Bahamas

Overall Context

The Commonwealth of the Bahamas is an archipelago of 700 islands and 2,400 cays in the Caribbean Sea, off the coast of Florida, that covers an area of 13,900 km². The climate is typically tropical with two seasons, dry from November to April, and rainy from May to October. Hurricane season lasts officially from June 1 to November 30. In October 2015, Hurricane Joaquin, a Category 4 hurricane, battered the southern islands and in October 2016, another Category 4 hurricane, Matthew, caused much flooding and damage but no fatalities (1).

The islands have creeks and bodies of brackish water but no fresh water rivers; water is obtained mainly from wells drilled into aquifers or through desalination. About 30 of the islands are inhabited; the population is estimated at 370,000 persons, 90% of whom live in New Providence, Grand Bahama, and Abaco. The seat of government is in the capital, Nassau, located in New Providence (2).

The Commonwealth of the Bahamas gained its independence from Great Britain in 1973. Since then, the country has maintained a Westminster form of democracy. A Governor-General is appointed as the representative of Her Majesty Queen Elizabeth II. The country is governed by a bicameral Parliament consisting of a Senate of 14 appointed members and a House of Assembly of 38 members popularly elected every five years.

The population has grown from an estimated 325,200 in 2005 to 369,670 in 2015, representing a 15% increase in the past decade. Much of that growth is due to immigration. Birth rates have decreased from 17.1 per 1,000 live births in 2010 to 16.7 in 2015. The non-Bahamian population in 2010 comprised one-sixth of the total population, a 25% increase from 2000; Haitians comprised 64.4% of the non-Bahamian population (3). Not only is the population growing, but its structure is changing (Figure 1). Increasing life expectancy (from 73.8 years in 2010 to 74.7 in 2015) and decreasing birth rates have resulted in an aging population, where the age group 65 years old and older has increased by 25%, while the group 45 64 years old has increased by 32%. Those changes, coupled with a decrease in the population under 15 years old (from 26.6% to 25.3%), have reduced the dependency ratio from 0.48 to 0.45.

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

The population increased 51.4% between 1990 and 2015. In 1990, the population had an expansive structure, especially in ages older than 30 years, and a slower expansion in younger age groups. By 2015, the pyramidal structure had shifted to ages older than 50 years, becoming more stationary under that age and even with a reduction in groups younger than 15 years of age. These changes were the result of a greater decrease in the birth rate and mortality in the last decades.

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

Despite increases in the labor force, unemployment rates remain quite high (12% 16% nationally), especially among youth (as high as 30%). The per capita annual income also is relatively high (US$ 21,570), as is the per capita gross domestic product (US$ 25,100), generated mainly through tourism (60%) and financial services (15%) to a lesser degree (3). These seemingly good indicators notwithstanding, one in eight (12.8%) residents lived below the poverty line¹ in 2013, up from 9.3% in 2001, with evidence of a widening income gap (4). Poverty levels were higher among Family Islanders² (one in six), among youth (20 29-year-olds accounted for nearly one-quarter of the poor), and among Haitian migrants, whose poverty levels were three times those of the national level. Migrants (mostly non-Haitian) can also be among the wealthier residents in the country, attracted to the Bahamas by its “tax haven” offers.

Informal shantytowns inhabited by mostly poor migrants have proliferated in certain areas. For the Bahamas, which mainly depends on a system of wells and cisterns that are easily contaminated by septic tanks and saltwater intrusion, these settlements are a matter of concern. Wells in shantytowns tend to be poorly constructed and are dug close to improper sewage systems, thus heightening the risk (5). Outside privies that serve many of these households, are often poorly constructed and not according to code. It is noteworthy that 93% of water samples from these areas failed laboratory tests and 79% were found to have fecal coliforms. Poor solid waste disposal leads to infestation of rodents and other vermin. According to the government’s 2008 2012 Socio-Economic Report, 1.6% of the population lived in overcrowded housing, 5% used shared toilet facilities, 3.2% used pit latrines, and 0.2% had no access to any toilet facilities (6).

