Montserrat

Overall Context

Montserrat is a self-governing Overseas Territory of the United Kingdom situated in the Lesser Antilles in the Eastern Caribbean. The territory’s 102 km² is mostly mountainous with a small coastal plain; it has volcanic sandy beaches and one white sandy beach. Montserrat’s Soufrière Hills Volcano began erupting in 1995, resulting in the destruction of the capital, Plymouth, and the evacuation of the southern and central parts of the island. Thousands moved to nearby Antigua, other parts of the Caribbean, or further afield. At the height of the crisis only some 30% of the original population remained on island. In the last decade the population has returned to 45% of the pre-volcanic eruption population. There was a new major eruption in February 2010; volcanic activity reported between 28 February and 31 October of that year indicated that activity had been low and that “there was no evidence of lava extrusion” at that time (1). The ongoing threat of further eruptions has curtailed any potential economic growth, as it is difficult to maintain a viable population and economic activity. Residents live in the northern third of the island, which is considered safe.

Montserrat is a member of the Organisation of Eastern Caribbean States (OECS) and the Caribbean Community (CARICOM).

Demographics

According to the 2011 Population and Housing Census, the population is 4,922, with a male-to-female ratio of 1.07:1. Montserrat has an aging population: there were 301 children under 5 years old (6.1% of the population) and 966 persons 60 years old and older (19.6%). The estimated population density is 49.3 persons per km2, with the urban population being 14.1% and a growth rate of 0.4 % (2). Figure 1 shows Montserrat’s population structure for 1991 and 2015. Most of the population is of African descent (88.4%), followed by those of mixed ethnicity (3.7%), and Hispanics (3.0%). There is no indigenous population. Of the private household population, 73% reported that they were Montserratians. Estimated life expectancy has risen steadily, with the most recent estimates for an overall life expectancy of 74.14 years (75.64 males, 72.57 females). Of the 2,335 households surveyed, 52.5% owned their homes and 39% rented them (2).

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

The population decreased 51.6% between 1991 and 2015. In 1991, the population structure showed a double shape?slow regressive growth above 40 years of age and expansive in the age groups younger than that age. By 2015, the structure became irregular, with slow regressive structure in the groups younger than 30 years of age, due to a high emigration and a decrease in birth rate and mortality among the residents who remained.

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

The Economy

The government’s general revenues are the main source of health care financing. For fiscal year 2015/16 the allocation to the Ministry of Health and Social Services was 15.1 million EC$ (US$ 5,557,804), 9.4% of the island’s recurrent budget for that year (3).

Social Determinants of Health

In 2011, of the 4,019 residents 10 to 70 years old and older, 96.5% were literate and 47 persons aged 25 years old and older had no schooling (2). Primary and secondary education is mandatory and free, and run in government facilities.

Montserrat continues to face certain poverty challenges. The 2012 Country Poverty Assessment report indicated that 36.0% of the population was poor, with children younger than 15 years experiencing by far the highest poverty rate, accounting for over one-third of the poor population. Persons over 30 years old, including the elderly, have a below-average poverty rate, with the elderly accounting for slightly more than 10% of the poor population. There is no difference in the incidence of poverty between males and females, nor is there a significant difference between male and female headed households (4).

The Health System

Montserrat’s 2008-2020 National Sustainable Development Plan, “A Healthy and Wholesome Montserrat,” places health front and center in the territory’s development. Montserrat has an effective primary health care system, but basic secondary care services are only available at one hospital, and there are no tertiary facilities available. To address this gap, the Plan states that residents of Montserrat should have access to secondary and tertiary health care at affordable prices by 2020 (5). This includes an agreement on a basic package of care to be offered on-island and establishing mechanisms for the referral of persons to off-island centers to access other needed services. The 2011 2014 Strategic Plan for Health sets the following strategic directions: enhancing primary and secondary health care, and mental health services; and improving environmental health services. A Gender Policy is being developed, and in 2016 Public Service Advertisements were developed that target behavior change in the male population to mitigate and reduce incidences of domestic violence. A community-based group is working with the Social Development Department to establish a group that will provide counseling and psychosocial support for female victims of domestic abuse.

