Pan American Health Organization

Grenada

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

Grenada comprises the island of Grenada, Carriacou and Petite Martinique, and several smaller uninhabited islands, all of which are accessible by sea and air. The country extends for 344 km2 and is located in the Caribbean’s southernmost region, 160 km north of Venezuela. Grenada’s tropical climate fluctuates between rainy and dry seasons. Grenada is a member of the Caribbean Community (CARICOM) and the Organisation of Eastern Caribbean States (OECS).

The 2011 population census 2011 put the country’s population at 106,667 (50.5% males; 49.47% females). The estimated population for 2014 was 109,374. The majority of the population is of African ancestry (82.4%), followed by mixed ethnicity (13.3%) and East Indian descent (2.2%).

In 2010, there were 7,839 children under 5 years old. There were 8,378 persons aged 65 years and older in 2010, a figure that rose to 11,666 in 2014, representing a 28% increase. The rate of natural increase is 7.2. The dependency ratio in 2010 was 53 per 100 and 44.6 in 2014 (). Life expectancy at birth was 70.1 years in 2010 and 74.1 in 2014, with females having a longer life expectancy (73.2 years) than males (67.7 years). Figure 1 shows the age and sex structure of Grenada’s population in 1990 and 2014.

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

Grenada’s population increased 10.9% between 1990 and 2015. In 1990, the population had an expansive structure, with most of population falling in the groups younger than 30 years. By 2015, the pyramidal shape had moved to ages older than 25 years, with the groups between 10 and 29 years old showing a regressive tendency and then a slow expansion in the first decade of life. These structural changes came about due to decreases in fertility and mortality in the last three decades.

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

Total births remained relatively constant in 2010 and 2014, at 1,735 and 1,782, respectively. Births to teenage mothers showed a decline between 2012 (207) and 2014 (175). The mortality rate in 2010 was 7.9 per 1,000 population and in 2014, it was 8.8. Table 1 shows birth and death rates for 2010-2014.

Table 1. Birth and death rates, Grenada, 2010-2014

  Year
Indicator 2010 2011 2012 2013 2014
Total births (No.) 1735 1829 1679 1860 1782
Live births 1712 1804 1658 1840 1750
Birth rate (per 1,000 population) 15.5 17.7 15.8 16.9 16.3
Still birth (No.) 23 25 22 20 32
Stillbirth rate (per 1,000 total births) 13.26 13.67 13.10 10.75 17.9
Infant deaths (No.) 21 20 15 30 23
Infant death rate (per 1,000 live births) 12.3 11.1 9.0 16.3 12.9
Neonatal deaths (No.) 18 11 11 25 19
Neonatal death rate (per 1,000 live births) 10.5 6.1 6.6 13.6 10.6
Fertility rate 59.4 66.7 60.5 54.4 114.3
Rate of natural increase 8.2 7.7 9.4 7.2
Births to teenage mothers 233 226 207 198 175
Teenage birth rate (per 1,000 population) 42.42 46.37 42.22 40.76 36.70
Death rate (per 1,000 population) 7.46 7.2 7.87 7.6 8.8

Source: Grenada, Ministry of Health, Births and Deaths Registry.

Grenada is classified as a “middle income” country. It shares a central bank (the Eastern Caribbean Central Bank) and currency (the East Caribbean dollar) with members of the Organisation of Eastern Caribbean States (OECS). In 2015, GDP growth was 4.6% and the per capita income was US$ 9,156. Tourism and agriculture are the main economic drivers, with tourism being the leading foreign exchange earner.

Primary and secondary education is mandatory and free. Enrollment levels in 2014-2015 were 11,865 for primary education and 9,082 for secondary education (). The literacy level is 98%.

As is the case in other Caribbean countries, Grenada’s resilience in coping with environmental changes and natural disasters is critical in determining its health outcomes. The Caribbean Development Bank has identified five priority areas in environmental management, of which three have health implications¾solid waste management, contamination of drinking water supplies, and inappropriate costal development.

The National Health System

The Ministry of Health is responsible for overseeing the health services and for formulating policies and regulations. Grenada has universal health, supplemented by minimal fees for service in public institutions. Primary and secondary health services are at public and private health care facilities that include 3 acute hospitals and 36 health facilities, which in turn encompass 6 health centers (one in each health district) and 30 satellite medical stations scattered within a 3 mi radius throughout the country. The primary health care policy adopted in 2015 guides the delivery of a range of services. As a member of the OECS Pharmaceutical Procurement Services, Grenada procures its pharmaceuticals at a reduced rate while guaranteeing the quality of the drugs provided.

