Pan American Health Organization

Barbados

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of BarbadosBarbados is the easternmost of the Caribbean islands. The island, which is composed mainly of coral limestone, is 34 km long, 23 km at its widest, and occupies 430 km2. Barbados is relatively flat, except for the Scotland District in the northeast where Mount Hillaby rises to 334 meters above sea level. The island is vulnerable to tropical storm systems originating off the west coast of the African continent, but is also considered to be outside the belt of countries typically affected by tropical storms and hurricanes.

Barbados is one of the most densely populated countries in the world. The mid-year population in 2015 was estimated at 276,633, comprising 48.1% males and 51.9% females. Figure 1 shows population pyramids for Barbados for 1990 and 2015. Total life expectancy at birth was 75.1 years with male life expectancy at 73.1 and female life expectancy at 77.9 years. The total fertility rate was 1.3 children per woman. Important indicators such as the dependency ratio are increasing in Barbados and are expected to continue to rise.

Figure 1. Population structure, by age and sex, Barbados, 1990 and 2015

The country’s population size increased 9.2% between 1990 and 2015. In 1990, the population structure reflected various growth periods, with an expansive structure for age groups older than 30 years of age and a regressive shape for those younger than 15 years old and with widened age groups in between. By 2015, the pyramidal structure moved to ages older than 50 years of age, with a stationary trend in men and a slightly regressive trend in women. Slow growth and an aging population help to account for drops in fertility and mortality.

Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 2015

The literacy rate is 97%. Primary and secondary level education is mandatory and free.

Barbados is considered to be a high-income country (). Its economy is service-based with tourism, international business, and retail trade being the main drivers of economic activity. Vulnerability to external shocks in the financial markets as occurred in 2008-2009 resulted in declining output and an increase in unemployment. The nominal GDP in 2010 () was US$ 3,626.8 million and increased marginally to US $3,971.1 million by 2015 (). Per capita GDP in 2015 was US $15,600. The average rate of inflation rose from 1.8% in 2013 () to 1.9% in 2014 () before falling to 1.1 % in 2015 () (see Table 1).

Table 1. Selected economic and demographic indicators, Barbados, 2011-2015

Indicator 2011 2012 2013 2014(R) 2015(P)
Real growth (%) 0.8 0.0 -0.1 0.2 0.8
Inflation (%) 9.4 4.5 1.8 1.9 1.1
Unemployment (%) 11.2 11.6 11.6 12.3 11.3
Life expectancy (years) 76.8 74.8 75.0 75.0 75.0
Expenditure on health as % of country total 12.1 11.2 11.2 10.6 12.2

Note: Figures for 2014(R) are revised and for 2015(P) are provisional.
Source: Compiled by the authors from reports for years 2011-2015 of: Barbados, Ministry of Finance and Economic Affairs, Barbados Economic and Social Reports (Bridgetown: Ministry of Finance and Economic Affairs).

The unemployment rate was 10.7% in 2010 and had increased to 11.7% by 2015. Most (47.7%) unemployed are in the 15 19-year age group indicating that youth unemployment is still challenging. The Country Assessment of Living Conditions conducted in 2010 () found that 15% of households lived below the poverty line of US$ 3,930 per year. Approximately 62% of poor households were headed by females and the unemployment rate among poor households was slightly more than 25%.

The Health of the Nation Survey (2015) estimated that one in every three employed persons has private health insurance (). Barbados’ first National Health Accounts Study in 2014 found that 55% of total health expenditure was paid from government tax revenue, 38% from out-of-pocket sources by households, and approximately 5% from private health insurance. Due to the rising costs of health care and the current economic situation of the country, the Ministry of Health has been consulting with stakeholders to examine methods and policy options that would lead to sustainable financing of public health services while ensuring universal health coverage.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

A draft National Action Plan to Combat Antimicrobial Resistance incorporating the objectives of the WHO-sponsored Global Plan was produced in 2015 and implementation has begun (Box 1).

