Jamaica is the largest English-speaking island in the Caribbean Sea . It is located 150 km south of Cuba and 160 km west of Haiti and covers an area of 11,424 km². It is divided into 14 parishes. There are two main cities, Kingston the capital and Montego Bay. The government is based on the Westminster parliamentary model. The Governor-General represents the Queen of England as the head of state. A cabinet of ministers, selected from the bicameral legislature and headed by the Prime Minister, forms the executive branch of government.

• GENERAL SITUATION AND TRENDS
  Jamaica is the largest English-speaking island in the Caribbean Sea . It is located 150 km south of Cuba and 160 km west of Haiti and covers an area of 11,424 km². It is divided into 14 parishes. There are two main cities - Kingston the capital and Montego Bay. The government is based on the Westminster parliamentary model. The Governor-General represents the Queen of England as the head of state. A cabinet of ministers, selected from the bicameral legislature and headed by the Prime Minister, forms the executive branch of government.
  
  Demography: In 2000, the population was estimated at 2.6 million. The annual rate of population growth declined from 1.0% in 1996 to 0.6% in 1999. The crude birth rate declined from 20.8 per 1,000 population in 1999 to 20.0 per 1,000 in 2000. Children age 0-14 years accounted for 31% of the total population in 2000. In 1998, life expectancy at birth was estimated at 75 years (73 for males and 77 for females). Approximately 86% of the population age 15 years and older are literate.
  
  Economy: The economy is open and import-dependent. Tourism, bauxite mining, and primary agriculture exports, including sugar and bananas, are the traditional mainstays of the economy. Private remittances from abroad continue to play an increasingly important role in the economy. In 1999, GDP at current prices was estimated at J$256.8 billion (approximately US$6.6 billion). The rate of inflation was 8.2%. Central government deficit was 5% of the GDP in the 1999-2000 period. An estimated 16% of the population was below the poverty line in 1998.
  
  Mortality: Infectious diseases, maternal and infant mortality, and childhood diseases have decreased significantly. In 1999, there were 15,372 certified deaths. There was an increase in the numbers of homicides and accidents; these were among the leading causes of death in 1999. Transport accidents comprised 85% of all accidents. The gender differential in mortality was greatest for these two external causes. Young males accounted for the most deaths from these two causes. Males had higher death rates than females for malignant neoplasms, heart disease, and HIV/AIDS. The risk of dying from cerebrovascular disease, hypertension, and diabetes was higher for females. Diseases of the circulatory system accounted for 31% of all certified deaths. Neoplasms accounted for 17%, and external causes for 13%. Conditions originating in the perinatal period accounted for 4% and communicable diseases for 4% of all certified deaths.
  

• SPECIFIC HEALTH PROBLEMS
  Analysis by population group
  Children (0-4 years): The infant mortality rate in 1999 was approximately 16 deaths per 1,000 live births, which is generally regarded as an underestimate. There were 941 certified deaths among children age 5 years and younger. Conditions originating in the perinatal period were the most important cause of mortality for this age group (67% of deaths). Congenital defects accounted for 9.1%, communicable diseases 5.0%, external causes 2.8%, and HIV/AIDS 2.2%. Homicides (10 deaths) and transport accidents (7 deaths) were the largest contributors to deaths due to external causes. Other leading causes of death included influenza, pneumonia, and nutritional deficiencies. Acute respiratory tract infections, poisoning, unintentional injuries, gastroenteritis, and violence were among the leading hospital discharge diagnoses.
  
  Schoolchildren (5-9 years): The main problems among approximately 1,200 children seen in government-operated child guidance clinics in 1999 include attention deficit, adjustment, and conduct disorders. Data from the accident and emergency departments indicated that schoolchildren accounted for 20% of accidental laceration, 14% of burns, and 10% of poisonings. In 1999, this age group accounted for 11% of cases of sexual assault and 6% of injuries inflicted with blunt objects. The number of children who lived on the streets increased; most of these children are boys.
  
