Saint Kitts and Nevis
- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
The Federation of St. Christopher and Nevis (St. Kitts and Nevis) is located in the Leeward Islands chain of the Lesser Antilles. St. Kitts is the larger and more populated island, with a total area of 168 km2. Nevis lies southeast of St. Kitts and occupies an area of 93 km2. The islands are almost fully composed of volcanic rock and are located in the hurricane belt, between the Atlantic Ocean and the Caribbean Sea. The Federation is divided into a total of 14 parishes, 9 of which are on St. Kitts and 5 on Nevis. The administrative and commercial capital, Basseterre, is located on St. Kitts.
The preliminary population estimate from the 2011 census was 47,196 (St. Kitts, 34,918; Nevis, 12,278). This figure showed a 1.9% increase from the 2011 census figure (). The urban parishes of St. Kitts (Saint George and Saint Peter) and Nevis (Saint Paul) account for 37% and 15% of the population, respectively. While the country retains a relatively young population, its population profile indicates that the number of persons in the 35–50-year age cohort is expanding (see Figure 1). Moreover, as the crude birth rate and fertility rate remain below replacement level, and life expectancy at birth increases (72.3 years in 2001 and 75.5 in 2011), it is likely that the population over 65 years of age will balloon over the next decade and a half. Overall, there is a ratio of 96.95 males per 100 females. The population is mainly of African descent (90%) followed by Caucasian (2.7%) and mixed (2.5%). UNICEF estimates the net migration rate for St. Kitts and Nevis at zero for 2010–2015. Figure 1 shows the country’s population structure, by age and sex, for 1990 and 2015.
Figure 1. Population structure, by age and sex, St. Kitts and Nevis, 1990 and 2015
The population increased by 24.7% between 1991 and 2015. In 1990, with the population structure being stationary in the age groups above 55 years, with slow expansion under that age; most of the population was under 25 years old. By 2015, the structure was expansive above 50 years of age, and the population under that age had stationary growth (with a slight declining tendency) in relation to aging and declining birth rate and mortality over the last five decades.
Source: Pan American Health Organization, based on United States Census Bureau, International Data Base. Last updated on August 2016.
St. Kitts and Nevis is classified as a high-income country and in 2013 had the highest annual per capita income in the Caribbean (US$ 13,330) (). The country had a Human Development Index (HDI) of 0.765 in 2015 ().
Subsequent to the closure of the sugar industry in 2005, diversification of the agricultural sector and stimulation of other economic sectors such as tourism, export-oriented manufacturing, and offshore banking were encouraged (). The economic situation has improved, with robust growth and a strong fiscal balance. In 2012 there was negative growth (–1%) largely due to a slump in the global economy, but there was a rebound to 6% in 2013–2014 (). The fiscal surplus remained high as a result of strong tax revenue, while the public debt-to-GDP ratio fell faster than anticipated following the successful completion of the Stand-By-Arrangement (SBA) with the International Monetary Fund (IMF).
Determinants of Health
There is universal access to early childhood, primary, and secondary education and education is free at all levels. The literacy rate is higher for females (97.4%) than males (96.5%) in the 15–24-year age group ().
A social determinants approach is being adopted to address the current epidemics of noncommunicable diseases (NCDs) and interpersonal violence (). The driving forces of excess consumption, price manipulation, and marketing are likely to be mitigated by enhanced consumer education and health-focused policy-making (). Interpersonal violence is less likely to thrive where there is concerted attention on social protection ().
Violence and Security
There has been an increase in the number of youths affiliated with gangs, which are generally not organized and engage in petty street crime, robberies, and the local drug market (). With a record high of 35 homicides in 2011, efforts are ongoing to encourage youth to disassociate themselves from gangs through targeted programs, services, and employment. There is no registered presence of transnational criminal organizations (). There were no confirmed reports in 2015 that St. Kitts and Nevis was a source, destination, or transit country for victims of human trafficking. The Office of the Ombudsman provides human rights services in the absence of a formal human rights desk.
Leading Environmental Problems
The 2014 Review of the St. Kitts and Nevis National Biodiversity Strategy and Action Plan () identified challenges in biodiversity conservation and sustainable land management. Land degradation has led to landslides and soil erosion. Demographic changes in the country have resulted in increased construction and generation of waste. The upsurge in cruise and cargo vessel traffic may raise levels of air and water pollution.
