- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Dominica, the most northerly, largest, and mountainous of the Windward Islands, is located between Guadeloupe to the north and Martinique to the south. The country stretches for just over 750 km2, and has a steep terrain, with slopes rising higher than 1,000 m in some locations; a few areas along the coast provide some flatlands. Most people have settled along the coast, which makes Dominica’s population and infrastructure particularly vulnerable to strong winds and high seas.
The country’s climate is humid tropical marine, with little seasonal variation between wet and dry seasons. Rainfall ranges from more than 500 cm in most locations to more than 900 cm in some. Such heavy rainfall results in landslides and flooding in low-lying areas. The island lies in the path of hurricanes and, consequently, has sustained considerable loss of life and damage to property.
Figure 1. Population structure, by age and sex, Dominica, 1990 and 2015
The population increased 5.1% between 1991 and 2015. In 1991, the population structure had an expansive shape, growing faster in age groups younger than 40 years. By 2015, the structure displayed a slower expansion, becoming stationary in age groups younger than 25 years old. This shifts were a result of decreases in fertility and mortality, especially in the last two and a half decades.
Source: Pan American Health Organization, based on US Census Bureau. International Data Base. Last Updated: August 2016.
According to the 2010 population census, Dominica’s population numbered 71,293, with a male-to-female ratio of 103.2:100. This represented a slight decline of 0.6% over the last census. The Central Statistics Office estimated the 2014 end-of-year population at 69,665. The census results also revealed that total births continued to register steady decreases, recording a significant 31.5% decline in two decades. Natural increase (births minus deaths) registered a sharp 49.5% fall over the last decade. Figure 1 shows Dominica’s population structure, by age and sex, in 1991 and 2015.
Between 1990 and 2010, there was a decrease in the proportion of children and young people, and an increase in the proportion of those aged 60 years and older. By 2014, the female population over 60 years old had increased slightly. Persons of African origin accounted for 84.7% of the population, a decrease from 86.75% in the last 10 years. On the other hand, the Kalinago indigenous population increased by 26.5%, accounting for nearly 4% of the population, up from 2.9% in 2001. The population of whites, or Caucasians, increased sharply, by 55%.
Life expectancy at birth stands at 72.8 years for males and 78.9 for females. Healthy life expectancy is 66 years for both sexes. Decreasing fertility rates and increasing longevity will continue to fuel the “greying” of Dominica’s population.
The International Monetary Fund (IMF) recently noted that the Dominican economy was hit hard by tropical storm Erika, with output estimated to have declined by 3.9% in 2015. Output growth was expected to remain subdued in 2016, at 1.3%, as the economy slowly recovers from the impact of the storm and investments in reconstruction accelerate. That said, growth is largely conditional on donor grants proceeding according to expectations. Beyond that, growth is projected to accelerate somewhat as economic recovery continues, and then to stabilize at 1.7% per year over the medium term. The current account is projected to deteriorate on the back of an increase in reconstruction investment, and then to gradually improve as agriculture, tourism, and manufacturing activities recover. The imbalances are expected to be financed primarily with external capital grants and official concessional loans. The Fund concluded that the fiscal outturn for fiscal year 2015/2016 would be strong, estimated at a surplus of 0.8% of GDP.
The unemployment rate, as reported in the preliminary census report of 2011, was 11.3% for both sexes, with males being more affected than females. A poverty assessment conducted in 2009 concluded that the country’s level of poverty had fallen from 39% in 2003 to 28.8% in 2009. Absolute poverty also had declined from 10% in 2003 to 3.1% in 2009. The vulnerability rate is estimated at 11.5%.
A disease that severely affected the banana crop resulted in a drastic decrease in earnings, from US$ 11 million to US$ 1 million between 2012 and 2015. A citrus greening disease almost wiped out the citrus industry.
Social Determinants of Health
Through interventions such as the Social Investment Fund, the Basic Needs Trust Fund (an initiative that aims to improve housing in the country), and the effort to provide universal secondary education, the government is attempting to improve health by addressing social determinants. The government also provides relief to the most vulnerable among the elderly with assistance with activities of daily living.
There is universal primary and secondary education for both sexes; the goal now is to attain universal early childhood education. The ratio of girls to boys in primary schools is 96.7:100, and in secondary schools, 96.3:100.
The indigenous people, the Kalinago, bore a greater burden of poverty 49% of the Kalinago were poor, compared to the national average of 28.8%. While this indigenous population represents about only 4% of the total population, they account for 7.8% of the country’s poor.