Initiatives to mitigate inequity, poverty, and unemployment include the INSPIRE and RISE³ programs, funded by the Inter-American Development Bank. The first, aimed at improving the quality of teaching and learning opportunities, intends to provide youth with skills to better their chances of gaining employment.

The Health System

In 2013/2014, 7.7% of the gross domestic product (GDP) was spent on health care; only 46% corresponded to public expenditures, with 29% being spent by households (7). In 2010/2011, 12.7% of the government’s budget was allocated to health (8).

Since the start of the millennium, the introduction of a national health insurance system has been on the country’s political agenda. According to the 2010 census, 47.2% of the general population has health insurance. In New Providence, approximately 49% of the population was medically insured. Females were slightly more likely to have health insurance (47%) than males (45%) (9). The National Health Insurance (NHI) Act, approved by parliament in August 2016, foresees a package of primary care benefits. Covered benefits would be free of charge at the point of service delivery for all Bahamians and most legal residents voluntarily enrolled in the system. Subsequent implementation stages expect to provide coverage for catastrophic conditions and secondary and tertiary care. The country’s planned model of care consists of a multi-payer system that involves a public insurer under private administration. The primary care package includes medical services, medications, and imaging and laboratory services.

Public primary health care services in the Bahamas are delivered through a network of public facilities (28 health centers, 33 main clinics, and 35 satellite clinics) located on the main inhabited islands. Secondary and tertiary care are provided in three public hospitals: the Princess Margaret Hospital (400 beds) and the Sandilands Rehabilitation Centre on New Providence, and the Rand Memorial Hospital (85 beds) on Grand Bahama. Sandilands Rehabilitation Centre is the main national provider of psychiatric, geriatric, and substance abuse services.

Private health care facilities include two private hospitals, the Doctors Hospital and the Lyford Cay Medical Facility, both in New Providence, and the specialized Okyanos Stem Cell Therapy Centre in Grand Bahamas. There also are walk-in clinics, private practitioners, and private medical offices.

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Leading Health Challenges

Critical Health Problems

Nutrition

The Bahamas is highly dependent on imported food more than 90.0% of food is imported; in fact, the agriculture sector contributes less than 2% of GDP. This leads to a high cost of food, which, in turn, may be a factor in the poor choice of foods. Foods higher in sugar, salt, and trans fat are less expensive. The government has issued the “Rebuilding Bahamian Agriculture: A 20-year Plan” strategy (10) in an attempt to boost local production of food. The Ministry of Agriculture, Marine Resources and Local Government has launched an island-specific program to promote growth in agriculture and fisheries. In addition, the Bahamas Agriculture and Marine Science Institute (BAMSI) has a program in North Andros and selected Family Islands that provides training to operate an agro-processing and food manufacturing enterprise.

An Unhealthy Lifestyle

With a limited public transportation infrastructure, the Bahamas lacks enough sidewalks, cycling routes (protected or unprotected), and open recreational public areas to encourage its residents to engage in physical activity. To address this, the government has developed the “Healthy Bahamas 2030” strategy as well as the Healthy Bahamas Coalition (11). These two initiatives target risk factors for noncommunicable diseases (NCDs) such as reducing tobacco and alcohol consumption, increasing physical activity, promoting healthy nutrition, protecting psychological and emotional well-being, promoting reproductive and sexual health, reducing environmental harms, and making roads and their surroundings safer, which underscores the government’s concern about the growing rates of such diseases.

Chronic Conditions

Six chronic NCDs neoplasms, ischemic heart disease, diabetes, chronic lower respiratory disease, cerebrovascular disease, and hypertension have accounted for nearly half (49%) of all deaths since 2009, as well as for 43% of all potential years of life lost (PYLL). In 2014, all NCDs accounted for 72% of deaths. Neoplasms were the greatest contributor, responsible for 18.5% of all deaths, with the average age of death being 61 years (accounting for 11.2% of PYLL) (Tables 1 and 2).