Health policies and programs
A comprehensive National Policy and Plan for the Prevention and Control of Non-Communicable Diseases () was developed in 2013. Hemodialysis services are now available in the Federation, and the implementation of a chronic disease self-management program has shown some success. Plans are under way for the establishment of a cancer center, which will complement cancer treatment services in Antigua and Barbuda.
The St. Kitts and Nevis National Social Protection Strategy 2012–2017 () seeks to address, among other things, the impacts of poverty on women and men, the effect of unemployment on heads of households, and challenges faced by at-risk children through various social and educational programs. The Men’s Desk at the Department of Gender Affairs, established in 2007, addresses a number of men’s issues, including sexual health, mental health and substance abuse, and chronic lifestyle illnesses. There is low representation of women in leadership roles in politics, and in 2015 women held only 20% of seats in the Parliament of St. Kitts and Nevis and the Nevis Assembly.
According to the 2007–2008 Poverty Assessment Survey, the prevalence of poverty in 2008 was 22% compared to 32% in 2002, with indigence declining from 11% to 1%. Of the poor, 52.2% were women and 47.8% were men (). Females are more likely than males to be among the indigent in St. Kitts, but in Nevis, men accounted for more of the non-indigent poor and vulnerable. The unemployment rate in 2014 was 6.5%. Women’s labor force participation is lower than men’s in both St. Kitts and Nevis ().
Complementing government-funded access to health care services for children and the elderly is a system of social protection that includes social insurance (Social Security) and safety net programs. Children under the age of 18 and persons over the age of 62 years are exempt from charges at public health services for basic health care; these services are not withheld for other groups due to inability to pay.
The Social Security System continued to meet its obligations during 2010–2015, with the number of beneficiaries receiving assistance benefits increasing from 15,828 in 2010 to 18,501 in 2015 (16.9% increase). Payments to beneficiaries increased by 61.8%, from US$ 15.4 million in 2010 to US$ 24.9 million in 2015. There are subsidies that apply to health and education services. Social assistance programs provide food and cash transfers to poor households and assist with unanticipated expenses, such as hurricane damage, fires, and special emergency medical expenses. Active labor market programs support working mothers with day care centers and provide training for unemployed youth. A range of employment-based social protection is available under the Social Security Act.
The National Health System
As a two-island federation, there are two ministries of health with parallel organizational structures. Each island has a Minister and Permanent Secretary who are responsible for organizing and managing public health services. The Ministry of Health on St. Kitts also has federal responsibilities, which include public health surveillance and disease prevention and control programs on both islands; reporting data; and creating national strategy. Each Ministry is organized into three programs: the Office of Policy Development and Information Management, which includes the health information unit; Community-Based Health Services, which includes family health services, environmental health, and health promotion; and Institution-Based Health Services, which includes patient care services. There is a single Chief Medical Officer for the Federation who is responsible for oversight of scientific and technical matters pertaining to public health policy, health status monitoring, and regulation of health professionals. Nurses are regulated by the Principal Nursing Officer and by the St. Christopher and Nevis Nurses and Midwives Council.
Leading Health Challenges
Critical Health Problems
Dengue is endemic in the country. Between 2011 and 2014, there were 63 cases of dengue fever reported, with an outbreak in 2011, and no cases were reported in 2015. Malaria is not endemic, but two cases of imported malaria were reported between 2011 and 2015.
In February 2014, the Federation recorded its first case of chikungunya fever, and by the end of the year 28 confirmed and 627 suspected cases had been reported. As of September 2016, there were three confirmed cases of Zika fever with no medical complications. Subsequent to the 2009 H1N1 influenza pandemic, influenza A(H1N1) circulates seasonally, but there have been no outbreaks. There have been no reported cases of cholera, rabies, leprosy, or other neglected diseases in the 2010–2015 period.
National policies to address antimicrobial resistance and, with the exception of HIV, disease-specific surveillance for antimicrobial resistance, are not yet in place ().
The national tuberculosis program has seen a decline in visibility over time due to the small number of cases reported annually. There were 12 reported tuberculosis cases in 2011–2015, a decrease from 15 reported cases in 2006–2010. In 2014, there were seven new confirmed cases (four imported), with no deaths or multidrug resistance.