Box 1. Combating Antimicrobial Resistance in Barbados

Barbados supports the global thrust to reduce antimicrobial resistance. A draft National Action Plan to Combat Antimicrobial Resistance incorporating the objectives of the Global Plan was produced in 2015. That national plan indicated that Barbados currently has only a rudimentary framework and capacity in-country to address the issue of antimicrobial resistance. The national plan highlights the following three goals:

Goal 1: Slow the emergence of resistant bacteria and prevent the spread of resistant infections.
Goal 2: Strengthen national “One-Health” surveillance efforts to combat resistance.
Goal 3: Improve international collaboration and capacities for prevention, surveillance, and control of antimicrobial resistance, and strengthen antibiotic research and development.

Efforts to improve education on infection-control measures in health institutions have started. Surveillance of antibiotic-resistance levels is routinely performed at the Public Health Laboratory for select community pathogens. Antibiotic-resistant strains of Salmonella, gonorrhea, Klebsiella pneumonia, and Staphylococcus aureus have been identified, including methicillin-resistant Staphylococcus aureus (MRSA) in human samples, and Salmonella strains with extended spectrum beta-lactamase (ESBL) (resistant to all penicillins, cephalosporins, and aztreonam) found in food sources. No multi-drug resistant (MDR) tuberculosis has been identified.

Antiretroviral therapy (ART) has been available since 2002 with standard options used for first-, second-, and third-line therapy. Clinic processes are set up to ensure that patients are adequately prepared to start antiretrovirals and maintain adherence to ART. Testing for drug-resistant HIV has recently been implemented at the Ladymeade Reference Unit laboratory in collaboration with the United States Centers for Disease Control and Prevention (CDC). Currently the majority of clients on ART are on first-line regimens (80%) while approximately 20% are on second- or third-line combinations.
In view of these concerns, Barbados can reiterate that successfully addressing antimicrobial resistance is needed to achieve the Sustainable Development Goals and, in particular, the health-related goals.

Dengue fever is endemic in the country and outbreaks occurred in 2013 and 2014. For the 2010-2015 period, there were 2,955 confirmed cases of dengue and 12 deaths with a case fatality ratio of 0.4%. All of the serotypes circulated in the country during the period with serotype 2 predominating in 2010 and 2011 and serotype 1 for the remainder of the period.

The chikungunya virus was introduced to the Caribbean in late 2013, and first diagnosed in Barbados in 2014. There were 139 laboratory-confimed cases and 1,851 clinically suspected cases in 2014; in 2015 there were 4 laboratory-confirmed cases and 63 suspected cases. The Zika virus was confirmed in three cases in late 2015 with no cases in pregnant women.

Yellow fever and malaria are not endemic but there were 28 cases of imported malaria and no deaths during 2010 to 2015. There were no cases of Chagas disease and leishmaniasis has not been identified in Barbados. There were 110 confirmed cases of leptospirosis and 3 deaths between 2010 and 2012.

Tuberculosis

During 2010-2015, 11 cases of tuberculosis were confirmed. Of these, two were imported and one was co-infected with HIV. None of these cases were rifampicin- or multidrug-resistant.

Adolescent Pregnancy

In 2011, 12.3% of total births were to mothers under 19 years of age. Abortions in the teenage group have been on the decline within the context of an increase in the number of abortions.

Chronic Conditions

Chronic, noncommunicable diseases (NCDs) continue to be the leading cause of ill health in the adult population. The 2015 Health of the Nation Survey revealed that 1 in 10 adults has a NCD, and that 80% of men and 90% of women have at least one risk factor, and up to one-third of adults are being managed for at least one NCD (). The WHO Global School Health Survey for 2012 conducted by the Ministry of Health with technical assistance from PAHO/WHO showed that 14.4% of children in Barbados are obese.