A National Action Plan to address any changes at the ports of entry required by the International Health Regulations (IHR) was finalized in 2013. As a result of the Plan, staff at both ports of entry were trained on IHR requirements.

The 2016 2019 Ministry of Health’s Strategic Plan considers as priorities areas such as the completion of a project to improve primary and secondary health care services; health services financing and management; the review of the environmental health department; the development of a policy and plan on active aging; and improved training for emergency response, search and rescue, and clinical skills. As of this writing, several staff categories already had received emergency response and search-and-rescue training.

While most persons are responsible for paying for their health care at the point of service, the 2002 Public Health Act exempts some groups and some types of care: full-time university students, children under 16 years old; senior citizens (those over 60 years old), up to two months’ free postnatal care for women, persons defined as “indigent,” some public servants, and prisoners. If someone cannot make a payment (on- or off-island), they may apply for means-tested medical assistance from the Social Services Unit. As part of employment benefits, the government also pays insurance premiums for public servants, and their spouses and children, who opt to be covered under the Civil Service Association Health Insurance Plan. Montserrat relies on non-national workers, some of whom are not English speakers, and anecdotal evidence suggests that these persons face barriers preventing them from accessing health care and some social services.
The Ministry of Health and Social Services is responsible for the provision and governance of health care in Montserrat.

Glendon Hospital provides laboratory, pharmacy, diagnostic imaging, and physiotherapy services; nutritional counseling; accident and emergency services; medical and surgical outpatient services; medical, surgical, and obstetric inpatient care; and ambulance services. Visiting specialists provide gynecology, ophthalmology, psychiatry, orthopedic, and cardiology services. The health centers offer prenatal and postnatal care, child welfare clinics, immunization services, family-planning services, mental health services, and nutrition services. Health center staff also conduct home visits for follow-up care and for those unable to attend clinics. There is a government-run dental clinic and an environmental health unit that is responsible for the Ministry’s vector control program, monitoring of food safety practices in commercial places, and monitoring of solid and liquid waste disposal contractors.

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Leading Health Challenges

Critical Health Problems

Vector-borne Diseases

The main challenge is the Aedes aegypti mosquito, which continues to be found in the territory, with indices ranging from 3 to 15. In 2011 2015, the Ministry of Health documented 32 cases of chikungunya (25 in 2014, 7 in 2015). Infection due to the Zika virus has recently been identified on Montserrat, with one imported case and three cases from reported local transmission in November 2016. There were no cases of dengue fever reported during the same period ((6–8)).

Tuberculosis

There were no cases of tuberculosis for 2010 2015.

Adolescent Sexual Activity

The mean reported age for the onset of sexual activity among boys is 12 years, and among girls, 14.5 years; 47.4% of young boys and girls reported having had sexual intercourse. According to the 2012 Youth Health and Sexuality Survey most of these young people (85%) believed that they had not been exposed to HIV, even though only 57% of them had used a condom at last sexual intercourse. Pregnancies among teenagers 13 19 years old accounted for 15% of all births between 2010 and 2015 (Table 1). In an effort to deal with these findings, the “Safeguarding of Vulnerable Children” project was launched in 2015, with assistance from UNICEF and the Lucy Faithfull Foundation. It is designed to generate policies and programs that safeguard and protect children.

Table 1. Teenage pregnancies, Montserrat, 2010-2015

Chronic Conditions

Noncommunicable diseases (NCDs) remain as the leading causes of morbidity and mortality; during 2010-2015 they were the leading causes of consultations at the district health centers and of admissions to Glendon Hospital. They also were the leading underlying causes of death. Hospital admissions for this period, disaggregated by major disease categories, highlight that diseases of the circulatory system account for 13.4% of all 3,584 admissions, followed by endocrine, nutritional, and metabolic disorders (12.1%) as a close second (6 8). Among the diseases of the circulatory system, the primary condition for which patients were admitted was essential hypertension, while the diagnosis of diabetes mellitus was the main endocrine, nutritional, and metabolic disease ((6–8)).

