Antigua and Barbuda
- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Antigua and Barbuda is located in the Northern Caribbean and includes the islands of Antigua, Barbuda, and the uninhabited Redonda. The islands have a total landmass of 442.6 km2, receive annual rainfall averaging 114 cm, and are known for their natural harbors and beaches.
Antigua and Barbuda gained independence from the United Kingdom in 1981 and is governed as a parliamentary democracy. The country is divided into six administrative regions called parishes and two dependencies, Barbuda and Redonda. Nearly 98% of the population lives in Antigua, with 26% living in the capital city, St. John’s, and 60% in the parish of St. John’s (). The population is mainly of African descent (90%).
According to the census taken in 2011, the population was 85,567, an increase of 11.3% since the 2001 census; the male-to-female ratio was 100:91.4 in 2011. The change in population structure between 1990 and 2015 is shown in Figure 1. About one-quarter (24.3%) of the total population of the country is under 15 years old, translating into a youth dependency ratio of 35.2%. When combined with the elderly dependency ratio (10.4%), the total dependency ratio is 46.6% (). Life expectancy at birth increased to 80.5 years for women and 75.2 years for men in 2015. The crude death rate increased from 5.5 per 1,000 population in 2011 to 5.9 in 2015.
Figure 1. Population structure, by age and sex, Antigua and Barbuda, 1990 and 2015
The population of Antigua and Barbuda increased by 48.3% between 1990 and 2015. In 1990, the population structure had a fast expansive structure in age groups 45 years and above, a regressive trend in the 10–20-year age group, and was stationary for those under age 10. In 2015, the pyramidal shape shifted to ages above age 45, while the population under 25 years old showed a slow regressive structure, owing to the decreased fertility and mortality rates since 1990.
Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 2015
The World Bank classifies Antigua and Barbuda as a high-income country (). The estimated GDP in market prices grew from US$ 1.13 billion in 2011 to US$ 1.30 billion in 2015. The economy is dependent on tourism (nearly 60% of GDP), construction, and financial services. The health sector received 2.77% of GDP in 2014.
The 2015 Human Development Report indicated that the human development index (HDI) value for the country in 2014 was 0.783, which is in the high human development category, and that the country ranked 58 of 188 countries (). Between 2010 and 2014, the HDI value showed an average annual increase of about 0.03% reflecting an increase in life expectancy, mean years of schooling, and GNI per capita ().
An arrangement with the International Monetary Fund provided financing to help cover the country’s balance of payments. Some fiscal measures implemented from 2011 to 2015 were the adoption of Automated System for Customs Data (ASYCUDA) World software at the Customs and Excise Department to enhance collection of revenues, and the implementation of the Citizen by Investment Program in 2013, which enables persons to acquire citizenship following investment in the country.
The unemployment rate in 2011 was 10.2 %; 11.2% in men and 9.4% in females. The highest proportion of unemployed was in the 15-19-year age group, followed by those 20-24 years old. There is no current information on poverty, but the 2005/2006 Survey of Living Conditions estimated that the at-risk population of vulnerable, poor, or indigent comprised 28.3% of the population (). In 2014, the National Housing Development and Urban Renewal Company was established to spearhead the provision of affordable housing with an emphasis on the most vulnerable population.
Antigua and Barbuda has a social security scheme that provides benefits to insured persons and beneficiaries when there is a loss or reduction of earnings due to sickness, pregnancy, disability, retirement, and death. Contributions to the scheme require a mandatory 4% salary deduction from all employed persons, which is matched by a 5% contribution from their employers ().
Primary and secondary education is free and compulsory. Adult literacy (older than 15 years) is 98.4%. Primary school enrollment was 10,294 in 2012 and 10,077 in 2015; 52% of enrollees were male. Secondary school enrollment grew from 7,700 in 2012 to 7,797 in 2015, and there were slightly more females enrolled (50.6%). Enrollment at the post-secondary level was about 1,800, with a male-to-female ratio of 1:2. Universal school access was introduced in 2013. For the 2011/2012 school year, 18,464 students were enrolled in primary and secondary school, evenly distributed between the sexes (50.9% males and 49.1% females); 56% were enrolled in primary school, 43% in secondary school, and less than 1% were enrolled in special education programs. Of enrolled students, 62.5% attended public schools and 37.5%, private schools ().
