GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

The Commonwealth of the Bahamas is an archipelago of some 700 islands with a total land mass of 5,382 mi.2 scattered over 80,000 mi2 of the Atlantic Ocean. Over 95% of the population lives on just seven islands. The two major population centers are Nassau, the capital, located on New Providence, and Freeport, located on Grand Bahama. The other populated islands and cays are called Family Islands. New Providence is the most densely populated island, with 2340.4 persons per mi2. Only three other islands/island groups have population densities greater than 100 per mi2. As of the 1990 census, New Providence accounted for 67.4% and Grand Bahama 16% of the population.

As an independent unitary state within the British Commonwealth of Nations since July 1973, the Bahamas is governed as a parliamentary democracy based on the Westminster/Whitehall model, with a Governor General who represents Her Majesty the Queen, a bicameral legislature including an elected House of Representatives, and an independent judiciary. The Cabinet of Ministers is headed by a Prime Minister who is also a member of the legislature. Government business is carried out by ministries, headed by a minister (political) and permanent secretary (administrative), and by quasi-governmental institutions. The 1992 elections brought the first change of government in 25 years, and this same government was returned to power in 1997.

The Government’s commitment to social development is evidenced by the fact that approximately 30% of the national recurrent budget is allocated to social sectors, with special attention given to education, health, and housing. The people enjoy universal access to health care, and basic services are available regardless of ability to pay.

In the 1996–1997 recurrent budget, US$ 102,021,118 (13.3% of the total budget) was allocated to the Ministry of Health, representing a per capita expenditure of approximately US$ 359. Since 1972 the exchange rate with the US$ has been 1:1.Although expenditure in the health sector has increased steadily between 1986 and 1995–1996, it has decreased as a percentage of the national budget from 15.6% to 13.6%.

Education is available to all segments of the Bahamian population and is compulsory to age 14 years. There are 213 schools in the country, 163 of which are in the public sector; total enrollment at the primary and secondary levels is about 61,500 and the teacher-to-student ratio is 1:18. Tertiary education is provided at the Government-owned College of the Bahamas, which offers both associate’s and bachelor’s degrees in the arts and sciences. There are also a number of privately run institutions that also offer associate degrees and are affiliated with tertiary educational institutions in the United States of America. Technical and vocational training is also available at the Bahamas Technical and Vocational Institute.

Tourism, including tourism-related commerce, constitutes by far the major economic activity, accounting for over 50% of the gross domestic product (GDP) and 60% of employment. Service industries (such as government services, tourism, banking, and insurance), fishing, and agriculture employ approximately 80% of the eligible labor force. According to data received from the Department of Statistics, the overall unemployment rate in 1996 was estimated at 11.5%, down from a high of 14.8% in 1992. Economic recovery from the 1991–1992 recession began in 1993 and has continued. Output grew by 1 % in 1995. That year, GDP was estimated at US$ 3,053 million (in 1990 dollars). The average growth rate in the period 1990–1995 was –0.5%. During the same period, GDP per capita fell from $12,291 to $11,059.

The main objectives of underlying monetary and fiscal policies pursued by the authorities remain the maintenance of macroeconomic stability, improvement in all aspects of competitiveness, and stimulation of sustainable development by the private sector in the short and medium term. A key issue in the Bahamas is diversification of the economy, which is to be accomplished by improving intersectoral linkages between the tourism sector and the rest of the economy and by improving infrastructure in the Family Islands to promote their economic development. This initiative, which started in 1994—particularly with regard to roads, airports, the water and sewerage systems, and electricity—has started to pay dividends, as evidenced by increased foreign investment outside of New Providence and Grand Bahama. The budget for 1996–1997 reaffirmed the Government’s commitment toward consolidating the improvements achieved in economic and social conditions, implementing necessary institutional reforms, and maintaining a climate conducive to domestic and international investment.

The 1996 midyear population of the Bahamas was estimated at 284,000. About one-third of the population is under 15 years of age and about 5% is over 65. Annual population growth was estimated at 1.97% between 1980 and 1990, while urban growth was 2.35%. At the time of the 1990 census the dependency ratio was 58.5. Life expectancy at birth has increased steadily, rising from about 60 years in the period 1950–1955 to approximately 73 years in 1990–1995 (76 years for females and 69 years for males). From 1988 to 1992 the crude birth rate fluctuated between 22.7 and 25.6 per 1,000 population. Thereafter, the rate fell steadily to 22.4 in 1995. The pattern of fertility has remained similar in the years between 1976 and 1995, with fertility being highest in the 20–24 and 25–29 age groups. There has been a marked decrease in fertility rates in these age groups in the last decade. However, in the 15–19 age group, which has the third highest fertility, and in the 40+ age group, there has been no change. The only group showing an increase is the 35–39 age group, probably because some women are opting to delay pregnancy in order to pursue a career.