Private institutions offer health insurance, which is the only form of medical insurance in Grenada to date. In consideration of the increase in the aged population, the Government is considering instituting a national health insurance program. Safety net programs are implemented to assists the most vulnerable groups in meeting basic needs.

A review of estimates indicates that total health expenditures in 2008-2014 were on average, 5%-6% of GDP annually (), which is consistent with WHO guidelines; expenditure on health is about 50% of total spending. In 2008-2014, out of pocket payments accounted for 47% of total health expenditure, with donor funding holding steady at 3%. The Government’s total expenditure on health accounted for 10%-12% of the total budget, which is comparable with other countries in the subregion, but is considered inadequate to finance the sector in a sustainable manner ().

Leading Health Challenges

Critical Health Problems

Emerging Diseases

Dengue is endemic in the country; there were 265 confirmed cases in 2010-2014. Most cases (101) cases occurred in 2013; there were 28 confirmed cases in 2014 with no deaths. Since the emergence of chikungunya and Zika in 2014 and 2016, respectively, cases for both diseases have climbed to epidemic levels. There were 26 laboratory-confirmed cases of chikungunya and 3,070 suspected cases of the disease between June and October 2014, with no associated deaths. Zika is of particular concern because of the disease’s complications with Guillian Barre syndrome (GBS) and congenital malformations. In 2016, Grenada recorded 112 laboratory-confirmed Zika cases, with 10 cases of GBS; congenital malformations (such as microcephaly) are anticipated, because 10 pregnant women contracted the disease during their first trimester of pregnancy. Household mosquito indices for the Aedes aegypti mosquito have ranged from 13.9 in 2010 to 10.6 in 2014. The Breteau index decreased from 21 in 2010 to 17 in 2014, and the container index dropped from 14.7 in 2010 to 13.3 in 2014 (). Prevention and control activities to reduce the mosquitoes continue as part of the program of integrated management for vector borne diseases.

Tuberculosis

There were nine cases of tuberculosis during 2010-2015, with annual numbers ranging from one to four. None of the cases was rifampicin- or multidrug-resistant.

Adolescent Pregnancy

The number of teenage births has been decreasing since 2006: by 2014 there was a 42% reduction, 299 teenage births in 2006 to 175 in 2014. In 2011-2014, teenage births as a percentage of all births ranged from 12.4% to 9.8%, the lowest level observed. Although the actual cause for this decrease is unknown, an effort is being made to counsel teens and teenage mothers on reproductive health and a healthy lifestyle.

Chronic Conditions

Chronic, noncommunicable diseases have consistently ranked as the leading causes of death in 2010 and in 2014. Malignant neoplasms ranked first in both years, followed by endocrine and metablolic conditions, ischemic heart diseases, and cerebrovascular diseases (Table 2). The burden of chronic, noncommunicable diseasees places an increasing demand for service ().

Table 2. Rank, number, and percentage of total deaths for the 10 leading causes of death, Grenada, 2010 and 2014

2010 2014
Cause Rank Total % Cause Rank Total %
Malignant neoplasms 1 164 19.8 Malignant neoplasms 1 172 18.0
Endocrine and metabolic conditions 2 109 13.2 Endocrine and metabolic conditions 2 115 12.0
Ischemic heart diseases 3 84 10.1 Ischemic heart diseases 3 99 10.0
Cerebrovascular diseases 4 79 9.5 Cerebrovascular diseases 4 86 9.0
Diseases of pulmonary circulation 5 72 8.7 Diseases of the respiratory system 5 80 8.0
Diseases of the respiratory system 6 70 8.5 Diseases of pulmonary circulation 6 80 8.0
Hypertensive diseases 7 43 5.2 Hypertensive diseases 7 41 5.0
External causes of morbidity/mortality 8 41 5.0 Diseases of the digestive system 8 37 4.0
Diseases of the digestive system 9 28 3.4 External causes 9 36 4.0
Diseases of the genitourinary system 10 18 2.2 Certain conditions originated in the perinatal period 10 28 3.0
Total 831 85.6 958 81.0

Source: Grenada, Ministry of Health, Births and Deaths Registry, 2010 and 2014.

Human Resources

During 2010-2014, the Government made gains in the availability of human resources for health in the public sector. As Table 3 shows, the number of health professionals increased in all categories during that period, except for nutritionists/dieticians, whose numbers remained unchanged. Even with these increases, the number of nutritionists, technicians, cardiologists, and oncologists and allied staff are insufficient to effectively cope with noncommunicable disease morbidities.

