ST. KITTS AND NEVIS

HEALTH FOR ALL BY THE YEAR 2000

 

 

1. TRENDS IN POLICY DEVELOPMENT

St. Kitts and Nevis is an independent Commonwealth Caribbean Country having assumed full sovereignty from Great Britain on September 19, 1983. The twin-island nation occupies the northern part of the Leeward Islands chain at 19E North Longitude and 62E West Latitude. St. Kitts is the larger of the two islands with a surface area of 176.2 square kilometres, while Nevis occupies an area of 93 square kilometres. Altogether, the size of St Kitts and Nevis is 269.2 square kilometres.

Political

Constitutionally, the State of St. Kitts and Nevis exists as a Federation with the Federal Parliament, which is the highest decision-making institution in the country, residing in St. Kitts. At the same time, Nevis operates a form of local government through its Island Assembly which allows a certain level of autonomy. Thus, almost parallel public service arrangements exist for both St. Kitts and Nevis, with the Prime Minister assuming general control of all aspects of the nation's business, but with the Premier of Nevis having an extensive range of local authority. It is noteworthy, for example, that separate Annual Budgetary Estimates exist for both St. Kitts and Nevis.

The key elements of the present development strategy as outlined in the 1995 budget address are as follows:

  • promotion of services industries such as tourism, informatics and offshore financial services.
  • encouraging light manufacturing and food processing which offer potential for niche marketing.
  • diversification of agriculture, with special emphasis on livestock production.
  • human resource development and technological development through education and training and incentives.
  • supporting and strengthening the social infrastructure.

At another level, commitment has been given to the upgrading of the main hospitals. The facilities that have been identified for imminent improvement are the J.N. France General Hospital in Basseterre, St. Kitts, and the Alexandra Hospital in Nevis. This development will provide a new fillip to the secondary care services in the State. The policy decision has been taken to review and update the schedule of user charges within the health sector. In doing so, safety nets will be established to ensure that no citizen is excluded on the basis of inability to pay.

A new post of Director of Women's Affairs has been created within the Ministry of Health and Women's Affairs to coordinate all activities geared towards the promotion of the interest and well-being of women.

2. TRENDS IN SOCIO-ECONOMIC DEVELOPMENT

2.1 Economic Trends

The economy of St. Kitts and Nevis has achieved only moderate levels of growth in recent years, by its own standards. The rate of real economic growth has not exceeded 5% in any year since 1990 and averaged 4.24% during the period 1991 - 1995.

The sectoral contributors to the Gross Domestic Product (GDP) have been government services, wholesale and retail trade, construction and communications. On the other hand, tourism has emerged as one of the most important economic activities impacting directly on a number of sectors including hotels and restaurants, transportation and retail trade.

The per capita income in St. Kitts and Nevis has shown a real growth of 11.6% between 1991 and 1995.

There is wide disparity between per capita incomes in constant prices vis a vis current prices. For example, the per capita income in constant prices in 1995 was EC$3,993 while the corresponding index in current prices was EC$12,079 - a differential of 202%. This suggests that a high rate of inflation exists in St. Kitts and Nevis thereby influencing the cost of living upwards (Table 2).

Unemployment in St. Kitts and Nevis is among the lowest in the Caribbean. According to the 1991 Population and Housing Census, only 4.9% of the population were unemployed at that time. A Labour Force Survey in 1994 conducted jointly by the Organization of American States and the Government of St. Kitts and Nevis confirmed an unemployment rate of just 4.3%.

The main area of occupational employment was the services industry (36.5%) where tourism-related activities dominate, followed by professional and technical services (13.6%), agriculture and fishing (12.9%) and construction and manufacturing (12.7%). In terms of household income, 21% earned between EC$15,001 and $25,000, while 15.5% fell in the income class of EC$10,001 to $15,000. Only 15% of households had incomes of $5,000 or below.

2.2 Demographic Trends

The population of St. Kitts and Nevis experienced a negative growth of 6.2% during the inter-censal period 1980 - 1991. This decline has been attributed largely to the effects of emigration.

The Planning Unit in the Ministry of Development and Planning estimated the population of St. Kitts and Nevis at 43,530 in 1995 with an almost equal distribution of males and females. Just over 40% of the population are under the age of twenty years, while about 12% are above the age of 60 years.

