Bermuda’s political structure has changed as the United Bermuda Party is now in power. However the Government’s commitment to the delivery of a good health service continues. This is highlighted by the Total Quality Management philosophy in health care. A health Insurance Scheme has been established, which provides nearly universal coverage. However, the Government has been having difficulties in its delivery of health care due in part to budget constraints. A Women’s hospital auxiliary program gives financial and welfare support to needy areas.

As a British dependent territory Bermuda receives support from Britain. The Bermuda dollar (BD$) is tied to the US dollar on an equal basis and inflation is estimated at around 2.6% per annum. The country generally shows a small balance of payments surplus. In 1991, the median annual household income was US$40,588. The consumer Price Index in 1993 was 142.7 representing a +2.5% change on previous year. Greatest gains in employment in terms of jobs have been made in the hotel and restaurant industry in 1995. Banks, Insurance and Business Services follows in second place. GDP 1992/93 at market prices was ($M) 1,697.6 - GDP 1992/93 at constant prices was ($M) 490.1. Public Finance, Capital Expenditure totaled $51.8 in 1993. Current expenditure for salaries and wages was $182.0, other goods and services were $79.7 and grants and contributions $64.3.

Bermuda’s population in 1995 was 59,807. According to the 1991 Census, there were 22,430 households on the island. This represents a shift from multiple family member household to smaller households with an average number of persons per household of 2.6 in 1991. Fifty-two percent of the population are female and 48% male. The percentage of population under 15 years of age, 19.7% has declined, while 9.8% were 65 years and older in 1995. The racial composition has not changed significantly over the past decade. In 1991, the population was comprised of blacks, 58% and whites, 42%. Population density was 3.2 per square mile. In 1995, life expectancy for females was 78 years compared with 70 years for males. The crude death rate in 1995 was 7.7 per 1,000 population. Fertility has declined since the 1970s. The general fertility rate in 1995 was 66.6 per 1,000, the birth rate 14.0 and the infant mortality rate 3.6. The country is largely urban. Hamilton is the capital of Bermuda. The central and western parishes include Paget, Warwick, Southampton and Sandys, usual referred to as Somerset.

Education is free in public schools and compulsory up to the age of sixteen. The literacy rate has been estimated at 97%. Living standards are high, with good housing and well developed communication systems. Roads are of a good standard and there is a well developed public transportation system. Private car ownership is high although restrictions limit this to one vehicle per household. 100% of the population has safe drinking water available in their homes, as well as an hygienic waste disposal system. Efforts to address the issue of racism has been addressed in fora such as Racism awareness workshops for hospital staff.

Most food supply for Bermuda is imported from the USA as the country has no natural resources of its own, agricultural or otherwise. With the sound economy of the country, poverty and its accompanying ills such as malnutrition is minimal. Obesity is a public health concern in the 5-9 year old group. Oral health in children is generally excellent. This is largely attributed to a preventive dental care program for infants and children, that provides free fluoride treatment. The voluntary school based program has maintained high participation levels.

Statistics are not available for trends of teenage pregnancies and abortions. However family planning clinics exist for those who need it. Alcohol consumption is a problem. Accidents were the leading cause of death in this group in 1995 and one of the major causes of hospital admissions along with pregnancy and respiratory diseases. No data is available on smoking and other substance abuse.

In the area of environmental health, regulations are enforced under the Public Health Act to ensure the safety of workers in the buildings where they work. Vector control has been successful since 1992.

Water quality in Bermuda is good, 100% of the population has safe drinking water as well as a hygiene waste disposed system. The Department of Health serves as a regulatory agency and monitors food safety, water and air quality and has been effective in this area.