Between 1984 and 2014, the number of reported HIV cases in St. Kitts and Nevis was 385, the number of AIDS cases was 149, and the number of AIDS deaths was 112. The total number of cases of HIV infection increased from 57 in 2006–2010 to 65 cases in 2011–2015 (see Figure 2). This may be due, in part, to the increased number of people accessing voluntary counselingand testing services, from 5,609 in 2006–2010 to a record high of 8,713 in 2011–2015. In 2011 and 2014, there was a greater prevalence of HIV diagnosis in males (0.9% in 2011 and 2.8% in 2014) than in females (0.2% in both 2011 and 2014). Deaths attributed to HIV doubled in 2011–2015 compared to 2006–2010, rising from 8 to 17 deaths. Antiretroviral treatment is available free of charge, and all confirmed cases of tuberculosis are tested for HIV. Since 2011 there have been no cases of HIV/TB coinfection.
Maternal mortality is limited to 1–2 cases per year. Women receive free antenatal care, including laboratory services, in public health facilities, and all births are assisted by skilled health personnel. Specialized services are provided in the primary care setting, and there is a focus on early identification and management of high-risk clients. Regular clinic hours have been extended to accommodate pregnant women.
Adolescents continue to face challenges in accessing reproductive health services, and are at risk for sexually transmitted infections and pregnancy. There has been a decline in teenage births, from 17% of all births in 2006–2010 to 14% in 2011–2015. The government has put measures in place through the Project Viola Program that allows adolescent mothers to be reintegrated into the education system. The Health and Family Life Education Curriculum has been restructured in schools to improve student access to sex education programs.
The 2011 Global School Health Survey indicated that 32.5% of secondary students (13-15-year-olds) were overweight and 14.4% were obese (). Although the majority of children under age 5 fall within normal anthropometric parameters for age, a significant proportion of children are obese. This has implications for persistence of weight problems into late childhood and increases risk for adult development of chronic NCDs, including type 2 diabetes. In contrast, severe undernutrition has almost disappeared.
The prevalence of diabetes mellitus in St. Kitts and Nevis has been estimated at 20% and diabetes was the third leading cause of mortality in the country in 2013 (see Table 1). Diabetes was among the leading causes of admission to the medical ward of the JN France General Hospital in St. Kitts for 2014 and 2015, accounting for 23% and 24% of admissions, respectively.
Table 1. Five leading causes of death, by sex, St. Kitts and Nevis, 2013
|4||Ischemic heart disease||26||16||10|
Source: St. Kitts and Nevis, Ministry of Health, Health Information Unit, 2016.
Mortality from circulatory disease during the 2010–2013 period accounted for approximately one-third of all deaths; 41% of these deaths were due to cerebrovascular diseases. Cardiac disease was the most frequent admitting diagnosis on the medical ward at the JN France Hospital. The 2008 WHO STEPwise approach to Surveillance (STEPS) survey revealed that 35% of adults had raised blood pressure (SBP = 140 and DBP = 90) (). An average of 727 hypertensive patients per year sought care at the health centers during 2011–2015. By the end of 2015, there were 1,221 hypertensive clients registered in the country, 378 males and 844 females. An annual average of 270 patients with asthma was seen at the JN France General Hospital in 2010–2014, with a high of 349 cases in 2011.
The Ministry of Health is in the process of drafting a policy with guiding principles and protocols to address issues and challenges relevant to recruitment, deployment, utilization, and retention of health professionals. In 2015, St. Kitts and Nevis had 23.3 physicians, 36.6 nurses, and 3.5 dentists per 10,000 inhabitants. Of the 118 physicians registered in 2015, 21% worked in the public sector and 32% worked in both the private and public sectors; the balance works exclusively in the private sector. Gaps in specialty areas in the nursing field and medical specialists are filled by recruiting personnel outside St. Kitts and Nevis. Some undergraduate degrees in medicine and nursing are readily available in-country, and scholarships are provided annually for general medical degrees and specialist training outside the federation. Continuing medical educational (CME) sessions for health care workers are ongoing and the Nursing Council requires CME for annual nursing registration.
