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Country Health Profile.
Data updated for 2001Turks and Caicos Islands Health Situation Analysis and Trends Summary Country Chapter Summary from Health in the Americas, 1998.
TURKS AND CAICOS ISLANDSGENERAL SITUATION AND TRENDSSocioeconomic, Political, and Demographic Overview The Turks and Caicos Islands, a British dependent territory, is located at the southeastern end of the Bahamas chain. The two island groups—the Turks Islands to the east and the Caicos to the west—extend for approximately 193 mi2. A Governor, who acts as the Queen’s representative, shares executive power with an elected House of nine seats that is headed by a Chief Minister. The Executive Council functions as the supreme executive body; the Governor presides over it. Tourism earnings outdistanced those from fishing and financial services; the latter two sectors now rank behind tourism in the economy. Most tourism development took place in Providenciales and has brought with it a rapid population growth. The total resident population, based on the 1990 census, was 11,465; 50.9% of whom were males. Approximately one-third of the population was under 15 years of age, with another 5% aged 65 years or above, for a dependency ratio of 37.2%. The most populated island was Providenciales, the business hub for the territory; its 4,821 residents accounted for 42% of the total resident population. The administrative seat of the Government is located on Grand Turk, the second most populated island, with 32.2% of the population. Fertility Patterns Data from the 1990 census showed the population of women in childbearing age (16–49 years old) was 3,050, 54.2% of the total female population. This percentage varied greatly across islands, however, from a low of 32.7% in Salt Cay to a high of 64.4% in Providenciales. The high percentage in Providenciales reflects the number of immigrants to that island, who contribute significantly to the fertility rate. Since the 1970s, the crude birth rate in the Turks and Caicos decreased from 33.3 per 1,000 population in 1970, to 23.5 in 1980, and to 20.9 in 1990. In 1995, there were 234 registered births, for a crude birth rate of 18.6 per 1,000. Mortality and Morbidity Profile Since the 1970s, mortality trends indicate an overall increase in both the number of deaths and the death rates, with periodic decreases. In 1970, there were 47 deaths, which decreased to 30 by 1980. In the 1980s, the number of deaths increased again, peaking in 1985 at 65, before dropping again to 45 in 1990. In 1995, 80 deaths were recorded in the Turks and Caicos Islands, the largest number recorded in recent times. The crude death rate was 636.4 per 100,000 population, up from the 1990 figure of 392.5. In terms of distribution by gender, most deaths in 1995 were among males (51.3%) in contrast to the previous year when there were more deaths among women (54.9%). Between 1990 and 1995, the highest age specific death rates were observed in the population aged 65 years old and older, followed by those in the age group under 1 year old. The lowest rates were in the school-age population, children aged 5–14 years. The number of infant deaths between 1991 and 1995 ranged from a low of 1 in 1991 to a high of 10 in 1995. The highest infant mortality rate for this period was 42.7 infant deaths per 1,000 live births observed in 1995. Between 1993 and 1996, the highest neonatal mortality rate was 34.2 deaths per 1,000 live births. During 1996, the estimated stillbirth rate per 1,000 deliveries was 16.7, compared to 13.5, 14.9, and 33.7 for 1995, 1994, and 1993, respectively. The highest number of stillbirths recorded at the hospital during this period was 6 in 1993. Among adults, the leading cause of death in 1995 was diseases of the circulatory system, accounting for 26.3% of all deaths, followed by deaths due to communicable diseases and external causes, both at 16.3%. Neoplasms accounted for 10 % and conditions originating in the perinatal period, for 7.5%. Of the 362 deaths for the 1990–1995 period, one of every four deaths (27.3%) was due to diseases of circulatory system, most of them resulting from strokes and heart attacks. Communicable diseases ranked second, primarily due to the rise in the number of deaths from AIDS, and accounted for 18%; deaths due to external causes ranked third, accounting for 13%. Of these deaths, 7.5% were the result of neoplasms, and another 5.2% were due to conditions originating in the perinatal period. Deaths due to symptoms, signs, and ill-defined conditions accounted for 14.4%. In 1996, there were 705 admissions to the general ward of Turks and Caicos General Hospital, up 14% from the 619 admissions recorded in 1995. Of these, 58.5% were female and 41.5%, male. Approximately one of every two inpatients (53.1%) admitted that year were between the ages of 15–44 years, one-fifth (20.4%) were patients under the age of 15 years, and 12.7% were 65 years old and older. Conditions associated with the gastrointestinal tract accounted for 12.3% of all inpatient stays in 1996; accidents and violence, primarily poisonings, stab wounds, and burns, were responsible for another 10.5%. Other conditions frequently recorded included hypertension (5.4%) and abortions (5.9%). During 1995, there were 402 surgical procedures performed at the hospital and the overall average length of stay was 3.4 days.The 1,755 outpatients recorded in 1995 represented an increase of 10.2% over the 1,593 visits recorded for 1994, and up 57.4% over the total visits for 1992.
