Over the period of the evaluation, the Commonwealth of The Bahamas continued as an economically sound and politically stable nation of the British Commonwealth. The current 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 to education, health and housing. The government subscribes to the internationally accepted principle that health is a fundamental human right and 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. The people of this country already enjoy universal access to health care and basic services are available, regardless of ability to pay. The concept of community participation is accepted as an extremely vital element of the philosophy for health. New national policy priorities which have influence on the Bahamas’ HFA initiative include: the introduction of Local Government in the Family Islands in 1996 -setting the tone for Family Islands development to be directed by the needs and desires of the people who reside there; infrastructural expansion to remote communitites; priority access to radio and television; improving community health services access; establishment of the Bahamas Environment, Science and Technology (BEST) Comission; devolution of public hospitals away from the central control of the Ministry of Health; development of local health systems; and, the national family planning policy.

2.1 Economic trends. The Bahamas continues to experience economic growth, with the overall performance of the GDP steadily increasing, in spite of the increases in the national external debt. The economic recovery from the 1991/92 recession, which started in 1993, has continued, and output grew by 1% in 1995. As of 1992, the GDP per capita stood at US$ 11,588 and the GNP was US$ 11,023. Tourism and tourism related commerce constitute by far the main economic activity of the country, and accounts for over 50% of the GNP and 60% of employment. Overall unemployment rate in 1996 was estimated at 11.5%. While economic levels in the more rural Family Islands will generally be lower than in the two main population centres of New Providence and Grand Bahama, these inequities do not translate into deprivation of health prospects.

2.2 Demographic trends. Between 1980 and 1990, the population growth was of 21.7%, slightly lower than the 23.6% experienced between 1970 and 1980. This decline in the rate of increase can be directly attributed to the steady decline, during the period, in two of the three components affecting changes in population, i.e., birth and migration rates. The total fertility rates for the Bahamas decreased by 21.8% between 1980 and 1990 (from 3.22 to 2.52 children per woman). In 1995 the TRF was 2.43 children per woman, the crude birth rate was 22.5 per 1000 population, and the crude death rate was 5.7 per 1000 population. Fertility is lower now than earlier years among virtually all age groups. Since 1976 the number of live births to females 15-19 years of age has decreased steadily, from about 124 live births per 1000 females to about 60 live births in 1995. Approximately 15% of all births in the Bahamas are among mothers under 20 years of age; valid data on abortions are not available and therefore not factored into overall fertility trends. The results of the 1990 census revealed a noticiable shift in the age structure of the population: the number of person over 15 years exhibited remarkable growth at the expense of the number of younger persons under 15. While the group under 15 years had an annual growth of 0.2%, those over 65 years had a growth of 3.3% annually, and even more significant was the growth rate of the very old (those over 75 years) which increased 5.3% per annum. An increasingly aging population has implications for overall death rates, disease patterns and health and nursing-home services. Many families are finding that they do not have the capacity to cope with aging and physically dependent relatives in the home. The Bahamas has been slow in responding to and preparing for the increasing demands and needs of the elderly; the government through its Ministries of Health, Social Welfare, Community Affairs in collaboration with relevant NGOs have been in discussions over the last 3 years aimed at developing and adequate nursing home programme. On the other hand, over the last three or so decades the influx of groups of migrants into The Bahamas has translated into demographic changes in a number of ways that impact health, the great impact being on fertility rates: in 1990, non-nationals accounted for 11.5% of the population, but produced 17.2% of the births that year.

2.3 Social trends. During the 1980-90 intercensal period, the school age population of the Bahamas increased by 4%; however, in the age groups needing primary and secondary education it actually decreased by 2% and 1%, respectively. Challenges in the educational sector come from the age groups needing post secondary education and/or vocational training; this group (age 18-24) increased by 18% during the 1980-90 intercensal period. The 1990 census found that the adult population (25 years ond over) was more advanced in terms of educational attainment that of ten years prior. At the primary and secondary levels, there are no significant differences between the number of males and females enrolled in school; however, in terms of post secondary education, more males participate in vocational training programmes than females whereas significantly more Bahamian females receive College or University level education than their male counterparts. The relationship between education and fertility is substantiated by the decrease in the mean children ever born (CEB) of women as the level of educational attainment increases. In 1990, women with the highest level of education (college level) had the lowest mean CEB (at 1,286 per 1000 women) while those with primary or less education had the highest (at 4,417 per 1000 women). Many of the public educational and community development programmes of the ministries of health, education, youth sports and community affairs, housing and social welfare have therefore been targeted.

