British Virgin Islands

Overall Context

The Virgin Islands, an overseas territory of the United Kingdom, is self-governed by a democratically elected House of Assembly, with the Governor representing Her Majesty, the Queen. Under the constitution, the Governor is responsible for foreign affairs, defense, and internal security, while the Government is responsible for internal affairs. The Virgin Islands’ total landmass of 59.3 mi2 includes some 50 islands, cays, rocks, and islets. Tortola (21.5 mi2), Anegada (15.2 mi2), Virgin Gorda (8.5 mi2), and Jost Van Dyke (3.2 mi2) are the largest islands.

The territory has an extensive road network and a high rate of private vehicle ownership. Transportation between the islands is mainly via ferry, with limited air transportation, mainly to Anegada.

The British Virgin Islands lies in the path of hurricanes and tropical storms and is vulnerable to wind damage, flooding, and landslides; it is is also at risk for earthquakes.

The territory’s 2010 population and household census placed the resident population at 28,054, with 83% residing in Tortola, followed by 14% living in Virgin Gorda. The average household size was 2.59 persons. According to Pan American Health Organization (PAHO) estimates for 2015, the population is 34,232.

In 2015 the population 60 years and older was estimated at 4,587 (13.3% of the population) and that of children under 5 years old at 1,919 (5%). According to the territory’s Central Statistics Office, in 2015 the male-to-female ratio was 1:1; blacks are the largest ethnic group. The territory depends on immigrant labor, which is reflected in the widening of the population structure for the 30-45-year age groups. In 2015, foreign-born persons accounted for approximately 60.3% of the population. This is a diverse category that includes “Belongers” who are born overseas but are “deemed to belong” to the British Virgin Islands, those who receive citizenship by descent, persons who are long-term residents and who may be naturalized, those who may have residency status and work permit exemptions, and immigrants on work permits from all over the world who come to work in the territory’s Financial and Tourism sectors. Figure 1 shows the British Virgin Island population for 1991 and 2015.

Figure 1. Population structure, by age and sex, British Virgin Islands, 1991 and 2015

In 1991, the territory’s population structure presented an expansive pyramid shape with “bulges” in the age groups over 25 years and under 15 years old. The widening of the pyramid could be related to immigration. In 2015, the population structure shows a regressive shape related to decreases in birth rates and in mortality.
Source: United States Census Bureau

The annual population growth rate has steadily increased since the 1980s, with 10% annual increases between 2006 and 2015. In 2015, the crude birth rate was estimated at 9.12 births per 1,000 population and the crude death rate was 4.67 deaths per 1,000 population; the total fertility rate decreased from 1.1 in 2006 to 0.98. In 2015, there were a total of 266 deliveries, down from 287 in 2014; given that some women have their babies overseas, an accurate fertility rate is difficult to determine. The estimated life expectancy for that year was 79.87 years, 77.12 for males and 78.46 for females (1). Table 1 shows the basic health indicators for the British Virgin Islands.

Table 1. Basic health indicators, British Virgin Islands, 2015 or latest available year

The British Virgin Islands utilizes the US dollar as its currency; its economy is based on tourism and international financial services, which together account for more than 70% of the territory’s GDP (2). Financial services contribute 51.8% of the Government’s revenue from license fees for offshore companies and payroll taxes relating to salaries paid within the finance sector. The annual per capita gross national income was US$ 42,300 in 2010.

School attendance is required for all children ages 5 to 17 years and public school is provided free to residents. There are 15 primary public and 4 secondary public schools. There are 10 private primary and 3 private secondary schools, with one public technical and vocational school. Higher education is free to residents at the local community college up to Associate degree level. In 2010, the literacy rate for 15 years and older was 97.7% (97.7% for males and 98.1% for females).

According to 2010 census data, unemployment was 2.8% and is high among young adults 15 to 29 years. The last poverty assessment, completed in 2003 by the Caribbean Development Bank, suggested that poverty in the Virgin Islands was 16% of households and 22% of the population (3).

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Leading Health Challenges

Critical Health Problems

Emerging Diseases

Zika, chikungunya, and dengue are health issues of concern for the territory’s health system. The first case of Zika was reported in July 2016, with 22 confirmed cases as of September 2016. Chikungunya was introduced in 2014 and 47 cases have been confirmed in the territory. The number of dengue cases spiked in 2012, but showed a significant decline in 2014 and 2015; there were 710 reported cases of dengue fever between 2010 and 2015. Malaria is not endemic and there were no imported cases in the reporting period.

