Overview of Health Care in St. Kitts and Nevis

Headnote

St. Kitts and Nevis, a small, two-island federation in the Caribbean, experienced a shift in its epidemiologic profile starting in the late twentieth century. During the colonial era, diseases related to overcrowding, poor environmental sanitation, poor personal hygiene, and nutritional deficiency, due to the poor social and economic conditions in which the majority of people in St. Kitts and Nevis lived and worked, dominated the public health profile. This picture has changed dramatically since the 1980s to a health situation in which lifestyle-related, noncommunicable conditions predominate. This article provides a summary of and historical context for the current health profile of the population, as well as outlines the challenges faced by healthcare administrators today in a nation in which the provision of health care is centered on universal coverage and access.

INTRODUCTION

Prior to the arrival of Europeans in the fifteenth century, the Kalinago people, who called the islands Liamuiga ("fertile island") and Oualie ("land of beautiful water"), inhabited the islands of St. Kitts and Nevis. Christopher Columbus sailed past St. Kitts and Nevis in 1493 and is credited with discovering the islands for Europe. Though Columbus named the islands San Jorge and San Martín, the names were later changed to San Cristobal and Nuestra Señora de las Nieves by Spanish sailors and later shortened to their current forms (Hubbard, 2002, 13). In 1623, Sir Thomas Warner established the first successful English Colony in the West Indies on St. Kitts, soon to be followed by the establishment of a French colony in 1625.

The era between 1620 and 1830 was characterized by violence and the colonial exploitation of enslaved labor to produce commodities such as tobacco, cotton, and sugar. Europeans seized the land from the islands' original inhabitants, and eventually massacred many of them, driving out those who remained (Dyde, 1999, 21). The inhabitants of St. Kitts and Nevis continued to suffer from a number of man-made and natural calamities during this period of colonial exploitation by the English, French and Dutch (Ibid.), a period during which the slave and sugar trades were prominent activities. Clearly, colonialism had a profound impact on the history of the islands. Though they achieved autonomy in 1967, it was not until 1983 that they were granted full independence from Great Britain (Hubbard, 2002, 154).

Today, the Federation of St. Kitts and Nevis has a population estimated at 51,967 (Martin, September 2009) and is a multiparty parliamentary democracy. As is true of the nations in the British Commonwealth, the titular head of state is the monarch of the United Kingdom, represented by the resident Governor General. The folk economy is based on the agricultural production of vegetables, fruits, meat, and fish. Sugar was a monoculture from the seventeenth century until 2005, when the government was forced to close the sugar industry (sidf, 2010). Currently, tourism is the major source of economic stimulus. Construction, offshore finance, and the manufacturing of electronics and beverages also support the economy.

BACKGROUND AND HISTORICAL PERSPECTIVE ON PUBLIC HEALTH

The governments role in health care in St. Kitts and Nevis is central and irreplaceable. Provision of care to the public sector is organized and coordinated for universal coverage, universal access, equity, relevance, high quality, affordability and sustainability. Prior to the 1980s, diseases related to overcrowding, poor environmental sanitation, poor personal hygiene, and nutritional deficiency dominated the health care scene, a legacy born from the colonial era. During this era, the major threats to survival were the deplorable social and economic conditions in which the majority of people lived and worked. These conditions had not improved much by the first half of the twentieth century, a period during which approximately 400 children per 1,000 births died before the age of one, and infections such as tuberculosis, diphtheria, and gastroenteritis were rampant. Protest ensued because of these unacceptable living conditions, resulting in the Buckleys Estate riots in 1935. Unrest spread outward from St. Kitts into other parts of the British Caribbean, forcing colonial authorities to establish the Moyne Commission in 1939 in order to address the widespread disaffection.

The corrective measures recommended by the Commission resonate today. The granting of universal adult suffrage in 1952 led to representative government and increased investment in primary health care, which took form in a network of community health centers and hospitals staffed by trained personnel. Other areas received attention as well. Universal access to education at all levels became a high priority, housing and sanitation improved, and piped delivery of potable water was established. The resulting rise in the standard of living led to a steady reduction of the burden of disease due to infections and poor sanitation.

Today, the death rate due to infections is less than 5% of total mortality. A newborn infant has a life expectancy of 73 years. The health profile has changed dramatically from that which characterized most of the twentieth century and is now dominated by lifestyle-related noncommunicable conditions. Chief among these conditions are obesity and related disorders, as well as interpersonal violence. The Federation has world-leading rates of diabetic amputations, new cases of cancer, and youth homicide. A central concern is that premature disability and premature death (i.e., death before age 70) will result in the loss of productive people from the labor force. This is a major challenge for the health sector: meeting the needs of a population with high expectations and expensive-to-control health conditions while the nation's economy struggles against the challenges of debt, global warming, globalization, and structural adjustment (Martin, 2005).