Mortality and Morbidity Profile

In 1995, 1,604 deaths were recorded, for a crude death rate of 5.75 per 1,000 population. The ten leading causes accounted for 86.3% of the deaths from defined causes. In 1996, mortality under-registration was less than 5%; and less than 2% of registered deaths in 1995 were classified as due to unspecified illnesses.

Diseases such as hypertension, diabetes, myocardial infarction, stroke, and cancers are major concerns for the population of the Bahamas. These diseases are among the leading causes of mortality and account for nearly 45% of all deaths in the country. These diseases also cause more morbidity than any other group of problems.

In 1995 the leading cause of death in the general population was diseases of the heart (102.9 per 100,000 population), which accounted for 18.2% of deaths. It was followed by AIDS (97.1 per 100,000 and 17.2%), malignant neoplasms (85.3 per 100,000 and 15.1%), cerebrovascular diseases (46.6 per 100,000 and 8.2%), and accidents, violence, and poisonings (39.8 per 100,000 and 7.0%). The three most significant causes of death among men were AIDS (a rate of 130.4 per 100,000 male population, 20.9% of deaths from defined causes), diseases of the heart (102.9 per 100,000 and 16.5%), and malignant neoplasms (91.3 per 100,000 and 14.6%).Among females the most frequent causes of death were diseases of the heart (102.8 per 100,000 female population, 20.3%), malignant neoplasms (79.4 per 100,000, 15.7%), and AIDS (64.5 per 100,000, 12.7%). The biggest difference among leading causes between men and women is in accidents, violence, and poisonings. Cerebrovascular diseases and diabetes mellitus are the only two causes that pose a greater risk to the lives of the general female population. Between 1984 and 1995 maternal deaths were very few (between one and four per year) and therefore the rate fluctuated widely—from 1.5 to 6.4 per 10,000 live births, where it peaked in 1995. There were only two years between 1988 and 1995 when more than one death occurred: 1989 (two deaths) and 1995 (four deaths).

SPECIFIC HEALTH PROBLEMS

Analysis by Population Group

Health of Children

In 1994 the under-5 years age group had the highest number of admissions to the Princess Margaret Hospital per 1,000 population. Diseases of the respiratory tract were responsible for more than 75% of all admissions of children under 5. At the community clinic level, upper respiratory tract infection (URTI)—excluding the common cold—was the most common illness seen in children under 5 years between 1992 and 1995. Acute gastroenteritis was among the top three causes in New Providence and the Family Islands, but was not among the top five causes in Grand Bahama. Thrush was among the top five causes in Grand Bahama and appeared as number five in New Providence in 1995, but was not among the most common causes in the Family Islands.

Children under 1 Year of Age. There has been a decline in infant mortality from the 1986 level of 30.2 per 1,000 live births to 19.0 in 1995. For the past two decades "certain conditions originating in the perinatal period" has been the principal cause of infant deaths. In 1995 it dropped to 8.8 deaths per 1,000 live births. Since 1989 "congenital anomalies" has been the second most frequent cause of death, with a rate between 2.4 and 3.9 per 1,000. Between 1989 and 1995 AIDS moved from the fifth to the third-ranked cause of death in infants; the rate increased from 1.2 in 1989 to 2.8 in 1994 and then dropped to 1.1 per 1,000 live births in 1995. This rate was expected to drop even further in 1996 because of the introduction of a program for treatment of HIV-positive pregnant women with AZT.

In 1993 it was estimated that approximately 10.2% of infants were born with a low birthweight (defined as less than 2,500 grams). Records for 1995 show that 9.8% of newborns at the Princess Margaret Hospital. In 1991 the leading cause of death at the Princess Margaret Hospital, accounting for 18.9%, was pneumonia and influenza, followed by intestinal infectious diseases (12.7%), certain causes of perinatal morbidity (12.5%), diseases of the upper respiratory tract (9.0%), and other diseases of the respiratory tract (5.4%). The most frequently reported infectious disease was gastroenteritis.

Children 1–4 Years of Age. In 1995 the age-specific mortality rate in the 1–4-year age group was 4.1 per 10,000 population. There was a dramatic reduction in the number of deaths in this age group between 1994 and 1995. Of the 28 recorded deaths in 1994 resulted from accidents, violence, and poisonings, while AIDS was responsible for 21.4%. In 1995 AIDS was replaced by congenital anomalies as the second leading cause of death (two deaths, 20%).

Children 5–14 Years of Age. In the 5–14 age group, 5 of the 20 deaths (25%) in 1995 were due to AIDS (9 per 100,000), and 3 (15%) each to pneumonia and to accidents, violence, and poisonings (5 per 100,000). Two deaths each (10%, 4 per 100,000) were due to malignant neoplasms and diseases of the heart. In recent years deaths in this age group have fluctuated between 10 (1993) and 20 (1991, 1994, 1995). The most common cause of death was accidents, violence, and poisonings until 1995, when it was replaced by AIDS.