Chronic Conditions

Chronic, noncommunicable diseases mainly cancer, diabetes, and hypertension contribute significantly to morbidity and mortality in adults. The prevalence of obesity, due mainly to a sedentary lifestyle and a diet high in processed or refined foods, is one of the leading health risks for chronic conditions in the territory, where it primarily affects women and children. A hemodialysis program was started in 2000, and as of May 2016, served 47 local patients. There is a vibrant referral program and renal clinic for Stage III patients. In addition, there is a living donor transplant program through referrals to the United Kingdom that has had some success, with seven persons having received transplants since 2009. Patients have been on dialysis a average of 7 years, but there are currently 18 persons who have been on dialysis longer than that one of them for 14 years.

The Ministry of Health and Social Development is implementing a 10-year strategy for the Prevention of Chronic Non-Communicable Diseases that relies on a multi-sector approach. To that end, this strategy strives to mobilize support and actions at a high level in education, planning, tourism, health, and the community or NGO sectors. The BVI Health Services Authority has developed a three-year action plan for the public hospital to implement the Chronic Care Model aimed at standardizing and improving care delivered to persons with diabetes and hypertension. In 2015, a cadre of community leaders was trained to administer the Stanford University’s School of Medicine’s Chronic Disease Self-management Programme, which is especially helpful for persons suffering from more than one chronic disease, as they are taught the skills to better manage their health and remain active.

Human Resources

There are no training facilities in the territory, so nationals train in the health professions elsewhere in the Caribbean, in the United Kingdom, and in the United States. In order to fill the necessary public- and private-sector health-personnel positions, staff is recruited from the Caribbean, the United States, Canada, the Philippines, and some African countries. The main regulatory bodies for health practitioners are The BVI Medical and Dental Council, the BVI Allied Health Professional Council, and the BVI Nursing and Midwifery Council. The majority of health care workers are employed in the public health sector (3).

In 2015, 102 physicians were registered to practice in the territory; of these, 88 were actively practicing, 45 of whom worked in the public sector. That same year, of the 13 dentists working in the territory, only 2 worked in the public sector (3). Of the 207 nurses registered to practice, 162 worked in the public sector. Opportunities for continuing education of doctors and nurses are available locally.

Health Knowledge, Technology, and Information

Most private-sector providers, as well as the public health system, utilize electronic health records and other forms of electronic data management. However, because management of the health sector’s data is fragmented among various providers, evidence-based decision-making is hindered. An electronic information system for managing civil registry data, called CRIS (Civil Registry Information System), has been in place since 2011. It links Peebles Hospital with the Civil Registry, Central Statistics Office, and Ministry of Health to ensure that data on births and deaths are accurate. There also is an electronic reporting system for communicable diseases, which utilizes an online survey tool to report data on vector-borne diseases in real time to the Ministry of Health and the Environmental Health Division. All other data are reported to the Ministry of Health on paper forms.

The Environment and Human Security

Water and Sanitation

Every home in the territory has a reliable supply of safe water through rainwater catchments, which are mandated by law unless the home has access to the municipal water supply. Municipal water distribution, derived from seawater desalination, is limited. The Water and Sewerage Department estimates that 95% of the population has access to safe drinking water and an equal proportion to adequate sanitation. Ministry of Health personnel monitor the quality of the water supply. Municipal sewage mains serve 2.6% of buildings; septic systems cover the remainder.

Air Pollution

With no heavy industry in the territory, outdoor air pollution is not a significant concern. Following concerns raised by surrounding communities regarding air pollution generated by the previous Pockwood Pond incinerator, the Ministry of Health has commissioned the installation of scrubbers on the new incinerator to further reduce emissions.

Solid Waste

The management of solid waste is a critical issue in the British Virgin Islands. As do other island nations, the territory has little land available for use as landfill, and this situation is aggravated by the British Virgin Island’s rolling terrain, which makes it difficult and expensive to engineer landfills. The territory has experienced a threefold increase in waste volume in the last decade; waste is either dumped or incinerated, and there are no recycling facilities currently in place. Waste disposal is mainly handled through incineration at the Pockwood Pond incinerator on Tortola, which has a 100 ton/day capacity, with additional landfills on the main islands of Tortola, Virgin Gorda, and Anegada. In 2012, a new incinerator was operationalized, with the scrubbers to be installed at a later date.

Climate Change

The territory, like most small-island developing states, is expected to experience climate-change consequences such as rising sea levels, changes in rainfall pattern, and an increase in the intensity and frequency of hurricanes. The Virgin Islands has developed and implemented a Climate Change Adaptation Policy and Strategy. The document addresses increased vigilance of shorelines, reefs, and drainage and sewerage systems; protecting wildlife and flora; and coping with climate change’s impact on human health.