Most of the population (81.6%) live in St. Kitts with the remainder occupying the sister island of Nevis.

The Annual Digest of Statistics, 1994 has set the total fertility rate at 2.63, down from 3.30 in 1990. The gross reproduction rate has been estimated 1.29 in 1994.

The crude birth rate has declined from 22.5 in 1991 to 17.4 in 1995, with an annual average rate of 20.0 over the period.

The average annual death birth rate for St. Kitts and Nevis during the period 1991 - 1995 was 9.1. This relatively high crude birth rate bears relationship to the infant mortality rate which has worsened over the past five years after showing encouraging decline previously.

2.3 Social Trends

In 1991 there were 11,789 students enrolled in public and private schools, representing 88.5% of the total population between 5 and 19 years. This despite the fact that school attendance is not compulsory. School enrollment in 1994 was 89.2%.

According to the 1991 Population and Housing Census, the highest level of education attained by most residents of St. Kitts and Nevis is secondary school education (39.2%), with an almost equal number reporting having completed primary school education (38.9%). Just over 5% of the population had the benefit of pre-university or university education.

In 1991, there were 12,056 households in St. Kitts and Nevis, an increase of 3.8% since the previous census of 1980. Most of these households were owner-occupied (74.0%) with 18.6% private-rented. The average number of rooms per household increased marginally from 3.2 in 1980 to 3.4 in 1995, while the average household size decreased from 3.7 to 3.5 persons over the period under review.

The constitution of St. Kitts and Nevis forbids discrimination by sex and offers equal rights to children born out of wedlock. At the same time, the House of Assembly has enacted laws to limit domestic violence.

The 1994 Labour Force Survey reported that 5,672 households (47%) were headed by women, 58.5% of whom were employed outside of the house. Only 3.61% of these women were actively seeking employment and could not find.

St. Kitts and Nevis is well served by a local television station and international cable television on one hand, and local and regional radio stations on the other hand.

2.4 Food Supply and Nutritional Status

St. Kitts and Nevis imports most of its food for consumption. This situation is the function of two major factors - the low level of crop and livestock production locally and the booming tourist industry which must be sustained. In 1992, livestock and crop production was valued at EC$8.38 million (1.9% of GDP), while the food import bill for that same year was EC$45.63 million (10.8% of GDP).

The annual average of mild to moderate undernutrition among the under 5 years population over the period 1991 - 1995 was 6.6% (Table 11). At the same time, overnutrition among children appears to be slightly on the rise with an annual average of 6.7% over the period.

In 1994, 75.8% of ante-natal women fell in the high category scoring 11 grams and over of haemoglobin levels, 23.9% were in the median range of 9.0 - 10.9 grams, while a mere 1.3% registered haemoglobin levels under 9 grams.

More than 90% of all newborns return a weight at birth of more than 2,500 grams (Table 12). During the period 1990 - 1994 an annual average of 9.0% of low weight babies at birth was observed, indicating an area for some attention.

2.5 Lifestyle

Births to teenage women continue to feature prominently among the natality statistics. In 1995, 16.7% of all births were attributed to teenage women, with the 20 - 24 age-group accounting for the largest percentage of births, 29.1%. This has been the pattern over the period 1991 - 1995 (Table 13).

Of the 9,484 reports made to the Police in 1994, 337 (3.6%) were offences against the person, defined as grievous bodily harm and wounding. A further 14.2% of the reports involved offences against property and included thefts, robbery, arson and praedial larceny. Twenty-nine of these reports were for rape and indecent assault. With respect to court convictions, 54 persons were found guilty of offences against the person.

Overall, violence in its broadest definition has been on the increase in St. Kitts and Nevis, with a 49% incline between 1990 and 1994. It is a situation that is being watched very carefully by the authorities.

It is reported that 25% of all psychiatric patients treated in the community mental health programme in 1995 were for alcohol or drug-induced psychosis. Among patients treated at the Psychiatric Ward at the J.N. France Hospital, 30% presented with a diagnosis of alcohol and marijuana and cocaine psychoses. A male/female ratio of 3:1 has been observed.

What is known with certainty is that a cumulative total of 195 reports of possession of dangerous drugs were received by the Police between 1990 and 1994. There were 50 convictions.