Mental Disorders

Regarding mental disorders, most admissions for adults have a diagnosis of schizophrenia or related disorders. The Youth Health and Sexuality Survey 2012 revealed that about 20% of young people had serious suicide ideations and 43% had made a suicide plan; of the latter group, 63% had actually tried to kill themselves on one or more occasions. Female respondents (73%) were more likely to have contemplated suicide than male respondents (60%) and also twice or more times likely to attempt suicide. Programs focused on the recommendations emanating from these findings are being implemented. The Mental Health Plan is aligned with the Pan American Health Organization (PAHO) Regional Plan of Action.

Human Resources

In 2011 there were 6 physicians, 45 nurses, and 1 dentist in Montserrat, a more than adequate level to serve the territory’s population. With a population that small, it is difficult to ensure that there is enough work to maintain performance and skill levels, or to adequately cover staff when they are on leave.

Health Knowledge, Technology, and Information

A multi-sectoral team is in the process of developing a health Information plan to coordinate the production, analysis, dissemination, and use of health data. Health information produced by health facilities and the hospital laboratory are largely paper-based.
Internet access and mobile telephone systems are available in-country, with the Montserrat Information Communications Authority reporting that 96.3% of households have fixed-line telephones and 44.4% have broadband internet services. The territory’s two mobile telephone providers report that 68% of the population has mobile telephones (9).

The Environment and Human Security

All residents have access to adequate reserves of potable, palatable water (2). The utility company routinely tests water for biological and chemical contaminants, and the Environmental Health Department routinely monitors the situation. Waterborne diseases have not been major concerns on Montserrat for many decades.

The disposal of solid and household waste is contracted to private companies, but is routinely monitored by staff of the Environmental Health Department; all residents have access to the garbage collection system. The disposal of commercial waste is the responsibility of the business owner. The Ministry of Health is responsible for the management of the island’s single landfill site where all solid waste is discarded.

Montserrat has a National Disaster Preparedness Plan. There are plans to revive the territory’s search-and-rescue training facilities and programs, and to host a climate change center for the OECS; the center would collect information and compile a database of climate change factors, features, and events relevant to the subregion, such as monitoring gas and particulate matter from the ongoing volcanic ash eruptions and their impact on seabed topography and ecology on the island. The center also would provide public education regarding climate change. International education and research institutions are expected to provide support so as to make the institution self-sustainable.

Aging

Montserrat’s is an aging population, with about 20% of the population being 60 years old or older. The extreme volcanic activity experienced between 1995 and 1997 led younger members of the population to migrate out of Montserrat, leaving many elderly persons behind. The Ministry of Health and Social Services gives priority to the implementation of policies and programs that address the needs of this growing group. The Ministry of Health is conducting an assessment of the status of older persons so that the information can be used to complete a policy for older persons. Two residential homes provide care for older persons, the Margetson Memorial Home and the Golden Years Home. More able-bodied persons who do not have a home or family support are housed at the Lookout Warden Assisted Apartments.

Migration

Migration has not been a significant issue for Montserrat between 2010 and 2015.

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

The Ministry of Health’s regulatory and enforcement functions are hindered by staffing and capability shortcomings. Nonetheless, the Ministry carries out various public health efforts. For example, while efforts already are under way to increase taxes on imported drinks with high sugar content and alcoholic beverages, further work remains to be done to prevent chronic NCDs and reduce their impact. The integration of mental health within the territory’s primary health care services has progressed, benefitting services for safeguarding children and minors. There is a small private medical services sector, and all tertiary care is provided in neighboring Antigua and Guadeloupe, and in the United Kingdom and the United States.

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Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

Maternal and child health services are provided in both primary and secondary health care facilities. Between 2010 and 2015, 100% of antenatal clients¹ sought care during the first trimester of their pregnancy, and all births on-island were attended by a trained health professional. All pregnant women were offered the opportunity to be tested for HIV and syphilis, and all accepted (10). As of 2016, Montserrat is being assessed for certification as having eliminated mother to child transmission (MTCT) of HIV and syphilis. Exclusive breastfeeding for infants 3—6 months old was between 40% and 50% in 2015.

There were no maternal deaths in 2010 2015.

Child Health

With mid-year population estimates at approximately 4,963 for the past five years, the estimated birth rates in the 2010 2015 period ranged between 8.3 and 12.4 per 1,000 population (Table 2). In the same period, there were no neonatal deaths, one infant death (in 2010), and nine stillbirths. In 2015, there were three infant deaths, two of which were neonatal deaths; there were no deaths in the 1 4-year-old age group ((6–8)).

