among the elderly was lower than the national average, possibly reflecting some success of targeted programs designed to assist the elderly. Among these are the non-contributory pension financed by the Belize Social Security Board and the government’s programs for the poor, such as the Conditional Cash Transfer and the Food Pantry Program. The former provides cash to select recipients and has a countrywide coverage; the latter provides basic food items at subsidized rates but has a more limited coverage. Above average poverty rates were also noted among the indigenous Maya, with a poverty rate of 68%, the worst among all ethnic groups ().

Data on the health status of Belize’s LGBT community can be gleaned from the Central American Behavioural Surveillance Survey (BSS) of HIV/STI Prevalence and Risk Behaviour in Most-at-risk Populations in Belize (). The report noted an HIV prevalence rate of 13.9% among men having sex with men, which was noted to be the highest in Central America. That group was also found to have a prevalence rate of 28% for the herpes simplex virus type 2. While the prevalence rate among female sex workers is much lower, at 1%, this group shows high levels of sexually transmitted diseases, including a 50% prevalence for herpes simplex virus type 2 and a 20% prevalence for chlamydia and trichomonas. The survey also reported that one-third of men and 13% of women admitted to using illegal drug in the 12 months prior to the survey. Marijuana, cocaine, crack, and ecstasy were the most widely used illegal drugs.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

Belize confronts various emerging health threats, including the Zika virus, chikungunya, dengue, and H1N1 (influenza A) virus. The first case of Zika was confirmed in Belize in May 2016, and since that time, there has been a notable increase in confirmed cases. By the end of September 2016, there were 46 confirmed cases of Zika, including six pregnant women (). At that time, three of the women had birthed babies who were normal but remained under constant monitoring by Ministry of Health. The Ministry is countering the spread of this virus with more aggressive spraying to control the mosquito population, national public information campaigns to elicit public support to reduce insect breeding sites, and targeted assistance to pregnant women.

Infant and Maternal Mortality

Belize’s 2013 Millennium Development Goals (MDGs) Report noted that the country did not meet its goal of reducing infant mortality by two-thirds (). From a baseline of 17.6/1,000 live births in 1990, the infant mortality rate averaged 15/1,000 between 2001 and 2005, increasing to 18/1,000 between 2006 and 2010.
In 2012, the rate was 15.7/1,000 live births, a noteworthy decline, but still above the two-thirds reduction required by the MDGs. Regarding the maternal mortality ratio, from a baseline of 41.7/100,000 in 1990, this indicator trended upwards, reaching 55.3/100,000 in 2010. In 2011, a milestone was achieved, in that for the first time Belize recorded no maternal deaths in a calendar year. A year later, however, there were three maternal deaths, for a 42/100,000 ratio in 2012 ().

Chronic Conditions

Trend analyses of the leading causes of death over the past years confirms that noncommunicable diseases are among the most critical health problems facing the country. Diseases of the heart, malignant neoplasms, and diabetes have been the three leading causes of death in Belize (Table 1). The International Diabetes Federation notes that with an age-adjusted comparative prevalence of 16.5%, and a raw prevalence rate of 14.2%, Belize has the highest prevalence of diabetes in North America and the Caribbean ().

Table 1. Number of deaths for the ten leading causes of death, Belize, 2008 – 2015

 
Diseases
Years
2008 2009 2010 2011 2012 2013 2014 2015 Total
Diseases of the heart 196 211 203 217 209 193 206 245 1,680
Malignant neoplasms 156 157 172 161 199 186 175 193 1,399
Diabetes mellitus 103 132 149 150 137 153 148 170 1,142
Unintentional injuries 133 107 113 96 120 125 138 141 973
Assault (homicide) 112 92 116 129 160 116 114 111 950
Human immunodeficiency virus (HIV) disease 62 106 114 99 109 110 100 110 810
Cerebrovascular diseases 68 90 84 94 101 96 99 93 725
Influenza and pneumonia 50 71 61 80 68 73 72 85 560
Certain conditions originating in the perinatal period 41 66 43 83 69 65 47 76 490
Chronic liver disease and cirrhosis 42 31 34 49 29 52 49 45 331
Total 963 1,063 1,089 1,158 1,201 1,169 1,148 1,269 9,060