In general, human resources for the provision of health services are adequate. There are 94 physicians in active practice on the island providing 15.7 physicians per 10,000 population in 1995. Nurses represent the largest group of health care providers in the country; there were 689 licensed nurses, including registered nurses, enrolled nurses and psychiatric nurses in 1995. Registered nurses constitute over 75% of the nurses on the island. The greater percentage of nurses are hospital based. There are 27 dentists in active practice; five are in the public health service. There are 4.6 dentists per 10,000 population. Most private dentists are in solo practice. Specialized dentistry, i.e. periodontics, orthodontics, etc. is available. Health care providers such as nurse midwives are registered but do not provide independent care. There are a variety of allied health personnel including: physiotherapists, speech-language pathologists, nutritionists/dietitians, medical lab technologists radiographers, occupational therapists. There are 38 pharmacists who provide a range of services from retail pharmacy to clinical pharmacology. Most pharmacists are employed on a salaried basis.

Primary health care services are delivered from private physicians offices, government health centers and hospital outpatients clinics. Additional ambulatory care services are provided through specialty clinics and the emergency room at the hospital. A significant proportion of primary health care is delivered through the private sector. The majority of physicians and dentists are independent, private practitioners. Most other health care providers are employed on a salaried basis by the hospitals, the public health service or by private physicians.

The majority of physicians are self-employed and in solo practice. There are a small number of multi-specialty group practices and a limited number of partnerships involving specialists. Salaried physicians are found in the public health service and in the hospitals. Primary care physicians constitute 50% of all physicians in active practice. General practitioners and other primary care physicians coordinate care and control access to other specialists. Access to primary care is generally available on demand. Office visits are a major portion of physician patient contact. Almost all physicians have admitting privileges at hospitals.

Responsibility for providing public health services rests with the Department of Health. It is mandated to provide disease prevention and control, and health promotion services. It serves as a regulatory agency, and monitors food safety, water and air quality. It also provides for a variety of public health services including personal health and dental health as well as environmental health services. The public health service provides personal health services and administers a number of traditional public health programs including: maternal and child health, school health, immunization, communicable disease control, as well as home health care, rehabilitation, health education and health promotion programs. Services are provided across socioeconomic lines and are facilitated by the division of the island into three health regions. The department operates a health center in each region. These centers offer antenatal care, family planning services, immunizations, child health and other primary care services, as well as dental clinics for children.

Private voluntary agencies assisted by Government provide some specialized services, (i.e. community based oncology nursing, personal services for HIV infected persons, etc.)Training of health personnel is a priority and PAHO/WHO through its Technical Cooperation Program provided training on annual basis in management, public health nursing, food technology and geriatrics.

2. Financial Resources For Health

The total expenditure for the Government in 1995-1996 was $390.4 million an increase of 6.8% over the revised figure for 1994-1995. From this amount, current account expenditure in thousands of dollars for the period 1995-1996 were: Ministry of Health, Social Service and Housing HQ, $670, Health Department, $10,133 and Hospitals, $46,242. Sources of financing for health include taxes, grants from international agencies such as PAHO and the Overseas Development Assistance Program. The health care system is financed through a variety of mechanisms. Health services are either paid through an insurer, by the government agency or by consumers. There is no universal, publicly funded health insurance. Hospitalization insurance is mandatory for all employed and self-employed persons. Both employers and employees contribute to hospitalization insurance; employers must contribute 50% of the premium costs. Insurance coverage is nearly universal; Administration of Hospital Insurance is provided through the Hospital Insurance Commission. Insurance sold by private companies and public agencies is regulated through the Commission, and must provide mandated, minimum benefits (the Standard Hospital Benefit). Health insurance schemes are provided through private companies, public agencies and employers. Government employees are insured through the Government Employees Health Insurance Scheme, while several major employers operate approved schemes to cover their employees. The Hospital Insurance Commission operates a health insurance plan as well, which has an annual enrollment period designed to ensure access to health (hospitalization) insurance for all residents. A Mutual Reinsurance Fund covers dialysis, kidney transplants, diabetes education and counseling, anti-rejection drugs, hospice care and long-stay (in-hospital) patients. It is funded by a levy on all health insurance premiums collected. The fund is administered by the Commission. Hospitalization is provided free-of-charge to children and the elderly; this is covered through a Government subsidy to the Bermuda Hospitals Board. These subsidies are also administered by the Commission. Public health services are generally free, or provided at modest cost and funded through general revenues. The prevailing method of payment for doctors and dentists is fee-for-service. There are no government controls on physicians fees; however a fee schedule for hospital based physician services is established on an annual basis by agreement between the Bermuda Medical Society and the Health Insurance Association of Bermuda. Government determines overall increases in hospital fees, regulates the acquisition of major equipment and service.