The Health System
Dominica has primary and secondary health services. Most tertiary care is provided outside of the country. For delivering primary health care, Dominica has been structured into seven health districts, grouped into two administrative regions under the supervision of a regional manager who, in turn, reports to the director of primary health care services. Each district has its own budget that is managed at the central level due to lack of human resources. Primary health care services include 52 health clinics/centers distributed in towns and villages throughout the country.
The main hospital, Princess Margaret Hospital, is managed by a tripartite team consisting of a hospital services coordinator, a medical director, and a matron. This management structure is not considered to be very effective. Construction has begun on a new general hospital.
Private services are limited-mainly outpatient care provided by private practitioners.
The country’s gender and health policies are applied in such areas as NCDs, pharmaceuticals, and communicable diseases. Dominica’s National Strategic Plan for Health 2009 2019 encompasses the following areas: the population’s health status; the influence of social determinants on the population’s health; the management of the health services and their response capacity, including quality; the organization and management of the health system; and the sustainability of the health services.
Leading Health Challenges
Critical Health Problems
Chikungunya virus was first introduced in Dominica in December 2013; subsequent cases were not linked to the index case (an imported case) or to any recent travel history. A total of 3,771 cases were reported, with only 173 being laboratory-confirmed. Females 10 59 years old were the most affected.
The first case of Zika was identified in March 2016; the person had no travel history. As of July 2, 2016, 723 cases had been reported, of which 65 were laboratory-confirmed. Five pregnant women were diagnosed with Zika; one patient, who was diagnosed with Guillain-Barre Syndrome, was treated in Martinique.
Dengue is endemic in Dominica, with cases increasing during the wet season in August to October. There were outbreaks in 2010 and 2013, with 641 and 233 cases, respectively. There was one reported death associated with dengue in 2010.
Neglected Diseases and other Infections Related to Poverty
Between 2010 and 2015, Dominica has experienced one outbreak of leptospirosis, with 41 reported cases, including 4 deaths, and a case fatality rate of 10%. The infected persons were mostly males, working as farmers or construction workers. A seroprevalence study of leptospirosis among rodents and domestic animals is currently under way.
In 2015 there were seven diagnosed cases of tuberculosis (TB)-six males and one female. All received free treatment through the directly observed therapy method. One case of rifampicin-resistant TB was diagnosed in 2013. During the last 5 years, only two cases of TB/HIV coinfection have been reported. There were two TB-associated deaths between 2010 and 2015.
Maternal mortality has been at one to zero deaths for several years, with three deaths between 2010 and 2015. Quality antenatal care is available to all women, and all births are attended by skilled health personnel.
Adolescent births remain at less than 15% of total births. Among females aged 15 49 years, 41.4% had their first child when they were 15 19 years old. Women in the lowest socioeconomic brackets (52.5%) were more likely to give birth at earlier ages than those from the highest socioeconomic brackets (37.4%). In addition, 3.5% of births occurred among girls younger than 15 years old, bringing the total of first births occurring to teenage mothers to 44.6%.
Overweight and obesity have replaced underweight and stunting as the main types of malnutrition among the 0 5-year-olds, and data for 2014 indicate an increase in obesity in that age group. According to the 2009 school health survey, one-quarter of all students 13 15 years old were overweight. Obesity is also a problem in the overall population.
During 2010 2015, the Ministry of Social Services’ welfare department received 1,095 reports of child abuse, including sexual, physical, and emotional abuse and neglect. Recently there has been great public outcry over some high profile cases of child sexual abuse.
According to the Central Registry on Domestic Violence, between July 2011 and December 2015, most of the reported cases of domestic violence were females (86.8%). The most common form of abuse was sexual (42.8%), followed by physical (27.6%), and psychological or emotional abuse (19.9%). For most sexual abuse victims (44.9%) the abuser was an intimate associate; 20.9% of abuse was spousal abuse.
Chronic NCDs are a significant problem in the country, with heart disease, stroke, cancer, diabetes, and chronic respiratory diseases ranking as the leading causes of mortality and disability. For additional details on the prevalence of chronic conditions in Dominica, please see the subsection on mortality under Health Situation and Trends, further on.
Persons with disorders related to substance abuse account for more than half of clients admitted to the inpatient care facility. The majority of admissions have a discharge diagnosis of schizophrenia or related disorders.
The 2009 Global School-based Student Health Survey (GSHS) showed that many adolescents and children reported using alcohol and other substances and having suicidal thoughts.
