Country Report: Dominica
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. Between 1990 and 2015, the population was relatively stable, reported as 69,665 in 2015. In 1990, the population structure was expansive, while in 2015, it had become stationary in groups under 45 years of age.
Between 1990 and 2010, there was a decrease in the proportion of children, adolescents, and young adults, and an increase in the proportion of people aged 60 and over.
Persons of African origin accounted for 84.7% of the population, down from 86.75% in the last 10 years. The indigenous Kalinago population, in contrast, grew by 26.5%, increasing to 3.7% of the population from 2.9% in 2001. The population of whites, or Caucasians, increased sharply, by 55%.
The economy is primarily based on agricultural exports, tourism, and manufacturing. However, it was seriously affected by Tropical Storm Erika in 2015 and is recovering slowly.
- In 2009, the Ministry of Health conducted a study on aging and health in order to learn about and classify the current situation of older persons. The purpose was to orient the development of a policy to guide the implementation of community programs for healthy aging.
- The health services currently have no specific services or programs for older persons.
- Over the next five years, the health sector will focus on the construction of the new general hospital. This venture will also require a review of human resources for health and the financing of health services.
- Renewal of primary health care will take place concurrently, as there will be a need to expand services, since secondary care services will be limited during the construction of the new hospital.
- A national environmental health strategy has been developed in line with the targets and indicators of the Sustainable Development Goals and the post-2015 development agenda.
Figure 1. Distribution of the population by age and sex, Dominica, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan-American Health Organization, World Health Organization, and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- In 2011, the unemployment rate was 11.3%. The poverty level fell from 39% in 2003 to 28.8% in 2009. Absolute poverty also decreased, from 10% in 2003 to 3.1% in 2009. The vulnerability rate is estimated at 11.5%.
- Indigenous peoples, the Kalinago, bear a greater burden of poverty: 49% of them are poor, compared to the national average of 28.8%.
- The "Yes We Care" program provides assistance to the most vulnerable older people who need assistance with their activities of daily living.
- The country provides universal primary and secondary education for both sexes; the goal now is to attain universal preschool education. The ratio of girls to boys in primary schools is 96.7:100 and in secondary schools, 96.3:100.
- At least 97% of the population has access to safe drinking water, and a Government project is under way to ensure that all households are connected to the sewerage system or a septic tank. The country has a nationwide solid-waste collection system, which picks up trash from every community and transports it to a landfill.
- A disease that severely damaged the banana crop caused a drastic drop in earnings, from US$ 11 million to US$ 1 million between 2012 and 2015.
- The island’s location and topography make it vulnerable to yearly tropical storms and hurricanes and prone to flash floods and landslides in low-lying areas. These phenomena pose a substantial risk of loss of life and property damage.
- Due to climate change, such events are expected to increase and put the country at even greater disaster risk.
- In 2015, Tropical Storm Erika caused landslides and flooding, with severe damage to infrastructure across the island. Some 28,000 people were affected, with 14 dead and 16 missing; 574 lost their homes, and 1,034 were evacuated from their homes.
- The impact on water, food, and health systems created a series of health risks for the population. Damage to the country was estimated at over 90% of the gross domestic product (GDP).
- In terms of internal population movements, many rural residents have migrated to the cities in search of employment, leaving many older people without family support. There is also immigration from Haiti and the Dominican Republic.
- There has also been emigration, especially to Anguilla, Antigua, and the United States, in search of employment. Young children remain behind in the care of their older relatives, who take on a parental role, which in many instances creates social problems.
HEALTH SITUATION AND THE HEALTH SYSTEM
- The maternal mortality rate for 2013 and 2014 remained at 0.0 per 1,000 live births.
- Antenatal care coverage is universal, and almost all births are attended by skilled health workers.
- The infant mortality rate between 2005 and 2014 ranged from a low of 9.4 per 1,000 live births in 2008 to a high of 30.1 in 2013.
- In the period 2010-2014, vaccine coverage was almost universal, at 98% for BCG and 97% for poliomyelitis, hepatitis B, Haemophilus influenzae type b, and DTP. MMR vaccine coverage was 96% for the first dose and 94% for the second. One case of non-neonatal tetanus was reported in 2013.