Table 1. Crude mortality rate, proportional mortality ratio, and Potential Years of Life Lost for the leading causes of death, Bahamas, 2008 2011

Table 2. Ratio of health professionals per 10,000 population, Bahamas, 2010 2014

Deaths due to neoplasms increased from a crude mortality rate of 104.9 per 100,000 population in 2008 to 108.0 in 2013. From 2009 to 2013, cancers of the digestive organs accounted for nearly one-quarter (24.9%) of all cancer deaths, followed by breast cancer (15.2%). Cases, as detected by the cancer registry based at the Princess Margaret Hospital, also increased, from 357 in 2008 to 400 in 2010 and 427 in 2014. Among cases of cancer, breast (26.2%), prostate (17.9%), and colorectal (11.5%) cancers were the most common. Cancers of the female reproductive organs accounted for another 11.7% of all cancers. Breast cancer cases increased 30% from 2010 to 2014, while colon cancers increased 34% and cancers of the female reproductive organs by 24%; prostate cancer cases showed a slight but steady decrease.

Between 2009 and 2013, ischemic heart disease accounted for 8.7% of all deaths and 3.7% of all PYLL, with an average PYLL of 6.3 years per death. Hypertension accounted for 9.1% of all deaths and 3.5% of all PYLL, with an average PYLL of 5.8 years. Cerebrovascular disease accounted for another 6.9% of all deaths and 3.1% of PYLL, with an average of 6.7 years lost per death. Self-reported prevalence of clinical hypertension appeared to increase from 9.3% in 2001, to 22.9% as reported in the 2005 STEPS risk factor survey, to 34.3% in 2012 (12). Altogether, cardiovascular disease, namely hypertension, cerebrovascular disease, and ischemic heart disease, accounted for approximately one-quarter (24.7%) of all deaths during 2009 2013.

Except for 2009 when the rate was 36.5 per 100,000 population, diabetes crude mortality rates varied between 24 and 30 deaths per 100,000 population, accounting for 5.1% of all deaths in 2009 2013. However, deaths occurred at earlier ages, as average PYLL per death increased from 6.3 years in 2009 to 8.8 years in 2013. Self-reported prevalence was 3.3% in 2001 and 9.2% in 2005, but estimated at 23.9% in the 2012 STEPS risk factor survey (12. The proportion of diabetes clinic visits in the public sector decreased from 7.2% in 2008 to 5.5% in 2014.

Mortality due to chronic lower respiratory disorders was low, accounting for less than 1% of all deaths, with crude mortality rates decreasing from 6.4 deaths per 100,000 population in 2009 to 3.3 in 2013.

Human Resources

In 2008, the ratios of health personnel in the Bahamas were 28 physicians per 10,000 population, 27 registered nurses per 10,000, and 14 clinical nurses per 10,000. Tables 1 and 2 show human resource information for 2010 and 2014. This figure has now decreased to 25 and 11.4 for physicians and clinical nurses in 2013, but remained the same for registered nurses. However, the ratio of medical laboratory technologists has been steadily decreasing, from 3.9 per 10,000 population in 2005 to 2.2 in 2014.

Assessments of the human resources for health have concluded that there is a shortage of health professionals in the public health clinics, in the Family Islands, and in some allied health professions. The main deficiencies seem to be in the distribution, skills mix, and human resource management practices.

Health Knowledge, Technology, and Information

The provision of health care services to a relatively small population scattered over a large discontinuous area is an enormous challenge. Telemedicine and other communication technologies for health are particularly important in this context. Laboratory point-of-care testing technologies are being implemented in the Family Islands as another measure to cope with the challenge.