The Ministry of Health has no human resource policy, plan, or management position to deal with human resources for health or health planning. Succession planning remains weak: although training priorities are identified each year, they are not followed through.
While the overall number of nonspecialist health workers and the ratio of health workers to population are generally considered adequate, anecdotal evidence indicates that the quality, skills mix, and distribution of health workers need improvement.
Between 2008 and 2014 24 nurses resigned from the nursing service, a decrease compared to the previous five years, when 73 nurses resigned. In 2015 alone, 17 nurses resigned, which could signal another wave of outmigration of nurses.
Health Knowledge, Technology, and Information
The Ministry of Health is moving towards an integrated electronic information system the D ominica Integrated Information Systems for Health (DIISH). All 52 primary health care centers will be linked to this network, which will allow them to back up information locally and use it off-line. Social media is widely used to convey health promotion messages, and chat rooms for conveying information to health care workers.
Access to health information is limited in that not all information needed is collected (e.g., mental health, health accounts, and human resources).
The Environment and Human Security
Dominica is experiencing climate change, as manifested by greater intensity of rainfall with fewer wet days. This pattern is expected to increase, placing the country at risk of population displacements, emerging diseases, and infrastructure damage, including that to the health care infrastructure.
In 2015-2016, the Ministry of Health examined the potential health vulnerabilities resulting from climate change and sought to identify measures that would improve the resilience of individuals, communities, and the health sector as a whole in coping with them. The government also appointed a focal point for climate and health, in keeping with the Pan American Health Organization (PAHO) Strategy and Plan of Action for Climate and Health. A national strategy for environmental health has been developed, in keeping with the Sustainable Development Goals (SDGs) targets and indicators and the post-2015 development agenda.
Water Quality and Sanitation
At least 97% of the population has access to potable water. The Environmental Health Department monitors water quality. The government has embarked on a project to ensure all houses are connected to either a sewer or septic tank.
Dominica has a nationwide solid-waste collection system, which picks up from every community and then transports the waste to a landfill site. Waste separation is limited, although there is an effort under way to separate plastic bottles and ship them overseas. Small composting units have been established by the organic farmers association and at some schools.
Food safety is ensured through surveillance activities that include inspection of food establishments, training and certification of food handlers, meat inspection, inspection of imported food, and mass gathering surveillance. In 2014 the government issued food safety guidelines, which were developed with technical assistance from PAHO.
Natural and Manmade Disasters
Dominica’s geographic position and topography make it vulnerable to tropical systems and prone to flash flooding and land slippage. In August 2015, Dominica was buffeted by tropical storm Erika. The storm dumped about 31 cm in 12 hours, after which the country experienced landslides and flooding that severely damaged infrastructure island-wide. The human toll also was high, with 28,000 people affected, 14 confirmed deaths, 16 reported missing, 574 left homeless, and 1,034 evacuated from their homes. The impact to water, food, and health systems presented a host of health risks to the general population. Damage to the country was estimated at more than US$ 1 billion (over 90% of GDP).
Post-disaster conditions such as solid-waste accumulation from debris, standing water, and more water being stored in containers after interruptions in piped water services promoted the proliferation of vectors such as mosquitoes.
According to the 2011 census, 14.7% of the total population was 60 years old and older, compared to 13.5% in 2001, with females outnumbering males by 1.14%. At the end of 2015, there were 22 centenarians on the island (3 males and 19 females). This aging process has been accompanied by dramatic changes in family structure and roles. Selected health personnel completed the PAHO course “Specialization in Health Management for Older Persons in 2013 -2014.”
In 2009, the Ministry of Health, in partnership with PAHO, conducted a study of aging and health as a way to classify the current conditions under which older Dominicans are living in order to steer policies and strategies for putting in place community-based, healthy aging programs. According to the study, the leading needs of older persons are timely access to health services, early diagnosis and treatment, the availability of rehabilitation services to improve functionality and mobility, long-term care services, acute-care services, and health promotion and disease prevention programs. Currently, the health services have no specific services or programs for older persons.
Although retirement age is set at age 60 years and social security benefits are paid starting at age 65, many older persons find that they need to continue working after they retire. According to a document jointly issued by PAHO and Dominica’s Ministry of Health, 72.4% of older persons had held a job at some point that paid them in money or goods. Because men tend to have had gainful employment more often and for longer periods (women tend to stay at home looking after the family), women tend to have fewer, if any, savings, and so are more likely to reach old age being poor.
The document also showed that only 6.6% of respondents smoked at the time of the survey, and those who did smoked cigarettes. Most respondents (78.4%) did not consume any alcohol.