Health of Adolescents and Young Adults (15–44 Years)

The five leading causes of death in the 15–44-year age group in 1995 were the same for both males and females, but the rank order differed. In both sexes the leading cause was AIDS and AIDS-related complex. In males the age-specific rate was 170.5 per 100,000 population, accidents, violence, and poisonings, at 85.5 per 100,000, heart and malignant neoplasms (both at 18.5 per 100,000), "other diseases of the respiratory system" ranked number five in 1995 (17.1 per 100,000). There was an increase in the total number of deaths of males in this age group from 180 in 1991 to 260 in 1995.

The age-specific mortality rate for AIDS in women was 83.3 per 100,000 population in 1995. The second most common cause of death among women was malignant neoplasms (29.2 per 100,000), followed by diseases of the heart and accidents, violence, and poisonings (both at 12.5 per 100,000). The number of deaths among women in the 15–44 age group increased from 103 in 1991 to 147 in 1995. Of 407 registered deaths in this age group, only six occurred among people aged 15 to 19 years.

The total fertility rate of women in the Bahamas was estimated at 2.43 for 1995. A comparison of recent age-specific fertility rates with those in the 1970s and 1980s indicates that fertility is declining among all age groups except women 35–39 years, in which it has been increasing since the mid-1980s. Women are choosing to postpone starting a family and are having babies for the first time at an older age. Although there has been a steady downward trend in the birth rate among women under 20 years of age, teenage pregnancy continues to be a matter of concern in the country. In 1994 approximately 15% of births were to women in the 15–19-years age group. One disturbing development is the recent increase in registered births to girls under 15 years of age—a jump from 7 and 5 births in 1991 and 1992, respectively, to 34 and 20 births in 1993 and 1994, respectively.

Health of Adults Aged 45–64 Years

Heart diseases, "other diseases of the digestive system," and diabetes, were the main causes of morbidity seen at the Princess Margaret Hospital. In 1995 the three leading causes of mortality, together accounting for 57% of deaths, were malignant neoplasms (21.0%, with an age-specific rate of 2,136 per 100,000 population), diseases of the heart (19.7%, 2,004 per 100,000), and AIDS (16.6%, 1,688 per 100,000).

Health of the Elderly (65 Years of Age and Over)

Mortality in persons 65 years and over is dominated by the chronic diseases. In 1995 the four leading causes of death accounted for 72% of mortality. The most common cause was diseases of the heart (28.4%), with an age-specific rate of 1,376.5 per 100,000 population. It was followed by malignant neoplasms (18.6%, with a rate of 900.3 per 100,000), cerebrovascular disease (14.3%, 692.0 per 100,000), and diabetes mellitus (10.7%, 520.8 per 100,000). Although the rates for all of these diseases increased in the three years prior to 1995, that for diabetes mellitus almost doubled: from 283 to 521. Diseases of the respiratory and circulatory systems are also among the most frequent causes of death in this age group.

Family Health

The rate of marriages (number of marriages during a given year per 1,000 population) was fairly constant between 1988 and 1995 at between 8.6 and 9.7. In 1994, the most recent year for which such information is available, the majority (55%) of women getting married were between the ages of 25 to 30, while 52% of men got married between the ages of 30 and 39. Just over half (53.3%) of all registered births were outside of wedlock in 1995. Of these births, 525 (23.1%) were to teenagers, 1,578 (69.3%) were to women aged 20–34 years, and 173 (7.6%) were to women aged 35 years and over. According to the 1990 population census, 25.3% of private households were headed by single parents. The majority of these household heads (57.1%) were females.

Workers’ Health

Currently, medical care and compensation to workers injured on the job remains the responsibility of the National Insurance Board (NIB). Through this institution, workers with job-related injuries receive full coverage of all medical bills, both locally and abroad, if the correct referral procedures are followed. Data from claims processed by the National Insurance Board suggest that in 1996 the five most common causes of absenteeism in the workplace were "female disorders," musculoskeletal problems, fractures, sprains/strains/dislocations, and infections, including AIDS. For invalidity, the five most frequent causes were AIDS, psychiatric disorders, cardiovascular diseases, arthritis/fractures/skin problems, and neurological disorders.

Health of the Disabled

In 1993 the Bahamas was included in the Caribbean Cooperation in Health (CCH) initiative’s Program on Community-based Rehabilitation. In preparation for the development of the project proposal, several islands were surveyed to identify prevalence and types of disability, so that pilot areas for this project could be established. An additional assessment was made from the National Insurance Board register. Out of a population of approximately 8,000, Eleuthera had 371 (4.6%) registered persons with disabilities. Of these, 108 (29.1%) had lower limb disabilities, 69 (18.6%) had impaired vision, 29 (7.8%) had a hearing deficit or were slow learners, 28 (7.5%) had speech problems, and 26 (7.0%) were mentally retarded. In Abaco 492 (4.8%) of the approximately 10,100 inhabitants were registered as disabled. As in Eleuthera, the most common disabilities were related to the lower limbs (130, 26.4%), with the second most frequent being sight-related (66, 13.4%), followed by hearing and speech deficits (43, 8.7%), upper limb problems (40, 8.1%), and mental retardation (39, 7.9%). In Long Island (north), 305 (16.0%) of the approximately 1,900 persons were registered as having disabilities. This was the site chosen to initiate the Community-based Rehabilitation Project.