Source: Belize, Ministry of Health, Administrative data, 2016

In an effort to cope with the rise in chronic conditions, the Ministry of Health provides economic support to NGOs that cater to diabetics, the HIV-positive population and cancer patients, and the elderly, among others. Other government agencies undertake multiple and diverse intervention methods to reduce the incidence of homicides, gang violence, and personal injury that consume an undetermined portion of the public health budget. The Government is also implementing a road safety demonstration project to help reduce the incidence of fatal traffic accidents. From a high of 90 deaths in 2001 (), fatal traffic accidents have gradually decreased to 60 road fatalities in 2015, for a per capita rate of 18/100,000, considered to be the fourth highest in Central America ().

Human Resources

Table 2 shows the breakdown of registered medical personnel and per capita health personnel (). Belize’s levels of health professionals have remained unchanged despite the country’s population increase, which has reduced the ratio of health care professionals serving the population. This scarcity is aggravated by the geographic distribution of these professionals: most are based in urban areas, particularly in Belize City, likely due to the fact that the country’s only tertiary health facility is there. The country has no medical facility where physicians are trained, although some categories of nurses, laboratory technicians, pharmacists, and social workers are trained at the University of Belize. The chronic shortage and low retention rates of certain categories of health care professionals requires that Belize import its medical personnel, leading to recurrent expenditures to acclimatize newly arrived health workers. Of the few nurses trained, many leave the country to work in Caribbean countries. Continuing education for health workers includes workshops, seminars, and other courses that are financed by the health budget or by cooperation agencies such as the Pan American Health Organization. Recently, continuing medical education programs for doctors and nurses have been launched by the Belize Medical and Dental Association.

Table 2. Number and density (per 10,000 population) of registered medical personnel, by category, Belize, 2010-2015

 
Category
Year
2010 2011 2012 2013 2014 2015
Physicians Number 241 241 395 371 371m 371
Density 7.5 7.5 11.5 10.6 10.3 10.1
Dentists Number 12 12 44 44 44 44
Density 0.4 0.4 1.2 1.2 1.2 1.1
Nurses Number 469 469 423 451 451 451
Density 14.5 14.5 12.3 12.9 12.6 12.3
Community health workers Number 208 208 287 282 282 282
Density 6.4 6.4 8.4 8.1 7.9 7.7
Pharmacists/pharmacies Number 112 112 112 112 112 112
Density 3.5 3.5 3.5 3.2 3.1 3.0

Sources: Belize, Statistics Institute of Belize, Abstract of Statistics 2013 and Belize, Ministry of Health, Administrative data 2016

Health Knowledge, Technology, and Information

The Ministry of Health relies on a nationwide health information system (Belize Health Information System) to record patient data and to integrate data sources electronically, thus facilitating analysis and reporting of health information. The National Health Insurance, on the other hand, uses a different system, known as the Registration and Clinical Activity Web Application (RAWA). The two systems do not work together, and there is room for improving the coordination between the two systems. According to Stanley Lalta (2013)(), having an up-to-date and comprehensive health information system would facilitate the country’s timely and systematic collection, organization, and retrieval of data for a broad range of purposes, including the ability to conduct prompt monitoring and reviews to inform decision making. Moreover, the Ministry of Health reports that despite the existence of its information system, physicians do not yet make full use of it ().

The Environment and Human Security

Belize is vulnerable to rising sea levels, with its concomitant health consequences such as a rise in temperature at sea and inland, changes in water quality and availability, increased frequency and intensity of extreme weather events, and potential economic loss from high food and energy costs. To one extent or another, many of these effects are being experienced in Belize, with additional challenges for the health system such as heightened risks for a range of infectious diseases. Specifically, nearly one in three Belizeans live near the country’s long, low-lying coastline, and large areas of Belize City, the main population center, are already below sea level. Belize’s territory includes more than 1,060 offshore islands, with virtually all the larger ones having permanent habitation, and all of these settlements are under direct threat or rising sea levels.