The country is prone to hurricanes and earthquakes that damage the physical infrastructure and agricultural production. Hurricane Gonzalo caused injuries to 12 persons and infrastructure damage in 2014. Changes in biodiversity (deforestation, pollution of aquifers, El Niño phenomena) contribute to the increase of vectors of disease such as the Aedes aegypti mosquito, for which targeted activities exist. During 2014, the gases released from Sargassum algae on beaches caused schools and hotels to close (). To address these hazards, measures were implemented, such as the development of a risk profile () and a Plan of Action for Public Education on Climate Change. The environmental policy framework is guided by several pieces of legislation, including the Beach Control, Beach Protection, and Dumping at Sea acts.
The country has employment legislation ensuring that there is equal pay for equal work regardless of gender. A national response to gender-based violence was developed and in 2012 training programs were organized for law enforcement and immigration officers, health care professionals, and social workers. Collaboration with a nongovernmental organization provided safe haven for abused women and children. At the political level, there are seven female Members of Parliament and one Minister of Government.
The Health System
Health services are delivered at the primary, secondary, and tertiary levels within the public and private sectors. At the primary level, Antigua is divided into six medical districts with a network of 25 public health clinics plus one clinic in Barbuda. Clinics are located within 3.2 km of every major community. The health team at the primary level provide services such as medical clinics, maternal and child health, community mental health, dental care, screening for noncommunicable diseases (NCDs), and prevention and control of communicable diseases. Secondary and tertiary health services are provided at the Mount St. John’s Medical Centre, a 187-bed facility in Antigua, and an 8-bed facility in Barbuda.
The health system is financed primarily through public taxation and levies in support of the Medical Benefits Scheme (). The Scheme is funded by a payroll tax of 7% that provides a dedicated revenue source for primary and secondary care. The government has taken preparatory steps to transition the Medical Benefits Scheme into a national health insurance program. Approximately 15,000 residents have private health insurance, largely provided through their employers.
Leading Health Challenges
Critical Health Problems
Dengue is endemic in Antigua and Barbuda, with the annual number of cases ranging from 31 in 2011 to 3 in 2015, and no associated deaths. In 2013, a cluster of six cases of chikungunya fever was confirmed, but no cases have been reported since then. Zika virus was first confirmed in 2016, with 14 cases. This outbreak included one pregnant woman who later delivered a baby without congenital abnormality. The vector control program mainly targets mosquitoes and rodents. In 2014, the household index for the Aedes aegypti mosquito was reported at 6.5% (above the 5% threshold recommended by the World Health Organization [WHO]) (). The country has implemented an integrated management strategy and other protocols for control and prevention of vector-borne diseases.
Antimicrobial resistance has emerged as a challenge for disease management, particularly methicillin-resistant Staphylococcus aureus (MRSA) and drug-resistant tuberculosis. In 2010, MRSA was confirmed in 13 patients, but annual incidence declined to 2 cases in 2015. Preventive measures were enhanced with public education and training, and surveillance was strengthened for health care-associated infections. Rifampicin-resistant tuberculosis was confirmed in one case in 2010.
The incidence rate of tuberculosis in 2014 was 3.3 per 100,000 population and between 2011 and 2015 the cumulative number of cases (mainly males) was 24.
The prevalence of HIV/AIDS in the general population was estimated at 1.39% in 2011; in 2014, the rate was 0.89%, with a prevalence of 1.5% in the 15-49-year age group. The number of new HIV infections declined across both sexes between 2010 and 2013, and in 2014, 55 new cases were diagnosed, with a male-to-female ratio of 1:1. For the 2011-2015 period, the cumulative number of reported cases was 215 (male-to-female ratio of 1.2:1), with 158 cases (74.0%) in individuals between 15 and 49 years old. Only one baby was diagnosed as HIV-positive, a reflection of the effective program for prevention of mother-to-child transmission of HIV. The prevalence of HIV infection among antenatal clinic attendees in the 2011-2015 period was 0.56%.