2.4 Food supply and nutritional status. The bulk of the foods consumed in the Bahamas are imported, which constitutes the main constraint to the food supply as well as the high food prices. Of significance as well is that imported foods are often processed, of low fibre and high in salt and fat content. These features predispose the population to increased risk for chronic non-communicable diseases which have become increasingly prevalent. Chronic dietary energy deficiency or malnutrition of the deficiency-type in children exist at negligible levels in The Bahamas. As of the late 1980s, The Bahamas was one of the nine countries within the Caribbean region reported to have less than 5% of its population under 5 years with undernutrition and there has not been any erosion to this situation since that time. Clinical evidence of iodine and vitamin A deficiencies have not been seen within the past 30 years; however, subclinical levels of these micronutrient deficiencies cannot be ruled out. Anaemia is a public health concern in pregnant women. The most recent data (1995) from government clinics which provides antenatal care to an estimated 80% of pregnant women indicate that approximately 19% of pregnant women have haemoglobin levels 10 gms or less at their first antenatal visit. Maternal and child health services continue to be available without cost at all government clinics and the maternal and child health strategy has been better targeted. Under the infant mortality reduction programme there is the lactation management project, which aims to improve the nutritional status of infants through breast-feeding, as well as the nutrition education for teen mothers project, targeted to improve the nutritional status of teenage mothers and their infants up to age five years. The school health services programme continues to provide regular services to school age children; the yearly assessment of all children in government schools in the first, sixth, and tenth grades provides surveillance of the health and nutritional status in this population and allows targeted intervention in at risk groups.

2.5 Lifestyle. While there is an increased awareness of the need for healthy lifestyles, this has not been translated into any significant action by the majority of the population. The chronic non-communicable nutrition-related diseases continue among the leading causes of morbidity and mortality, largely as a result of unhealthy behavior and lifestyle practices, the most notable of which are indiscriminate eating and lack of physical activity. The teenage birth rate remains problematic accounting for approximately 15% of total births in 1994 and 1995. Additionally, there are increasing trends in violence and accidents, particularly in children 5-14 years and males and females 15-44 years. With reference to substance abuse, while new cases of cocaine addiction have decreased, there are disturbing trends in alcohol consumption and marijuana use, especially among youth. HIV/AIDS continues to be a public health problem of significant magnitude and remains at the forefront of the national efforts to reduce the incidence of this disease. The government appointed a consultative committee on youth in 1993, which gave far ranging recommendations on strategies to address identified issues. A locally developed model for promoting healthy lifestyles was tested nationally over a 6 month period in 1993. This initiative highlighted the benefits of physical activity, weight control, tobacco cessation and alcohol reduction, as well as automobile safety and the promotion of seat-belt use. Resource constraints inhibited the continuation of the programme nationally. An adolescent health initiative has been implemented to address various issues including teenage sexual health and violence, introducing in the primary schools a violence prevention programme in 1997. The AIDS Secretariat continues to focus on the promotion of the messages of condom use and abstinence, although the development of messages that are culturally sensitive and appropriate for The Bahamian population is another constraint.

3.1 General protection of the environment. Continued emphasis has been placed upon adequate solid waste management and the control and elimination of pollution, particularly maritime pollution and protection of ecosystems. A comprehensive pre-investment study on solid waste and hazardous materials management has been carried out through an agreement with the IDB, and has resulted in a solid waste master plan, completed in 1996, which recommends, i.a., waste reduction, rationalization of the collection system and sanitary landfilling. Waste generation studies indicated that the total solid waste generation is 2.6 kg/person/day. The government proposes to privatize the collection of commercial waste. Several air pollution monitoring stations to measure particulate matter have been installed in New Providence and Freeport, which together comprise 95% of the urban area, as part of the air pollution prevention and control strategy. Most fuel stations in The Bahamas now provide unleaded gasoline, anticipating a significant reduction of lead in the environment. Concerted public interventions to address the severe overpopulation of stray dogs in the country, the integration of food safety with solid waste management, and accelerate training programmes for environmental health technicians are other areas of concern within the environment which are targeted for action in the future.

3.2 Water supply and sanitation. 96% of urban population and 86% of rural population have access to drinking water, according to 1995 data; 100% of the population, both urban and rural, has adequate access to basic sanitation and 99% of urban population also has regular collection of solid waste. A major concern with regards to drinking water quality is the proliferation of private shallow water wells: especially in residencial and commercial areas, with on site sanitation, the groundwater quality is compromised by nitrates, pathogens and substances related to the commercial activity. Although this well water is mostly used for washing purposes, cross connections have been reported and could affect the potable supply. Use of private wells is discouraged.