Analysis by Type of Disease

Communicable Diseases

Vector-Borne Diseases. Malaria is not endemic to the Bahamas. However, the large number of illegal immigrants from countries where malaria is endemic, along with the presence of the Anopheles mosquito, increases the risk of this disease being reintroduced. Between 1993 and 1995 there were from 1 to 3 imported cases each year. No cases were reported in 1996. Although there has not been a case of yellow fever in the Bahamas for over three decades, the Aedes aegypti mosquito is indigenous to the islands and the threat is ever-present. The risk of an outbreak of dengue fever is high. There was one confirmed case of dengue in 1995. Prior to that, the last reported cases (numbering 87) were in 1989.

Vaccine-Preventable Diseases. Immunization of children against diphtheria, tetanus, whooping cough, poliomyelitis, measles, mumps, and rubella is available free of charge through the community health clinic system. BCG is not included in the country’s EPI protocol.

Like the rest of the Region, the Bahamas was declared free of poliomyelitis. The country’s participation in the subregional initiative to eradicate measles has resulted in no confirmed case of measles being recorded since 1990. There was a sharp increase in hepatitis B cases between 1993 (92 cases) and 1994 (246). Since then, case numbers have declined steadily to 137 in 1996. As of that year, the policy was to provide hepatitis B immunization to medical personnel and all members of the uniformed services. Donated blood is routinely tested for hepatitis core antibody, as well as hepatitis B and C.

Cholera and other Intestinal Infectious Diseases. The threat of to the Region in 1991 put the Bahamas on full alert. Active public and environmental health teams were put in place for the prevention and control of this problem. During May and June of 1991, a localized outbreak of seafood-related illness occurred in New Providence. Upward of 380 cases were reported during the peak week of the outbreak. This illness was primarily associated with (1) the consumption of raw conch obtained from wet storage sites in the waters of Nassau Harbor; and (2) contamination resulting from the food-handling practices of the vendors in that area, combined with the sanitation conditions in the area itself. In spite of these efforts, intermittent outbreaks of foodborne illness due to the ingestion of raw conch continue. The identified pathogen was Vibrio parahaemolyticus in all outbreaks. The number of reported cases of foodborne diseases in 1996 was 1,061. In the over-5-year age group, the number of diarrheal diseases was low in 1993 and 1994, more than doubled in 1995, and increased another fivefold in 1996.Intestinal infectious diseases are not a common cause of admission to hospital.

Chronic Communicable Diseases. In the Bahamas, "directly observed treatment, short course" (DOTS) is being used to treat tuberculosis. In 1996, 59 cases of tuberculosis were reported; this number has been constant since 1992 (63 cases). HIV-positive persons accounted for over 65% of all tuberculosis cases in 1996 (40 out of 59). A recent study of the incarcerated population demonstrated a positivity rate for tuberculosis of 20%. An alarming developing situation is the occurrence of an unknown multidrug-resistant strain of the bacillus in New Providence and the Family Islands. Its existence has been confirmed by the government research laboratory in Canada. Moreover, active tuberculosis has recently been identified in staff working in several acute care institutions. Leprosy is not endemic in the Bahamas, but a case was diagnosed in 1996. The last known indigenous case was diagnosed in 1982.

Acute Respiratory Infections. This group, represented by diseases of the upper respiratory system like pneumonia, influenza, bronchitis and asthma were the second most common reason for admission to the Princess Margaret Hospital, between 1990 and 1995 after complications of pregnancy. At the Rand Hospital, ARI was the third most common reason for admission, but cases have been declining since 1990. The most commonly affected age group is children under 5 years old, who account for more than 50% of the cases. More male children than females were affected. In 1995, diseases of the respiratory system constituted the second leading reason for consultation

AIDS and Other Sexually Transmitted Diseases. The incidence rates of syphilis and gonococcal infection have been decreasing from 1,804 in 1987 to 92 in 1995. Estimates of the prevalence of chlamydia were obtained from a study conducted in Grand Bahama in 1995. Results indicated that approximately 13% of all prenatal patients were infected. AIDS and HIV infection are now the second most frequent cause of death in the general population. Furthermore, it has become the leading cause of death among all males and among males and females 15–44 years of age. As of 31 December 1996, a total of 2,481 cases had been reported, of which 63% had died and 7% (173) were pediatrics AIDS. A further 3,941 individuals were known to be HIV-positive, without symptoms of the disease. The disease occurs primarily among heterosexuals (87%), with a male-to-female ratio of 1.6 to 1. Freebase/crack cocaine addicts represent approximately one-third of individuals with HIV infection and AIDS. A seroprevalence study carried out in 1990–1991 indicated that about 2.9% of prenatal clients were HIV-positive; in 1996 this figure was estimated at 3.2%. HIV prevalence figures for STD clinic patients were 10% and 5.2% in 1992 and 1996, respectively. In 1995, a program to give AZT to selected pregnant women was implemented. There have been no cases of HIV linked to blood transfusion since HIV testing began in 1985 in the Bahamas. Screening revealed that the prevalence of HIV-positive potential blood donors was 0.4% in 1996.