The influenza preparedness plan was revised in 2015. Cases of fever and respiratory symptoms continue to be used as a surveillance indicator for influenza activity, and since 2010 there have been 10,191 such cases (0.11%).
The adolescent fertility rate (births per 1,000 women between 15 and 19 years old) for the years 2010 to 2014 decreased from 52 to 46. There were 91 babies born to girls 14-16 years old, and 582 babies to girls 17-19 years old.
The government of Antigua and Barbuda has recognized the morbidity and mortality associated with chronic NCDs. See Box 1 for details on one of the strategies being pursued by the Ministry of Health. These conditions are known to be lifestyle-related, and the Medical Benefits Scheme has included prevention activities, particularly for youths, as part of its programs (). Prevention activities focus on obesity, diet, exercise, and reduction in tobacco and alcohol use. With support from the Medical Benefits Scheme, medication and supplies are available free of cost for 11 diseases.
Box 1. Antigua and Barbuda Battles Non-communicable Diseases
The Plan, drafted with assistance from the Pan American Health Organization (PAHO) and launched in 2016, sets forth a multi-sectoral approach to reduce preventable morbidity and premature mortality due to NCDs, as well as to control the risk factors attributed to these diseases. The Plan targets five areas: reinforcing the coordination and management of NCD prevention and control, strengthening the approach to NCDs and risk factors throughout the health system, identifying NCD risk factors and protective factors, building healthy and active communities through multi-sectoral policies and partnerships, and increasing surveillance, research, information availability, and education.
A Wellness Committee has been established to coordinate the implementation of the Plan. It is chaired by the NCD Coordinator and brings together technicians from the Ministry of Health and the Environment, the Medical Benefits Scheme, and Mount St. John’s Medical Centre.
Premature deaths from NCDs are of concern, and of a total of 493 deaths in 2012, NCDs were responsible for 58% or 288 (156 men, 132 females). The three leading causes of death were cancer, heart disease, and diabetes (see Table 1).
Table 1. Rank and number of deaths (by sex) for the ten leading causes of death, Antigua and Barbuda, 2012
|No. of deaths|
|Accidental and intentional injuries||7||12||15|
|Diseases of the respiratory system||7||21||6|
|Infectious diseases and HIV/AIDS||6||19||16|
|Diseases of the genitourinary system||9||12||4|
|Diseases of the digestive system||8||13||7|
|Diseases of the nervous system||10||2||8|
|Other causes of death||17||15|
Source: Elaborated by the author with information from the Antigua and Barbuda Ministry of Health.
The Global Burden of Disease Study for 2004 showed that diabetes was the leading cause of disability-adjusted life years (DALY) in Antigua and Barbuda (). In 2012, diabetes was the third leading cause of death (53 deaths) and accounted for 10.8% of all deaths, with a male-to-female ratio of 1.4:1.
Heart disease accounted for 95 deaths (19.3% of all deaths) and was the second leading cause of death in 2012. In 2009 and 2011 it was the first cause of death. Ischemic heart disease was the leading cause of years of life lost due to premature death. Hypertensive heart disease ranked sixth in 2010 and fifth in 2012 as a leading cause of death. In 2012, there were 37 deaths (7.5% of all deaths) attributed to hypertensive disease, with more females than males dying from the disease. Cerebrovascular disease ranked as the seventh leading cause of death in 2009 and fourth in 2012. In 2012, there were 38 deaths (7.7% of all deaths) attributed to this condition.
Chronic Respiratory Disease
Deaths from respiratory diseases ranked seventh in causes of deaths and accounted for 27 deaths (5.5% of all deaths) in 2012. The male-to-female ratio of these deaths was 3.5:1.
Human resource management is primarily driven by civil service considerations and not by evidence-based needs for health service delivery. Preservice degree training for nursing, midwifery, pharmacy, and medicine is available in Antigua, but most students obtain medical training outside the country. Outward migration of skilled professionals such as doctors and nurses does not occur as frequently as in most other Caribbean Community (CARICOM) countries.