  Adolescents (10-14 and 15-19 years): One in every five Jamaican is an adolescent. They accounted for only 2% of deaths in 1999. The major causes of hospitalization were injuries, respiratory diseases, including asthma, and neoplasm. Adolescents accounted for 23% of intentional injuries and 20% of accidental injuries treated at accident and emergency departments. Injuries and respiratory diseases were also the main causes of deaths occurring in hospitals. Among the 15-19 years age group, obstetrical conditions among females and intentional injuries among males were the leading causes of hospital admissions. Injuries, cardiovascular diseases (associated with rheumatic heart disease) and HIV/AIDS were the leading causes of death. Adolescents age 10-19 years accounted for 53% of cases of sexual abuse seen in accident and emergency departments. Rates of HIV infection were three times higher in adolescent girls than boys, while AIDS was among the five leading causes of death in this age group.
  
  Adults (20-59 years): In 1999, the prevalence of hypertension and diabetes was high among women age 20-59 years. Diabetes accounted for one of every nine deaths, and the rate of diabetes among women increased from 51.8 per 100,000 population in 1990 to 59.9 per 100,000 population in 1999. Breast and cervical cancers were leading causes of cancer mortality in this group. The Women's Crisis Centre's profile of abused women showed that sexual assault was reported by 59% of respondents and physical assault with or without a weapon by 90%. Of those injured, only 26% reported the incident to the police. In 2000, maternal mortality was estimated at 110 deaths per 100,000 live births. Complications such as hypertension in pregnancy and postpartum hemorrhage were the main causes of maternal mortality. In 2000, syphilis and hemoglobin testing were carried out on 75% and 74% of women attending clinics at health centers, respectively. The level of syphilis in the prenatal population declined from 6% in 1996 to 2 % in 2000. The prevalence of anemia in pregnant and lactating women remained high at 15 % but these levels may also reflect pre-pregnancy levels, as testing is done at the first prenatal visit. Of the 1,925 prenatal attendees, 1.2 % tested positive for HIV. The highest number of positive cases (36%) was in the age group 20-24 years. The Constabulary Statistical Department reported that 100 women were victims of homicide. 50% of women of reproductive age were current users of a family planning method. In 1999, cardiovascular diseases and diabetes mellitus were among the leading causes of hospital admission and death among adult males. Injuries were the leading causes of morbidity among men age 20-44 years. Men accounted for over 60% of all intentional injuries seen at accident and emergency departments. Cancer of the prostate, trachea, bronchus and lung, and stomach were the five most common causes of cancer death among males. Accidental injuries and motor vehicle accidents were also more common in men.
  
  Elderly (60 years and older): In 1999, cardiovascular disease were the leading cause of admission among persons 60 and older, followed by diabetes mellitus. The leading cause of hospital deaths in 1999 was cardiovascular disease, followed by diseases of the respiratory system. In 2000, persons age 60 years and older accounted for 9.7 % of the population. The main non communicable diseases affecting the elderly were hypertension, arthritis, overweight, and diabetes.
  
  Workers Health: In 1999, the Ministry of Labor monitored factories whose workers comprised 5% of the employed labor force. The Ministry reported 223 accidents from these factories, for an accident rate of 4.8 per 1,000 workers. The case fatality rate among these workers was 2.2 deaths per 100,000 in 1999.
  
  The Disabled: Almost 10% of the population was disabled with physical disability ranking as the highest type (29%). Persons with visual disability accounted for 12%, multiple disabilities 14%, mental illness 8%, and mental retardation 5%.
  
  Analysis by type of health problem
  Natural Disasters: Between 1996 and 2000, the major disasters in Jamaica were floods in the parishes of Portland and St. Mary.
  
  Vector-borne diseases: An outbreak of dengue occurred in 1998 with 1,509 reported cases. In 2000, there were 25 cases. No indigenous cases of malaria were reported; however, there were 7 imported cases.
  