Tobacco imports in 1992 totalled EC$0.86 million, down from EC$1.0 million in the previous year. This translates into an annual per capita expenditure on tobacco of between EC$18.00 and $24.00.

3. HEALTH AND ENVIRONMENT

A new Ministry responsible for Culture and the Environment was created in St. Kitts and Nevis in 1995. The key role is to preserve cultural heritage and implement Government's programme for the protection of the environment.

The vast majority of householders (89.1%) receive their domestic water supply from the communal system whether piped into their premises or from public standpipes. About 9% of households utilize their own private supply system, while 1.6% of household access their water from public wells.

A significant development since 1980 has been the increase in the number of households with water piped into their dwellings from 28% to 50% in 1991 as opposed to those using public standpipes. This is yet another clear indication of improving economic circumstances impacting positively on living standards.

The public water supply system is managed by the Public Works Department in the Ministry of Communications and Works. The supply is chlorinated routinely to maintain bacteriological quality.

3.2.2 Sewage Disposal

Significantly, the water closet septic tank system is now the most common form of sewage disposal system in use in St. Kitts and Nevis. This is a reversal of the trend of the last 20 years when the pit latrine was dominant. Of relevance as well is the fact that 85.5% of households have exclusive use of their toilet facilities, while 11.1% share the facilities at their disposal. Although 3.4% of households have no toilet conveniences, it is noteworthy that the situation has been on the improve over the years.

4. HEALTH RESOURCES

4.1 Human Resources

The health services of St. Kitts and Nevis are administered and operated by a team of 21 different categories of workers. These range from the highly skilled technician in the acute care institutions of the J.N. France and Alexandra Hospitals to the community outreach worker providing domiciliary care.

In the country there are 10.7 medical doctors per 10,000 population, 1.8% dentists, 62.9% trained nurses, 2.8% laboratory technologist, 1.4% radiographers and 4.4% public health inspectors.

4.2 Financial Resources

The actual government recurrent expenditure on health for the entire Federation has averaged 10.5% of total recurrent disbursements over the period, 1991 - 1995. This ranks health as the third largest recipient of government's financial resources, behind finance (26.6%) and education (15.4%). This level of expenditure on health translates into just 3.5% of the Gross Domestic Product. Personal emoluments account for just 36% of the total recurrent budget but 62% of health expenditure. The per capita expenditure on health was EC$439.78 in 1995.

4.3 Physical Infrastructure

There are four hospitals in St. Kitts and Nevis. These include the main J.N. France Hospital (150 beds) in Basseterre, the capital; the less-equipped Alexandra Hospital (54 beds) in Charlestown; Nevis, and two small rural hospitals - Pogson and Mary Charles. In addition, there are the Cardin Home (50 beds) for infirmed and geriatric persons and a 22-bed infirmary in Nevis which caters to the needs of psychiatric patients and the aged-poor. There are also 17 Health Centres spread throughout St. Kitts and Nevis.

The physical infrastructure has been battered repeatedly by hurricanes since 1989. The worst hit has been the J.N. France Hospital which has suffered major structural damage. Interim repairs have been effected to the building, but final preparations are now in train for the construction of a new facility at an estimated cost of EC$40 million. Meanwhile, continuous refurbishment and maintenance have taken place at the other facilities.

Considerable investments continue to be made in the purchase of high technology equipment.

The number of health facilities is considered adequate and no increases are contemplated, particularly with the stabilizing of the population growth.

4.4 Essential Drugs and Supplies

St. Kitts and Nevis has been an active subscriber to the Eastern Caribbean Drug Service, the regional pooled procurement scheme for pharmaceuticals and medical supplies. The approved budget in 1995 for the purchase of pharmaceuticals in the St. Kitts arm of the partnership amounted to 6.4% of total health expenditure. Similar figures for Nevis could not be accessed.

A National Formulary guides the type and range of drugs that are purchased within the government system. However, a very comprehensive list of drugs are available within the private system.

The trade in pharmaceuticals and medical supplies is largely unregulated, except for those classified as dangerous drugs and for which specific approval must be sought. This situation is unlikely to change significantly unless the current regulations are updated and a system of drug inspection is enforced.

