Country Report: Montserrat
Montserrat is a British Overseas Territory located in the Lesser Antilles in the Eastern Caribbean. It has an area of 102 km2. The island is composed almost exclusively of volcanic rock and is primarily mountainous, with a small coastal plain.
Between 1990 and 2015, the population declined by 50.6% to just 5,241 in 2015. Much of the population shrinkage followed the eruption of the Soufrière Hills volcano in 1995, which destroyed the capital, Plymouth, and forced the evacuation of the population to the northern third of the island, considered safer given the continuing risk posed by the volcano. A significant portion of the population emigrated to Antigua, other parts of the Caribbean, and even beyond.
Most of the population is of African descent (88.4%), followed by people of mixed ethnicity (3.7%) and Hispanics (3.0%). There is no indigenous population, and 73% of residents are native to Montserrat.
Estimated life expectancy has risen steadily, with the most recent estimates at 74.4 years overall (75.64 in men, 72.57 in women).
The persistent risk of volcanic activity has effectively limited the potential for economic growth, since it is difficult to maintain the population and the economy at sustainable levels.
- A national Mental Health Policy and Plan, adopted by the Cabinet in 2015, is now being implemented. The plan is aligned with the PAHO Regional Plan of Action.
- The plan gives priority to specific issues identified by surveys, especially depression and suicide attempts. To this end, the recent implementation of a computerized system has contributed to better detection and identification of depression in the population.
- The Mental Health Plan calls for the full integration of mental health services into primary care. Implementation of the mental health services system in primary care began in 2015.
- Efforts to better inform the population about mental health issues are expected to reduce the level of stigma and discrimination associated with these conditions.
Figure 1. Distribution of the population by age and sex, Montserrat, 1990 and 2015
Proportional Mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan American Health Organization and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Note: Population data for 2015 have been derived according to national estimates by the Statistics Department, Montserrat.
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- In 2011, 96.5% of the 4,019 residents aged 10-70 and over were literate. Primary and secondary education are compulsory, free, and run by the government.
- In 2012, 36.0% of the population was poor, with children under 15 exhibiting sharply higher poverty rates than other age groups.
- The island has sufficient reserves of clean drinking water, to which 100% of residents have access.
- All inhabitants have access to the refuse collection system. The Ministry of Health and Social Services is responsible for refuse management and the sanitary landfills where all solid waste is discarded.
- The intense volcanic activity between 1995 and 1997 led many younger people to emigrate from Montserrat, leaving older people behind. Implementation of policies and programs to address the needs of this growing age group is a priority.
- Two nursing homes, the Margetson Memorial Home and the Golden Years Home, provide care for the elderly. More able-bodied individuals who do not have a home or family support are housed at the Lookout Warden assisted apartments.
- Immigration into the territory is not very significant, but Montserrat depends on foreign workers, some of whom are not English speakers.
HEALTH SITUATION AND THE HEALTH SYSTEM
- There were no maternal deaths between 2010 and 2015. In that same period, there were no neonatal deaths, but there was one death of a child under 1 year of age in 2010. In 2015, there were three deaths of children under 1 year, two of which were neonatal deaths; no deaths occurred in the 1-4 age group.
- There is universal coverage of prenatal care and delivery attended by trained health workers.
- Coverage of the vaccines administered under the Expanded Program on Immunization (DPT, hepatitis B, Haemophilus influenzae type b, MMR) was 100% for children and adolescents in 2010-2015. There are ongoing efforts to increase coverage among adults (including health workers) to immunize them against diseases such as tetanus and influenza.
- The number of deaths per year averaged 44 between 2010 and 2015. In 2015, there were 49 deaths, 86% of which were among persons aged 60 and over. The leading groups of causes were circulatory system diseases (37% of all deaths), endocrine disorders (23%), and neoplasms (14%).
- The leading specific causes of death were diabetes mellitus and heart disease. Among neoplasms, cancers of the prostate, breast, and colon were the most frequent.
- Malaria and yellow fever are not endemic to the territory, and no recent cases of zoonotic diseases have been diagnosed.
- The main challenge is the Aedes aegypti mosquito, which continues to be found in the territory, with indexes ranging from 3 to 15. In 2011-2015 the Ministry of Health documented 32 cases of chikungunya virus infection (25 in 2014, 7 in 2015).