  Diseases preventable by immunization: Immunization coverage in 2000 was 94% for BCG, 86% for DPT, 86% for polio, and 88% for MMR. During 1996-2000, there were 15 cases of congenital rubella. There were 36 laboratory-confirmed cases of hepatitis B infection in 1996 and 174 in 2000.
  
  Respiratory diseases: Respiratory tract infections accounted for 12% of all visit to accident and emergency departments of hospitals in 1999, with asthma accounting for 49% of these visits.
  
  Zoonoses: In 2000, 24% of samples were seropositive for Leptospira, compared to a seropositivity rate of 51% in 1998.
  
  HIV/AIDS: The national incidence of AIDS in 2000 was 352 per 1,000,000 population. The main mode of transmission was heterosexual (61% of cases). The cumulative number of AIDS cases from 1982-2000 was 5,099 for a male to female ratio of 1.6:1. The case fatality rate was 61%. There were 414 cases in children with a case fatality rate of 54%.
  
  Sexually transmitted infections: There were 17 cases of congenital syphilis in 1999 compared to 36 cases in 1996.
  
  Cardiovascular diseases: In 1999, cardiovascular disease was the second leading cause of death for a rate of 84.6 per 100,000 population. It was the leading cause of death among hospital inpatients, accounting for 33% of deaths.
  
  Malignant neoplasms: There were 2,407 deaths due to malignant neoplasms in 1999 (93.2 per 100,000). Among males, prostate cancer caused 30% of cancer deaths, lung 17%, and stomach 9% with death rates of 28.9, 15.9, and 9.1 per 100,000 respectively. Among females, breast cancer caused 18% of deaths, cervix uteri and other unspecified uteri 14%, colon and rectum 8%, with death rates of 15.8, 12.9, and 7.1 per 100,000 population respectively.
  
  Accident and violence: In 1999, three surveyed hospitals documented more than 12,000 injuries in a 6-month period. Injuries accounted for 17% of hospital discharge diagnoses (excluding obstetrics) in 1999. Violence related injuries accounted for 49% of injury visits at accident and emergency departments. 3 % of all visits to the accident and emergency departments were for accidental injuries and 2% for motor vehicle accidents.
  
  Emerging and re-emerging diseases: There were 17 cases of Haemophilus influenzae meningitis during 1999-2000, 75% of the cases were children between the ages of 6 months and 5 years.
  
  Mental Health: In 2000, schizophrenia accounted for 49% of patients seen at mental health clinics.
  
  
  

• RESPONSE OF THE HEALTH SYSTEM
  National health policies and plans: The Ministry of Health revised its health policy in 1997 and identified major health policy goals and operational objectives. Three-year corporate plans and annual operational plans were developed with the involvement of stakeholders.
  
  Health sector reform: The main elements of the reform process are decentralization and integration of services; restructuring the Ministry of Health at the central level; promotion of quality assurance standards; broadening financing options; and creating partnerships with the private sectors.
  
  Development of legislation: Several acts were passed in 1997: the National Health Services Act, the Decentralization of Management of Health Care Act, and the Mental Health Act. With respect to quality assurance, there were amendments to acts governing the health care practice of various professionals and requiring registration of additional groups. Promotion of individual responsibility for health was supported by the Seat Belt Law (1999). Three new regulations under the Public Health Act were enacted in 2000, including food establishment and facility regulations impacting on tourism.
  
  Decentralization of health services: The Ministry of Health is divided into two broad areas--administrative and technical services. The Permanent Secretary is responsible for the administrative services while the Chief Medical Officer is responsible for the technical services. Decentralization of the health sector began in 1996 with the creation of Regional Health Authorities. Thus, decision-making capacity was removed from individual hospitals and parishes and vested in the Authorities. Some central level functions were devolved to the Authorities.
  