4.5 International Partnership in Health

At the present time, the European Union is assisting the Government with the "re-development of the health sector". This assistance will be applied to the rehabilitation of the two main hospitals, essentially.

There is recognition of the need for new approaches to the development of the health sector. Government's response has been two-fold. One is to become more strategic in national planning to foster self-sufficiency within the social sectors including health; and the other has been supporting regional initiatives for health, working in close collaboration with established international and regional organizations such as PAHO/WHO and CARICOM. Its support for and involvement in the Caribbean Cooperation in Health Initiative is perhaps the best example of the latter.

5. DEVELOPMENT OF THE HEALTH SECTOR

5.1 Health Policies

The National Development Plan (1986 - 1990) outlines what it describes as "the policy objectives, goals and targets" of the Government with respect to health care delivery. It identified the basic tenets for the improvement and further development of the health services as follows:

  • good health is a fundamental right of every citizen;
  • every individual, and the community as a whole, has a responsibility to preserve conditions conducive to good health;
  • improvement of health is fundamental to the country's socio-economic development programme;
  • the mass of the people must become actively involved in the process of achieving a qualitative health care delivery system.

5.2 Cooperation

The concept of intersectoral cooperation is well recognized as an important strategy in development planning and programme implementation.

5.3 Organization of the Health System

The hierarchy of the health sector includes the Minister of Health who has responsibility to Cabinet for implementing relevant policy decisions, the Permanent Secretary who performs the role of Chief Administrative Officer, and the Chief Medical Officer whose responsibility is to coordinate the delivery of health services throughout the State. These positions are federal in scope and applicable to both St. Kitts and Nevis. Under the unique federal arrangement, however, Nevis enjoys considerable autonomy and has its own Minister responsible for Health and Chief Secretary who directs the administration of the local health services. For all practical purposes, there are two independent systems.

A process of re-organizing the health services in St. Kitts only has been in train for the last two years. The programme areas for service delivery have been reconstituted and now fall into five categories only - administration, preventive services, hospital services, nursing education and long term care. One obvious benefit of this development is the facility of clear measurement of resources allocated to discrete programme areas. At the same time, a number of new positions have been created consistent with the process of re-organization.

5.4 Managerial Process

The reform in the organization of the health services that is taking place currently has precipitated certain adjustments in the management structure. At least four very senior technical and administrative positions have been created:

  • Health Planner. This officer holds responsibility for coordinating planning processes within the sector, primarily. The main concentration at this time is on the organizational reform process that is being undertaken.
  • Director, Primary Health Care Services. This subsumes the functions of the Medical Officer of Health and involves responsibility for technical development and supervision of all primary care services.
  • Director, Health Institutions. This brand new portfolio incorporates the administrative supervision of all health institutions under the purview of the Ministry of Health.
  • Director, Health Advocacy and Health Promotion. This officer is responsible for the technical and administrative supervision of the Health Education, Nutrition and Family Planning services.

5.5 Health Information System

The systematic collection and analysis of data for the purposes of management information and decision-making is a relatively recent development in St. Kitts and Nevis. The thrust has come from the PAHO/IDB Community Health Information Systems Project.

The way forward involves clear policy guidelines on the programme areas from which health information should be gathered, enforcement of a system for ensuring compliance and upgrading the technical and support staff within the Unit.

5.6 Community Action

Community participation in health is a deliberate and on-going strategic if not a common feature in St. Kitts and Nevis, despite the policy commitment to this effect. Traditionally, there has been a high level of participation by the community in the utilization of the services offered, but there has been no commensurate involvement in the planning and implementation of health programmes.

Still, the support for health from some sections of the community should not be overlooked. For example, it has been reported that the Ophthalmic Unit at the J.N. France Hospital has been fully equipped recently with donations from the private sector.

5.7 Emergency Preparedness

A National Disaster Management Agency has been established for the purpose of coordinating disaster management efforts throughout the State. This Agency has a full-time administrative staff of four persons and receives directions from a Cabinet-appointed Board of Management.

To date, two National Disaster Plans have been implemented (1982 - 1987 and 1988 - 1992) and the preparation of an update is now in progress. The plan covers aspects such as disaster management, crisis management, disaster assessment, relief operations, public information and liaison with non-governmental organizations.