Health Knowledge, Technology, and Information
Electronic health information systems are used in several health care settings in the country. The Health Information Division manages an electronic patient information system to monitor the care and treatment of persons diagnosed with HIV/AIDS. Epi Info software is used for the analysis of data on births, and the Mortality Medical Data System is used for classification of deaths. The Medical Benefits Scheme provides patients who qualify for access to specialized health care with the use of a Smart Card. In addition to biometric information and contributor status, the Smart Card stores information on client history specifically related to medications prescribed. There is also an electronic information system at the Mount St. John’s Medical Centre.
The Ministry of Health established an Institutional Review Board in 2012 with a qualified research ethicist as its chair. This was facilitated through a Caribbean Public Health Agency (CARPHA) initiative to strengthen human resources for health.
With technical support from the Pan American Health Organization (PAHO), the Health Metrics Network was launched and stakeholders accepted the proposed Health Information System Policy Framework and Strategic Implementation Plan. A Health Information Systems Technical Working Group was formed with defined terms of reference and chaired by the head of the Health Information Division of the Ministry of Health.
Active epidemiological surveillance is in place, with weekly reviews of data from sentinel sites. The major areas of surveillance are: NCDs, HIV/AIDS, accidents and injuries (including motor vehicle accidents), communicable diseases, and health indicators, including mortality and births. Capacity building in epidemiology was done through a Field Epidemiology Training Program that was recently concluded.
The Environment and Human Security
Antigua and Barbuda has historically suffered from natural disasters, and the effects of climate change, such as sea level rise, storm surges, increased severity of tropical storms and hurricanes, and decreased rainfall, have harmed the country’s agriculture and food security, fisheries, marine and terrestrial biodiversity, energy and tourism sectors, availability and quality of water, and human health. The extent of these effects is expected to increase (). The government has taken several measures to adapt to and mitigate the impacts of climate change based on energy conservation and utilization of renewable energy.
Most households (86%) are served by the public water supply system, and where this is not available, cisterns or wells are used. Toilets are used by 84.3% of households, and pit latrines by 10.6%. Where residents store water because of drought conditions, containers usually are not adequately covered to prevent the breeding of mosquitoes. Inadequate drainage in certain areas results in flooding when there is heavy rainfall. These factors contribute to the spread of communicable diseases such as dysentery, chikungunya, and Zika.
The 2010 UNDP Citizen Security Survey found that 22.4% of the population feared that their house would be broken into at night (). One of the lowest homicide rates for Antigua and Barbuda and the region was in 2005, when the rate was 3.5 homicides per 100,000 inhabitants. The rate peaked in 2007, with 19.8 homicides per 100,000 inhabitants (17 murders). In 2012, the rate was 11.3 and in 2015 it was 6.0. In 2015, there were 32 cases of rape, and robbery was the most reported crime. Gangs mainly comprise youths who engage in petty crime.
As of 2015 there were 10,965 persons 60 years or older (with a male-to-female ratio of 1:1.2), or 12.1% of the population; 9.3% of the population is 65 years or older, and about one-third of this cohort is 75 years and older. Life expectancy at birth is 76.4 years. A National Policy on Aging was developed in 2013. NCDs and disabilities present the most pressing challenge to the health and social well-being of the elderly. Institutional care for the elderly is provided at the publicly operated Fiennes Institute.
The 2011 census showed that domestic migration (movement into the capital, St. John’s) has been reduced by 6.2% compared to the 2001 census report. Most international migrants are from CARICOM countries (). Immigrants have access to health care, but their impact on service demand or specific health threats has not been measured. The agriculture sector, including government-owned farming operations, depends largely on labor of noncitizens. Although the country is a signatory to various international instruments against human trafficking, its resources for policing are limited.
Monitoring the Health System’s Organization and Performance
As part of the process of developing a national strategic health plan, the Ministry of Health is evaluating its role in leadership of the health sector. Legislation is under review for the Food Safety Act and the Public Health and Quarantine Acts.
Measures to advance policies for family health programs and to develop manuals to guide these programs have been initiated. Selected aspects of health promotion activities for HIV/AIDS were evaluated to better integrate them into the primary health care system. The introduction of the human papilloma virus (HPV) vaccine for adolescents is under way, which will serve to revitalize the cervical cancer prevention program.