Prevention and control of NCDs is an essential strategy of the overall work-plan of the Ministry of Health, and it is critical that the appropriate coordinating mechanisms exist to spearhead policy and program development.

Cardiovascular Diseases

The Barbados National Registry showed that in 2014 there were 584 stroke events of which 81% were classified as ischemic and 16% as hemorrhagic. The incidence of strokes increased with age for both sexes. In 2014, of the 256 persons admitted to Queen Elizabeth Hospital with strokes, 129 (27%) died there (). In the same year, 407 patients experienced 411 acute myocardial infarctions and/or sudden cardiac deaths. Of the 411 events, 346 (84.2%) had a definite acute myocardial infarctions diagnosis ().

Malignant Neoplasms

In 2010, there were 150 (65 males and 85 females) hospital admissions for malignant neoplasm of the colon, 154 for malignant neoplasm of the female breast, 75 for malignant neoplasm of the prostate, and 24 for malignant neoplasm of the cervix. Cancer of the prostate and female breast continue to be in the leading causes of death.

Diabetes Mellitus

In 2010, there were 261 hospital admissions for diabetes (105 males; 156 females) (). In 2015, almost one in five adults had diabetes (18.7%) and of those around the age of 65 years, nearly half (45%) had diabetes.

Hypertension

In 2015, 33% of hypertensive women were treated for hypertension, with 11% of women diagnosed with hypertension not being treated; 19% of men were treated for hypertension, with 18% of hypertensive men not being treated. Approximately 78% of persons in the age group 65 years and older have hypertension.

Obesity

The Health of the Nation Survey indicated that overweight and obesity are highly prevalent in the adult population. Two of three adults are overweight, and one of three is obese. The prevalence of obesity is almost twice as high in women (43%) as in men (23%). Another concern is the prevalence of “gross” obesity, with about 1 in 10 women and almost 1 in 20 men having a body mass index (BMI) of 35 or greater ().

Mental Health

Mental disorders fall into a broad spectrum of conditions that also include neurological and substance abuse disorders. Readmissions were responsible for 78% of total admissions to the Psychiatric Hospital, underscoring the need for community-based treatment and rehabilitative services to facilitate seamless continuity of care on discharge from hospital. An average of 13% of all patients admitted to the Psychiatric Hospital between 2010 and 2012 were patients admitted on order of the courts and were usually related to substance abuse ().

Human Resources

Barbados has largely become self-sufficient in meeting its demand for human resources for health. Doctors are primarily trained at The University of the West Indies (UWI), while nurses and other health care professionals are trained at the Barbados Community College (BCC). All medical personnel must be registered with the Barbados Medical Council, which has statutory responsibility for the regulation of all medical practitioners. The Nursing Council of Barbados, Dental Council, Pharmacy Council, and the Paramedical Professionals Council hold similar responsibility for their respective professions.
In 2012 there were 21 doctors per 10,000 population (1 doctor per 516 persons) and 44 nurses per 10,000 population, or one nurse for every 227 Barbadians (see Table 2). This equates to an average of 2.3 nurses per doctor, which meets the Region’s benchmark (Goal 4) for Human Resources for Health of having at least a 1:1 ratio of qualified nurses to physicians. In 2010 2015, Barbados also exceeded the standard set for the Region of having 25 health professionals per 10,000 population (Goal 1) ().

Table 2. Human resources for heath, per 10,000 population, Barbados, 2012

Category No. of workers Density (per 10,000 population) Population per worker
Doctors 582 21.1 474.6
Dentists 69 2.5 4,002.9
Hospital administrators 10 0.4 27,619.9
Veterinarians 27 1.0 10,229.6
Social workers 11 0.4 25,109.0
Nutritionists/Dietitians 9 0.3 30,688.8
Nurses 1,215 44.0 227.3
Nursing assistants 355 12.9 778.0
Radiographers (Diagnostic) 29 1.0 9,524.1
Laboratory technologists/technicians 28 1.0 9,864.3
Pharmacists/Dispensers 261 9.4 1,058.2
Physiotherapists 46 1.7 6,004.3
Occupational therapists 12 0.4 2,316.6
Dental auxiliaries 9 0.3 30,688.8
Environmental health officers 117 4.2 2,360.7
Environmental health assistants 92 3.3 3,002.2
Statistics and medical 74 2.7 3,732.4

Source: Barbados, Ministry of Health, Records Unit.