More than half of the country’s population is covered by a modern system of solid waste disposal that is environmentally sound. The system serves a continuum of population centers that start in San Pedro to the east, go through Belize City, and end at the western border, having passed through the towns of San Ignacio and Santa Elena. More than 29,000 metric tons of garbage were recycled through this system in 2015. Additional corridors in other areas of the country are planned. While illegal dumpsites remain a problem, vigorous monitoring, prosecution, and public education campaigns have reduced the number of these sites.
Data from the Multiple Indicator Cluster Survey () indicate that 96.1% of the population has access to potable water and 87.1% has access to improved sanitary facilities that are not shared ().

According to a 2013 study on homicides worldwide conducted by the United Nations Office on Drugs and Crime, Belize’s homicide rate was 44.7 per 100,000 population, one of the highest in Central America (). Since then, the homicide count has escalated, continuing to stress the country’s underfunded and understaffed public health system. Most homicides are the result of internecine gang warfare and mainly occur in Belize City. There is evidence of the presence of regional gangs in the migrant communities outside Belmopan.

Human trafficking also is of grave concern. The United States States Department now rates Belize as a Tier 3 country, the worst rating by that department in that regard. According to the U. S. State Department’s 2016 Trafficking in Persons Report, “Belize is a source, transit, and destination country for men, women, and children subjected to sex trafficking and forced labor…. Sex trafficking and forced labor of Belizean and foreign women and girls, primarily from Central American, occur in bars, nightclubs, brothels, and domestic service. LGBTI men, women, and children are vulnerable to sex and labor trafficking. Foreign men, women, and children-particularly from Central America, Mexico, and Asia-migrate voluntarily to Belize in search of work and are often exploited by traffickers who recruit victims using false promises of relatively high-paying jobs.” ().

Aging

As life expectancy increases, so does the percentage of the population older than 60 years. The most recent information from the Statistical Institute of Belize shows that the population 60 years old and older accounted for 5.9% of the total population, or 22,196 persons (11,498 males and 10,698 females) in 2015. This segment of the population has a higher hospital utilization rate as well as a higher cost per capita.

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

As part of the health sector reform initiative which started in 1998, the Ministry of Health reorganized its services into four health regions (Northern Region, Central Region, Western Region and Southern Region), headed by regional health managers. All regional hospitals are urban, with the rural population being served by a network of health clinics, health posts, and mobile health clinics. The introduction of the National Health Insurance Scheme, initially as a pilot in the south side of Belize City (2002), later extended to the Southern Region (2006), and more recently extended to the Corozal District (2016), focused on primary care services delivered through a network of primary care providers that focused on the health of a defined geographic and population base that was identified as poor.

Belize’s health system is substantially dependent upon public financing. For the ongoing financial year, the government has budgeted some $ 126.4 million to the Ministry of Health, which equates to some 11% of the national budget and 3.5% of GDP (). Though there continue to be nominal increases in the budgetary allocations to the Ministry, a deeper analysis of the budget data reveals that the Ministry actually has received a reduced allocation, when measured in terms of real non-personnel revenues. This is because the budget data cited reflects salary increases that averaged 7% over the financial years 2014/15 and 2015/16. Since such percentage salary increases exceed the percentage increase in the Ministry’s budget, it can be surmised that salary increases accounted for the entire increase in the ministry’s budget. Further, given that employment in the Ministry is on a rising trend from 2014/15, it can be further surmised that an increasing percentage of the ministry’s budget is skewed towards salaries and personnel expenditure () (Table 3).

The above notwithstanding, Lalta (2013), focusing specifically on Effectiveness of Health Spending, defined as using aggregate measures of health status and health financing indicators, states that “the evidence suggests that Belize’s health system is performing quite creditably compared to other countries in Central America and the Caribbean” ().