In 2012, the National Food and Nutrition Security Policy was launched to ensure that all citizens achieve a state of nutritional well-being (). The government, in collaboration with the Food and Agriculture Organization (FAO) and PAHO/WHO, developed and implemented the Zero Hunger Program in 2013. Backyard gardening activities were part of the Zero Hunger Challenge. The planned target of 400 gardens within a two-year period was surpassed, and by 2015, over 450 gardens were established and an estimated 700 people had registered for the program. FAO continues to support the program through national and regional initiatives ().
The Food Safety Program focuses on preventing food-borne illness by training and monitoring food handlers, and over 1,600 food workers are trained annually.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
Maternal and reproductive health services are offered free of cost at all community health clinics, and services are also available in the private sector. Prenatal services cover 100% of women, and all births are delivered in hospital by trained personnel. Despite these achievements, there were three maternal deaths between 2010 and 2015. This has led to a critical review of the services offered, in order to improvements through additional training for staff, the procurement of additional equipment to detect potential problems, and increased patient education. Antiretroviral drugs are provided at no cost to patients with HIV, including to pregnant women.
Child Health (Under 5 Years Old)
The infant mortality rate declined from 18.6 deaths per 1,000 live births in 2010 to 13.8 in 2015. The under-five mortality rate of 17.2 deaths per 1,000 live births in 2014 is higher than the Millennium Development Goal (MDG) target of 8.0 deaths per 1,000 live births by 2015. More than 70% of infant deaths occur during the neonatal period, with the main causes being birth asphyxia, prematurity, and injuries.
Coverage with recommended vaccines (poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, Haemophilus influenzae type b, measles/mumps/rubella [MMR]) is between 96% and 100%, and no morbidity has been reported from these diseases. Initiation of exclusive breastfeeding is 95% or more, but monthly child health clinics report an average of 30% of infants receive exclusive breastfeeding up to 6 weeks of age.
Health of Schoolchildren (5-9 Years Old)
Children in the 5-9-year age group represent 7.6% of the population (). There is a national school meal program that offers hot school lunches to children in primary schools. For 2011-2015, there were five deaths in this age group and four of these were related to complication from burns. There was one HIV-related death in this age group.
Health of adolescents
Adolescents 10-14 and 15-19 years old represented 16.9% of the population in 2011 (). The Global School-based Student Health Survey was conducted in 2009 among 13-15-year-olds. Of students interviewed, 58.8% reported they consumed carbonated soft drinks one or more times per day during the 30 days preceding the survey, and 54.8% stated they spent three or more hours per day doing sitting activities. The survey indicated that 31.8% of students were physically active for at least 60 minutes per day on five or more days in the seven days prior to the survey. Of the students who had ever smoked, 89.9 % had tried a cigarette before age 14, and 53.2% of students reported that people smoked in their presence on one or more days during the seven days before the survey. In addition, 7.3% of students reported they had smoked cigarettes on one or more days during the previous 30 days ().
Health of Adults
Adults (20-59 years old) represented 56.7% of the population in 2011 and are classified as active members of the labor force (). The 20-24-year age group had an unemployment rate of 20.3%, the 25-29-year age group had 11.5%, and 55-59-year age group had 6.1% unemployment (). The main health problems among adults and the elderly are obesity and diet-related NCDs. Over 60% of adults who were screened in community clinics between 2003 and 2010 were classified as overweight or obese.
Health of the Disabled
In 2011, the most common disabilities were related to vision, ambulatory, memory, and hearing impairments. The CARE Project, started in 2008, caters to the needs of disabled and abandoned children and adults with disabilities. Ninety persons (an equal number of males and females) with cerebral palsy, autism, blindness, and other physical and mental challenges are enrolled in CARE. The government supports the project with significant contributions from the private sector and civil society.