Table 2. Number of total births and birth rates, Montserrat, 2010 – 2015

Coverage for the vaccines included in the Expanded Program on Immunization (DPT, hepatitis B, Hib, MMR) was 100% for children and adolescents in 2010 2015 (6 8). As part of the immunization program, there are ongoing efforts to increase coverage among adults (including health workers) for conditions such as tetanus and influenza.

Health of Schoolchildren (5 9 Years Old)

Children aged 5 9 years old were estimated to be 6.3% of the population in 2011. This cohort benefits from routine health checks at school and has access to free medical and dental care in the public sector as part of the school health system. Records for 2010 to 2015 indicate 100% coverage for all age-appropriate vaccines and zero deaths in this age group ((6–8)). There have been no cases of diseases against which vaccines are administered. The introduction of the HPV vaccine is under discussion.

Health of Adolescents (13 18 Years Old)

Adolescents also benefit from free medical and dental care as part of the school health system, but they are seen less often than younger children. According to the 2012 Youth Health and Sexuality Survey, most young people in this age group (63%) had consumed alcohol, the most widely used substance. Cigarettes had been tried by 19%, and 17% had tried marijuana. Less than 6% had tried tobacco products besides cigarettes, or other drugs besides marijuana. Family support and motivation, as well as community and teacher engagement, were important protective factors in the use of these substances. Respondents reporting high family support and motivation were less likely to have tried cigarettes and marijuana or consumed alcohol, compared to those reporting low family support and motivation.

Mortality

There was an average of 44 deaths each year in 2010 2015. The leading causes of death were diabetes mellitus and heart disease (Table 3), followed by neoplasms, with cancers of the prostate, female breast, and colon being the most frequent sites. In 2015, there were 49 deaths, of which 86% were among persons 60 years old and older and 59% were among those 80 years old and older. The male:female ratio was 1:1 ((6–8)).

Table 3. Leading causes of death, and number of deaths, Montserrat, 2010 2015

Morbidity

According to the 2011 census, of the 4,775 persons living in private households, 487 (10.2%) were self-reported cases of diabetes, with more females than males, while information from the clinic register put the total at 374. The prevalence rate in 2011, according to clinic data, was 76 per 1,000, population, but this figure may be an under-representation, because some people with diabetes seek care from private sector providers. That same year, the prevalence rate for hypertension alone, according to clinic registry information, was 62.1; for diabetes and hypertension together, it was 56.0 per 1000 population. Between 2006 and 201, there were 11 diabetes-related amputations and 46 deaths; the figures for 2011 2015 were 10 and 51, respectively. In 2010 2015, diseases of the circulatory system, followed by endocrine, nutritional, and metabolic diseases, were the two main causes of admissions to hospital. In 2015, communicable diseases such as acute gastroenteritis and respiratory diseases accounted for 9% of hospital admissions. One case of HIV was diagnosed in 2015 ((6–8)).

Communicable Diseases

Malaria and yellow fever are not endemic to the country and no cases of zoonotic diseases were diagnosed (11).

Nutritional Diseases

A review of annual school assessment data shows that the proportion of school-aged children with unhealthy weight is on the rise. In 2010 2015, some 26% of children² assessed were either overweight or obese, with 10-year-old boys being more overweight than girls and teenage girls being more overweight than their male counterparts (12). In response to this trend, structured educational and other practical interventions were designed for children and their parents, such as visits to schools and meetings between parents and teachers, and health camps for different age groups during summer and Easter breaks. Mass media campaigns sought to disseminate information on healthy lifestyle choices.

Accidents and Violence

There were three homicides reported in 2011 2015. This is an unusually high figure compared to the last decade, when homicides averaged one every five years. There were 584 motor vehicle accidents investigated by the Royal Montserrat Police Service in that same period, with one fatality, in 2015.