  Private participation in the health system: Private health care is provided by general physicians and specialists, and by private laboratories, pharmacies, and hospitals. Non-governmental organizations also provide ambulatory health care, targeting the poorer segments of the population.
  
  Modalities of health insurance and their respective coverage: There is only one specialized health insurance provider that offers individual and group plans. Life insurance carriers also provide group health plans. Difference by consumption quintile exist, ranging from almost no coverage for the poorest quintile (0.4%) but steadily increasing with each successive quintile, to a high of 33% coverage in the wealthiest quintile. Persons age 60 years and older had significantly lower levels of health insurance coverage compared with younger individuals.
  
  Organization of regulatory actions: The Ministry of Health established the Standards and Regulation Division in 1999. The Division developed standards for maternity centers and nursing home staff; protocol for the management of chronic diseases were developed and a criterion-based clinical audit was introduced to survey the competence of health professionals in the management of major obstetrical emergencies. The Government chemist is responsible for testing drugs and other chemicals and the Bureau of Standards is responsible for monitoring food standards and safety. The Environmental Control Division conforms with international chemical and biological standards for food safety, water, and sewage. Management of municipal solid waste falls under the jurisdiction of the Ministry of Local Government. The Pesticide Control Authority is responsible for minimizing the adverse effects of pesticides on the environment and human health.
  
  Organization of public health care services: The health promotion strategy focuses on changing lifestyles. The HIV/STI program focuses on surveillance, STI control, behavior change communication, laboratory testing, research, monitoring and evaluation.
  
  Health analysis, epidemiological surveillance and public health laboratory systems: Communicable disease surveillance was conducted using both active and passive systems. In 1999, the Jamaica Injury Surveillance System was established in hospitals with computerized information systems. Special projects include the physician-based sentinel surveillance system and the survey for Invasive Bacterial Meningitis, Septicemia, and Pneumonia in Children. Public health laboratories, including the National Public Health Laboratory, provide testing services in public hospitals.
  
  Organization of individual health care services: The health system offers primary, secondary, and tertiary care. Ambulatory care at the community level is delivered through a network of 343 health centers. Secondary and tertiary care are offered via 23 government hospitals and the teaching hospital of the University of the West Indies , with a combined capacity of 4,802 beds. Approximately 38% of the population utilize the public sector for ambulatory care, 57% use the private sector, and 5 % use both sectors. Private sector health services are provided through an extensive network of professionals offering specialist services, and by family doctors throughout the island. A number of non-governmental organizations provide health services for a nominal fee. The blood bank receives blood from 12 blood collection centers. All blood is screened for HIV, HTLV, HbsAg, HCV, and VDRL. Rehabilitation services in the public sector include physiotherapy, social work, speech pathology, and occupational therapy. Non-governmental organizations provide specialty support for the disabled.
  
  Health supplies: Jamaica has a national formulary; a vital, essential, and necessary drug list, and policies relating to the use of generic drugs.
  
  Human resources: Training programs have not been able to meet the demand for health personnel except in the area of medical doctors, dental nurses, and community health aides. Shortages are compounded by the continual loss of public sector personnel to the private sector, and by migration of personnel to other countries.
  
  Health research and technology: The use of evidence-based data to guide program development has been merged with the concept of Essential National Health Research with linkages with the University of the West Indies and other national, regional, and international organizations. Advances in health technology and the purchase of new diagnostic equipment have increased service delivery options and contributed to decreased morbidity and length of stay for many surgical conditions.
  
  Health sector expenditure and financing: The Ministry of Health's budget grew from US$118.2 million in 1995-96 to US$188.2 million in 1999-2000. The Ministry's budget as a percentage of the Government budget was 7.0 % in 1997-1998 but fell to 4.7% in 1999-2000.
  
  External technical cooperation and financing: Technical cooperation and financial support are received from regional institutions, intergovernmental organizations and international organizations, as well as through bilateral and multinational agreements.