The Bahamas is in the process of developing an integrated health information system, called the integrated Health Information Management Systems (iHIMS). This single system will bring together information from all public health facilities, including hospitals and ambulatory centers, as well as from other health information resources.⁴

The establishment of a health research council responsible for encouraging and coordinating health research has been proposed, which will be especially useful as the country funds the National Health Insurance system and strengthens its health system. To this end, the Health Improvement/Innovation Incubator (HEALinc©) has been conducting health research in collaboration with the Ministry of Health’s Department of Public Health and Public Hospitals Authority, and the Pan American Health Organization (PAHO) (13). Other research activities include forays into stem cell research with international partners and various research efforts by The University of the West Indies residency, nursing, and clinical medicine programs.

The Environment and Human Security

Dependent as it is on the surrounding ocean for food, transportation, and recreation, the Bahamas is extremely vulnerable to environmental shifts. The consequences of climate change, such as rising water tables and sea levels, and increased storm activity, would adversely affect the country’s environment and directly and indirectly affect health. A mere 1 m rise in sea level could eliminate 80% of the country’s landmass.

Given its susceptibility to storms and hurricanes, the Bahamas has improved its capacity to mitigate injury and death by strengthening building codes and enhancing emergency preparedness and response. In 2013, the Government of the Bahamas, along with eight other territories, signed the Caribbean Challenge Initiative Leaders Declaration, designed to accelerate and expand efforts to safeguard the region’s marine and coastal environment, by protecting and sustainably managing 20% of the Caribbean’s marine and coastal ecosystems by 2020 (14).

The Bahamas also has committed itself to the Montreal and Kyoto protocols governing harmful emissions. Burning of waste at landfills and dumpsites continues to harm air quality and may contribute to respiratory disorders. The government is exploring partnerships with the private sector to establish a recycling facility and improve the management of landfills.

The cutting down of native trees for fuel, especially in the shantytowns, results in air pollution and deforestation. The Forestry Act of 2010, and its 2014 amendment, seeks to strengthen forest management and conservation (15, 16). The introduction of the Environmental Planning and Protection Bill in 2015 established a Department and Advisory Council dedicated to addressing these issues.

Injuries and violence are responsible for an estimated one-quarter of all PYLL in the Bahamas, and for an average loss of 35.5 years of life for each injury death during 2009-2013. During that period, deaths due to injury steadily increased, accounting for 12.5% of all deaths in 2013, an increase due mainly to homicides which made up approximately half of all fatal injuries (125 of 257). The rates for transport injuries have remained stable, but homicide rates increased from slightly more than 25 deaths per 100,000 population in 2009 to slightly more than 30 deaths in 2013. The 250 300 injury deaths each year, with an average of injury by 34 years of age, especially among males, represents a loss of productivity that the nation can ill afford. The government has launched the Project Safe Bahamas to fight crime and reduce violence. These initiatives have been supported by activities such as the development of a National Strategic Plan to Address Gender-based Violence and the National Anti-Drug Strategy 2012 2016.

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Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

Maternal deaths averaged 3.5 deaths per year for 2008 2013, with rates ranging from 0.0 to 13.1 per 1,000 live births and accounting for 0% 5.3% of deaths of women of childbearing age. Pap smears increased slightly, from 2.5% in 2004 to 2.7% in 2014 with increasingly more smears being performed prenatally, because even fewer women present for postnatal care.

Child Health

Infant mortality rates increased from 17.6 per 1,000 live births in 2007 to 22.7 in 2013. The leading causes were perinatal respiratory disorders, congenital pneumonia, and perinatal pulmonary hemorrhage. Low birthweight rates have increased from 10.9% in 2006 to 13.8% in 2014; 66.2% of infant deaths occurred among low birthweight babies. In 2014, 52.9% of pregnant women received antenatal care within the first 16 weeks, a slight increase from 44.9% in 2008; 12% of babies were low birthweight, and multiparity⁵ rates of 17.6%, 31.8%, and 40.1% were reported in 2010 for women 25 29 years old, 30 34 years old, and 35 39 years old, respectively.