There is a health component to the National Disaster Plan with the main aspects being mass casualty management, water supply management and environmental sanitation. It also includes a section on maintenance of health facilities.

6. HEALTH SERVICES

The newly-established Health Advocacy and Health Promotion programme area is an attempt to consolidate the efforts of the traditional health education, nutrition and family planning services in order to achieve greater economy of scale. The challenge facing this entity will be to expand its horizon from merely public information, education and training to impacting on issues of public policy, stimulating intersectoral cooperation, mobilizing community support and developing linkages with the media, all of which are enshrined in the Caribbean Charter on Health Promotion.

It is important to note that Health and Family Life Education has been incorporated into the curriculum of all schools.

Women and children have been identified among the "vulnerable groups" in the society requiring special attention. Thus, specialized programmes relating to ante-natal and post-natal care and family planning services have become institutionalized.

The primary care services cater specifically to the needs of all pregnant women through its weekly ante-natal sessions at all health centres. Based on ante-natal attendance at health centres, each woman makes an average of about three visits during the period of pregnancy.

The contraceptive prevalence rate in St. Kitts and Nevis is known to be relatively high. In 1991, 56.7% of the women in the childbearing age-group were registered as active family planning users. And, although the number declined slightly to 51.3% in 1995, the level of contraceptive protection remained quite high. Oral contraceptives remain the most popular method of birth control among women (52.3%), followed by the intra-uterine device (10.7%) and injectables (9.1%). A large category listed as "Other" accounted for 27.8% of current users.

All active family planning clients are offered cervical cancer screening services as part of their routine health care. The number of pap smear examinations conducted at the J.N. France Hospital has increased by more than 150% since 1991. Similarly, the number of abnormal smears encountered has increased three fold.

6.3 Immunization

A full coverage of immunization against the common childhood illnesses among children under one year of age has been reported consistently since 1991 and, although the prefect score was fractionally tarnished in 1995, the record remains excellent. It must be noted, however, that immunization against BCG is not included in this analysis since the vaccine is not given until age five years in St. Kitts and Nevis. The Community Nursing Service reports that 587 BCG vaccines were administered in 1995 covering 63% of five year olds.

There are no vaccines given routinely, for tetanus in pregnant women or in respect of Hepatitis B.

6.4 Prevention and Control of Endemic Diseases

The endemic diseases of concern in St. Kitts and Nevis at the present time are gastroenteritis, tuberculosis and dengue fever. The main methods employed in their prevention and control are information and education, investigations and inspections and environmental control.

The incidence of gastroenteritis has declined by more than 50% since 1991 due in large measure to the consistent monitoring of water quality and improved infant feeding practices. However, the 221.1/10 000 reported in 1995 indicates room for further improvement .

An aedes aegypti mosquito control programme has been in operation for almost 20 years and seeks to apply source reduction and chemical methods as the main strategies. The household index of 6% reported in 1995 was still higher than the acceptable levels of 3 - 5%. The success of this programme is limited by the fact that it is not island-wide, thus allowing for continuous re-infestation of target areas.

The figures reported for tuberculosis are very small (4 in 1995) but a programme of contact-tracing and effective treatment and follow-up of patients is maintained. A similar approach is used in the control of sexually transmitted diseases.

6.5 Treatment of Diseases and Injuries

St. Kitts and Nevis has maintained a well-organized health system for the treatment of common diseases and injuries. The primary services available at health centres provide the first level care, while secondary care services are available at the referral hospitals.

7. TRENDS IN HEALTH STATUS

7.1 Life Expectancy

Using the abridged life table as the mode of calculation, the life expectancy at birth for the combined sexes was estimated at 68.89 years at the end of 1994 (Annual Digest of Statistics, 1994). The disaggregated figures for that year were 67.41 years for males and 70.35 years for females. In 1991, the corresponding figures were 65.10 years for males and 70.08 years for females.

7.2 Mortality

It has been observed that St. Kitts and Nevis exhibited a relatively high crude birth rate - 8.8 in 1995. Almost 70% of these deaths occurred among the senior population (65 years and above) but, even so, the somewhat elevated infant mortality rate - 25.1 in 1995 -must still evoke some measure of concern. Maternal mortality is almost non-existent with only a single death occurring in each of the years 1992, 1993 and 1995. There were no reported maternal deaths in 1994.