4.1 Human resources for health. The Bahamas is well served by physicians and dentists. The number of doctors increased from 373 (14.1 per 10,000 population) in 1992 to 417 (14.9) in 1997. A total of 235 physicians were in the government services and 182 (excluding consultants) in the private sector. The number of dentists increased from 58 (2.2) to 80 (2.9) in the same period. Of these, 21 are in the government facilities and 59 in private practice. With respect to registered nurses, data for the public sector only are available. These figures show that the number of registered nurses in The Bahamas increased only marginally between 1989 and 1995 (from 623 to 653), so the rate per 10,000 population has decreased from 25.0 to 24.1 The number of registered nurse midwives in the public sector is estimated at 220. There are no medical and dental schools in the Bahamas. Nursing training is carried out at the College of the Bahamas (COB); a main problem in the training of nurses at COB is that the programme has not produced the numbers of graduates anticipated. Shortage of qualified applicants has contributed to the deficiency. Overseas recruitment has been undertaken from time to time. A career marketing programme targeting high schools has been introduced in the Ministry of health. Emphasis has been placed on establishing a more attractive conditions of service including improved career paths, for the nursing scale. There is a need for a fourfold increase in trained pharmacists to adequately service the community and rural facilities. A new category of workers being introduced since the last HFA evaluation has been the local health systems executive officers; to date they have been posted to a few selected areas, as a pilot project.

4.2 Financial resources for health. The government of the Bahamas continues to make substantial investments in health; the proportion of the total government expenditure devoted to the Ministry of Health has remained at 14% during this third evaluation period. Government health expenditure per capita was estimated at US$ 350 in the 1994/95 fiscal period. A significant policy decision since the second evaluation has been to establish a Hospital Corporation to be directed by a board which will be responsible for the effective management and direction of the Corporation. This decision was taken because of the recognition that the highly centralized bureaucracy was not conducive to the effective, efficient, and timely operation of the public hospitals. The public treasury will continue for some time to be the major funding source of the hospitals corporation, but alternative means of funding are being explored. While a national health insurance scheme has been discussed, there appears to be no immediate intention of pursuing this route of financing. The selective privatization of certain components in the health care delivery system is being pursued. Primary components of the recurrent health budget include personnel emoluments, which accounts for over 83% of the actual expenditure, and drugs and medical and surgical supplies, which make up over 9% of the budget. There has been no new national action, during the period of this evaluation, to mobilize financial resources for health. However, a number of new policy decisions have been taken in an effort to develop ways to ensure their efficient use to influence health and health status. International aid for health as a percentage of the national health budget has varied from 0.5% to 0.8% anually, with modest increasing trend in recent years.

4.3 Essential drugs and other supplies.

5.1 Health policies and strategies.

5.2 Intersectoral cooperation.

5.3 Organization of the health system.

5.4 Health information system.

5.5 Community action.

5.6 Health research and technology.

6.1 Health education and promotion. A significant number of health promotional activities were undertaken during the third period of evaluation, but due to a fragmented approach minimal tangible impact has resulted. This situation was corrected in early 1997, when the policy decision was taken to integrate the efforts of all areas engaged in health education and promotion. Despite this fundamental organizational constraint, the health education component of programmes primarily within the public health department continued and were intensified in some instances; the lactation management (encouragement of breastfeeding) is noteworthy. The vector control programme based upon behavior changes in the schoolage population has shown some impact. The prevention and control of AIDS programme mantains a strong educational component; the adolescent health initiative has a strong peer counselling educational component. Action has been undertaken to identify and prepare as necessary strong leadership for the health education department, the training of health educators, and the promotion of intersectoral collaboration.

6.2 Maternal and child health-family planning (family and reproductive health). Maternal and child health services in The Bahamas have been reviewed and restructured in keeping with the strategy for HFA. The infant mortality reduction project was launched and received much attention. A major component of this project was to improve the obstetrical management, documentation, record keeping and reporting systems for perinatal information. Emphasis has been placed on management of project/programs, particularly at the peripheral levels. Close monitoring and evaluation of services are on going. There have been on going training programs for all health teams; such programs include neonatal resuscitation workshops and breastfeeding/lactation management for the health care providers, mothers, fathers, siblings and extended family members. Community participation is an integral part of the process and community leaders have been actively involved. Additionally, antenatal clinical protocols have undergone extensive revision and a new document has been distributed nationally. The national family planning/reproductive health programme is one of the subcomponents of the broader family health initiative of the Ministry of Health. A national policy on family planning was formulate to encapsulate the parameters within which the national programme would operate. A four component national programme was developed and has been launched in April, 1997, namely: comprehensive clinical services, training programme, health education/promotion component, and strategies for collaboration between government and non-governmental organizations. A significant constraint to the family planning programme has been in the are of human resources; this impacted upon other maternal and child health programmes.