Mortality and Morbidity
Infectious diseases, including HIV/AIDS, and accidental and intentional injuries continue to feature among the 10 leading causes of mortality. NCDs account for more than 85% of all deaths, and for most of the patient visits to primary health care facilities. Respiratory and diarrheal illnesses were reported as the main communicable diseases. In 2010, community clinics reported 1,708 cases of diabetes and 3,543 cases of hypertension. The main causes of hospital admissions and discharges are complications arising from diabetes and hypertension . In 2015 the Cabinet approved the National Policy and Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases.
A mental health policy was developed in 2013 with a focus on accessibility, prevention, and comprehensive care. The government supports a 132-bed mental health hospital. An assessment carried out in 2011 classified the main diagnoses of 112 patients discharged from the hospital as: drug induced disorders (21%); schizophrenia, schizotypal, and delusional disorders (39%); mood (affective) disorders (20%); and other mental illnesses (7%). All primary health care centers have access to mobile mental health teams to conduct home visits and community care ().
In 2014, childhood undernutrition was reported at 2.9% among children under age 5 attending public health clinics. In 2012, public sector clinic data indicated that 29.3% of adults were overweight and 36.5% were obese. Guidelines were disseminated to promote healthy eating habits and active lifestyles, in line with the National Food and Nutrition Security Policy launched that same year. One of the key objectives of this policy is to ensure that all citizens achieve a state of nutritional well-being through food choices and consumption that reflect recommended dietary allowances ().
Other Health Problems
There is a decentralized oral health service for the general public with an emphasis on 6-12 year olds; the service provides outreach in 54 schools. In 2011, an oral and maxillofacial surgical program was introduced, and since then, more than 300 cases have been reviewed and treated. A component of the program relates to the early detection of oral cancer.
Diabetic retinopathy is the most pervasive eye health problem in Antigua and Barbuda. It is estimated that in excess of 2,000 adults suffer from significant diabetic retinopathy and about 400 of them need or would benefit from laser treatment (). No national policy or plan for the management of diabetic retinopathy has been articulated. Screenings are conducted at the Mount St. John’s Medical Centre and referrals are received from district clinics and private facilities. Patients obtain treatment in the private sector or overseas, and these services are paid for by the Medical Benefits Scheme. In 2014, the Mount St. John’s Medical Centre received international assistance for equipment and training for doctors and nurses specific to retinopathy treatment.
Risk and Protective Factors
The risk factors that account for the greatest burden of disease in the country are high body mass index, diet, and high blood pressure. In 2010, the leading risk factor in children under 5 years old was suboptimal breastfeeding; for adults (15-49 years old) the leading risk factor was alcohol consumption. While physical education is in the school curriculum, participation is optional.
Road fatalities increased from 10 per 100,000 population in 2011 to 13 in 2015. In 2010 there were 1,804 traffic accidents, compared to 1,366 traffic accidents in 2013, a reduction of 24.3%. In 2011 2015, more males (321, or 54.4%) received injuries from road accidents than females (269, or 45.6%). In that period, the mean number of road accidents with injuries, by gender, showed that males were injured in 64.2 accidents and females in 53.8.
In 2016 the Cabinet of Antigua and Barbuda endorsed the National Strategic Plan for Health 2016-2020. This comprehensive document provides a blueprint for advancing the attainment of optimal health and wellness for all residents of Antigua and Barbuda. It establishes medium-term priorities for the health sector, defines the manner in which the resources of all partners will be synergized, and balances national needs with available resources.
The three strategic goals articulated in the plan are: 1) to empower individuals and families to manage their own health, 2) to strengthen health systems and community support mechanisms, and 3) to expand strategic partnerships. These objectives are aligned with the sustainable development dimensions articulated in the Medium-Term Development Strategy (2016-2020) of the government.
The Ministry of Health is investing in strengthening the health system and is utilizing WHO’s six core components or “building blocks” of a health system as its framework. Although a stronger health system using the above initiatives will assist the Ministry in fulfilling its obligations to the International Health Regulations, other specific activities will be conducted in this area. These include strengthening the surveillance system, finalizing and implementing the Chemical Emergency Preparedness and Response Plan, and improving the capacity of the public health laboratory.
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1. Covered diseases include cancer, epilepsy, leprosy, and Parkinson’s disease.