HEALTHCARE MANAGEMENT, COORDINATION AND FINANCING

The Ministry of Health - through its policy and legal framework for leadership, governance, regulation, and financing - is responsible for managing and coordinating the delivery of essential public health services such as health situation monitoring, epidemiologic surveillance, training guidelines, accreditation of professionals and facilities, quality and impact assessment, and research for health (Martin, September 2009). At the frontline of care is the Community Health Service, with its network of seventeen community health centers that serve as the primary centers for health promotion and prevention, the health of the family, and the health of the environment. Every household is within fifteen minutes of a community health center (as well as a public school). The government also owns and operates the Federation's two general hospitals and two satellite urgent care centers that provide a full range of secondary care and limited tertiary services. Government and private sector providers operate senior citizen homes.

According to the World Bank, "public financing is an essential feature of most if not all, public health successes around the world" (Jamison, et ah, 2006, 174). In St. Kitts and Nevis, the government, whose responsibility is to ensure barrier-free access to community-based and institutional services, heavily subsidizes health services. Projected government expenditure on health services for 2010 was US$18 million or US$370 per capita, representing 3.3% GDP. In contrast, per capita expenditure on health care in the United States is approximately $8,000.

There have been meaningful successes resulting from the investment in public health in St. Kitts and Nevis. Access to potable water and waste collection is 100%. Immunization rates are over 95%, and as a result, the incidence of vaccine-preventable diseases (e.g., measles) is zero. HIV seroprevalence is 0.5-1% (Ministry of Health, 2009), incidence of tuberculosis is rare, and cholera and malaria are non-existent. The only endemic infectious disease is dengue fever, which arises at six to seven year cycles and appeared most recently in 1995, 2001, and 2008. Because of the relatively low prevalence of communicable diseases, mortality related to such diseases is less than 5% of the total mortality. Maternal mortality is virtually zero. The infant mortality rate ranges between fifteen and twenty per 1,000 live births with newborn immaturity and congenital anomalies accounting for the overwhelming majority (88%) of deaths in this age group. In comparison, the infant mortality rate for the U.S. as a whole is seven out of 1,000 live births; in the state of Virginia it is seven out of 1,000 live births. However, for African Americans in the Charlottesville, Virginia area, the infant mortality rate approaches twenty-five out of 1,000 live births (Gurka and Peake, 2008).

CURRENT HEALTH CHALLENGES

Chronic diseases and injuries now dominate the epidemiological profile of St. Kitts and Nevis. Like industrialized countries, the major health risks are lifestyle related including an unhealthy diet, physical inactivity, and the harmful use of substances are major contributors. The leading causes of death in adults are disorders of the circulatory system, cancer, diabetes and external injuries, all of which account for 75% of all adult deaths (Martin, September 2009). Adult prevalence rates for obesity and hypertension are 36% and 34%, respectively (2008 paho Chronic Disease Risk Factor Survey, 2008). Twenty percent of teens are overweight (Caribbean Food and Nutrition Institute) and 10% of primary school children are obese (Ministry of Health). Officially, mental illness affects 1% of adults (Community Mental Health Register) however the true prevalence is estimated to be 5-10% of adults (paho). The principal mental disorders are depression, schizophrenia, and substance abuse disorders (Martin, September 2009).

Healthcare costs continue to rise faster than general inflation. Drivers of escalating healthcare expenditure include care for catastrophic illnesses, an aging population, energy insecurity, the cost of technology, consumer clamor for high-tech care, and new and re-emerging infections (Martin, January 2009). The recent global financial crisis has led to a contraction in government revenue, which threatens the sustainability of social services. There is truth in the saying, "When the U.S. economy has a cold, the Caribbean has pneumonia." In addition, climate change portends either increased rainfall or periods of drought. A wetter climate would increase the risk of mosquito-borne infections; a drier climate would limit indigenous food production. A rise in sea level would likely cause salination of potable water aquifers.

POLICY OUTLOOK

In St. Kitts and Nevis, it is believed that safeguarding the health of the nation is a fundamental role of the government. Health is viewed as a central, irreplaceable basic human capacity, as a prerequisite for individuals to achieve self-fulfillment, and as a building block of a democratic society (Martin, September 2009). It is understood that the health and wealth of a nation go hand and hand, and that both conditions are enhanced when people work together for the common good (Ibid.). National policy asserts that people are entitled to the highest attainable level of health with the proviso that individuals have the obligation to take control of their health. Thus, services are designed to address the social determinants of health, to meet the legitimate needs of citizens by ensuring barrier-free access, and to provide financial risk protection in the event of catastrophic illness.

The guiding principles of healthcare policy in St. Kitts and Nevis are consistent with the principles espoused by the World Health Organization as central to a primary healthcarebased health system. These include: social justice, responsiveness to legitimate needs, quality orientation, participation, intersectoriality, sustainability, and government accountability. The overall themes of service delivery incorporate prevention, health promotion, care of the family throughout the life-cycle, and the health of the environment. More specifically, the core structural and functional elements of the primary healthcare orientation include: guaranteed universal coverage and access; optimal organization and management based upon sound policy, legal, and institutional frameworks; high-quality programs and services that are available, accessible, affordable, acceptable, and quality-enhancing; decision-making based on the well-being of families and communities; participation by families and communities in decision-making; an emphasis on health promotion, prevention, and health maintenance; comprehensive, appropriate, integrated frontline/first contact services; an adequate mix of prepared, inspired, motivated personnel; and adequate and sustainable financing. The ultimate vision for population health and personal medical service delivery is comprehensive, holistic and integrated care rendered by coordinated teams of knowledgeable and skilled providers.