Health Knowledge, Technology, and Information

The phased implementation of a health information system as part of an eHealth strategy in Barbados has been one of the most vital measures used to address inefficiencies in clinical and support functions. Support for this strategy was provided by the second HIV/AIDS World Bank project and PAHO/WHO. A Health Information Policy and Legislative Notes and a Health Data Dictionary have already been developed. Barbados’ electronic health information system, known as MedData, has been put into service in five of the nine polyclinics. Modules for electronic health records, admissions, discharge records, transfers, and appointments are already in place. MedData has been applied in the Medical Records Department at the Queen Elizabeth Hospital to facilitate admissions, discharges, coding, and census functions. The Health Metrics Assessment and WHO eHealth Assessment were conducted in 2014 as the basis for the development of a health information systems strategic plan for the Ministry of Health.

The Barbados National Registry for NCDs was established in 2009 as a joint collaboration between the Chronic Disease Research Centre at the University of the West Indies and the Ministry of Health. This population-based registry has documented all cases of stroke, heart attack, and cancer since 2009 and provides information on the burden of NCDs within the population. The Registry has published five annual reports, which show that, on average, there is one stroke in Barbados per day and two heart attacks every three days. Population surveys in 2010 and 2014 were conducted to document and understand the risk factors that contribute to the NCD profile of Barbadians. The conclusion was that Barbadian adults are at high risk from NCDs due to the high prevalence of biological and behavioral risk factors, and that urgent action is needed to address these factors.

A palliative care needs assessment was completed in 2012 and it was concluded that half of the most common causes of death in Barbados are from conditions recognized as having palliative phases in their disease trajectories. It was estimated that 326 patients with non-cancer illnesses could be in need of supportive palliative care in the last year of life, while up to 125 patients (with non-cancer illnesses) could be in need of inpatient hospice care. A model combining specialist and generalist palliative care was one of the favored recommendations of the needs assessment ().

The health system supported ongoing syndromic surveillance including that for rash and fever. Weekly reports were made on data captured from 13 sentinel sites and from hospital surveillance reports.

The Environment and Human Security

Some of the leading environmental challenges affecting health include indoor and outdoor air quality, vector-borne diseases, solid waste disposal, and water scarcity.

Land slippage within the Scotland District is an ongoing environmental challenge. One entire community experienced persistent landslides that damaged access roads and other infrastructure. Efforts were made to relocate the community.

Indoor air quality issues have affected at least five schools on the island. The response included an inter-sectoral approach with input from the relevant ministries as well as the private sector.

Barbados was one of seven countries that participated in the United Nations pilot project “Piloting Climate Change: Adaptation to Protect Human Health” funded by the Global Environment Facility. Its objective was “to increase the adaptive capacity of the national health system institutions, including field practitioners, to respond to and manage long-term and climate-sensitive health risks.”. Some of the project achievements are: an early warning and response system providing timely information on likely incidence of climate-sensitive health risks; disease prevention measures piloted in areas of heightened health risk; and enhanced current rainwater storage facilities to prevent breeding of the Aedes aegypti mosquito.

There were no major diseases that affected plant crops or animals during the reporting period that impacted food security on the island.

There were 504 cases of salmonellosis during the 2010 to 2015 period. Over 4,000 food service workers including street food vendors were trained in food service sanitation techniques by the Ministry of Health during the period under review.