SPECIFIC HEALTH PROBLEMS Analysis by Population Group Health of Children During 1995, 10 deaths in infants (0 to 4 years old) occurred, and most of them (7 deaths) occurred during the first 7 days of life. Causes of death were listed as prematurity, respiratory distress syndrome, septicemia, acute gastroenteritis, and other conditions originating in the perinatal period. Acute respiratory infections and diarrheal diseases are a problem in children between the ages 1–4 years. Between 1993 and 1996, there were 2,674 acute respiratory infections reported. The 465 cases reported in 1994 represents the lowest annual figure for the period, and the 830 cases reported during 1995, the highest. There were 707 cases of gastroenteritis reported, most of them (209) reported in 1995. Vaccines are given for DTP, OPV, and MMR, and in 1996 coverage for all neared 100%. Of 552 growth monitoring visits carried out in 1995, 18.3% were considered obese. The school health program offers booster shots, revaccinations, vision and ear screening, and general health education; vision problems are referred to an ophthalmologist. During the 1994–1995 school year, 1,625 primary and 1,058 secondary schoolchildren enrolled in the territory’s 10 primary and 4 secondary schools. Grand Turk had the largest proportion of secondary students and Providenciales had the highest number of primary schoolchildren, which reflects the large number of women of childbearing age on the latter island. Data from the Department of Social Welfare indicates a considerable number of orphaned, unsupported, and abandoned children. Drug abuse and AIDS also have affected many families, resulting in even more children being placed on welfare. Health of Adults According to the 1990 census, persons between the ages of 15 and 64 account for approximately 63% of the total population. The percentage of males between 15 and 49 years old is greater than that of females in that age group, but the percentage of females between 50 and 64 years old surpasses that of males in that age group. The unusual preponderance of males between 15 and 64 may very well reflect the gender distribution of the resident migrant population, most of whom are male in the productive age groups. During 1996, only 25.1% of the 283 new prenatal clients in Providenciales made their first visit within the first 16 weeks of gestation and 17% did not make their first visit until after the 28th week. Observed low hemoglobin levels during pregnancy have raised concern about women’s health. Overall, 16.6% of 283 prenatal clients in Providenciales in 1996 were found to have low hemoglobin levels (<10 g) and 24.4% of 98 tests performed in Grand Turk were low. Health of Women Family planning services also are offered through the Community Health Clinics. In 1996, 75 new family planning clients were seen at the clinic in Providenciales, 35 for oral contraceptives and 40 for injectibles. Total clients seen for the year was 677, 63.4% of them between the ages of 25–34 years; 13 were under age 20. Data for 1996 from the Female Health Maintenance Clinic in Grand Turk revealed that of 38 Pap tests performed. Cervical cancer screening services are available for all women, but women of childbearing age are specifically targeted. Clinics also offer breast examinations. Health of the Elderly The Government requires that employees retire at age 55 but National Insurance benefits do not begin until age 65, and noncontributory pensions do not start until age 68. Government services are channeled through the Department of Social Welfare, with welfare benefits provided for most persons starting at age 60. Based on the 1990 census, 574 residents in the Turks and Caicos Islands were aged 65 years old and older, representing 5% of the total population—322 (56.1%) were females and 252 (43.9%) were males. In the fiscal year 1994–1995, 73 elderly persons received monthly welfare payments. Some churches also provide assistance for their elderly members, as do other, mostly church-affiliated, community groups. Analysis By Type of Disease Communicable Diseases Between 1993 and 1996, the most frequently reported communicable diseases in children under 5 years old were influenza (3,361 cases), acute respiratory infections (2,674), and gastroenteritis (707). Seven cases of the mumps were reported in 1993, followed by three in 1994; the last known cases of measles were four cases reported in 1993. After several years with no reported cases of tuberculosis, three cases were reported in 1996. There were 30 reported cases of gonorrhea between 1993 and 1996, with 16 cases reported in 1996 alone. The number of syphilis cases during the period was 21, with 6 reported in 1996. One case of hepatitis was reported in 1996. AIDS continues to be a major public health problem as a cause of death and as a contributor to years of life lost, as well as in terms of its socioeconomic impact on the community. From 1985, through December, 1996, there were a total of 94 AIDS cases diagnosed in the territory—53 (56.4%) of them were males and the predominant mode of transmission was heterosexual contact. Persons aged 20–44 accounted for 63.8% of all cases, with the age group 30–34 years old alone responsible for one-fourth (25.6%). Only three pediatric cases (under 5 years old) were identified. Most of the cases (38.3%) were from Providenciales, followed by those in Grand Turk and South Caicos with 27.7% and 24.5%, respectively. Through December 1996, 75.5% of all cases were known to have died. Annual HIV-infection tests are performed on applicants for resident and