ST. KITTS & NEVIS HEALTH SITUATION

Health Status Indicators &

Socioeconomic Determinants of Health.

PATRICK MARTINCHIEF MEDICAL OFFICER

12/12

RATIONALE FOR DATA USE

• Planning Starts With Data• Operational Data drive Analysis

• Without Data, One Is Opinionated • No Measure, No Manage, No Money

WHY HEALTH SITUATION ANALYSIS? A SYSTEM PERFORMANCE EVALUATION (“GUT CHECK ” )

PROMOTES EVIDENCE-BASED PROGRAMMING & DECISION-MAKING

A: OBJECTIVE HEALTH

Life Expectancy, Mortality, Morbidity/Disability

POPULATION AND BIRTHS2001 2002 2003 2004 2005 2006 2007 2008

Pop. 46,325 47,280 48,035 48,720 49,350 49,990 50,640 51,300

Live Births

803 758 738 654 668 662 690 709

Birth Rate

17.3 16.0 15.4 13.4 13.5 13.2 13.6 13.8

Teen Births

168 140 145 117 128 135 105 107

2006 - 2008• Life Expectancy @ Birth

– Increased from 70 years in 2003 to 73 years in 2006

• Compared to 2001-2005– Estimated population increased by 3.9%– Ave. # of live births decreased by 6.7% (724 to 687). – Net increase in population due to inward migration

(death rate also dropped)

HEALTH INDICATORSDate Estimate Source

Infant Mortality Rate7 2008 11.3 Min. of Health

Maternal Mortality Ratio8 2008 141 Min. of Health

Teen Motherhood (%) 2008 15 Min. of Health

Dental Caries (%)9 2008 70 Min. of Health

Excess Weight (% adults) 2008 78 STEPS (WHO)

Hypertension Prevalence (% adults) 2008 34.5 STEPS (WHO)

Diabetic Prevalence (% adults) 2008 20 Min. of Health

Mental Illness Prevalence (% pop) 10 2008 1.2 Min. of Health

HIV Incidence (per 10, 000 pop) 2008 2.2 Min. of Health

Homicide (per 10, 000 pop) 2008 4.6 PPRO11

Persons per Physician 2008 840 Min. of Health

Calorie Intake (kcal per capita) 2003 2960 CFNI12

Major MorbiditiesAdults Children

1.Excess Weight2.Hyperlipidemia3.Hypertension4.Diabetes5.Schizophrenia6.Depression7.Substance Use

1.Cavities2.Gastroenteritis3.RTIs4.Excess Weight5.Asthma

CHRONIC NON-COMMUNICABLE DISORDERS

• Dominated the epidemiologic profile since the early 1980’s.

• Risk factor Survey (STEPS - SK, WHO, 2008) – Prevalence Findings– Adult Overweight - 75% – Hypertension - 36%.

• Diabetic prevalence (est.) - 15-20% adults– Extrapolating from the public sector diabetic clinic register. – 80% due to obesity (2006 CCHD)

NON-COMMUNICABLE DISORDERS External Injury

• Violence-related injuries continue to increase.

• JNF Hospital – Cases of assault (non-gunshot) and wounding – [2001-2005] = 3 x [1996 – 2000]

• Homicides– 56 in 2006-2008 vs. 42 in 2001-2005– Most were attributed to drug-trafficking gang activity (RSCNPF; UNODC)

• The increase in homicide reflected in the increase in deaths of persons 20-59 years

NON-COMMUNICABLE DISORDERS

Mental Illness

• Prevalence– ~ 1.2% of the total pop. registered in the public

sector’s mental health program.

• Major mental illnesses– Schizophrenia, Depression and Substance Abuse

Disorders.

MAJOR DISABILITIES

• Mental/Neurological– Depression, Paranoia, Substance Abuse, Dementia, Epilepsy

• Learning/Behavioral/Developmental– Reading, Mathematics– Conduct Disorders associated with Parental Dysfunction– Brain Disorders e.g. Cerebral Palsy

• Diabetes-Related Amputations

• External Injury-Related

COMMUNICABLE DISEASES • Account for less than 5% of deaths.