Table 3: Select health financial indicators, Belize, 2012/13 to 2016/17

Year: 2012/13 2013/14 2014/15 2015/16 2016/17
GDP ($ B) 3,147.2 3,251.7 3,435.7 3,557.0 3,640.0 (est.)
Belize government budget, by FY 854,001,007 1,022,900,244 1,072,391,771 1,211,126,349 1,148,597,600
Allocation to Ministry of Health 93,782,927 107,221,181 118,380,028 120,710,128 126,426,342
Ministry of Health allocation of GDP (%) 3.0 3.3 3.4 3.4 3.5
Ministry of Health allocation as percentage of budget 11.0 10.5 11.0 10.0 11.0
No. of Ministry of Health employees NA 1,740 1,740 1,815 2,084

Sources: Belize, Ministry of Finance and author’s calculations

Prospects

Despite the many successes the country has seen in terms of health, Belize’s health system will face daunting challenges in the short and medium term. The list is long. On the one hand, NCDs will continue to rise in importance as leading causes of mortality, emerging viral diseases also will continue to pose a threats, and the costs of trauma and urban violence will continue to escalate, all of them burdening the health system. And the health system itself must address the difficulty in attracting and retaining crucial health personnel. Further, given Belize’s vulnerability to environmental stressors, climate change will pose additional risks to the health and other sectors.

Box 1: Selected Successes in Health, Belize

  • Polio and measles have been nearly eradicated. There have been no reported cases of measles or poliomyelitis since 1981 in Belize. The last cases of neonatal tetanus, non-neonatal tetanus, and congenital rubella syndrome were reported in 1997. No confirmed cases of diphtheria have been documented since 1982 ().
  • Given Belize’s total expenditures in health on a per capita basis, as a percentage of the national budget, and as a percentage of GDP the country’s health system achieves regionally comparable outcomes in terms of life expectancy and other health status indicators. This is regarded as efficiency ().
  • The country has consistently attained high immunization rates: According to the 2015 Multiple Indicator Cluster Survey, immunization rates were: tuberculosis, 97.6%; measles, 90.2%; polio, 83.1%; and pentavalent (DPT3), 83.4%. Full immunization coverage, defined as the percentage of children aged 24 to 35 months who received all vaccinations recommended in the national immunization schedule by their first birthday, was 77.5% ().

Tourism will continue to increase over time, and while this will bring revenue and be good for the country’s economy, the added influx of people may force the health sector to respond to identified public health threats and emergencies. Migration, too, will likely further stress the health system’s capability to respond. Belize’s depends largely on export industries that employ large numbers of seasonal workers, functioning as a magnet to migrant workers that easily cross the country’s porous borders. Undocumented migrants also come in search of employment, settling in far-flung communities where access to health care remains problematic. The health system will have to absorb the care of all these people.

The country also must strive to consolidate any health gains made, including those gains in achieving health-related Millennium Development Goals. This will be difficult considering the Ministry’s dependence on public financing, the negative developments in government’s revenues ushered in by adverse macro circumstances, unbudgeted contingent liabilities, and rapidly rising public debt.

Finally, given the current climate of fiscal austerity and shrinking financial resources, coupled with the fact that an increasing percentage of Ministry of Health’s budget goes towards salaries, the Ministry ought to undertake a Public Expenditure Review. Such a review would be able to objectively ascertain if its budgetary allocations reflect its policy priorities. In addition, while seeking to compare efficiency levels among similar decision making units such as regional hospitals, community hospitals, health centres, and clinics it would also seek to identify areas where savings are possible and would redirect saved resources to areas where they are likely to have a greater impact.

References

1. Statistical Institute of Belize. Annual report 2016. Belmopan: SIB; 2016. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/AnnualReport_2016.pdf.

2. Statistical Institute of Belize. Belize population & housing census: country report 2010. Belmopan: SIB; 2013. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/Census_Report_2010.pdf.

3. Statistical Institute of Belize. Abstract of statistics 2013. Belmopan: SIB; 2013. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/2013_Abstract_of_Statistics.pdf.