Table 3. Number and density of health professionals,a by category, Grenada, 2010 and 2014

  Year
  2010b 2014c
Category No. Density No. Density
Physicians 80 7.6 110 10.0
Dentists 9 8.6 9 0.8
Dental auxiliaries 4 0.4 4 0.4
Registered nurses 315 30.0 339 31.0
Nurse practitioners 3 0.29 2 0.2
Nurse assistants 192 18.3 233 21.3
Nutritionists/dieticians 1 0.1 1 0.1
Lab technologist 13 1.2 22 2.0
Radiographers 6 0.6 15 1.4
Pharmacists 21 2.0 24 2.2
Physiotherapists 1 0.1 2 0.2
Environmental health officers 13 1.2 17 1.6

a Per 1,000 population.
b The population in 2010 was 105,038.
c The population in 204 was 109,374.
Source: Grenada, Ministry of Health.

Bilateral assistance from Cuba is used to fill the shortage of specialists, such as oncologists, obstetricians and gynecologists, and internal medicine physicians. Moreover, scholarships from China, Cuba, and other countries also provide support for specialist training in such fields a obstetrics and gynecology, ophthalmology, and pathology. The St. George’s University and the T.A. Marryshow Community College provide in-country training for certain key categories of health workers. St. George’s offers undergraduate training for doctors, nurses, and medical technologists, as well as a master’s in public health. Marryshow Community College offers courses for pharmacists and nursing assistants, as well as courses in general nursing.

By law, the professional bodies that regulate nurses, physicians, and pharmacists require a continuing education certificate for re-licensure. The Ministry of Health, the Pan American Health Organization, and St. George’s University provide technical updates and training in such areas as palliative care mental health, and breastfeeding counseling. There is no structured succession planning.

The remuneration package is one of the lowest in the OECS. Incentives are offered mainly to doctors through allowances for housing and private practice. Emigration of health professionals decreased in 2014-2016, with nurses migrating to Bermuda, Canada, Tortola, Trinidad and Tobago, the United Kingdom, and the United States of America ().[7]The pattern of outmigration of health personnel is for nurses to leave the country in search of employment, while physicians tend to move from the public sector to the private sector.

Knowledge, Technology and Health Information

Grenada’s Health Information System (HIS) is mostly paper-based, with partial implementation of electronic technology. Health information is managed by the Ministry of Health’s Epidemiology and Information Unit (EIU), which mainly collects data from the community health services (CHS), the hospital services, the Registrar General Department (births and deaths), the private health sector, and the Central Statistical Office (CSO). The Registrar General Department is also partially computerized, and coverage is almost universal. Bedside registration is done at the public hospitals, where over 98% of births occur. All deaths must be registered prior to burial. Community health service data is collected monthly from the districts, then is analysed by EIU to produce the annual CHS report. Data collection forms were revised to allow disaggregation of data by age and sex. Three of the most populated districts are participating in a pilot project to transition into an electronic compilation of reports.

In terms of scientific output in health, there is no research agenda, although the Ministry of Health, through its Research Oversight Committee, actively supports research projects. The Windward Islands Research and Education Foundation, which is headquartered at St. George’s University, is the research institution in Grenada; the Ministry of Health has a memorandum of understanding with the University for the conduct of health sector research. The Pan American Health Organization and USAID also support research activities, mainly regarding policy development and emerging public health threats. Research papers are published in peer reviewed journals.

In 2012, the Laboratory Information System was implemented at the main laboratory, which allowed for lab results to be accessible at the three main hospitals. In 2015, an electronic immunization registry was implemented as part of a wider strategy to install the Health Information System and electronic medical records, with support from the Centers for Disease Control and Prevention and the Pan American Health Organization. In 2016 a Picture Archiving and Communication System was launched at the two main hospitals, and a pharmaceutical software was installed at the Central Medical Store.

The Medical Records Unit at the General Hospital compiles monthly inpatient statistics on admissions, discharges, and bed occupancy rates by ward, based on individual patient discharge records. Mortality rates disaggregated by diagnosis (using ICD-10 codes), by sex, and by age groups, are also compiled; these deaths are obtained from the Registrar of Births and Deaths. The General Hospital submits monthly and annual inpatient utilization reports to the EIU.

The Environment and Human Security

Grenada has experienced changes in rainfall patterns since 1960, with decreases in the mean rainfall of 0.5 mm per month per decade from June to August, and increases of 12.0 mm from September to November. According to the 2014 Country Document on Disaster Risk Reduction, temperature has also increased by 0.6°C since 1960. In 2015, a prolonged drought threatened water supplies in many communities. There are no specific policies and interventions to address potential health impacts resulting from climate change.