Noncommunicable Diseases and Other Health-Related Problems

Nutritional Diseases. 

The diet-related noncommunicable disorders—such as obesity, cardiovascular disease, type II diabetes, hypertension and stroke, and accidents—are the leading causes of morbidity and mortality among adults. Between 1992 and 1995 approximately 19% of the prenatal clients screened had hemoglobin levels <10g/dL. Protein-energy malnutrition among children 0–5 years of age is not a serious public health problem, nor are deficiencies of micronutrients. The National Health and Nutrition Survey (NHNS), 1988–1989, revealed that 6.7% of children 5–14 years of age were obese (based on NCHS standard weight-for-age). Overall, 48.6 % of the population was obese (body mass index >25), with more females (53.6%) being affected than males (43%). Findings from a 1988–1989 survey of preschool children indicated that a very small number of infants were exclusively breast-fed up to 4 months of age. Furthermore, 80% of the infants were introduced to bottle-feeding as early as the first week of life—90% of that group while in hospital—although 63% of mothers attempted to breast-feed.

Cardiovascular Diseases. Based on results from the National Health and Nutrition Survey, it was estimated that 13% of the population 15–64 years of age of the Bahamas could be classified as hypertensive in 1989. The percentage was slightly higher for males (15%) than for females (12%). Another 17% could be considered borderline. Among the elderly (65 and over), 38% were hypertensive. During 1991, there were 404 hypertensive patients admitted to the Princess Margaret Hospital, and in 126 (31.2%) of them, hypertension was the primary diagnosis a trend consistently observed over the last five years. Data available for the same period from the Rand Memorial Hospital indicated a total of 120 admissions, 29 (28.4%) of which had a primary diagnosis of hypertension. Of these, 62.5% were female. Diseases of the heart is the most common cause of death in the overall population and the leading cause in females. It was also the leading cause in males up until 1994, when it was replaced by AIDS.

Malignant Tumors. Between 1991 and 1993 malignant neoplasms were the second most common cause of death for all ages and both sexes. In 1994 and 1995 this cause moved to third place. Between 1970 and 1984 the rate per 100,000 population almost doubled, from 57.1 to 102.2. Thereafter, it slowly declined to 85.3 in 1995. This trend was found in both sexes: among men the rate went from 51.4 per 100,000 to 122.9 to 91.3, while among women it changed from 63.4 per 100,000 in 1970 to 87.5 in 1989 to 79.4 in 1995. Between 1992 and 1995 the two most common sites of fatal cancer in males were the prostate and the trachea, bronchus, and lung. In 1995 cancer of the prostate caused 22.2% of all cancer deaths in males, while cancer of the trachea, bronchus, and lung accounted for 17.5%. The two most common causes of cancer deaths in women are cancers of the breast and the cervix uteri. Deaths due to breast cancer comprised 23.2% of total female cancer deaths in 1995 and 3.6% of all deaths in females. Cervical cancer accounted for 9.8% of female cancer deaths and 1.5% of all female deaths.

Accidents, Violence, and Poisonings. In 1995 accidents, violence, and poisonings ranked as the fourth leading cause of death. This cause group is a leading reason for emergency room visits and admissions to both major hospitals. About 25% of these injury-related hospital admissions were due to violence, the main cause being homicide and injuries purposely inflicted by others. The problem is most significant among men, particularly those in the 15–44 age group, and among children 5–14 years of age, especially for accidents. In 1995 approximately 23 % of all deaths of men 15–44 years old were due to accidents and violence.

Behavioral Disorders. Alcoholism and other substance abuse, particularly cocaine addiction, are major health problems that remain at unacceptably high levels. Between 1988 and 1994 the three most common disorders presenting at the clinic were drug abuse, alcohol abuse, and depression. Psychotic and psychosocial disorders rounded out the top five.

Oral Health. According to data available from the Community Health Clinics, the most common problem noted among 5–14-year-olds in the school system is dental caries. This problem is most severe in New Providence, and least in Grand Bahama. Between 1993 and 1995 the percentage of children with caries in New Providence schools increased from 24.1% to 39.4%, while that in the Family Islands rose from 20.5% to 34.0%. On the other hand, in Grand Bahama the rate fell from 14.7% in 1993 to zero in 1995.

Natural Disasters. The Bahamas was hit in 1996 by two hurricanes, Bertha and Lili, but they were less powerful than the severely destructive Hurricane Andrew in 1992. The 1996 hurricanes caused infrastructural damage (power outages and disrupted telephone communications) and property damage in several Family Islands, but no deaths and few personal injuries. Several cases of post-traumatic stress syndrome were reported. Concerted efforts were made to reinstall services, remove debris, control insect proliferation, provide bottled water, and advise the public to boil drinking water.