Health Knowledge, Technology, and Information
The country’s National Information Policy and Plan includes a health sector component. Data collection involves various public and private systems, including registration and billing records, medical records, and health surveys, that mainly rely on entering data manually. Health information is collected at the points of contact with the patient in both the public and private sectors, although there are challenges in collecting data from private physicians. The Caribbean Civil Registry and Identity System (CCRIS) was developed in 2013 to facilitate computerized birth and death registration and provide timely vital statistics. Birth registration is done at the hospitals, where over 99% of births occur, and all deaths must be registered prior to burial, so coverage is nearly universal. In 2015, the citizen medical information card began to be used. It is issued at the hospital and aims to decrease the risk of human error and reduce processing times; there are plans to widen the use of this card in all public health centers. The government established a national information and communication technology governance board and introduced an e-government interactive platform in February 2016. Such a platform will allow the Ministry of Health to set up an e-payment system and easily share information with other ministries. The Ministry of Health is currently updating its health information system, a project that is expected to improve data collection and analysis. There is no formal health care ethics committee, and ethical approval for research is granted through the Office of the Chief Medical Officer.
The Environment and Human Security
The Federation is committed to addressing the adverse effects of climate change. Efforts to better understand the country’s vulnerability and adaptive capacity in the face of extreme weather events, changes in precipitation and temperature, and sea level rise have been evident in recent years. A knowledge, attitudes and practices survey on climate change conducted in 2007 revealed that the major health issues identified by respondents were food- and waterborne diseases ().
The potential burden of vector-borne diseases, particularly dengue, malaria, chikungunya, and Zika fever, is a cause for concern on the islands. The tropical climate and central forested mountains are suitable conditions for mosquito proliferation and may become more favorable depending on climate conditions. The House Index (HI) and Breteau Index (BI) for Aedes aegypti mosquitoes remained below the recommended 5% threshold in 2012 (2.6% and 2.7%, respectively) and had decreased from 3.5% and 5.9%, respectively, in 2010. Prevention and control activities for Ae. aegypti mosquitoes continue through the program of integrated management for vector-borne diseases.
Deforestation and Land Degradation
Land degradation has occurred as a result of the historic overuse of lands for sugar cane cultivation as well as from the clearing of land for residential and tourism development, squatting, and unregulated settlements. In Nevis, there is the challenge of regulating privately owned quarries, which are a major contributor to siltation in terrestrial and coastal waters.
Air quality legislation is governed by the Public Health Act of 1969 and vehicular emissions are the main source of air pollution.
Natural and Manmade Disasters
Flooding and tropical storms are the most frequently occurring natural hazards in the country, but the threat of volcanic eruption from Mount Liamuiga (northern part of St. Kitts) also exists. Drought conditions related to the effects of El Niño in 2015–2016 put pressure on drinking water resources and agriculture production. Post-disaster mitigation projects were aimed at advancing disaster response and preparedness, as well as improving building and construction techniques and the management of shelters (). There is understanding that some vulnerabilities are self-imposed through environmental degradation and unsustainable practices that have compromised the community’s ability to effectively manage some types of disasters ().
Food Safety and Security
The development of a National Food and Nutrition Security Policy is in its final stages. Implementation of the policy will ensure that the national food production network and the food safety and agricultural public health systems are capable of providing safe, adequate, nutritious, and affordable food for the people of St. Kitts and Nevis (). The prevention and management of food-borne diseases through standardized food safety programs includes inspection of restaurants and food shops and certification of food handlers. Surveillance of food-borne illness is ongoing as well as health promotion activities.
There was one outbreak of bacterial gastroenteritis in 2001-2012.
Water Supply and Sanitation
An estimated 98% of the population in the country had access to potable water in 2015 and 87% had access to improved sanitation facilities in 2007. Surface water and groundwater sources are susceptible to agricultural pollution as well as to saltwater intrusion due to the islands’ low-lying position. The health sector actively supports increased protection of watershed and underground aquifer areas. Morbidity from waterborne diseases is negligible.
The Solid Waste Management Corperation (SWMC) is responsible for the management of solid waste on both islands. The average volume of waste generated daily was 116.62 metric tons in 2015, an increase from 90.44 metric tons in 2011.
Persons 65 years and over accounted for 7.5% of the population. Increased life expectancy at birth (73.1 years for males and 78.0 years for females in 2011) is anticipated, thereby expanding the aging population, particularly women. This population transition represents an increase in old-age dependency ratios, which will escalate the burden on the working segment of the population. Retirement age in the public sector is 55 and social security provides support post-retirement. Between 2010 and 2015 the number of beneficiaries receiving a long-term pension increased by 50%, from 2,094 persons to 3,131, and benefits almost doubled, from US$ 9.1 million to US$ 16.8 million. An aging population signals increased demands on the social protection and health services. Poor, older persons are not only vulnerable to economic hardships but are also at risk for neglect, abuse, discrimination, hunger, and loneliness ().