The mortality profile is dominated by the chronic disease conditions with cerebrovascular diseases, heart diseases and malignant neoplasms together being responsible for 48.3% of all deaths in the Federation between 1991 and 1995. The most common sites for the malignant neoplasms have been the genito-urinary organs (prostate and uterus) and digestive organs and peritoneum (stomach and colon).

Importantly, infectious diseases have shown declining significance in the rank order of causes of death. And, nearly all the deaths in this category (90.7%) have been attributed to septicaemia. It is to be noted also that conditions which fall under the rubric of Accidents and Injuries now occupy a place among the ten leading causes of mortality. Together, these two factors demonstrate the epidemiological transition which has been taking place over the last two decades.

A total of 23 deaths from AIDS have been recorded between 1991 and 1995, with 60% occurring in the second half of that period. Alongside this must be viewed the fact that there have been a total of four deaths from Tuberculosis between 1993 - 1995 while none had occurred in the immediate past three-year period. No association between the two has been reported.

The ten major causes of death account for 86.6% of all mortality. As such, the overwhelming majority of important disease conditions are captioned in Table 22.

7.3 Morbidity

It is not possible to present a comprehensive analysis of the morbidity data for St. Kitts and Nevis over the time period under review with utmost conviction or certainty. In some cases the data are simply not available, while in others the Nevis component is not compiled and the picture is therefore incomplete. The best estimates suggest that hypertension and diabetes are the main causes of morbidity. In 1995, there were 1,147 hypertensives and 882 diabetics registered at health centres throughout St. Kitts and Nevis and, in the case of the latter, accounted for 38, 140 attendances.

From the point of view of infectious diseases, gastroenteritis has been the most common, with a rate of 221.1 per 10,000 population, followed by sexually transmitted diseases (Genital Discharge Syndrome, Gonococcal Infections and Syphilis together account for 44.5 per 10,000 population) and dengue fever with 6.2 per 10,000. It must be noted as well that viral hepatitis and leptospirosis have been a consistent feature of the morbidity statistics.

7.4 Disability

The prevalence of disability in any or all of its forms is still an unknown quantity in St. Kitts and Nevis. While about 88 disabled and abandoned children are enrolled in four different institutions, there have never been studies to determine the magnitude of the problem. Such studies will be extremely useful in formulating a national strategy and plan of action to address the problem.

The number of registered psychiatric patients has increased from 222 in 1991 to 358 in 1995. At the same time, no real increase in the number of attendances among patients taking advantage of the community mental health services has been observed. About 51% of registered psychiatric patients nation-wide have been diagnosed as schizophrenic while 10% have been treated for depression.

The Mental Health Programme has benefited from the services of a national psychiatrist since 1992. The emphasis is on developing an integrated approach linking hospital and community services.

8. OUTLOOK FOR THE FUTURE

8.1 Assessment and Strategic Issues

There is much evidence of economic growth and prosperity in St. Kitts and Nevis. With an average annual real growth of 4.24% in Gross Domestic Product over the past five years, a real growth of 11.6% in per capita income over the same period, an unemployment rate of less than 5%, and steadily improving social conditions in housing, water and sanitation, the Federation looks poised to face the future with confidence.

Health Status. Chronic diseases constitute the major causes of morbidity and mortality among the population, with cerebrovascular diseases, heart diseases, and neoplasms being foremost. This situation is likely to exacerbate with increasing affluence and life expectancy, unless urgent strategic action is taken.

Although the absolute numbers are small (20 in 1995), an infant mortality rate of 25.2 in St. Kitts and Nevis at this time must engender concern.

Although not generally recognized, disability is a problem of some significance. Using the figures from institutions which cater for children with disabilities and abandoned children alone, the rate of disability in the society is 20.2 per 10,000 population. It is a large enough cohort to be taken seriously in terms of health and social development.

Health Policy. The broad health policies are articulated in the National Development Plan (1986 - 1990). These policies conform to the basic tenets of the HFA declaration in particular regard to health as a fundamental human right, provision of accessible and affordable health services, community participation and intersectoral cooperation, and commitment to national socio-economic development.

Health Resources. Both the numbers and categories of human resource for health appear adequate, in general terms. Certainly doctors, dentists and dental auxiliaries, pharmacists and public health inspectors are well represented.