Industrial Accidents. No major industrial accidents have been recorded in the Bahamas, but an emission of noxious gas in Freeport, Grand Bahama, resulted in the relocation of a school that was near the industrial site. During 1996 a fire in an old oil holding tank of the Bahamas Oil Refinery in Grand Bahama caused some concern. Although the fire itself was contained, residents worried about the potential for air pollution.

RESPONSE OF THE HEALTH SYSTEM

National Health Plans and Policies

The Government of the Bahamas subscribes to the internationally accepted principle that health is a fundamental human right, not a privilege, and to the view that quality health care must be universal in its application. There is full commitment to the global goal of "health for all," and community participation is accepted as a vital element of the health strategy. The people of the Bahamas already enjoy universal access to health care. However, the production of health services is inconsistent with the level of per capita government expenditure on health. The monitoring, evaluation, coordination, and planning of services need to be improved. Therefore, current emphasis is on upgrading managerial capacity, quality of care, and intersectoral coordination for development of local health systems. In this context, much attention is being paid to the development of human resources, establishment of norms and standards, and the strengthening of not only information systems but also the capacity to make effective use of them for planning, evaluation, and monitoring.

The Bahamas is experiencing a shift in its epidemiologic patterns away from deaths due to communicable diseases and toward those caused by chronic noncommunicable diseases, AIDS and AIDS-related complex, and accidents, violence, and poisonings. These changes, coupled with increasing health care costs, have served to highlight the importance of health education and promotion as a vital component of the health care system.

An important adjunct to the maternal and child health program is the establishment of an adolescent health care program. This program involves intersectoral collaboration between the several ministries. As an initial phase, a clinic for adolescents has been established at one of the comprehensive clinics on New Providence. The purpose is to promote healthy lifestyles in boys and girls, to reduce teenage pregnancy, and to encourage community-based services for adolescents. There is now a Minister of State for Youth, Sport, and Culture to give continued emphasis to youth issues since April 1995.

The Ministry of Health has formulated a National Family Planning Policy, which was mandated by the Cabinet following the Caribbean subregional follow-up meeting (hosted by the Bahamas) to the UN International Conference on Population and Development (ICPD). This policy is seen as a priority within the overall health policy, which aims "to improve the quality of, and provide the opportunity for a productive life for every Bahamian . . ." The policy stipulates that all members within a family should have access to information and services that empower them to enrich their quality of life.

A major NDC program aimed at demand reduction is well under way. Substantial support for this program was obtained under a special project funded by the United Nations International Drug Control Program. This project emphasizes the following demand reduction plans over the next three years:

community prevention,  prevention education, treatment and rehabilitation.

The Ministry’s recent decision to undertake a National Family Health Care Initiative, which will incorporate a mental wellness component (with emphasis on preventing family violence and coping with stress), will help solidify a comprehensive mental health program.

The HIV/STD 1993–1996 Medium-Term Plan II (MTP II) fostered a supportive social environment for the effective implementation of risk reduction and behavioral interventions directed toward vulnerable populations: young people between the ages of 10 and 19 years, females of childbearing ages, persons with multiple partners, pregnant women, incarcerated populations (past and present), and blood donors. All of the aforementioned groups include persons from the Creole community.

In response to growing dissatisfaction with the erratic availability and the high cost of pharmaceuticals to the public sector, the Ministry put in place a system of procurement and distribution of pharmaceuticals to ensure the population’s access to essential drugs. The Bahamas Drug Agency was established in 1994 to address these issues as well as the development and maintenance of the pharmaceutical formulary for the country.

The Ministry has extended basic laboratory services to selected Family Islands, including services to facilitate the diagnosis of STDs. The laboratories at the Princess Margaret and the Rand hospitals participate in several WHO quality control programs and make full use of the facilities of the Caribbean Epidemiology Center for monitoring of blood bank and transfusion services.

The 1995 data on water supply indicated that 88% of houses in urban areas were connected to the drinking water supply system, while another 8% of urban houses had reasonable access to water. The situation was reversed in rural areas, where 86% of houses had reasonable access to water but no indoor connections. In contrast to the water supply situation, only 16% of houses in urban areas are connected to a public sewer, but the remaining 84% have adequate on-site excreta disposal. In the rural areas, 100 % of the houses have an adequate on-site excreta disposal system. In addition, regular collection of solid waste is provided to nearly all (99%) of the houses in urban areas, but to none in rural areas.

In terms of human resource development, particular attention is being paid to the areas of maternal and child health, the health inspectorate, disease surveillance/epidemiology, hospital administration, program management, and project design and management. The Ministry recognizes that adequate human resource planning, coupled with development for health professionals and staff at all levels and in all areas, is a key to success.

Other Ministry programs include strengthening of the health information system and infrastructural development of hospitals and community clinics.