Chronic diseases take a toll on the quality of life in the older segment of the population. Halting and reversing the exposure to risk factors and the impact of chronic diseases can lessen the burden of care for the elderly.
The CARICOM Single Market and Economy (CSME) allows for free movement of selected categories of highly qualified nationals within the CARICOM region. According to the 2011 census, compared to the 2001 census, there have been marginal population increases (31%) in urban parishes in both St. Kitts and Nevis. Nevis has experienced a rise in the number of housing projects in the rural parish ofSt. Paul, which has led to an increase by one-third in the population there.
Monitoring the Health System’s Organization, Provision of Care, and Performance
Health leadership and governance are guided by health policy, with essential services codified in legislation (). The National Strategic Health Plan, which is being updated, guides program performance and assessment; operational plans define the deliverables of programs and sub-programs. There are gaps in regular monitoring of performance. Attention paid to “customer service” and overall patient satisfaction have improved but need to be optimized by the implementation of a “Patient Charter” and a policy governing quality of care ().
Health care in the public sector is financed through government allocations and from minimum fees for service. The total health allocation as a percentage of GDP rose marginally from 2.54% in 2010 to 2.72% in 2014, which was insufficient to meet the demands of the health sector. Funding streams are under consideration to sustain public sector service delivery through a tax-financed health benefits plan. One of the major drivers of health sector reform was the overall public sector reform initiative, an effort that is part of the IMF SBA. The expectation is that, through these reforms, government agencies (including the Ministry of Health) will operate according to cost-minimizing modalities already in place in the private sector, while maintaining high-quality services.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
Maternal mortality was limited to 0–2 deaths per year with a total of 5 deaths for the 2011–2015 period; the mortality rate in 2015 was 158.2 deaths per live births. The most common cause of maternal death was eclampsia. The Federation is in the process of eliminating mother-to-child transmission (MTCT) of HIV, syphilis, and hepatitis B; to this end, all pregnant women are tested for all three diseases and, where indicated, treatment is prescribed to both mother and infant. Available family planning data are limited to the services provided by the Community Health Department. According to data from that department, injectable contraceptives have replaced oral contraceptive pills as the most commonly used birth control method.
Child Health (Under 5 Year Olds)
In 2015, children under 5 years old made up 6.6% of the population. Infant mortality declined by 18.4% from a total of 65 deaths during the 2006–2010 period to 53 during 2011–2015. The infant mortality rate per 1,000 live births was 12.0 in 2011, 9.4 in 2012, 14.6 in 2013, 23.4 in 2014, and 25.3 in 2015. Neonatal mortality accounted for 74% of infant deaths and declined from a total of 52 deaths in the 2006–2010 period to 39 deaths in 2011–2015. The neonatal mortality rate per 1,000 live births was 4.5 in 2011, 6.3 in 2012, 14.6 in 2013, 15.6 in 2014, and 22.2 in 2015. The main causes of neonatal death were birth asphyxia and respiratory distress of the newborn.
Vaccine coverage for all administered vaccines was over 90% for 2010–2015. A 2011 national survey revealed that 3.1% of pregnant women tested positive for hepatitis B surface antigen (HbSAg), and the hepatitis B vaccine was reintroduced to newborns in 2015 as a part of the childhood vaccination schedule (). There were no reported cases of vaccine-preventable diseases covered by the immunization schedule, with the exception of hepatitis B infection in adults. Acute respiratory infections and gastroenteritis were the main causes of morbidity in children under 5 years old.
Health of Schoolchildren (5 to 9 years old)
In 2011, the population between 5 and 9 years old was 7.4%. A school health program offers ophthalmic and dental screening for primary schoolchildren.
Health of adolescents
Studies conducted in the last decade indicated that adolescents are exposed to significant health risks. These included overweight and obesity, physical inactivity, substance abuse, physical violence, and sexual violence. Children are assessed as a part of the school health program prior to enrolling and at the completion of their secondary school education. In 2011 there were six adolescent deaths, five of which were homicides.