As a way to document pollution’s harm to health, a study followed 52 pregnant women from 10 Caribbean countries and found that Grenadian women had the highest level of mercury in their blood, showed lead contamination in all their blood samples, and found higher levels of pyrethroids metabolite concentrations in their urine ().[8] Further, a 2015 study found that pregnant Grenadian women were exposed to several harmful pesticide chemicals: more than half (60%) of women tested had been exposed to organophosphates and 20% had been exposed to phenoxyacetic acids, chemicals that can cross the placenta and affect the fetus (). Clearly, additional studies are needed and preventive interventions must be adopted.

Grenada has been actively preparing for natural and man-made disasters since it suffered the devastation caused by hurricanes Ivan and Emily in 2004 and 2005, respectively. The National Disaster Management Plan updated the country’s preparedness and response capacity by training health personnel in mass casualty management, emergency care and treatment, and management of health emergency operations center; senior health managers also received training in disaster management. All public health care facilities were assessed using the Hospital Safety Index Assessment tool; as a result of this exercise, in 2016 seven facilities in Grenada, including the Princess Alicia Hospital, began participating in the SMART initiative for health facilities initiative, a four-year effort designed to make health facilities in the Caribbean safe and green. In addition, the Ministry of Health has drawn up a Multi-hazard Disaster Emergency Management Plan for the health sector.

Food safety is a matter of concern in Grenada: street vended selling food in urban centers remain unregulated and food safety practices (HACCP) are yet to be adopted by all food handlers. The 2010 National Food Safety Policy led to the passage of various food safety laws in 2015. The overuse of antibiotics in livestock is raising concern: studies are under way to determine the extent of antibiotic resistance in livestock, but monitoring and surveillance systems have yet to be developed. Inspection of meats and other comestibles is conducted at the port of entry. Laboratory facilities on the island test questionable foods destined for human consumption.

The population’s access to clean drinking water was 98% in 2014, with 95% of residents having water piped to their houses and 2% using standpipes. That same year, 8.2% of the population had access to public sewer services, 53.1% relied on septic tanks, and 36.3% used pit latrines; 66.6% of the poor used pit latrines ().[10]

Waste collection services are available to 98% of households, 87% served by government services and 11% rely on private services. Based on current per capita waste generation of 2.2 kgs per person per day, it is projected that waste generation will be approximately 38,000 tons by the end of 2016 (). Commercial waste collection is entirely handled by private enterprises ().

Aging

In 2014, the population 60 years old and older was estimated at 14.54 of the population. In that same year, 8 of every 100 persons in the population were 65 years and older, with a male-to-female ratio of 1:3 (). In Grenada persons retire at age 60 years, with contributors to the social security scheme receiving a monthly pension; those unable to finance or take care of themselves receive a government monthly subsistence. Primary and secondary care services are free, with a nominal fee of US$ 1.85 (ECD$ 5.00) charged for medications. Twelve geriatric homes house more than 350 elderly persons. A program that is under the government’s purview (Community Caregivers) caters to the needs of the elderly by offering home visits to help with personal care, management of medications, exercise, and some errands.

Migration

International and regional migration or in-migration is not a significant issue in Grenada. Most Grenadians travel to the United States of America followed by Trinidad & Tobago (). The number of Grenadians migrating between 2010 and 2014 was 9,241.

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

The Ministry of Health is charged with the development of national health policies. The following policies were developed in 2011-2015: adolescent health (2013), sexual and reproductive health (2013), oral health (2013), and the chronic, noncommunicable disease policy and action plan (2015). The National Health Sector Strategic Plan (2016-2025) was adopted in 2015. The Food Safety Bill (2014) was enacted into law in 2015, which covers the safety of food produced, imported, and exported. A National Food Safety Committee was established to improve standards of domestic food production.

The Ministry of Health is managed by a policy team headed by the Minister.

The country is committed to universal health coverage through the National Health Insurance (NHI) scheme. A NHI Advisory Committee, appointed in 2013, conducts studies to inform policy decisions. Primary health care was expanded, and the Medical Assistance Programme, which provides assistance to the vulnerable segments of the population, was established.

The health sector operates with outdated legislation and regulations; the Public Health Act, for example dates to 1958. This obsolescence hinders operations, such as the compliance with commitments such as the Inernational Health Regulations (IHR). Grenada is a member of several international and regional health institutions including the Pan American Health Organization/World Health Organization, the Caribbean Community (CARICOM), the Caribbean Public Health Agency (CARPHA), and UNAIDS.