Although older persons in Dominica consume 1 to 3 fairly balanced meals daily, only 78% eat fruit and vegetables at least twice a day. Most of the older persons in Dominica lead sedentary lives, as confirmed by the fact that 63% did not exercise.
In terms of internal population shifts, many rural residents move to the cities in search of employment, leaving many older persons with no family support. In addition, many Dominicans have emigrated to Anguilla, Antigua, and the United States in search of employment. Young children are left in the care of older “parents,” which in many instances poses a social problem.
Many Haitians and some Dominicans have immigrated to Dominica. Most Haitian migrants are not immunized, which is threatening the country’s consistently high vaccination coverage rates. Outreach activities were conducted to ensure that these immigrants were vaccinated. Communicable diseases, such as malaria and tuberculosis, which are endemic in Haiti, threaten to reemerge in Dominica.
Monitoring the Health System’s Organization, Provision of Care, and Performance
The Ministry of Health is charged with the leadership and governance of the health care system. The steering role of the Ministry needs to be strengthened. Strategic policy frameworks are limited and the Ministry lacks the institutional capacity to exercise its regulatory and enforcement functions.
Health care is provided free of cost to everyone at the primary health care level. Dominica is committed to achieving universal health care for all of its citizens.
The government has embraced the “health in all policies” (HiAP) approach, particularly in the fight against NCDs. Some services, such as mental health services, have been integrated into primary health care, but some level of fragmentation persists.
Many laws related to health are outdated, but the country lacks the capacity to revise them. Among them are the draft Sexual Offences Amendment Bill for 2016, which will soon be taken to Parliament for approval; the levy of 10% tax on drinks with high sugar content, alcoholic beverages, and tobacco products; and the establishment of an environmental health court set up to assist in the fight against vector-borne diseases.
There are mechanisms in place for consulting with civil society on public health issues. For example, the Health Promotion Resource Center works with such ministries as agriculture, social services, and education and with nongovernmental organizations and faith-based organizations. The successful partnership with the Ministry of Agriculture to reduce the prevalence of iron-deficiency anemia in the La Plaine health district also is a noteworthy example.
The health services are predominantly financed through general taxes. With support from PAHO, Dominica is working to identify short-term options for addressing financing shortfalls. As part of this effort, the country is reexamining funding avenues in light of the financial strains resulting from rebuilding after tropical storm Erika. Additional recommendations include: reviewing the user-fee policies in effect at the Princess Margaret Hospital, reassessing dispensing fees for drugs, exploring how to increase billing and collection efficiency, achieving better management of funds for overseas care, planning for greater autonomy and flexibility in the operations of the new hospital, and assessing human resource in health needs that focus on the new hospital.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
Reproductive health services in the public health service are well organized and available to all at no cost. Exclusive breastfeeding for the first six months is encouraged. In 2014, at least 32% of infants were exclusively breastfed. Contraceptives are provided mainly through the Dominica Planned Parenthood Association. Reproductive health services need strengthening. Fertility rate remains on the decline, ranging from 1.82 in 2010 to 1.79 in 2014. The maternal mortality rate for the years 2013 and 2014 remained at 0.0 per 1,000 live births.
Child Health (Under 5 Years Old)
The infant mortality rate has fluctuated between 2005 and 2014, from a low of 9.4 per 1,000 live births in 2008 to a high of 30.1 in 2013, with the overall trend in that period being towards lower infant mortality.
Immunization coverage in 2010 2014 for vaccines that are part of the Expanded Programme on Immunization was 98% for BCG; 97% for poliovirus, hepatitis B, Haemophilus influenzae type b (Hib), and DPT; 96% for the first dose of measles, mumps, and rubella (MMR); and 94% for the second dose. Influenza (Hib) vaccine has been introduced on a limited basis; other vaccines, such as meningitis and yellow fever vaccines, which are required for travel, are available on demand. One case of non-neonatal tetanus was recorded in 2013.
Health of Schoolchildren (5-9 Years Old)
Schoolchildren’s health is monitored by family nurse practitioners through the school health program, which is in force in every district. School entrants are screened for vision, hearing, and other abnormalities.
Health of adolescents
The health system has not focused on adolescent health up to now. Several attempts have been made to develop an adolescent health policy and plan of action. As part of the situation analysis, a small survey was conducted in 2015-2016 to determine the health-seeking behaviors of adolescents.
In terms of vector-borne diseases, mosquitoes continue to be most prevalent vector in Dominica. Routine larval surveys are conducted and the results used in the implementation of prevention and control measures. An integrated vector management and prevention plan was developed with assistance from PAHO.