• HIV/AIDS– In 2006-2008, HIV incidence 40 cases; AIDS deaths 6; 2009 – 8 cases– in 2001-2005, 73 and 14.

• Tuberculosis – 2006-2008 - Average annual incidence of 3 cases– 2005 - 1 case

• No cases of the diseases covered by EPI • Endemic Vector-Borne Diseases

– Dengue Fever - Outbreaks every 6-7 years. Dec. 2008 - 60 confirmed cases – Malaria and cholera are non-existent.

MORTALITY

TREND ANALYSIS

Mortality Category 2001 2002 2003 2004 2005 2006 2007 2008

Total deaths 375 353 374 398 361 373 353 359

Crude mortality rate (per 1,000 population)

8.1 7.5 7.8 8.2 7.3 7.5 7.0 7.0

Infant deaths 10 17 13 11 9 9 14 8

Neonatal deaths 5 15 11 10 8 9 14 8

Infant mortality rate (per 1,000 lb)

12.5 22.4 17.6 16.8 13.5 13.6 20.3 11.3

Neonatal mortality rate (per 1,000 lb)

6.2 19.8 14.9 15.3 12.0 13.6 20.3 11.3

Maternal deaths 2 0 2 0 0 1 0 1

Late fetal deaths 15 6 15 12 11 11 7 12

Late fetal death rate (per 1,000 lb)

18.3 7.9 19.9 18.0 16.2 16.3 10.0 16.6

Mortality Category 2001 2002 2003 2004 2005 2006 2007 2008

Total deaths 375 353 374 398 361 373 353 359

Crude mortality rate (per 1,000 population)

8.1 7.5 7.8 8.2 7.3 7.5 7.0 7.0

Infant deaths 10 17 13 11 9 9 14 8

Neonatal deaths 5 15 11 10 8 9 14 8

Infant mortality rate (per 1,000 lb)

12.5 22.4 17.6 16.8 13.5 13.6 20.3 11.3

Neonatal mortality rate (per 1,000 lb)

6.2 19.8 14.9 15.3 12.0 13.6 20.3 11.3

Maternal deaths 2 0 2 0 0 1 0 1

Late fetal deaths 15 6 15 12 11 11 7 12

Late fetal death rate (per 1,000 lb)

18.3 7.9 19.9 18.0 16.2 16.3 10.0 16.6

Mortality Category 2001 2002 2003 2004 2005 2006 2007 2008

Total deaths 375 353 374 398 361 373 353 359

Crude mortality rate (per 1,000 population)

8.1 7.5 7.8 8.2 7.3 7.5 7.0 7.0

Infant deaths 10 17 13 11 9 9 14 8

Neonatal deaths 5 15 11 10 8 9 14 8

Infant mortality rate (per 1,000 lb)

12.5 22.4 17.6 16.8 13.5 13.6 20.3 11.3

Neonatal mortality rate (per 1,000 lb)

6.2 19.8 14.9 15.3 12.0 13.6 20.3 11.3

Maternal deaths 2 0 2 0 0 1 0 1

Late fetal deaths 15 6 15 12 11 11 7 12

Late fetal death rate (per 1,000 lb)

18.3 7.9 19.9 18.0 16.2 16.3 10.0 16.6

Category 2001 2002 2003 2004 2005 2006 2007 2008

Total deaths 375 353 374 398 361 373 353 359

1-4-years 7 5 2 1 1 3 6 2

5-9-years 3 3 0 0 2 0 0 2

10-14-years 2 1 2 2 2 1 0 0

15-19-years 2 5 6 8 1 3 4 4

20-59-years 78 75 72 82 82 87 92 94

60-79-years 132 116 149 142 111 118 108 120

≥ 80 years 141 130 130 152 153 147 129 127

MORTALITY• Average crude death rate decreased to 7 deaths per 1000

population compared to 7.5 in 2001-2005.