work permits, pregnant women, and blood donors. In 1995, of 101 prenatal clients tested on Grand Turk, 8 (7.9%) tested positive. In 1996, of 283 tests of prenatal clients performed in Providenciales, 11 (3.9%) were found to be HIV-positive. Of the 8 HIV-positive cases positive in Grand Turk in 1995 and the 11 in Providenciales in 1996, 87.5% and 81.8%, respectively, were non-nationals. Noncommunicable Diseases and Other Health-Related Problems Accidents and Violence. Deaths due to accidents and violence have risen from a single case in 1980 to 2 in 1985, representing 3.1% of all deaths. In the 1990s, the impact of accidents and violence increased to 5 cases in 1990 and 13 in 1995, representing 11.1% and 16.3% of all deaths, respectively. During 1992-1995, there were 36 deaths due to either intentional or unintentional injuries, accounting for 13.7% of all deaths. Twenty-six, or approximately three of every four of these deaths (72.2%), were males. The age group with both the highest actual number of deaths and death rate per 100,000 population was the 25–44-year-old age group, accounting for 13 (36.1%) of the 36 deaths for a rate of 87.8 per 100,000. This was followed by persons aged 15–24 years, with 8 deaths (22.2%) and a death rate of 80/100,000. The major causes of death due to external causes are motor vehicle accidents, drowning, and homicides and these three causes accounted for two of every three such deaths. Motor vehicle accidents were responsible for 10 deaths, 27.8% of all deaths due to external causes during this period. There were 9 drowning deaths. Homicides and injuries purposely inflicted by others accounted for 5 deaths. Three deaths were the result of accidental falls and two were due to suicide. Injuries that result from acts of violence or accidents are among the leading causes for hospitalization, accounting for approximately 10.5% of all admissions in 1996. Other common causes of admission include poisonings and burns; fish poisonings are by far the most common. Not reflected in the mortality statistics but of increasing public health concern is the escalating incidence of violence against women. Cultural patterns leave many episodes unreported, or, when reported, unpunished. Malignant Tumors. From 1992 through 1995 there were 23 deaths attributed to malignant neoplasms. Of the total, 13 (56.5%) were male and 10 (43.5%) female. Cancer remained a disease predominantly of the elderly, with 65.2 % of all deaths occurring in persons 65 years old and older. During this same period, 7 deaths (30.4%) were due to cancer of the genitourinary organs, 4 of which were males who died from prostate cancer. Cancers of the digestive organs and the peritoneum were the cause of six (26.1%) deaths, four of them males; stomach cancer accounted for four of these six deaths. In addition, there were two deaths due to cancer of the larynx, two due to leukemia, and two females who died as a result of breast cancer. Cardiovascular Diseases. Cardiovascular diseases or diseases of the circulatory system are the leading causes of death. In 1995, these conditions were responsible for 29% of all deaths, disproportionately affecting females (among whom cardiovascular diseases were responsible for 38.5% of all deaths), compared to males (19.5% of all male deaths). When data for the 1992–1995 period were combined, results were similar, though not as obvious. Of the 263 total deaths occurring during this period, 76 (29%) were due to these conditions, with the percentage in females (33.3%) again greater than that in males (24.4%). For the 1992–1995 period, leading causes within this group were cerebrovascular diseases (31.6%) and myocardial infarctions (25%). Of the 76 deaths, 58% were female. Mortality rose significantly with age, with persons 65 years old and older exhibiting the highest death rates. Almost 9 of every 10 deaths (87.5%) were to persons 45 years old or older. Hypertension or conditions resulting from hypertensive diseases are recognized as one of the leading causes of hospital admissions. In 1996, approximately 5% of all persons admitted to the general ward of the hospital in Grand Turk had hypertension specifically recorded as the cause of admission, with considerably more having it mentioned as a contributing factor. Oral Health. Oral health services in the territory suffer from a serious personnel shortage. A single government dentist, assisted by a dental nurse, works out of Grand Turk’s main dental clinic, and there is one private dentist in Providenciales. The government dentist and dental nurse make schedule visits to the other islands. The main clinic on Grand Turk offers most dental services, including radiology, periodontics, endodontics, oral surgery, minor prosthetic services, and restorative dentistry. Dental care elsewhere in the territory depends on facilities available on each island. Preventive care, which is mainly carried out through an active school dental health program, also is a priority. Along with educational lectures provided by the department’s professional staff, this program also includes screening schoolchildren every five years for decayed, missing, and filled teeth (DMFT) and to assess periodontal index; administering fluoride treatment to every child; and applying sealants for the children’s primary and permanent teeth. There is a fair amount of fluorosis, which is thought to be partly due to excessive intake of fluoride that occurs naturally in well water. Disaster Preparedness. The main threats to the Turks and Caicos Islands are hurricanes, floods, fires, and massive transportation accidents such as airplane crashes. As a result of efforts of the National Disaster Committee, disaster preparedness has become better structured. Education and training through simulation exercises, the dissemination of information, procurement of equipment and supplies, treatment and referrals, data collection and needs assessment; epidemiological surveillance and the control of communicable diseases, and psychological support are areas that have been emphasized. Within the National Disaster Management Plan, the Primary Health Care Disaster Management Plan serves as the health sector’s blueprint of action following a disaster. The nine government and two private health centers/clinics located throughout the islands are the focal points for the health response to disasters.