Health of Adolescents

The 2013 Global School-based Student Health Survey showed the following results among adolescents aged 13 15 years old: 44.7% were overweight and 21% were obese; in the week prior to the survey, 29.6% had not engaged in any physical activity and 83.4% had consumed fewer than five fruits and/or vegetables; 28.6% had drunk alcohol in the month prior to the survey; 13.7% were current smokers, 15.1% had used drugs, 19.3% had ideated about suicide and 13.6% had attempted suicide; 40% had engaged in fights during the year prior to the survey; and 11.1% were members of a violent group.

Males consume more alcohol than females, which makes them more susceptible to road traffic injuries and intentional injuries as both victim and perpetrator. In 2011, 18.4% of deaths in males were due to injuries.

Health of the Elderly

The group older than 65 years is the fastest growing age group in the country and the group that will generate the greatest demand on health services. The introduction of the National Health Insurance system will serve this group well, as it is prone not only to chronic NCDs but also to social isolation and mental health disorders such as Alzheimer’s and depression. Prostate cancer is also prevalent among older men, accounting for 4.4% of deaths among males and highlighting the need for screening and early detection and management.

Health of the Disabled

In 2010, 2.8% of the population was disabled (17). Of those, 7.3% had no education, compared to 1.5% of the able population. Further, 82.4% of those older than 14 years were unemployed and 72% had no health insurance. Legislation has been passed to protect the disabled from discrimination and ensure their right to amenities that the abled currently enjoy, such as accessible transportation, employment etc. (18).

Morbidity

Communicable Diseases

Vector-borne diseases have been detected in the country. The Bahamas harbors the Anopheles mosquito (carrier for malaria) and the Aedes aegypti mosquito (carrier for dengue, chikungunya, and Zika viruses). The 2008 malaria outbreak in Exuma, with 12 cases, was controlled through an aggressive, multipronged approach involving integrated surveillance, education, and community participation that targeted larval source reduction and use of mosquito adulticides. Aedes aegypti surveillance on New Providence showed moderate reduction in the Breteau index, from 6.3 in 2010 to 5.6 in 2011, although the house index remained constant at 3.9. In 2013, there was 1 imported case of dengue, followed by 14 cases the year after, and 3 cases in 2015. Chikungunya was first detected in 2014, when an outbreak of 104 cases was reported; 4 cases were recorded for 2015. Zika virus was first detected in 2016, with 10 cases reported by mid-2016, of which 8 were autochthonous. Nationwide efforts continue to reduce the Aedes aegypti population through community cleanup campaigns and the use of mosquito adulticides.

Trends in HIV/AIDS and other sexually transmitted infections have been mixed. There were 267 cases of HIV/AIDS in 2014, of which 63 (24%) were diagnosed as AIDS, and of these “late-to-test” cases, 12 (19%) died. Age-adjusted mortality for HIV/AIDS has decreased from 38 deaths per 100,000 population in 2004 to 22 in 2014. Incidence also decreased by 28%, from 370 cases in 2005, although incidence among 15 24-year-olds increased by 85%. Overall prevalence was 2% and the mother-to-child transmission rate was 3% two mothers who refused to take or adhere to HIV treatment during pregnancy.

Gonococcal infections and chlamydia cases increased from 2005, with the former peaking in 2010 (incidence from 147 to 418 per 100,000 population) and the latter peaking in 2009 (from 30.4 to 82.5 cases per 100,000 population). Incidence rates of other sexually transmitted infections (candidiasis, vaginosis, pelvic inflammatory disease, chancroid, genital herpes and warts) were all below 20 per 100,000 population.

The incidence of tuberculosis continues to fall, from 17 per 100,000 population in 2005 to 12 in 2014, with 45 new cases, of which 14 were coinfected with HIV and 3.7% were multidrug- resistant.