Health of adults
The STEPS survey of risk factors in 25–64 year olds conducted in 2007 () revealed high levels of overweight and obesity (33.5% and 45%, respectively) (see Table 2). The survey showed that 54% had elevated systolic blood pressure or were taking hypertension medications.
Table 2. Percentage of adults who are overweight or obese, by sex, St. Kitts and Nevis, 2008
|Adults aged 25-64 years (incl. 95% CI)||Both sexes||Males||Females|
|Overweight or obese (BMI ≤ 25 kg/m2)||78.5%
|Obese (BMI ≤ 30 kg/m2)||45.0%
Source: St. Kitts and Nevis, Ministry of Health, Noncommunicable Disease Program, 2008 STEPwise approach to chronic disease risk factor survey report, 2008.
Health of the Disabled
The Association of Persons with Disabilities (SNAPD)was founded in 1982. The government is currently working on a Registry of Disabled Persons, which will be followed by the development of a Policy and Plan to support persons with disabilities.
In 2013, the leading causes of mortality in adults were malignant neoplasms (163.8 per 100,0000 population), followed by cerebrovascular diseases (71.1), diabetes mellitus (62.5), ischemic heart disease (32.3), and intentional injuries (25.9) (see Table 1). Average annual cancer deaths increased from 63 in 2006–2009 to 337 in 2010–2013, with 97 deaths, the largest number, reported in 2010.
Chronic, Noncommunicable Diseases
The leading causes of morbidity in adults are excess weight, hyperlipidemia, hypertension, diabetes mellitus, schizophrenia, depression, and substance abuse. As of 2015, there were 1,072 diabetics registered at community health facilities, 70.9% of whom were female. The prevalence of hypertension in adults was estimated in 2008 to be 35%, with higher rates among males than females (38.2% versus 31.9%). There were 314 cases of malignant neoplasm reported from 2011–2014. The most frequent cancer sites were breast (19.1%), uterine cervix (19.7%), and prostate (19.7%).
A nutritional study of 6–9 year olds was carried out by the Ministry of Health in 2012. The prevalence of anemia among the study participants was 37% (); 10% of the children were obese, and 23% were overweight or obese; and only 1% of the children were stunted. Caregivers of the children in the study had a mean age of 35 years; 90% were female; and 32% were overweight, and 46% obese.
Accidents and Violence
The leading causes of trauma seen and treated at the emergency department of the JN France General Hospital during 2011 to 2014 were due to physical assaults (1,108), motor vehicular accidents (1,060), stab wounds (142), and gunshot wounds (109).
Integrating mental health into primary health care is a priority of the Ministry of Health. The major psychiatric disorders seen from 2011 to 2015 were schizophrenia (793 cases), schizoaffective disorder (297), bipolar disorder (190), depression (120), and cannabis-induced psychosis (54). St. Kitts and Nevis has a total of four mental health clinics and there is newly constructed mental health day treatment center. A draft Mental Health Policy and Substance Abuse Strategic Plan and Mental Health Act are being finalized.
Other Health Problems
Surveys on oral health knowledge, attitudes, and practices and decayed, missing, and filled teeth (DMFT) were conducted in 2014 and 2015 among schoolchildren. The preliminary DMFT values were 2.4 for 6 year olds, 1.2 for 12 year olds, and 1.8 for 15 year olds.
St. Kitts has been making the transition from Millennium Development Goals to Sustainable Development Goals, primarily through restructuring of the national debt (with a significant reduction in the debt-to-GDP ratio), development of a draft Food and Nutrition Security Policy, and continued emphasis on human development. Perceived risks to sustainable development may be due to climate and environmental vulnerability. In the coming years, equity-oriented strategic health planning, universal access to health care, and investment in medical equipment are needed to address chronic and serious illnesses. Reform in the delivery of community health care (especially for older people) will be a major focus for the health system in St. Kitts and Nevis. The government is exploring the introduction of a National Health Insurance Scheme, which would be financed by the segment of the population productively employed.
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1. An economic program involving financial aid to an IMF Member State in need of financial assistance, normally arising from a financial crisis. In return for aid, the economic program stipulates needed reforms in the recipient country aimed at bringing it back on a path of financial stability and economic sustainability.
2. Health Information Unit, Chief Medical Officer (CMO) report.
3. Percentage of houses infested with Aedes aegypti larvae and/or pupae.
4. Number of positive containers per 100 houses inspected.