Health Sector Reform

In keeping with Region-wide developments related to changing national health systems, and as a part of the overall public sector reform efforts, the Bahamas’ focus for health sector reform is on issues of modernization and decentralization; the organization and operation of services; complementarity with the private sector; and rationalization of human and financial resources.

Devolution of Hospitals. The decision to devolve the management of hospitals resulted from a determination that highly centralized government bureaucracy militates against the efficient and effective operation of the hospitals. The long-range goal is the establishment of a hospital corporation, directed by a board that will be responsible for the executive management and direction of the corporation. Some services within the hospital have already been privatized and the decision taken to contract out selected services.

Selective Privatization. Selective privatization grew out of the need and desire of Bahamian physicians to deliver quality health care to all residents of the Bahamas, in both the private and public facilities. The central feature of selective privatization is the relationship between the management of the Princess Margaret Hospital and a private entity, the Physicians Alliance. Through this partnership, the Physicians Alliance provides capital for the purchase of equipment and for the renovation of the facilities and is responsible for equipment selection, transport, installation, maintenance, and replacement. In addition, the Physicians Alliance is responsible for employing the clerical and administrative staff, managing the service, and paying the technical and medical personnel.

The Princess Margaret Hospital contributes the physical plant, staff for renovation of facilities, housekeeping and security staff, and funds for utilities payments and customs duties on imported equipment and supplies. The other feature of the partnership is the equal sharing of any profits between the Physicians Alliance and the Princess Margaret Hospital. The policy of the Alliance is that indigent patients are not denied service. Fees for public patients are much lower than those charged in the private sector; fees for private patients, while higher, are set at competitive rates and are still significantly lower than the fees charged in the private sector.

Development of Local Health Systems. The concept of a local health system was first realized on Grand Bahama in 1985, when all the health services on the island were brought under one administrative umbrella. This arrangement afforded the maximum utilization of hospital-based skills, to the advantage of the entire system, and allowed for a two-way sharing of resources. During 1993–1994 this system was evaluated and a study was done to assess the feasibility of implementing a similar system in the Family Islands. As a result, a modified form of the system was introduced on the islands of Andros, Eleuthera, and Long Island. These islands are divided into health districts, each with its own health team. This system has not only brought the management of the services closer to the population being served, but has also facilitated the sharing of resources between districts. With the establishment of local government during 1996, it has become necessary to find ways to manage the health system within the mandates of local government to the benefit of the population. The phased extension of the system to other major Family Islands is proposed.

Organization of the Health System

Government Sector. In April 1997, following elections, responsibilities within the public sector of the health system were reordered. The Ministry of Health has overall responsibility for ensuring the health of the nation. It discharges this responsibility through establishing national policies and strategic plans for personal health; providing public services and facilities to support these interventions; and ensuring that public health regulations and activities for disease control and health promotion are maintained.

The Ministry is headed by the Minister of Health, who is assisted by a Parliamentary Secretary with specific responsibility for updating health legislation. The administrative structure is managed by the Permanent Secretary, and the technical head is the Chief Medical Officer. The senior technical directorate is completed by the Chief Hospital Administrator and the Director of Nursing.

The service areas and programs of the Ministry that fall directly under the purview of headquarters management include the Health Education Division, the AIDS Secretariat, the National Drug Council, Materials Management, the National Drug (Pharmaceutical) Agency, the Human Resources Development Unit, the Health Information Coordinating Unit, and the Health Planning Unit.

Hospital Services. The public sector operates three hospitals, the two largest of which are located on New Providence. The Princess Margaret Hospital, with 436 beds, provides general acute and specialized services including intensive care, hemodialysis, cardiology, and urology. The Sandilands Rehabilitation Center provides both psychiatric/mental health care on an inpatient and outpatient basis (352 beds) and geriatric care (130 beds). The third institution, the Rand Memorial Hospital, is in the nation’s second largest city, Freeport, on Grand Bahama. It provides general acute care as well as basic levels of specialized services, and has a bed complement of 82.

Public Health Services are delivered through a network of 57 community clinics and 54 satellite clinics in New Providence and the Family Islands. They also encompass community-based programs such as home and district nursing, disease surveillance, and home-based rehabilitation. The management team in this area consists of an Administrator, Medical Staff Coordinator, Principal Nursing Officer, and Medical Officer of Health. There is a unit specifically responsible for coordinating service delivery to the Family Islands. Public health services include general practice, maternal and child health, and dental health.

Environmental Health Services. The environmental concerns of the Ministry are managed by the Department of Environmental Health Services (DEHS), whose functions are conducted through three divisions: the Health Directorate, Environmental Monitoring and Risk Assessment, and Solid Waste Collection and Disposal. The management team comprises a Director, Deputy Director, and the Assistant Directors responsible for the three divisions. In April 1997 this department was transferred from the Ministry of Health to the Ministry of Consumer Affairs and Aviation.

Since the Bahamas is heavily dependent on the tourism sector for its economic survival, sustained tourism development is vital. The Government has established the Bahamas Environment, Science, and Technology Commission (BEST) within the Office of the Prime Minister to address the issue of sustainable development.