Solid Waste

Barbados disposes of 1,000 tons of solid waste daily, or an average of 3.7 kg per capita per day. All households have access to the Government’s solid waste collection system. A policy to reduce, reuse, and recycle waste was introduced and a public-private entity was established to reduce the quantity of waste from the solid waste stream.

Migration

Barbados is a signatory to international laws, declarations, treaties, and covenants that promote the health and rights of migrants as indicated in the Pan American Health Organization’s Health of Migrants Resolution (CE158.R16). The Ministry of Health provides free health services to all non-nationals in circumstances of genuine emergency as well as for antenatal care, immunization, conditions of current public health significance, and STI/HIV treatment.

Monitoring the Health System’s Organization, Provision of Care, and Performance

The Ministry of Health has statutory responsibility for the provision of health care. The Ministry defines policies, sets strategic directions, regulates the sector, and finances the public health services. Decision-making is centralized and there are no local health authorities (). A medium-term growth and development strategy has been developed to address the cross-cutting issues in the Government’s work, including health systems development, family health, NCDs, mental health, communicable diseases, and environmental health.

Primary health care services are very well developed and readily accessible. The Queen Elizabeth Hospital is the main provider of secondary and tertiary care for the population. Some levels of specialized care have to be accessed outside of the country (). Access to essential medicines is secured by way of the Barbados National Drug Formulary, which is administered by the Barbados Drug Service ().

Barbados faces the challenge of developing a resource base to finance the health services. In 2015 it commenced a national dialogue on health financing with a series of town hall meetings across the country. Stakeholders sent a clear message that Barbados must not only reform its health financing structure, but that the health care delivery system should be made more efficient. In the 2011/2012 financial year, health expenditure as a percentage of total government expenditure was 12.1% (), declining over the next three years to approximately 10.6% in 2014/2015 (see Table 1).

The Ministry of Finance and Economic Affairs commissioned an Institutional Assessment and Expenditure Review of the Health Sector and the Queen Elizabeth Hospital in 2012. The assessment found that the delivery of health care was satisfactory with regard to comprehensiveness, coverage, and accessibility. Challenges were identified such as continuity and coordination of care across the network of services, insufficient community-based services, outdated operational policies and procedures, and inadequate regulation of health institutions in the private and public sector (). Recommendations from the report will be implemented in the new Ministry of Health strategic plan.

The 1969 Health Services Act and the Drug Services Act (1980) provide the legislative framework for universal access to health care. The Government’s policy of providing free health care services at the point of delivery, the strategic placement of community-based polyclinics, a medical aid scheme, the Barbados Drug Service, and extended hours of service are some of the measures put in place to ensure that health care is accessible to all Barbadians. Nine primary health care facilities are fully staffed and equipped to deliver a range of services and are located within easy access of their catchment areas. The services include family health, mental health, dental health, nutrition counseling, rehabilitation, and general medical clinics. The ninth primary care facility was opened in 2015 to serve the population of the rural parish of St. John.

The Queen Elizabeth Hospital is the main facility that provides secondary and tertiary care. Other public health facilities include a psychiatric hospital, a long-term care facility for persons with disabilities, and an assessment and rehabilitation center for children with physical and mental challenges and a geriatric hospital and three district hospitals which provide long-term care for the elderly. At the community level, there is a program for alternative care for the elderly, which is a public/private contractual arrangement between the Ministry of Health and private nursing and senior citizens’ homes to provide care for elderly persons.

Prospects

Barbados has seen many gains in the 2010 2015 period (see Box 2), and efforts are under way to secure additional achievements. The country is in the initial stages of preparing a strategic plan for health for 2016-2021. This plan will chart the country’s strategic directions in keeping with the UN Sustainable Development Goals, the Caribbean Cooperation in Health (CCH IV), and the goal of universal health coverage. The series of stakeholders’ consultations in 2016 on health care financing reform have provided the Ministry of Health with perspectives for considering new policy objectives in respect of re-organizing and strengthening primary care, the prevention and management of NCDs, performance management in the health services, strengthening the monitoring and evaluation framework across the health services, and an examination of new mechanisms for financing health services.