The Health Care Facilities of Bermuda are partially funded through public funds. Other sources of funding include donation and fund raising efforts through voluntary auxiliary groups. These long term facilities are operated by the Hospitals Board and the Government. Other existing facilities include a hospice for individuals with AIDS and other terminal illnesses. It is operated by the Hospitals Board and partially subsidized by public funds. There are 11 residential care facilities for the elderly including nursing homes that provide limited nursing care and personal services and domiciliary care homes that provide room and board and limited assistance with personal services. Most of these are partially funded from public sources as are Health centers.

There have been no important negative changes in the availability of essential drugs and supplies. Vaccines are made available through the EPI revolving fund.

Bermuda, as a dependent territory of Britain shares international links with Britain for aid in health. In areas in which specific health services are limited, partnerships exists with other territories. For example, in view of the limitations of a secondary and tertiary referral system regarding hospital services, these are traditional links for the provision of tertiary care with the USA, UK and Canada.

PAHO/WHO also provides support for development of health manpower and health care.

The Minister of Health sets public policy and reports to Cabinet, the Ministry of Health has responsibility for health planning and evaluation. However in November 1995, the Minister of Health appointed a Cabinet Sub-Committee to review Health Care in Bermuda. Issues which impact on equity in health include the high cost of prescription drugs. There is a perception that with one major supplier, drug prices are fixed and should be controlled. Two other major areas which have required urgent review are the care of the elderly and mental health. Consumers are encouraged to be personally responsible in health care decisions through health education.

The relative small size of the country lends itself to intersectional cooperation for the purposes of planning and implementation of health programs. For example the Health Care Review Committee which was established in 1994 is comprised of members of the Health Team, a Consumer Representative and a Statistician form the Department of Statistics. The Quality of Care Task Group also formed in 1994, sought inputs from a cross-section of interests such as the Women’s Resource Center, the Women’s Advisory Council, the Portuguese/Bermuda Organization, the Bermuda Physically Handicapped Association, the Coalition for the Protection of Children, Health Watch and Age Concern.

Primary Health Care functions are well defined in Bermuda. The island is divided into three health regions. The Health department operates a health center in each of these regions. These center offer primary care services which include antenatal care, family planning services, immunizations and child health as well as dental clinics for children. Staff at this level include fully trained Public Health Nurses, midwives, doctors and pharmacists. Patients are referred to North America for tertiary care.

In 1994, committees were established to review the Health Care System and make recommendations in the management of areas such as: Health Care Review, Health Care Financing, Quality of Care, Health Care costs, Health Care Needs Assessment. One of the important areas of legislation affected is Health Insurance which provides coverage for all.

CAREC has provided much assistance to Bermuda in the area of Health Information Systems.

Training by CAREC included: epidemiology, disease surveillance, compilation of statistics and reports of the statistics, use of epidemiology computer software, planning health studies and surveys, interpretation of data, investigation of food outbreaks and water borne illnesses, protocols, investigation of contact follow-up of persons with tuberculosis. Continued training would help.

Community action for health has increased since the last evaluation. This is reflected in the formation of groups which includes members of non Government organizations and who are not members of the team, review issues such as quality care. Community volunteer programs also assist the hospitals in the provision of equipment and supplies. Review of the quality of health care is directed towards receiving the strategy for health for all.

In 1995, Bermuda completed a Health Disaster Management Work Plan, which is evident of the Governments commitment to having an efficient health sector in disease situations. Various activities were planned in cooperation with the Emergency Preparedness and Disaster Relief Coordination Program. The location of Bermuda as a Caribbean Island means that it has to be on the alert for effects of tropical storms on an annual basis.