6.3 Immunization. During the third evaluation period, the level of immunization coverage was well maintained, ranging between 80-90% for the diseases under the espanded programme on immunization. Vaccines continue to be acquired through the PAHO/WHO revolving fund for vaccine procurement. Childhood immunization against tuberculosis, which was discontinued in the early 1980s, has not been reintroduced and epidemiological data supports this policy decision. Two new vaccines have been considered for introduction into the national programme, namely hepatitis B and hemophilus B influenza. The Bahamas has been in the forefront of measles erradication effort and it appeared to be measles free by late 1996. However, one case of measles has been documented in 1997 and the national campaign was intensified. Within the third evaluation period there have been no cases of whooping cough, none of polio nor neonatal tetanus. The national expanded programme on immunization remains one of the most successful health programs, both in delivery and public education. The constraints are mainly due to some compliancy in the community because of the absence and/or small number of cases of the target diseases for almost a decade. There is little ‘institutional memory’ of diseases such as polio and neonatal tetanus in the Bahamas.

6.4 Prevention and control of locally endemic diseases. HIV infection and AIDS continued to present a major challenge during the third evaluation period. In 1994 AIDS emerged as the leading cause of death overall in males and the second leading cause in females. The disease occurs primarily among heterosexuals with a male:female ratio of 1.6:1. During the third evaluation period, the gap between sexes has disminished. Freebase crack cocaine addicts represents approximately one third of cases. HIV/AIDS is intensively addressed through the national programme with the national AIDS secretariat as the coordinating body. Major educational programmes has been mounted; moreover, the policy decision was taken to adopt a unified approach to STD and AIDS control. Malaria and dengue are not endemic in The Bahamas, however, the large number of immigrants from countries where malaria and dengue are endemic increases the risk of these diseases being imported. The vector borne disease will continue to be monitored and the control of vectors and rodents will remain a top priority program in the department of environment. The strategy of community education and participation has been adopted.

6.5 Treatment of common diseases and injuries. Diseases such as diabetes, coronary disease, cardiovascular disease and cancers remain the major cause of morbidity in the adult population. In childhood acute respiratory infections is the major cause of morbidity. In 1993 health promotion strategies were launched directly at encouraging healthy eating patterns and physical activity Actions has already commenced in the development of a food and nutrition policy and programme: national dietary guidelines are being developed by a multidisciplinary, intersectoral committee; a national fitness program is being encouraged, emphasis being placed upon the schoolage section by the population; dietary counselling is being made available in community clinics and in hospital follo-up clinics; risk assessment and intervention programmes are being developed to address diabetes and hypertension. Also of critical concern is the level of trauma experienced by the population, particularly those injuries resulting from acts of violence, ranked as the 4^th leading cause of death in 1995.

7.1 Life expectancy. In The Bahamas, life expectancy at birth has been steadily increasing. Over the last five decades it has increased by 22%, moving from about 60 years in 1950/55 to approximately 73 years by 1990/95 (76 years for women; 69 years for men). Life expectancy at age 65 was estimated (in 1989/91) at 15 years for males and 18 years for females. These increases in life expectancy recorded in The Bahamas are primarily as a result of improvements in economic and human development.

7.2 Mortality. There were 1,604 deaths recorded in The Bahamas in 1995, giving a crude death rate of 5.7 per 1000 population. During the period of this evaluation, the number of deaths and deaths rates have been slowly increasing; the major contributor to this increase has been the AIDS epidemic. Diseases of the heart is the number one cause of death in the general population. 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. Deaths due to injuries continue to be a priority concern. There are singnificant differences in the mortality levels and patterns between males and females. The latest estimate of the infant mortality rate for The Bahamas is 19.0 per 1000 live births in 1995. The national goal is to reduce this rate to 12 per 1000, or below, by the year 2000. AIDS is now a common cause of infant death, along with perinatal conditions and congenital anomalies. Maternal mortality is low, ranging between 1 and 4 deaths annually in the past two decades.

7.3 Morbidity. Morbidity due to diarrhoeal diseases is no longer a major cause of morbidity in early childhood. Illness due to acute respiratory infection is the leading cause of admissions to hospital in this age group. Morbidity due to HIV/AIDS has increased during the period. The reported incidence rate in 1995 was 140.3 new cases per 100,000 population; this represents an increase in the incidence of 63.7% between 191 and 1995. A disease of special interest is foodborne illness; intermitent outbreaks of seafood related illnesses is a continuing concern.

7.4 Disability. There is no estimate of the overall prevalence of blindness in The Bahamas. Blindness due to vitamin A deficiency and other nutritional deficiencies is not a concern. However, visual impairment due to the sequelae of diabetes and cerebrovascular disease due to hypertension is of major concern in both the middle-aged and the elderly. Services for the prevention of disability and for rehabilitation are still inadequate to cope with the increasing incidence of accidents, strokes and other injuries. Various strategies have been adopted at the national level with varying degrees of success. A major constraint is that disability programmes do not receivbe appropriate priority on the health agenda.

8.1 Overall assessment and strategic issues.

8.2 Futures vision.

8.3 Proposed strategies.