Prospects

As is the case in many developing countries, in Grenada chronic diseases have been the leading causes of morbidity and mortality, followed by the threat of emerging and re-emerging diseases.

The country has many successes to be proud of. For example, Grenada’s robust vaccination program has kept vaccine-preventable diseases under control. Moreover, the effectiveness of the country’s maternal and child health program has progressed to the point where Grenada is poised to declare the elimination of Mother to child transmission of HIV.

As the country looks ahead, the issues of health care access and equity will serve as a driver for the development and implementation of policies. Maintaining a robust national health insurance, for example, is the linchpin for achieving universal health coverage, thus guaranteeing accessibility and equity for all Grenadians. Better health promotion and disease-prevention strategies also will be central to that effort. Specifically, greater attention will be placed on empowering vulnerable groups with the necessary education and opportunities to practice health living. The country has already started to target men’s health as a way to narrow life expectancy differences between the sexes. Other vulnerable groups¾lesbians, gays, bisexuals, transgenders, men who have sex with men, and commercial sex workers, to list a few¾will also be given special attention. Among other activities, focus will be placed on HIV/STI management system and the involvement of community groups. Funds will be allocated so as to ensure that gains made over the last decade can be sustained.

Finally, the Government of Grenada is aware of the impact that climate change can have on human health, and is committed to supporting and investing in the public response to climate change. In this regard the Ministry of Health continues to build capacity to reduce vulnerability, increase resilience, and promote disaster risk reduction ().

References

1. Central Statistical Office (CSO) 2016 — Unpublished

2. Ministry of Education and Human Resource Development Statistical Digest, 2014-2015

3. WHO/GHO, 2014

4. Hatt, et al, 2011

5. Vector Report 2010-14. — Unpublished

6. CNCD Policy Document

7. World Bank Document HR Audit 2010

8. Prenatal Exposure to Persistent Organic Pollutants (POPs) and Polybrominated Diphenyl Ethers in 10 Caribbean Countries

9. Evaluation of Exposure to Organophosphate, Carbamate, Phenoxy Acid, and Chlorophenol Pesticides in Pregnant Women from 10 Caribbean Countries

10. Central Statistical Office — 2015 Unpublished

11. National Waste Management Strategy

12. Grenada Solid Waste Authority

13. Central Statistical Office, 2015 — Unpublished

14. Immigration Department, RGPF, 2014 — Unpublished

15. Epidemiology and Information Unit, MOH

16. Births and Deaths Registry, 2010-14 — Unpublished

17. Births and Deaths Registry, 2010-14 — Unpublished

18. Births and Deaths Registry, 2010-14 — Unpublished

19. Vector Report, 2010-14 — Unpublished

20. Epidemiology and Health Information Department – Ministry of Health, 2014

21. PAHO/WHO, 2013; Government of Grenada, 2011; Martin, 2011

22. Martin, Francis – Ministry of Health Grenada, 2011 — Unpublished

23. Grenada Food and Nutritional Council Survey – 2014

24. Traffic Department – Royal Grenada Police Force — Unpublished

25. Licensing Department – Royal Grenada Police Force — Unpublished

26. WHO AIMS report on Mental Health – 2008

27. Mental Health Report 2015

28. PAHO/WHO STEPS – 2011

29. Inter-American Drug Abuse Control Commission (CICAD) – 2013

30. Global Status Report on Alcohol and Health – WHO 2014

31. Global School-based Health Survey – WHO 2008

32. The Cost of a Balance Economic Meal – Government of Grenada 2013

33. Grenada Food and Nutrition Council and Statistical Office Ministry of Finance – 2013

34. PAHO/WHO, 2011; CDC, 2008; GoG, 2005

35. Drug Prevalence Survey – Ministry of Education

36. National Infectious Control Unit – Ministry of Health 2014–2015

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Reference/Note:

1. Based on the number of persons under 16 and the number of persons older than 60 years.

2. Out-of-pocket payments cover such costs as private care, medicines, and minimal user fees.

3. Donor funds are destined to renovation and upgrade of medical facilities, some equipment purchasing, and technical assistance.

4. The Hospital Safety Index developed by the Pan American Health Organization “provides a snapshot of the probability that a hospital or health facility will continue to function in emergency situations, based on structural, nonstructural and functional factors, including the environment and the health services network to which it belongs.”

5. Based on z scores.

6. Based on BMI percentiles.

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