Health research is a priority area and subcommittees were established in 1994 to collect data on formulating discussion aimed at improving health care delivery. In addition, as part of a CARICOM initiative, the Institute of Social and Economic Research of the University of the West Indies requested Bermuda’s cooperation to provide data on sharing of health services, current utilization patterns and other options. A main constraint is the absence of a unit to conduct overall research.

PAHO/WHO has supported training of staff in the area of health promotion with an intersectional local workshop in Jamaica. Health Promotion activities have included education on HIV/AIDS, maternal and child health, and nutrition. School age children and youth have been targeted for programs related to nutrition and HIV/AIDS. Insufficient trained staff is a main constraint in the implementation of Health Education/Promotion programs.

In 1995, there were 3 deaths of infants and the infant mortality rate was 3.6 per 1,000 live births. The main causes of death were congenital anomalies and conditions originating in the perinatal period. For infants, respiratory diseases were the leading cause of hospitalization. For children 1- 14 years old, the leading causes were respiratory diseases and accidents. In general, maternal and child health indicators are good. Maternal morbidity and mortality continue to be low. In 1995, over 95% of pregnant women received prenatal care. 97% were fully immunized against tetanus and all births took place in hospital and 7% of newborns had a birth weight of 2,500 grams or less. In the area of adolescent health, programs for responsible parenthood are implemented in schools and with non government youth groups.

The incidence of vaccine preventable diseases is low. Immunization against all five of the common preventable childhood diseases (measles, rubella, DPT, polio and mumps) have been maintained at consistently high levels. Reported cases of mumps and measles declined considerably after the introduction of the triple vaccine MMR in the 1980s. Immunization against H influenza was introduced in 1990.

Through Caribbean Cooperation in Health Initiative, most countries in the Caribbean have been involved in the implementation of a Vector Control Project aimed at eradicating diseases such as Dengue and other vector borne diseases. Although Bermuda is not a participating country in this initiative, the country has implemented its own successful course of action. Support has been given by PAHO/WHO for the training of Environmental Specialists. Programs of surveillance have also been implemented and laboratory facilities are available for effective diagnosis of diseases.

Malaria has been eradicated from Bermuda. Diseases such as respiratory infections (ARI), and diarrhea are being adequately managed, both at the community and health facilities levels. For infants, respiratory diseases were the leading causes of hospitalization. For children 1-14 years old, the leading causes were respiratory diseases and accidents. In youths 15-19 years old, accidents were the leading cause of death and one of the major causes of hospitalization admissions along with pregnancy and respiratory diseases. Oral Health in children is generally excellent. This is largely attributed to preventive dental care Program for infants and children, that provides free fluoride treatment. The voluntary school based Program has maintained high participation levels. Obesity is a public health concern, but approximately 90% of the children in the 5-15 years old age group have correct weight for age. Management of non communicable diseases such as cardiovascular diseases, cancer and diabetes are adequately managed at the health care level and their risk factors are modified both at the community and health care level. Neither distance, age, gender or income are barriers to health care. However, one constraints is recent financial cutbacks.

In 1995, life expectancy for females was estimated at 78 years compared with 70 years for males Although life expectancy at birth has continued to improve, the difference between the sexes has widened.

Mortality patterns have remained relatively stable and mortality rates for the population as a whole have not changed substantially. The crude death rate was 7.7 per 1,000 population in 1995. Between 1992 to 1995, the crude death declined from 7.2 to 7.5. The infant mortality rate fluctuated - due primarily to a small population - from 8.8 per 1,000 live births in 1992 to 3.6 in 1995 after increasing to 9.9 in 1993 and 12.2 in 1994. In 1995, the 0-4 age group consisted of 4002 children, of which 2,000 were males and 2062 were females. The number of deaths for this group was 14 in 1992 and 16 in 1994. Thirteen (13) of the deaths in both years were due to conditions originating from the perinatal period. Deaths from vaccine preventable disease are negligible.