• Absolute infant mortality decreased from average 12 to 10 deaths per year– Rate fluctuations reflect larger changes in the numerator (infant deaths)

compared to the denominator (live births).

• Neonatal (<28 days) deaths, especially in the first week of life, account for all infant deaths (80% in 2001 – 2005)– Deaths in this age group are largely due to conditions originating in the

perinatal period, chief among them respiratory distress syndrome associated with the immature lungs of premature infants.

• 2 maternal deaths; similarly for 2001-2005.

LEADING DEATH CATEGORIES - SKN

• 2006-2008 1. Circulatory System Disorders (34%)

• Heart Disease; Stroke

2. Other Diseases (27%)• Diabetic Complications

3. Neoplasms (18%)

4. External Injuries (12%)• Homicide

LEADING CONDITION / DISEASE CAUSES OF DEATH

• Adults1. Heart Disorders2. Stroke-related

Disorders3. Diabetes

Complications4. Homicide

• Children1. Prematurity2. Congenital Anomalies

[2006 – 2008] vs. [2002 – 2005]Re Actual Deaths (No data for 2001)

• Decreases – Communicable diseases (by 50%)– Circulatory disorders (37%)

• Deaths due to heart diseases increased • Stroke syndromes remained unchanged

– Perinatal conditions (20%)

• Increases – Neoplasms (30%)– External injuries (33%).

St. KittsNevis

St. Kitts & Nevis

0%

20%

40%

60%

80%

100%

1% 5%2%

18% 14%17%

47%42% 46%

3%1% 2%

10%

8% 9%

20%28% 23%

1% 1% 1%

2006 MORTALITY CATEGORIES BY PERCENTAGE

Ill - Defined

Other

External

Perinatal

Circulatory

Neoplasm

Communicable

St. KittsNevis

St. Kitts & Nevis

0%

20%

40%

60%

80%

100%

120%

6%5%

5%

21%13% 19%

32%

30% 30%

4%13% 7%

13%13% 13%

25% 32%27%

0% 0%0%

2007 MORTALITY CATEGORIES BY PER-CENTAGE

Ill - Defined

Other

External

Perinatal

Circulatory

Neoplasm

Communicable

St. KittsNevis

St. Kitts & Nevis

0%

20%

40%

60%

80%

100%

5%3%

4%

14% 24%17%

33%

40%

35%

2%

2%

2%

13%

11%

12%

32%17%

28%

1% 2% 1%

2008 MORTALITY CATEGORIES BY PERCENTAGE

Ill - Defined

Other

External

Perinatal

Circulatory

Neoplasm

Communicable

Nevis 2006Nevis 2007

Nevis 2008

0%

20%

40%

60%

80%

100%

120%

5%5%

3%

14%13% 24%

42%

30%

40%

1%

13%

2%8% 13%

11%

28% 32% 17%

1% 0%2%

NEVIS MORTALITY BY CATEGORY 2006 - 2008

Ill - Defined

Other

External

Perinatal

Circulatory

Neoplasm

Communicable

B: SOCIAL & ECONOMIC DERTERMINANTS OF HEALTH

Demographic and Socioeconomic DataDate Estimate Source

Population 2008 51, 300 Statistical Unit

Life Expectancy at Birth (years) 2006 73 WHO1

GDP (US$ x 106) 2009 566 CSO, EECU ECCB2

GDP per capita (US$) 2009 11,000 Min. of Health3

GDP Growth (%) 2008 3.2 IMF

Government Health Exp.