Vaccine-preventable diseases have been kept under control to date. Vaccination rates higher than 95%⁶ have been sustained, thus reducing the occurrence of diseases covered under the Expanded Program on Immunization.⁷ From 2013 to this writing, there have been no cases of those diseases. After 2009, when the rate reached 98%, coverage against measles, mumps, and rubella varied between 93.6% and 91.5%, so there now is a growing population of susceptibles, although no cases have been reported. Concerns remain, because of the difficulty of measuring vaccination rates in school-aged populations and among immigrants.

Food- and waterborne illnesses are of grave concern in the Bahamas, not only because of their potential impact on the tourism industry. The Caribbean Public Health Agency has launched a “Healthy Tourism” program to improve food hygiene and safety and reduce the risk of food-borne illness. The most common food-borne infections were ciguatera poisoning, with 324 in 2013 and 351 in 2014; the incidence decreased from 266 cases in 2015 to 36 as of this writing in mid-2016. There were fewer than a score of confirmed cases of shigellosis and salmonellosis each year. Gastroenteritis was also reported 40 cases in 2013, 55 in 2014, and 34 in 2015, approximately one-third of these cases occurred in children under 5 years.

The surveillance system reports that cases of acute respiratory infections are decreasing, from 143 in 2013, to 99 in 2014, and 26 in 2015. Of these, 48, 34, and 10, respectively, occurred in children under 5 years old, approximately one-third each year.

Mental Health

Mental illness is a significant cause of morbidity in the Bahamas. On average, there were 1,000 discharges each year from the Sandilands Rehabilitation Centre between 2010 and 2014. The leading reasons for discharge were schizophrenia and schizotypal disorders (35%), followed by mood affective disorders (12.3%) and mental and behavioral disorders due to use of cannabinoids (11.1%), alcohol (7.4%), multiple drugs (6.2%), and cocaine (2.3%). A total of 27% of mental health discharges were attributable to legal and illegal drugs. In addition to the contribution of drug-related mental illness to intentional and unintentional injury and their attendant costs, depression costs the Bahamas US$ 27 million a year in lost productivity. With support from PAHO, the government has launched a Mental Health Gap Action Programme (mhGAP) to promote the early identification and management of mental health problems within the primary health care services. The National Anti-Drug Strategy is currently developing a national substance-abuse survey to help fill the information gap in this matter.

Risk and Protective Factors

The increase in the prevalence of and mortality due to neoplasms, cardiovascular disease, and diabetes is congruent with the increase in risk factors for these conditions, namely smoking, poor nutrition, and low levels of physical activity resulting in obesity (Table 3). According to the 2012 STEPS risk factor survey, 1 in 6 adults smoked, with the prevalence in males being fourfold that in females (26.9% vs. 6.4%) and higher among persons living in poverty, those living with mental illness, those with less than a high school education, or those employed in jobs involving physical labor (12). Alcohol consumption levels are high: 57.1% of respondents to a 2005 survey reported that they “ever drank” alcohol, and 40.8% stated that they were “current drinkers” in 2012. The government will attempt to reduce the level of consumption by incorporating cessation programs within primary care services.

Table 3. Prevalence of risk factors, male/female ratio, Bahamas, 2005, 2008, and 2012

Overweight and obesity, already extremely high in the Bahamas, are worsening. The percentage of the overweight population reached 79.2% in 2012, up from 70.5% in 2005, with no significant difference by sex. Obesity also increased, so that every other person in the Bahamas has a BMI > 29.9. Another contributing factor is low levels of exercise, although perception of this problem is low in the population, especially among men. In 2011, only 36.7% of males and 63.2% of females reported exercising at low levels (12). Furthermore, 90% of respondents reported eating fewer than five servings of fruits and vegetables a week, up from 47.3% in 2005, and with no significant difference by sex. Breastfeeding rates⁸ are also low, varying between 10.9% and 29.2% between 2005 and 2011. The government intends to revise the food basket, and to undertake other initiatives aimed at strengthening nutrition practices in schools and monitoring nutritional status of vulnerable groups.