Mortality increased in the population 25-44 years old, between 1996 and the present due primarily to AIDS and HIV infection, particularly in males. The leading cause of death in 1995 for persons 25-34 years old was accidents. AIDS was the main cause of mortality in those 35-44 years old. To date, of the 339 cases of AIDS recorded, 269 have died. In 1995, there were 22 deaths from AIDS - 19 males and 3 females. Deaths from chronic diseases and cancer are a concern. One of four deaths in 1993 was from cancer. Rates increases are primarily a result of increased deaths from cancer of the breast and the lung. In 1995, the leading causes of death were: Malignant Neoplasms (ICD 140-208) with 117 deaths (46.5% female) Ischemic heart disease with 106 deaths (45.3% female) Cerebrovascular disease (430-438) with 43 deaths (53.5% female).

The major current health problems for Bermuda include cancer, ischaemic heart disease, cerebrovascular disease (stroke) HIV infection, AIDS, and motor vehicle accidents. In 1992, there were 7 reported cases of tuberculosis. Incidence rates for sexually transmitted diseases have not altered significantly over the past five years. Rates of reported cases of syphilis, chlamydia and non specific urethritis have increased slightly. For infants, respiratory diseases were the leading cause of hospitalization. For children 1-14 years old, the leading causes were respiratory diseases and accidents. In youths 15-19 years old, accidents were one of the major causes of hospital admissions along with pregnancy and respiratory diseases. The incidence of vaccine preventable diseases is low. Immunization coverage against all five of the common preventable childhood diseases have been maintained at a high level. Reported cases of mumps and measles declined considerably after the introduction of the triple vaccine MMR in the 1980s. Decreases in the incidence of dental decay have been dramatic over the past decade and oral health in children is generally excellent. This is largely attributed to a preventive dental care program for infants and children that provides free fluoride treatment. The most important causes of morbidity in the age group 25-64 years are chronic diseases, accidents and violence. The major causes of hospital admissions for adults age 25-44 years included childbirth and accidents. For those aged 50-64 years, diseases of the circulatory and digestive systems and cancers are the leading causes. In 1995, over 95% of pregnant women received prenatal care and 99% were fully immunized against tetanus. All births took place in hospital; 7% of newborns had a birth weight of 2,500 grams or less.

To reduce the impact of disability, policies are in force to enable disabled persons to remain independent as long as possible. However, data on disabilities are not available. In the area of mental health, occupancy in the rehabilitation wards was reduced in 1993 by 8.6% over the previous year while the occupancy of the community care beds increased by 100%. This shows the shift being made in community care. The child and adolescent unit has been increasing at a phenomenal rate. In 1993, an average of four new referrals were seen per week with an increase of 23% over the previous year. The follow-up visits by psychiatrists and other professional staff increased by 13% from 1993 to 1994.

The overall health status of Jamaica is good and similar to that of any developed country.

Government health policy emphasizes several areas including: maternal ANC child health, health of the school-age, community nursing for the elderly, dental health, control of communicable diseases, mental health, and alcohol and drug abuse. Targeted population groups include mothers and infants, school-age children, and the elderly. Public policy on health is based on: 1) Government should be provider of last resort, but should serve as the guarantor of public health; 2) All residents should participate in determining the priorities of the health care system; 3) Individuals, the community and the government share responsibility to maintain the public health and assure conditions to improve health status.

Primary health care services are delivered from physicians offices, government health centers and hospital outpatients clinics. Additional ambulatory care services are provided through specialty clinics and the emergency room at the hospital. A substantial proportion of primary health are is delivered through the private sector. The majority of physicians and dentists care independent, private practitioners. Most other health care providers are employed on a salaried basis by the hospitals, the public health service or by private physicians. There are no health maintenance organizations (HMO); independent practice associations (IPA); or preferred provider organizations (PPO’s). There are no provisions for pre-paid medical care.