Areas of environmental concern include pollution from automobiles, solid waste management, protection of the natural environment, coastal zone pollution, drinking water supply, and sewage disposal. Legislation. Health legislation has not kept pace with the health care industry, technological advances, or the many environmental concerns that currently confront the country. New categories of staff and new types of facilities, especially within the private sector, need to be accommodated. Current legislation only covers the registration of doctors, nurses (including midwives), and dentists. Top priority is being given to laws governing the registration of pharmacists and laboratory technologists, and work has begun on laws pertaining to such disciplines as X-ray technology, optometry, podiatry, chiropractic, and physiotherapy.

Private Sector. The private sector provides primary care services, emergency services, secondary inpatient care, and specialized clinical, diagnostic, and treatment services in both the medical and dental fields. There are two private hospitals providing secondary care. Doctor’s Hospital has 72 beds and its services include emergency care, specialized medical care (including rheumatology and nephrology), surgery (including cardiovascular and neurosurgery), obstetrics, and diagnostic services (including nuclear medicine). The other private hospital, Lyford Cay, has 12 beds. It provides specialty services in cardiology, plastic surgery, urology, and podiatry. In addition, a number of private practices have birthing facilities but are not classified as hospitals.

Specialized ambulatory services are available in the areas of cardiology and nephrology. The Bahamas Heart Center offers a full range of cardiac evaluation techniques, including nuclear stress testing and cardiac catheterization. Pacemaker implantation is also available. Renal House offers kidney dialysis.

There is no national health insurance scheme, but the National Insurance Board provides medical benefits for job-related injuries and illness. Partial salary replacement is provided during illness, as well as paid medical care for industrial injuries. Other benefit types include maternity, disability, and death. In addition, provision is made for invalidity, retirement, and survivor’s benefits. Several options for health and dental insurance are available through the private insurance system.

Health Services and Resources

Health Resources

Human Resources. The Bahamas is well supplied with physicians and dentists. Doctors increased from 373 (14.13 per 10,000 population) in 1992 to 417 (14.98) in 1995, and dentists from 58 (2.2 per 10,000 population) in 1992 to 80 (2.9) in 1995. In terms of distribution, 235 physicians were in government service and 182 (excluding consultants) were in the private sector. Consultants work in both the private and government sectors. Less than 20% of the physicians in public service are assigned to Community Health Services. Of the 80 dentists in the country, 21 are in government service, 6 to the Community Health Services and 59 in private practice. The number of registered nurses in the government service increased only slightly between 1989 and 1995 (from 623 to 653). Twenty per cent of graduate nurses and 15% of the trained clinical nurses (TCNs) are assigned to Community Health Services. There is no medical or dental school in the Bahamas.

Most national doctors and dentists are trained at the University of the West Indies or in North America. As of April 1997 the Bahamas Government entered into an agreement with the University of the West Indies, whereby the Princess Margaret Hospital and community health facilities will provide clinical experience to medical students from the University.

Nursing training is carried out at the College of the Bahamas. The nursing department offers a program in midwifery, an associate of science degree in nursing, a continuing education program, and, since 1995, a bachelor of science degree nursing program for registered nurses. The Health Sciences Department of the College of the Bahamas offers an associate’s degree in environmental health. An associate of science degree in health sciences, with options in medical technology, pharmacy, occupational health, and physiotherapy is presently being developed.

Expenditures and Sectoral Financing

The national health expenditure by the Government has shown a steady increase since 1970, mirroring the increase in the total national recurrent expenditure. The percentage of the total government expenditure devoted to health increased from 10.8% in 1970 to 15.6% in 1986. Since that time, the proportion has fluctuated and has tended to fall; in the 1995–1996 budget it amounted to 13.6%. Nevertheless, because of the strengthening of the national economy, the actual amount spent has increased. The distribution of expenditure between the different divisions of the Ministry has remained fairly constant, with approximately 15% going to administration, 65.5% to hospitals, 8% to environmental health, and 11% to community health services. It is not possible to determine how much is spent on preventive as opposed to curative services, since both types of services are provided through the public health system. The financial resources for health provided by the central government come from the consolidated fund. In addition, limited amounts are obtained from inpatient charges and fees for clinical and diagnostic services.

In addition to medical benefits, the National Insurance Board has provided funding for the construction of 11 health facilities on New Providence and five of the Family Islands, and another 5 are under construction.

The out-of-pocket expenditures of families for physician’s fees, medications, diagnostic services, and private health insurance contribute to private sector resources. The IDB has estimated that private health expenditure amounts to 2.2% of GDP and 45.6% of the total health expenditure in the country.

Several nongovernmental organizations provide health services of one kind or another. Some of these organizations take an active part in government-sponsored health programs. Notable among these are the Cancer Society, Crippled Children’s Committee, AIDS Foundation, Family Planning Association, Crisis Center, and Diabetic Association. Other organizations exist in the areas of drug abuse and care for persons living with AIDS.