RESPONSE OF THE HEALTH SYSTEM National Health Plans and Policies The Government, which is the main provider of health care, has had a policy that holds that health care should be available, accessible, and affordable to all residents of the islands. It also acknowledges that nongovernmental organizations and individuals must share in this responsibility if optimal health for the majority is to be a reality. Health Sector Reform In 1989, the Government of the United Kingdom financed a comprehensive health sector adjustment program in order to identify and address the many shortcomings in the health care industry in all British dependent territories in the Caribbean. The program targeted the following five areas for improvements: management structures and processes, planning approaches, financial strategies, quality of care, and health outcomes. Now in its second phase, the program has established operational plans for the Turks and Caicos through the year 2000. Policies continue to address infrastructure and personnel deficits that must be dealt with if the quality of services is to improve, as well as the control over health care costs. Priorities are human resource development; access to financial resources; development of an effective health information system that will lead to better program planning and monitoring; improvement to the health infrastructure, particularly at Grand Turk Hospital; the consolidation of ties with nongovernmental organizations; environmental health; drug procurement; health promotion; nutrition; prevention and control of noncommunicable diseases; and the control of HIV and AIDS. Because practices such as dietary patterns and food choices play important roles in the etiology of many noncommunicable diseases, a National Nutrition Policy was developed in conjunction with the Caribbean Food and Nutrition Institute (CFNI) and PAHO’s nutrition consultant in the Bahamas. The plan will become an important element in the fight against such diet-related conditions as obesity, heart disease, diabetes, and various forms of cancer, which are among the leading causes of morbidity and mortality in adults. Organization of the Health Sector Institutional Organization Health services in the Turks and Caicos Islands comes under the aegis of the Ministry of Health, Education, Youth, and Sports. There is some degree of decentralization, and services are categorized into three general areas—medical, dental, and environmental—each with its own budget. The hospital located in Grand Turk is a 36-bed secondary care institution that serves as a referral center for all of the islands; it has a maternity ward; a geriatrics ward; and a general ward that handles all other inpatients. In 1995, the hospital added a hemodialysis unit that can treat up to three patients simultaneously. Before hemodialysis was available, patients had to be transferred abroad for the procedure, at a very high cost. There are nine community health clinics on six islands: a maternal and child health complex, offering maternal and child health services, female health maintenance, family planning; and school health services on Grand Turk; a general clinic, offering preventive, curative, and rehabilitation services to all age groups, also on Grand Turk; a 10-bed government clinic, providing 24-hour service for general and maternal and child health care on Providenciales; two clinics each on Middle Caicos and North Caicos; and one each on South Caicos and Salt Cay. Depending on demand, clinics are staffed with public health nurses, registered nurse midwives, clinical nurses, and/or community health aides; physicians make scheduled visits. There are two private clinics located on Providenciales. Many Turks and Caicos residents also regularly travel abroad to the Bahamas or elsewhere for medical care. Organization of Health Regulatory Activities The certification and practice of health professionals in Turks and Caicos is governed by the 1978 Health Practitioners Ordinance, which has established a Health Practitioners Board. The 1992 Public and Environmental Health Ordinance governs the work of the Department of Environmental Health, which is responsible for safeguarding environmental quality—including the preservation of water, air, and soil; housing quality; and chemical safety—and for food protection and safety. Organization of Services for Care of the Population Health Promotion. Acknowledging the importance of health promotion to the attainment of health for all, the Government of the Turks and Caicos Islands has embraced the Caribbean Health Promotion Charter and is working to incorporate health promotion activities throughout its programs. The Community Health Department is directly responsible for implementing these programs and activities, many conducted in