4. Ministry of Finance (Belize). Approved estimates of revenue and expenditure for fiscal year 2016/2017. Belmopan: Ministry of Finance; 2016. Available from: http://cdn.gov.bz/belize.gov.bz/files/ApprovedBudget%202016-17.pdf. Accessed on 9 July 2016.

5. United Nations Development Programme. Human development reports: Belize. New York: UNDP; 2016. Available from: http://hdr.undp.org/en/countries/profiles/BLZ.

6. Statistical Institute of Belize. Labour force survey (LFS) April 2016. Belmopan: SIB; 2016. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/LabourForce_2016-04.pdf.

7. Belize Tourism Board. Belize travel and tourism statistics digest 2015. Belize City: BTB; 2015. Available from: http://belizetourismboard.org/wp-content/uploads/2016/09/BTB-TRAVEL-DIGEST-2015-FINAL.pdf.

8. Halcrow Group Limited. Belize country poverty assessment 2009. Final report. Volume 1. Belmopan: Caribbean Development Bank; 2010. Available from: http://www.caribank.org/countries/country-poverty-assessment-reports.

9. Ministry of Health (Belize). Central American Behavioural Surveillance Survey (BSS) of HIV/STI prevalence and risk behaviour in most-at-risk populations in Belize. Belmopan: Ministry of Health; 2014.

10. Channel 5 News (Belize). MOH hold press conference to give update on Zika in Belize [Internet]. 28 Sept 2016. Belize City: Great Belize Productions Limited; 2016. Available from: http://edition.channel5belize.com/archives/135617. Accessed on 28 September 2016.

11. United Nations Development Programme. Millennium Development Goals report and post-2015 agenda. Belmopan: UNDP; 2013. Available from: http://www.bz.undp.org/content/dam/belize/docs/Millennium%20Development%20Goals/MDG%20Report%20and%20Post%202015%20Agenda%20Belize%202013.pdf.

12. International Diabetes Federation. IDF diabetes atlas. 7th ed. Brussels: IDF; 2015. p. 83. Available from: http://www.diabetesatlas.org.

13. Ministry of Health (Belize). Belize health sector strategic plan 2014-2024. Belmopan: Ministry of Health; 2014. Available from: http://health.gov.bz/www/attachments/article/801/Belize%20Health%20Sector%20Strategic%20Plan%202014-2024-April%202014.pdf.

14. Pan American Health Organization. PAHO/WHO country cooperation strategy: Belize 2017-2021. Washington, D.C.:PAHO; 2017. Available from: https://www.paho.org/blz/index.php?option=com_docman&view=download&alias=248-ccs-2017-2021&category_slug=mandates-and-strategies&Itemid=250.

15. Lalta S. Final report on analysis of existing health accounts of the Ministry of Health, Belize. Consultancy report prepared for PAHO–Belize. Belize City: Pan American Health Organization; 2013.

16. Statistical Institute of Belize; Government of Belize; United Nations Children’s Fund. Belize Multiple Indicator Cluster Survey 2015: key findings. Belmopan: SIB; 2016. Available from: http://www.sib.org.bz/wp-content/uploads/2017/05/MICS5_KeyFindingsReport_2015.pdf.

17. United Nations Office on Drugs and Crime. Global study on homicide 2013: trends, contexts, data. Vienna: UNODC; 2014. Available from: https://www.unodc.org/documents/gsh/pdfs/2014_GLOBAL_HOMICIDE_BOOK_web.pdf.

18. Department of State (United States). Trafficking in persons report 2016. Washington, D.C.: U.S. Department of State; 2016. Available from: https://www.state.gov/j/tip/rls/tiprpt/2016/.

19. Gayle H, Mortis N. Male social participation and violence in urban Belize: an examination of their experiences with goals, guns, gangs, gender, God and governance. Belize City: RESTORE Belize; 2010. Available from: http://dbzchild.org/uploads/docs/complete_pgmale_social_participation_and_violence_in_urban_belize_grand.pdf.

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