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Prospects

At least for the next decade, the Bahamas will continue to confront the alarming incidence of risk factors for chronic disease in its population. Increasing rates of overweight/obesity, unhealthy eating, and sedentary lifestyle are of particular concern. Overweight and obesity start early in life in the Bahamas, affecting children and adolescent in high numbers. Moreover, chronic NCDs are being detected at ever-earlier stages in life, when they can exert a stronger long-term impact on the health of future generations of adults. Increasing violence and gang-related incidents among vulnerable youth also pose challenges at early stages of life.

To address these and other problems, the Government of the Bahamas is developing its National Development Plan: “Vision 2040,” a road map for policy development, decision-making, and investment over the next 25 years. The initiative’s four pillars are the economy, governance, social policy, and the environment (19). A second initiative, the National Health System Strategic Plan 2010-2020, promotes the empowerment of individuals and communities for optimal health, longevity, and quality of life.. It is critical for these initiatives to involve communities, rather than being solely driven by the government, because few gains will be made unless a broad base of community groups and individuals are fully engaged in the conception and execution of these plans.

The importance of population health, following a “Health for All” approach, must be further emphasized within the National Development Plan. The government, in turn, must seek intersectoral integration and coordination that extends beyond the health care sector to include broad societal actors

The Bahamas is a country with paradoxically high levels of wealth and high levels of poverty, combined with marginalization of important groups of society, especially the growing migrant population. One of the critical debts in social development that the public sector owes the people of the Bahamas has been the lack of universal health coverage. After years of debate and negotiations, the National Health Insurance (NHI) Act was finally approved in 2016 (details of this legislation have been given earlier in this report). The legislation still needs to address sources of additional funding, the role of private insurers, the pooling of risk and resources, beneficiary participation (voluntary), provider engagement, and the level of coverage in subsequent stages.

Furthermore, universal health must not stop at universal coverage, but should guarantee access to appropriate and high-quality care. The country’s national health authorities are working toward strengthening the health system to complement National Health Insurance in the effort to achieve universal health.

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References

1. International Federation of Red Cross and Red Crescent Societies. Bahamas responds to Hurricane Joaquin [news release]. 21 Oct. Geneva: IFRC; 2015. Available from: http://www.ifrc.org/en/news-and-media/news-stories/americas/bahamas/bahamas-red-cross-responds-to-hurricane-joaquin-69521/.

2. Department of Statistics, Census Section (Bahamas). Population projections 2010-2040. Nassau: DOS; 2015. Available from: http://www.bahamas.gov.bs/wps/wcm/connect/22f9b2b0-68fa-4a26-8bd8-474952e42dc2/Population+Projection+Report+2010-2040.pdf?MOD=AJPERES.

3. National Development Plan Secretariat (Bahamas). State of the Nation report: Vision 2040- National Development Plan of The Bahamas. Nassau: NDPS; 2016. Available from: http://www.vision2040bahamas.org/media/uploads/State_of_the_Nation_Summary_Report.pdf.

4. Department of Statistics (Bahamas). Household expenditure survey 2013 report. Nassau: DOS; 2016. Available from: https://www.bahamas.gov.bs/wps/wcm/connect/5312dd47-5cd9-45f5-bf6c-dea99f3a6226/Bahamas+Household+Expenditure+Survey+2013+Report_v2.pdf?MOD=AJPERES.

5. Department of Environmental Health Services (Bahamas). Bahamas shanty town project report 2013. Nassau: DEHS; 2013. Available from: https://issuu.com/ministryofehbahamas/docs/shantytownreport.

6. Department of Statistics, Census Section (Bahamas). Socio-economic report 2008-2012. Nassau: DOS; 2014. Available from: https://www.bahamas.gov.bs/wps/wcm/connect/d5899539-d31b-4234-af37-88a3cbf8dbe5/Socio-Economic+Report+2008-2012.pdf?MOD=AJPERES.