collaboration with the education and communications sectors. There is, however, a recognized need for a more comprehensive health promotion strategy. External assistance provides funds for several ongoing health promotion programs, most of them targeting AIDS and drug abuse. Disease Prevention and Control Programs. Most communicable diseases are reportable by law, and with most of the population routinely attending government clinics, reporting coverage is believed to be quite good. The Community Health Department is responsible for disease prevention, including epidemiological surveillance. Programs such as immunization for mothers, infants, and children; health education activities; cancer screening for adults; screening of schoolchildren; and health education activities are the cornerstones of the Department’s prevention activities. The Department’s frequent collaboration with other departments, particularly the Environmental Health Department, is essential for the success of such programs as vector control and efforts to control waterborne diseases, foodborne diseases, and diseases that result from biological or chemical contamination. The integrated vector control project is noteworthy for its efforts to engage the community in the control of mosquitoes and mosquito-borne diseases, especially Aedes aegypti and dengue fever. Initially sponsored by the Government of Italy and subsequently funded by the Government of the United Kingdom, the project led to significant reductions in the household index for all mosquitoes, including Aedes aegypti, and it was particularly important to those islands near Haiti, where dengue fever is endemic. Water Supply, Sewerage Systems, and Solid Waste Disposal. Potable water in the Turks and Caicos Islands is mainly obtained through reverse osmosis process, then is distributed from public issue points or via trucks, and finally is stored in water tanks. The public water supply is chlorinated and regularly checked for chemical and bacterial contamination. Many households also rely on well water, a practice that can only be encouraged if the supply is properly treated against bacterial contamination. The current Planning Ordinance requires all new construction to provide for water supply, but many households remain without water storage tanks. The availability of wastewater and sewage treatment facilities is mandatory. Based on the 1990 census, most households (52.6%) use septic tank systems, but many (43.6%) still use pit latrines. Large facilities such as hotels have mechanical treatment plants. Because the islands face a chronic water shortage, many hotels, government buildings, and private dwellings use saltwater for flushing systems. The Environmental Health Department is responsible for the collection and disposal of all waste in the territory. On some islands, residential and business collection is handled by private contractors for a small fee. Independent private haulers also provide the service for a fee. Waste is disposed in landfills. Food Protection and Safety. Food protection and control is important for consumer health and for the economy of the Turks and Caicos Islands, particularly because of the reliance on tourism and fishing. Department of Environmental Health officers trained in food inspection methodologies periodically inspect food preparation, food service, and food dispensing facilities for compliance with sanitation and safety policies and procedures. Human Resources Because many health sector areas have shortages of qualified health professionals, the Government must continually recruit foreign nationals. Many of them are hired through short-term contracts, which severely hinders long-term planning efforts. Recent data indicate that the Ministry of Health employs 5 doctors, 1 dentist, and 34 nurses at various levels; 22 of the nurses had received training as registered nurses or higher. In addition, an allied health staff comprised of eight community health aides, eight geriatric aides, two laboratory technicians, five environmental health officers, and nine vector control officers form part of the public health sector. Expenditures and Sectoral Financing The Government’s recurrent expenditure for the 1991–1996 period reveals the rising cost of health care in the Turks and Caicos. The actual cost of health care services to the Government for the 1995–1996 period was 42.3% higher than that for the 1991–1992 period. Health infrastructure development in Providenciales, particularly the new health center that became operational in 1994, is largely responsible for the increase. During the 1995–1996 period, the total amount of the budget allocated to health care was US$ 4,340,652, almost $US 1 million over the 1994–1995 figure and representing 14.3 % of the total Government expenditure. For the same period, total revenue was $US 179,100, 72% of which came from medical fees and charges. In terms of operational expenses, most funds were allocated for medical care services, including the hospital and all clinic services, followed by environmental health. With the cost of services provided at the health center in Providenciales included, the operational budget for medical services for 1995–1996 was $US 1,619,674, a 27% increase over that for 1994–1995. Again, this was due mainly to the increase allocated to the health center in Providenciales, whose range of services were expanded. For the same fiscal year, the operational budget for environmental health services was $US 323,543, 21.6% over that of the previous year.
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