It is expected that the use of information and communication technology will be expanded to strengthen health systems primarily through the provision of real-time data for evidence-based decision making. This use of technology for forecasting, planning, and making determinations on resource allocations for programs will result in improved monitoring and evaluation of program areas and, ultimately, improved health outcomes for the population.

Box 2. Reform of the Drug Service in Barbados

During the period under review, steps were taken to strengthen the financing of the Barbados Drug Service (BDS) by introducing a policy whereby the cost of dispensing drugs provided under the Formulary at private participating pharmacies would be paid by the beneficiaries. Under the new policy, the public is required to pay the handling fee for drugs under the benefit scheme accessed through private pharmacies. This policy enhances the sustainability of the BDS, reduces wastage associated with patients hoarding medication, and facilitates rational prescribing through the assessment of the cost implications to the patient.

Barbados Diabetes Foundation
In 2013, the Government negotiated a fee-for-service arrangement with the Barbados Diabetes Foundation to receive referrals from the primary health care system to its diabetes speciality clinic. Referred patients have either uncontrolled diabetes or at risk for complications. Management at this clinic is for a period of 6 months after which patients are referred to their primary health care providers. The primary health care physicians and nurses also completed a continuing medical education course developed by the Diabetes Foundation to build skills at the primary care level and to ensure continuity of care.

Implementation of the “Treat All” Initiative
Since 2009, the policy of the Ministry has been that persons with HIV and with a CD4 count of less than 350 were eligible for treatment with antiretroviral drugs. The CD4 count is a marker of the level of immunity and decreases over time in persons with chronic HIV. Recent studies have revealed that there are significant clinical and public health benefits to starting therapy sooner rather than later; the health of individuals with HIV is improved and there is a significantly reduced risk of further transmission of HIV to partners. In 2015, the World Health Organization advised all countries that persons with HIV should be given antiretroviral therapy irrespective of their CD4 count. The Ministry has now adopted this policy as advocated by WHO and treatment for all is now the minimum global standard in HIV management.

References

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2. Ministry of Finance and Economic Affairs, Division of Economic Affairs (Barbados). Barbados economic and social report 2010. Bridgetown: Ministry of Finance and Economic Affairs; 2011. Available from: http://www.economicaffairs.gov.bb/archive.php?cid=10.

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11. Ministry of Health (Barbados). Barbados palliative care needs assessment. Bridgetown: Ministry of Health; 2013.

12. Pan American Health Organization. Health systems profile Barbados. Bridgetown: PAHO; 2008. Available from: https://www.paho.org/hq/dmdocuments/2010/Health_System_Profile-Barbados_2008.pdf.

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14. Ministry of Health (Barbados). Discussion Paper on Health Financing Reform in Barbados. Bridgetown: Ministry of Health; 2014. Available from: https://www.gov.bb/fileadmin/template/documents/GovernmentPapers/Discussion_Paper_on_Health_Financing_in_Barbados_January__R4__2016.pdf.

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17. United Nations Children’s Fund. Barbados 2015 Child Protection Statistical Digest [Internet]. Bridgetown: UNICEF Office of the Eastern Caribbean Area; 2016. Available from: https://www.unicef.org/easterncaribbean/ECAO_BARBADOS_Child_Protection_Statistical_Digest_2015.pdf.

18. Bailey C. Crime and violence in Barbados. IDB Series on Crime and Violence in the Caribbean. Bridgetown: Banco Interamericano de Desarrollo; 2016. Available from: https://publications.iadb.org/bitstream/handle/11319/7774/Crime-and-Violence-in-Barbados-IDB-Series-on-Crime-and-Violence-in-the-Caribbean.pdf?sequence=4.

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