There are a small number of multi-specialty group practices and a limited number of partnerships involving specialists. The majority of physicians are self-employed and in solo practice. Salaried physicians are found in the public health service and in the hospitals. Primary care physicians constitute 50% of all physicians in active practice. General practitioners and other primary care physicians serve as gatekeepers and co-ordinate care and control access to other specialists. Access to primary care is generally available on demand. Office visits are a major portion of physician patient contact. Almost all physicians have admitting privileges at the hospitals.

The Department of Health is mandated to provide disease prevention and control, and health promotion services. It serves as a regulatory agency, and monitors food safety, water and air quality; and provides personal, dental and environmental health services. Personal health services include: maternal and child health, school health, immunization, communicable disease control, as well as home health care rehabilitation, health education and health promotion programs. The delivery of public health services is facilitated by the division of the island into three health regions. The department operates a health center in each of these regions, which offer antenatal care, family planning services, immunizations, child health and other primary care services as well as dental clinics for children.

There are two acute care hospitals on the island with 234 total beds and a psychiatric hospital with 166 beds. Both hospitals are operated by the Bermuda Hospitals Board which is appointed by the Government. There are no private hospitals on the island. The general hospital services include: Medicine, Surgery Pediatrics, Obstetrics and Gynecology, Rehabilitation and Geriatrics. In addition, the general hospitals provide some specialized and intensive care services, including oncology, medical and surgical intensive care, and renal dialysis. A neonatal care unit is being developed. Both hospitals undergo periodic accreditation reviews by the Canadian Council on Hospital Accreditation. The average length of stay at the general hospital was 8.7 days per admission in 1993; this has remained stable for several years. Average occupancy was 75% and there were 63,905 patient days. There are no urgent care or freestanding outpatient surgery centers. Outpatient surgery is provided through the hospital. There were over 29,238 patient visits to the Emergency Room in 1993. In addition to its specialty, ambulatory care clinics, the general hospital operates a primary care clinic for indigent patients. There are no secondary, or tertiary referral hospitals on the island. However, there are traditional links for the provision of tertiary care with the USA, UK, and Canada. Funding for the hospital is provided through a variety of mechanisms, including: insurance and Government subsidies. The Government provides an operating grant to the psychiatric hospital.

St. Brendan’s provides care and treatment for both mentally ill and mentally handicapped individuals. The hospital operates a day hospital, an outpatient clinic and provides community based services. It maintains a half-way house and is developing additional supported facilities in the community. With the exception of the psychiatrist in private practice, all of the consultant psychiatrists on the island are employed by the Hospitals Board on a salaried basis.

Long-term care facilities are operated by the Hospitals Board and the Government. Skilled nursing center facilities provide 147 beds. A facility was opened in 1991 to provide care for individuals with AIDS and other terminal illnesses. It is operated by the Hospitals Board and partially subsidized by public funds. There are 11 residential care facilities for the elderly including nursing homes. Most of these facilities are partially funded through public monies.

In response to community concerns about escalating health care costs and the quality of health care, a comprehensive review of the health care system was initiated in 1993, involving all care providers. The review focused on four major areas: health care costs, financing, quality and needs assessment. The family physician will probably continue to be the gatekeeper for access to secondary care. However, more formal arrangements with preferred providers in the USA and Canada for tertiary care and some secondary care are expected. Insurers are facing increased pressure to expand coverage and increase benefits, particularly for the treatment of addictions and preventive services. Both the Public Health Service and the Bermuda Hospitals Board have focused on the development of additional ambulatory and community-based services, and greater integration of existing community services, particularly for the elderly. There are already expectations that these services should be funded through insurance.

Strategies defined for future national health development are:

• To promote equity in health care, a review of health costs and their containment are recommended.
• To strengthen health promotion and protection through increased community involvement and focusing consumers on continuous quality improvement efforts within the health care system.
• To develop and strengthen programs for the elderly and provide additional ambulatory and community based services and programs, including ongoing evaluation of the effectiveness of mental health, long-term care, maternal and child health, emergency and pre-hospital care, palliative care, health promotion and disease prevention.
• To apply appropriate health technology including computer technology for planning and evaluation.
• To strengthen international partnerships with PAHO/WHO by requesting more technical assistance.