7. World Health Organization. Health system financing profile by country: Bahamas. Geneva: WHO; 2016. Available from: http://apps.who.int/nha/database/Country_Profile/Index/en Accessed November 2016.

8. Ministry of Health, Health Information and Research Unit (Bahamas). Basic health indicators 2013. Nassau: MOH; 2014. Available from: https://www.bahamas.gov.bs/wps/wcm/connect/c5623e5f-86f7-477c-acfc-2f792490b8be/HIRU+Brochure+Nov.+2014%28Final%29.pdf?MOD=AJPERES.

9. Department of Statistics (Bahamas). Bahamas population and housing census 2010. Nassau: DOS; 2012. Available from: https://www.bahamas.gov.bs/wps/wcm/connect/f484ec3e-c780-459d-937f-54e26aa67fa5/2010+Census+Final+Disability+Report.pdf?MOD=AJPERES.

10. Ministry of Agriculture, Marine Resources and Local Government (Bahamas). Rebuilding Bahamian agriculture: a 20-year plan. Nassau: MAMRLG; 2013. Available from: http://www.bamsibahamas.com/assets/rebuilding-bahamian-agriculture-20-year-plan—final.pdf.

11. Healthy Bahamas Coalition. Healthy Bahamas Coalition [Internet]. Nassau: HBC; 2017. Available from: https://www.healthybahamascoalition.com/about-us.

12. Ministry of Health (Bahamas). Bahamas (Site) STEPS survey 2012: fact sheet. Nassau: MOH; 2013. Available from: https://www.bahamas.gov.bs/wps/wcm/connect/e6091699-8e84-4304-a1b5-813fde735f6e/FactSheet_-2013+BAH+-+060314+Update+Final.pdf?MOD=AJPERES.

13. Health Improvement/Innovation Incubator. HEALinc© [Internet]. Nassau: HEALinc©; 2017. Available from: http://www.thehealinc.com/about/.

14. Caribbean Challenge Initiative. CCI “20 by 20” challenge [Internet]. St. George’s, Grenada: CCI; 2016. Available from: http://caribbeanchallengeinitiative.org/index.php?option=com_content&view=article&id=39&Itemid=179#.V-BdvYWcHIU.

15. Extraordinary Official Gazette (Bahamas). Forestry Act, 2010. (No. 20 of 2010). 6 Jul. Nassau: EOG; 2010. Available from: http://www.bahamas.gov.bs/wps/wcm/connect/655c6d2f-9d01-416d-8a51-54adf053c692/Forestry+Act+2010.pdf?MOD=AJPERES.

16. Extraordinary Official Gazette (Bahamas). Forestry (Amendment) Act, 2014: An Act to Amend the Forestry Act. (No. 6 of 2014). 2 May. Nassau: EOG; 2014.
Available from: http://extwprlegs1.fao.org/docs/pdf/bha144582.pdf.

17. Department of Statistics (Bahamas). 2010 Census disability report. Nassau: DOS; 2014. Available from: https://www.bahamas.gov.bs/wps/wcm/connect/f484ec3e-c780-459d-937f-54e26aa67fa5/2010+Census+Final+Disability+Report.pdf?MOD=AJPERES.

18. Extraordinary Official Gazette (Bahamas). Persons with Disabilities (Equal Opportunities) Bill, 2014. (No. 31 of 2014). 12 Aug. Nassau: EOG; 2014. Available from: https://www.bahamas.gov.bs/wps/wcm/connect/678cadc1-08d9-43d3-bc55-d10c99f9064c/Final+Clean+1+July+2014+Persons+With+Disabilities+%28Equal+Opportunities%29+Bill.pdf?MOD=AJPERES.

19. National Development Plan Secretariat (Bahamas). Vision 2040: National Development Plan of the Bahamas [Internet]. Nassau: NDPS; 2016. Available from: http://www.vision2040bahamas.org Accessed 5 December 2016.

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