- In 2014, diseases of the circulatory system were responsible for 44% of deaths and neoplasms, 18%. These two groups of causes account for almost two-thirds of all deaths in the country.
- Cases of chikungunya fever have been reported since the introduction of the virus in late 2013. Up to 2016, 3,771 cases had been reported, 173 of which were laboratoryconfirmed. Between March and July 2016, 723 cases of Zika virus infection were reported, 65 of which were laboratoryconfirmed. Five pregnant women were diagnosed with Zika, along with one patient with Guillain-Barré syndrome, who was treated in Martinique.
- Dengue is endemic in Dominica. Outbreaks occurred in 2010 and 2013, with 641 and 233 cases, respectively. One dengue-associated death was reported in 2010.
- In the past 5 years, Dominica has been grappling with a leptospirosis outbreak, with 41 reported cases, including 4 deaths (a case-fatality rate of 10%).
- In 2015, 7 cases of tuberculosis were reported; all received directly observed treatment free of charge. In 2013, a single
case of rifampicin-resistant TB was reported.
- In the past 5 years, only 2 cases of TB/HIV coinfection have been reported.
- In 2014, the incidence of HIV infection was 0.26 cases per 1,000 population. The HIV epidemic continues to predominantly affect males.
- Diabetes prevalence is 17.7% (22.0% in men and 12.0% in women). The main complications observed are amputations of the lower extremities and diabetic retinopathy leading to blindness.
- The prevalence of hypertension in adults is 32.1%, with relatively similar rates in both sexes.
- Cerebrovascular disease was the leading cause of death in Dominica in people aged 65 and over in the period 2009-2014.
- Overweight and obesity have replaced stunting and low weight-for-age as the main indicators of malnutrition in children aged 0-5 years, and data for 2014 indicate an increase in obesity in that age group. In 2009, one-quarter of all students aged 13-15 were overweight.
- The Ministry of Health is charged with leadership and governance of the health care system. The Ministry’s governance role needs strengthening.
- Dominica is committed to achieving universal health care for all its citizens.
- The National Strategic Plan for Health 2009-2019 emphasizes the following priority areas: the health status of the population; the social determinants of health; health service management and response capacity, including quality and sustainability; and health system organization and management.
- Several health policies have been drafted in recent years, along with implementation plans, although greater effectiveness in their adoption is needed. The Government has embraced a Health in All Policies approach, particularly in tackling noncommunicable diseases.
- The health services are financed largely by general taxes. Primary care services are provided at no cost.
- Both primary and secondary care are available. Most tertiary care is provided outside the country. The health system has been organized into seven districts, grouped into two administrative regions. Each district has its own budget, which is administered centrally due to lack of human resources. Health care facilities include 52 dispensaries or health centers and 2 district hospitals.
- The Princess Margaret Hospital is the main hospital in Dominica. Construction of a new general hospital has begun.
- Private health services are limited and consist mainly of outpatient care provided by private practitioners. The majority of tertiary care is provided outside the island.
- The system is affected by the emigration of nurses. From 2008 to 2014, 24 nurses resigned from the nursing service; in 2015 alone, 17 resigned.
- The Ministry of Health is adopting an integrated electronic information system, known as the Dominica 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. Access to health information is limited, and the adoption of a unique national identifier remains an unmet need.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- Dominica continues to face the challenge of advancing toward the achievement of universal health coverage, which requires a high level of financial protection. However, the government has a very small budget that must be distributed across highly diverse and competing priorities.
- The incidence of stroke, due mainly to uncontrolled hypertension, is high. Some cultural practices and a high level of nonadherence to treatment are cause for concern among health practitioners.
- Declining fertility rates and increasing longevity will continue to fuel the aging of Dominica’s population.
- Through interventions such as the Social Investment Fund, the Basic Needs Trust Fund (an initiative designed 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. It also provides relief to the most vulnerable elderly population through assistance with activities of daily living.
- It is essential to ensure better coordination in managing the funds allocated to transfer patients abroad for treatment.
- An expansion of primary care is also considered necessary, as secondary care services will be limited during the construction of the new hospital.
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