Males continue to bear the brunt of the HIV epidemic in Dominica, with an average yearly incidence. Figure 2 shows the incidence of HIV/AIDS in 2005 2014. There is a sharp increase in the rate of women living with HIV/AIDS, however, which may be explained by the fact that women tend to adhere better than men to antiretroviral therapy.
Figure 2. Number of cases and rates of HIV, Dominica, 2005-2014
Chronic, Noncommunicable Diseases
The prevalence of diabetes is 17.7% in both sexes, 22.0% among males and 12.0% among females. In 2010, the disease ranked as the second leading cause of death in the country, peaking as the leading cause in 2011. The 2007 STEPS survey revealed that 57.2% of respondents had a family history of diabetes, and more than one-quarter (28.2%) had fasting blood glucose levels of over 110 mg/dL, was currently on medication for diabetes, or had been previously diagnosed with the disease. Lower-limb amputations (greater among males than among females) and diabetic retinopathy leading to blindness are the main complications from diabetes in Dominica.
Cerebrovascular disease was the leading cause of death in Dominica for persons aged 65 years and older in 2009 2014. The incidence of stroke, mainly due to uncontrolled hypertension, is high. Some cultural practices and a high level of non-compliance with treatment are issues of concern to health practitioners.
The prevalence of hypertension among adults is 32.1%, with males and females being equally affected. Results from the STEPS survey conducted in 2007 -2008 revealed that more than one-quarter (26%) of respondents who were not receiving treatment for elevated blood pressure levels exhibited blood pressure levels at or higher than 140/90 mmHg, and one-tenth (10%) had blood pressure values at or above 160/100 mmHg. Prevalence was higher among males who were not receiving medical treatment for this condition.
Accidents and Violence
Deaths due to road traffic crashes are emerging as the leading causes of death among 15 24-year-olds. Males are more likely to be affected than females.
Other Health Problems
Eye-care services are well organized and available at the community level. The most important causes of blindness in Dominica are cataracts, glaucoma, diabetic retinopathy, and uncorrected refractive errors. Dominica has a well-established diabetic retinopathy program.
During the next five years, the health sector will focus on the construction of the new general hospital. This venture will also require that human resources in health and the financing of health services be reviewed. Expansion of primary health care services will take place concurrently, as secondary care services will be limited during the construction phase of the new hospital.
1. Central Statistical Department (Dominica). 2011 Population and Housing Census: preliminary results. Roseau: CSD; 2011. Available from: http://finance.gov.dm/index.php/statistics.
2. Ministry of Health (Dominica). Strategic Plan for Health: investing in health—building a safer future. Volume 1: health situation analysis 2010. Roseau: MOH; 2010. Available from: http://healthpromotion.gov.dm/multimedia/publications.
3. Kairi Consultants Limited; Ministry of Finance National Assessment Team (Dominica). Country poverty assessment—Dominica. Volume 1, main report. Tunapuna, Trinidad and Tobago: KCL/Caribbean Development Bank; 2010. Available from: http://www.dominica.gov.dm/cms/files/dominica_cpa_2009_main_report_final.pdf.
4. Augustine S. Moving towards age-friendly primary health care centres in Dominica. 2014. Unpublished.
5. Simpson A; Ministry of Health (Dominica). PAHO situational analysis—Dominica data. 2012. Unpublished.
6. Pan American Health Organization; Ministry of Health (Dominica). Aging and health in Dominican elders. 2010.
7. Government of Dominica. Draft national policy on alcohol and other drugs—Dominica. 2016.
8. Dominica Gazette. IMF Executive Board concludes the 2016 Article IV Consultation with Dominica [news release]. 21 Jul. Roseau: Dominica Gazette; 2016. Available from: http://www.dominicagazette.com/imf-executive-board-concludes-the-2016-article-iv-consultation-with-dominica/.
9. Government of Dominica. National policy and plan of action 2016–2020 [draft]. 2016.
10. Ministry of Health and Environment (Dominica). 2015 Annual Health Statistical Digest [draft]. 2016.
11. Pan American Health Organization, Health Information and Analysis Program. Health in the Americas: basic indicators 2011. Washington, D.C.: PAHO; 2011. Available from: http://ais.paho.org/chi/brochures/2011/BI_2011_ENG.pdf.
1. The poverty assessment combined a national survey of living conditions, a household budgetary survey, a participatory poverty assessment, and an institutional assessment.
2. This study was funded by the Pan American Health Organization.