% GDP 2009 3.3 Min. of Health

Per Capita ($US) 2008 370 Min. of Health

Human Development Index 2006 51 UNDP4

Poverty Rate (%) 2008 21.8 CDB5

Dependency Ratio (%) 2008 51.9 WHO

GINI Coefficient 2008 0.445 IMF6

Public Sector Debt (% GDP) 2008 178 IMF

COMPARISIONS

HOSPITAL MORTALITY

2006 2007 2008

JNF 3.4 3.2 3.0

Alexandra 3.4 3.9 5.2

SKN Hospitals

3.4 3.4 3.5

SKN USA

Life Expectancy 73 79.4

Infant Mortality 11.3 (2008) 6.7 (2006)

% Low Birth Weight 7.8 8.3

General Mortality Rate - All Causes 7 (2008) 5.4

Hospital beds per 1000 5.5 3.1

% Immunization Coverage – Measles @ 12m 99 92

GINI Coefficient 0.445 (2008) 0.463 (2007)

Per Capita Public Exp 3.3 (2009 est) 7.8 (2007)

Gross National Income per Capita (US$ ppp) 11, 000 45, 840

Dependency Ratio (100 pop) 51.9 49.7

MAJOR WORK AHEAD• Health Systems & Regulation

– Financing – Universal Benefits Plan• Reduce personal bankruptcy• Reduce burden on treasury• Restructure of the National Health Authority

– Legislation• Registration• Environmental Health• Pharmacy• Mental Health • Laboratory

MAJOR WORK AHEAD• Other

– Community Health Worker (Outreach)• Key to service delivery to homes

– Patient Charter– Continuing Education Credits

• Time-limited registration

– Environmental Health Department• Food Safety; Effects of Climate Change; Port Health

– Emergency Medicine Specialist• International best practices

MAJOR WORK AHEAD• Reduction of Risk & Burden of Disease

– Dietary Guidelines– Oral Health

• Cavities the major infectious disease in children

– Cancer Registry– Wellness Revolution esp Men– Active Ageing– Violence & Injury Prevention (VIP)

• Youth Anger; Adult Conflict (Relationships; Politics)• Speeding; DUI; DWD

– Substance Demand Reduction• Substance Culture

HEALTH RISKS[WHO]

• 75% of Coronary Heart Disease caused by– Alcohol Consumption– High Blood Glucose– Tobacco Use– Overweight– High Blood Cholesterol– Low intake of Fruit & Vegetables– Physical Inactivity

HEALTH RISKS[WHO]

• 25% of all deaths caused by– Childhood underweight– Unsafe Sex– Alcohol Misuse– Unsafe Drinking Water– Poor Sanitation & Hygiene– High Blood Pressure

HEALTH RISKS[WHO]

• 25% of child deaths caused by unsafe and unhealthy environments

• 45% of cancer caused by 9 environmental & behavioural risks + 7 infections

• 71% of Lung Cancer caused by Tobacco Smoking

MINISTRY OF HEALTH POLICY OUTLOOK

Philosophy: “Nation’s Health Is Its Wealth”

Value Statement: Health Care is a Human Right and a contributor to individual wellbeing and national development

Principles Quality Equity Universality Sustainability

Strategies Effective Stewardship Health Promotion Primary Health Care Integrated Service Delivery

NATIONAL STRATEGIC PLAN - HEALTH

Priority Areas 2008 – 2012

• Reducing Chronic Non-Communicable Diseases• Improving Mental Health and Reducing Substance Abuse• Prevention and Control of Sexually Transmitted Infections• Safeguarding Health of the Environment• Promoting the Health of the Family• Health Systems Development• Human Resource Development

EXPECTED OUTCOMES: By 2015Life Expectancy 72 80 y

Infant & Maternal Mortality (5 year mean) [Nevis] < 10 [≤3] & < 3 [≤ 1]

MorbidityAdult Overweight

Mental IllnessExternal Injuries

HIV Seroprevalence

< 60%Fully Staffed by 20%< 2%

Dependency Ratio 55% < 50%

Government’s subsidy of secondary+ care: 90% 50%

Service Features

• High Quality; Impactful; Affordable & Sustainable; Satisfactory

GOOD HEALTH

Disease/Injury Prevention/Early Intervention

Impairment

Major Disorder/Disability

Dependency

Secondary Care

EC $$$$

Primary Care

EC $$$

THE FINAL ANALYSIS

Tertiary Care +

US$$$$$

Pri

mary

Healthcare

THANK YOU FOR YOUR ATTENTION