Other Health Problems

According to an oral health survey conducted by the Dental Unit, among 6-, 12-, and 15-year-olds in 2011, the mean decayed, missing, and filled teeth (DMFT) scores were 2.3 (for 6-year-olds); 1.2 (for 12-year-olds); and 1.74 (for 15-year-olds). While these results were all within the range recommended by the World Health Organization (WHO), the findings among 6-year-olds prompted active monitoring of that younger cohort (13). Plans are well advanced to conduct a similar survey in January 2017. In 2015, there were 2,273 persons receiving dental care, of which 55% were children. Amalgam restoration, including fissure sealant, was a frequent dental service required by the children. Oral health is an integral part of the school health program (6 8).

The Ministry of Health provides vision screening for all registered clients with diabetes as part of their annual checkups, with referrals to the visiting ophthalmologist as required. Vision screening is also conducted as part of the annual school health program.

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Prospects

The Ministry of Health and Social Services has developed a three-year strategic plan that aligns with the Government of Montserrat’s Policy Directive and the Sustainable Development Plan. Continued success is anticipated in those areas, such as preventing and eliminating diseases (for example, vaccine-preventable diseases), and maintaining optimum maternal and infant mortality indicators.

Regarding the prevention and control of chronic diseases, the Ministry of Health and Social Services will seek to strengthen links with regional and international partners to make greater gains in this effort. Some advances already have been made in using a multi-sectoral approach to reduce risk factors that lead children to become obese.

The battle to control the ubiquitous Aedes aegypti mosquito will continue. As part of this effort, the Ministry will continue to engage with regional stakeholders to help harness the community’s participation in eliminating breeding sites, and thus reduce the risk of local transmission of dengue, chikungunya, and Zika.

Finally, the territory has seen encouraging improvements in its mental health services. A national Mental Health Policy and Plan was adopted by the Cabinet in 2015 and is now being implemented. As the implementation of the Mental Health Policy and Plan moves forward, mental health services will eventually be fully integrated into the primary care setting. Perhaps just as important, efforts to better inform the population about mental health issues will reduce the levels of stigma and discrimination associated with these conditions. Further, the recent implementation of WHO’s Mental Health Gap Action Programme (mhGAP) interventional approach has led to better identification of depression in the population.

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References

1. Montserrat Volcano Observatory. Report to the Scientific Advisory Committee on volcanic activity at Soufriere Hills: open file report (OFR) 10-02a. Salem: MVO; 2010. Available from: http://www.mvo.ms/pub/Open_File_Reports/MVO_OFR_10_02a-MVO_Report_to_SAC_15.pdf.

2. Statistics Department (Montserrat). Census 2011: Montserrat at a glance. Brades: SD; 2012. Available from: http://www.gov.ms/wp-content/uploads/2011/02/Montserrat-At-A-Glance.pdf.

3. Ministry of Finance and Economic Management (Montserrat). Budget statement, 2014: restoring growth, expanding opportunities. Brades: MoFEM; 2014. Available from: www.gov.ms/pubs/ministry-of-finance/.

4. Halcrow Group Limited; National Assessment Team (Montserrat). Montserrat survey of living conditions, 2009. Brades: Government of Montserrat; Caribbean Development Bank; 2012. Available from: http://www.gov.ms/pubs/cabinet-secretariat-publications-2012/.

5. Ministry of Economic Development and Trade (Montserrat). Montserrat Sustainable Development Plan, 2008–2020. Brades: MoEDT; 2010. Available from: www.gov.ms/publications/SDP_MONTSERRAT.pdf.

6. Ministry of Health and Social Services (Montserrat). Medical records statistical report, 2007–2011. Brades: MoHSS.

7. Ministry of Health and Social Services (Montserrat). Medical records statistical report, 2012–2014. Brades: MoHSS.

8. Ministry of Health and Social Services (Montserrat). Medical records statistical report, 2015. Brades: MoHSS.

9. Government of Montserrat. National Information & Communication Technology Policy, Strategy & Implementation Plan [draft]. Brades: GOM.

10. Ministry of Health and Social Services (Montserrat). Draft report for the elimination of mother to child transmission of HIV and syphilis, August 2016. Brades: MoHSS.

11. Ministry of Health and Social Services (Montserrat). Annual communicable disease surveillance reports, 2011–2015. Brades: MoHSS.

12. Ministry of Health and Social Services (Montserrat). Annual school health reports, 2011–2015. Brades: MoHSS.

13. Ministry of Health and Social Services (Montserrat). Report on DMFT survey. Brades: MoHSS.

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