- Zika virus infection has recently been identified in Montserrat, with one imported case and three cases from local transmission in late 2016. No cases of dengue were reported between 2014 and 2016.
- No cases of tuberculosis were recorded in the period 2010-2015.
- According to the 2011 census, 10.2% of the population reported suffering from diabetes mellitus. The prevalence rate in 2011, according to clinical data, was 76 per 1,000 population, but this figure may reflect underreporting, given that many diabetics seek care in the private sector. In the period 2010-2015, approximately 26% of children evaluated were overweight or obese.
- Three homicides were reported between 2011 and 2015, as well as 584 motor vehicle accidents, with 1 fatality in 2015.
- In 2012, 63% of young people reported having consumed alcohol, 19% had smoked cigarettes, and 17% marijuana.
- The government’s general revenues are the principal source of health care financing. In fiscal 2015-2016, 9.4% of the recurrent budget for the year was allocated to the Ministry of Health and Social Services.
- While people are generally responsible for covering the cost of medical care, many groups are exempt from payment, including students enrolled full-time in school or university, children under 16, adults over 60, pregnant women (until two months after giving birth), the indigent, civil servants, and prisoners.
- People who cannot cover their share of the cost of medical care (on or off the island) can apply for means-tested medical assistance from the Social Services Unit.
- As part of employment benefits, the government also pays insurance premiums for civil servants who opt for coverage under the Civil Service Association Health Insurance Plan, with immediate dependents also covered by the regimen on payment of nominal premiums.
- The Ministry of Health and Social Services is directly responsible for providing and overseeing health care in Montserrat. The principal health care facility is the government-run Glendon Hospital. There are also four health centers that offer primary and secondary care.
- Glendon Hospital has a series of hospital services or units: laboratory, pharmacy, diagnostic imaging, physiotherapy, and nutritional counseling; accident and emergency services; outpatient medical and surgical services; inpatient medical, surgical, and obstetric care; and ambulance services. These are supported by housekeeping, laundry, and maintenance services.
- Gynecology, ophthalmology, and cardiology services are provided under the Visiting Specialist Program.
- The other health centers offer prenatal and postnatal care, child wellness clinics, and services in the areas of immunization, family planning, mental health, and nutrition. Health center staff also conduct home visits for follow-up care and for patients unable to visit clinics. There is a government-run dental clinic and an environmental health unit.
- The integration of mental health into primary health care is moving ahead and has had a positive impact on services for protecting children and youth.
- The private medical sector is small. All specialized tertiary care is provided on neighboring islands (Antigua and Guadeloupe), as well as in the United States and even the United Kingdom. The services of a growing number of visiting specialists have been made possible by the provision of new equipment and a budget to cover the costs of the specialists.
- In 2011, there were 6 physicians, 45 nurses, and 1 dentist in Montserrat, a density sufficient to serve the territory’s population. The provision of specialized services such as obstetrics and gynecology, orthopedics, urology, psychiatry, and diagnostic imaging is supported by visiting physicians and other professionals.
- The 2011-2014 Strategic Plan for Health calls for strengthening primary and secondary health care, mental health services, and environmental health services.
- The priority areas in the Strategic Plan of the Ministry of Health and Social Services for 2016-2019 are the completion of a project to improve primary and secondary health care services and the financing and management of health services; a review of the environmental health department; development of a policy and plan on active aging; and improvement of emergency response, search and rescue, and training in clinical skills.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- The Ministry of Health and Social Services has put together a three-year strategic plan aligned with the Government of Montserrat’s Policy Directive and the Sustainable Development Plan for the island.
- The plan is expected to bring advances in critical areas such as the prevention and elimination of diseases (for example, vaccine-preventable diseases) and maternal and child health. This progress should be reflected in improved indicators.
- Greater emphasis will be placed on the prevention and control of chronic diseases, with the assistance of regional and international partners.
- Health workers are encouraged by the steady (albeit slow) progress in the use of a multisectoral approach to reduce risk factors that lead children to become obese.
- The Ministry of Health and Social Services will continue working with other regional entities to address the problem of the Aedes aegypti vector to reduce the risk of local transmission of dengue, chikungunya virus, and Zika virus.
- The Government of Montserrat is studying the design of a hospital and considering various proposals for how to finance health care delivery and the rebuilding of the health and social service sectors.
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