The need for continuing education within the health sector has been emphasized, given the dynamic nature of health services delivery. Special reference has been made, for example, to the nursing establishment and the need for constant updates. That argument also holds good for all categories of technical staff.

If international criteria were applied, with a 3.5% of GDP allocation, the health services would be considered under-financed. Without the benefit of documented plans and programmes and specific operational guidelines, it appears that the financially disadvantaged areas may be the primary care services and the procurement of pharmaceuticals. This conclusion is entirely notional and points to an area in which clarification is needed.

Development of the Health System. A process of organizational reform of the health sector is proceeding apace.

A sine qua non at this time appears to be the development of a National Health Sector Plan to give strategic focus to the organization and operation of the health services. In doing so, due cognizance should be given to the process as much as the product.

In this context, the Health Information System becomes pivotal. Actions are required to move it into a more efficient and responsive mode.

Health Services. There is no problem with availability and accessibility of health services in St. Kitts and Nevis. Trained health personnel respond on demand to the health care needs of the population whether at the Health Centre or Hospital levels. If deficiencies exist, they are to be found in two areas:

(i)The physical plants which house the main hospitals are structurally defective. However, there areplans for new construction and retrofitting to be undertaken in the short-term. These actions will have to be followed through.

(ii)Maintenance of equipment, both preventive and restorative, is unsatisfactory. Measures ought to be taken to acquire the skills to perform these functions.

International Partnership for Health. The level of extra-budgetary support and technical assistance for health from the international donor community has declined drastically in recent years. This means that countries must look inwards, more and more, for resources for health.

The strategy is to incorporate health into national planning programmes and to strengthen regional initiatives for sharing of health services and expertise.

8.2 Future Vision

Indications about the future vision for the health sector can be gleaned from a variety of sources of reports/documents and from discussions with key officials. Objectives for the future are as follows:

  • Strengthening the planning capability in order to proceed with strategic and operational planning at all levels of the system. The aim is for each sub-sector to develop its own planning process consistent with guidelines established within the national framework. The recent creation of the post of Health Planner is the first step in that direction.
  • Reducing the impact of chronic diseases within the society. This will be done through an aggressive health advocacy and health promotion programme. It will involve all schools, non-governmental organizations, service clubs and community groups.
  • Improving the infrastructure of the main hospital. New facilities will be constructed to replace the structurally defective buildings which now house the J.N. France and Alexandra Hospitals. The Pogson Hospital will also be refurbished substantially. Simultaneously, the range of services at the main hospitals will be expanded to provide the full gamut of secondary care, limited only by the availability of resources.
  • Exploring alternative sources of financing to supplement Government's input. The sources contemplated are direct cost recovery for services provided, private sector contributions/donations and payment directly by the Social Security Scheme for services provided to members.
  • Strengthening the human resource base. It is anticipated that the system will develop to the point where inservice training programmes for technical staff and management training can be undertaken locally. The need to improve the management capabilities of key health personnel is fully recognized.
  • Providing specialized programmes for the elderly and mentally ill. These two categories of "disabled" persons are considered to be the responsibility of the State. The emphasis will be on community rather than residential care.

All of the above are being contemplated over and above the programmes that are being undertaken successfully. The enlistment of the support of the Community and the collaboration of all sectors will also be promoted.

8.3 Proposed Strategies

Equity for Health. The social orientation of the Government commits it to providing for the needs of all vulnerable groups. The policy is that the social needs of all persons should be adequately satisfied irrespective of financial means, race or religion.

Health Promotion and Protection. A special unit has already been established to promote health advocacy and health promotion. The efforts are expected to be pervasive with the major emphasis being on healthy lifestyles.

Strengthening the Health Sector. The process of organizational reform of the health sector which has already begun will be further streamlined by applying the planning framework and active involvement of key personnel in the decision-making process.

Specific Health Programmes. Consistent with the morbidity and mortality patterns, programmes aimed at reducing the incidence and prevalence of chronic diseases will feature prominently. Additionally, programmes targeted to women and children, urban and rural poor and the elderly and disabled will be reinforced.

International Partnership for Health. Emphasis will be placed on joint regional initiatives working closely with Governments, PAHO/WHO and CARICOM in accessing financial and technical assistance.