STRATEGIC RESPONSE TO HEALTH SITUATION

The Ministry of Health's strategic response to the health care needs and challenges articulates conceptual approaches such as primary health care and health promotion. The specific agenda is described by the Strategic Plan for Health (2008-2012), the objectives, indicators, and targets of which were informed by an in-depth analysis of the health situation. The strategic plan describes a number of priorities: food and nutrition, physical activity, chronic noncommunicable diseases, sexually transmitted infections, mental health and substance abuse, family health, environmental health, human resource development, and health systems development.

KEY OUTCOMES

Using the current health situation as a baseline, the Ministry of Health has identified specific targets to be achieved by 2015. The targets shall be used to monitor and evaluate the health system's performance. Key indicators of health progress include high and healthy life expectancy; low maternal and infant mortality; low prevalence of communicable diseases; and a reduction in the frequency of non-communicable conditions, mental illness, and external injuries.

To this end, the Ministry of Health continues to formulate and implement policies and programs that strengthen leadership, governance, and financing; build human resource capacity; secure adequate provisioning; enhance information systems; and continually improve the overall quality of service delivery. With a health policy outlook and national Strategic Plan in place, the development agenda includes the review and upgrading of existing legislation, the renewal of primary health care, the use of health promotion strategies, the implementation of a universal payment plan for health services, and the publication of a patient's charter. Other activities include investing in training as well as appropriate diagnostic, information and communication technologies; facilities retrofitting; and improved regulation of provider performance. The international accreditation of instimtions and training programs is also being pursued.

CONCLUSION

St. Kitts and Nevis, the smallest nation in the Western Hemisphere, is a democratic, middle-income, two-island federation in the East Caribbean. Healthcare is oriented around primary health care, with the government as the major provider and funder. Thus, health services in government facilities are either free or heavily subsidized.

The challenges facing the nation are significant. While colonial-era disease burdens have been effectively eradicated or ameliorated by public health practices, the contemporary burdens are neither vaccine-preventable nor amenable to hygiene and sanitation interventions. Disorders of lifestyle are chronic, incurable, and expensive to control. Addressing them effectively requires self-discipline on the part of the individual, and behavior change at this level must be supported by robust public policy.

All lifestyle disorders can be prevented or detected early, and good health can be maintained through a commitment to wellness. Hence, the Ministry of Health's policy is to provide information and services that empower persons to adopt and sustain healthier habits. The primary focus of spending and programming is therefore on prevention, health promotion, and primary health care, which emphasize integrated, multidisciplinary interventions directed at the whole person within the context of families and communities.

Notwithstanding its steering role, all of the Ministry of Health's policies and programs call for the full participation of all sectors of civil society. Since all activities of and within a country impact health and health policy, the formulation and achievement of national health goals is the responsibility of all.

Health policy is positioned to contribute to the development agenda of St. Kitts and Nevis. The challenges of lifestyle disorders, insecurity, emerging infectious diseases, and climate change necessitate creative policy formulation, innovative and systematic planning, appropriate levels of investment, and strategic implementation. It is only through decisive public health leadership and governance that these challenges can be addressed effectively and national health gains can be sustained well into the future.

Universal access to high quality health care services is an entitlement that the Ministry of Health regards with the utmost importance. With personal well-being and sustainable national development at stake, the commitment to health entitlements, equity, and solidarity is unshakable.

References

REFERENCES

Dyde, Brian. 1999. St. Kitts: Cradle of the Caribbean. Oxford: Macmillan Education.

Gurka, Kelley and Lilian Peake. 2008. "Community Health Status Assessment." Mobilizing for Action through Planning and Partnerships, Virginia Department of Health, 85-96.

Hubbard, Vincent. 2002. A History of St. Kitts: The Sweet Trade. Oxford: Macmillan Education.

Jamison, Dean, Joel Breman, Anthony Measham, et al. 2006. Priorities in Health. Washington, D.C.: The WorldBank.

Martin, Patrick September 2009. "Health Care and Health Policy Outlook in St. Kitts and Nevis." Presentation. Martin, Patrick 2005. "Meeting Healthcare Needs in St. Kitts and Nevis: Guidelines for Entrepreneurs, Donors, Charity Mission Organizers." Draft.

Martin, Patrick January 2009. "Overview of Health Care in St. Kitts and Nevis." Presentation.

Ministry of Health, St. Kitts and Nevis. July 2009. "St. Kitts and Nevis Health Situation." Basseterre.

Pan American Health Organization. 2008. Health Situation in the Americas: Basic Indicators.

The Sugar Industry Diversification Foundation of St. Kitts and Nevis. 2010. "About the Federation of St. Kitts & Nevis, West Indies." http://www.sidf.org/about-st-kitts-nevis/.