Migration

Approximately 60% of the territory’s population is foreign-born. Immigration is a complex issue that directly touches on nationality and citizenship issues, which are governed by the British Nationality Act. Persons born in the territory to foreign nationals are not automatically granted citizenship. Many births occur in the United States and, to a lesser extent, in other territories. The proportion of transient migrants in the territory is considerably smaller, predominantly working-age; conditions in this group are not well documented. This has implications for access to care, particularly for non-English speakers and undocumented persons who will not have National Health Insurance coverage and therefore will have to pay out-of-pocket for health care.

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

Since 2004, public health care services have fallen under the responsibility of the BVI Health Services Authority, a statutory corporate body. Public primary health care services are provided through 10 health centers and 4 health posts; public secondary care is provided at the Peebles Hospital, a bed institution that offers services in the major medical disciplines. There is a well-developed private health care system that includes a private hospital. Visiting specialists from the English-speaking Caribbean, Puerto Rico, and the United States provide care at public and private institutions, mostly on a monthly basis, depending on demand. Visiting specialist services cover areas such as neurology, rheumatology, urology, ophthalmologic subspecialties, and plastic surgery. Most tertiary care is provided in the United States, Puerto Rico, the United Kingdom, and elsewhere in the Caribbean.

Health services are financed through National Health Insurance, which was put in place in January 2016. The NHI receives contributions from employers and employees in addition to government direct investment and reimbursement for care provided in both the public and private sector. All legal residents are mandated by law to participate in the National Health Insurance, which acts as the legal primary health insurer in the territory, covering a set, comprehensive benefits package that includes medical, dental, and vision benefits. Co-payments are 0% at public clinics; 5% at the Public Hospital: 10% at private in-network facilities: and 20% at out-of-network facilities: 20%.

The Ministry of Health reviews and updates its legislative framework on an ongoing basis to improve its leadership and governance roles. The improvements in the monitoring and evaluation of efficacy, customer service, quality of patient care, and access of all persons interfacing with the system will also be facilitated through improved access to care provided for by the National Health Insurance System. These changes are expected to lead to overall strengthening and improvement of the entire health system.

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Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

No maternal deaths have been recorded in the territory in the last 10 years. All deliveries almost exclusively take place at Peebles Hospital and are all attended by skilled birth attendants. The proportion of low birthweight infants fluctuated between 2008 and 2015 with a high of 11.9% and a low of 5.2%. A program for the prevention of mother-to-child HIV transmission is in place, and has been evaluated by PAHO. Among the main findings of this evaluation was the need to strengthen quality control at the Peebles Hospital Laboratory; other elimination components were considered adequate.

Child Health

Children under 5 years old accounted for 9% of the population, and children 5-9 years old represented 8% of the population. From 2013 to 2015, there were 835 births recorded, with low birthweight infants accounting for 6.9% of births in 2013 and 8.7% in 2015. Infant mortality fluctuated between 2006 and 2015, ranging between 26.7 deaths per 1,000 live births and 11.3 deaths per 1,000 live births. The leading causes of death in children under 5 years old were conditions originating in the perinatal period followed by congenital anomalies. Acute respiratory infections and gastroenteritis are the leading causes of illnesses in this age group.

In 2015, vaccination coverage against diphtheria/pertussis/tetanus (DPT), hepatitis B, Haemophilus influenza type b, and poliomyelitis was 97% higher than the figures for 2014 (80%) and 2013 (82%). Immunization coverage was 100% for the first dose of measles, mumps, and rubella (MMR) in 2015, and 88% for the second dose. These figures represent an increase over those in 2014: first dose of mumps, measles, and rubella (MMR), 90%, and second dose of MMR, 76%. The switch from trivalent (tOPV) to bivalent polio vaccine (bOPV) and inactivated polio vaccine (IPV) occurred in 2016. IPV targeted children aged 2 months.

Health of Schoolchildren

A well-organized school health system includes screening for vision, hearing, and disabilities; the program also includes dental health. The program spans child and adolescent periods.

Adolescent Health (10 19 years old)

In 2015, births to adolescent mothers were 9%; in 2010 2015, live births among adolescents were consistently registered at under 12% live births annually. The 2009 Global School-based Student Health Survey (GSHS) that covered students 13 15 years old showed that approximately one-third of students surveyed had at least one alcoholic drink in the 30 days prior to the survey. Of students interviewed, 15.7% had seriously considered attempting suicide in the year prior to the survey, and 12% had attempted suicide. One in every three (35.7%) students had engaged in sexual intercourse, with 76.0% of those engaging in their first sexual encounter before age 14 years. Condom use at last sexual intercourse was high at 71.6%.

Health of the Elderly

Dependency is low, with the proportion of elderly being relatively small due to immigration of working-age groups. According to the 2010 census, there were 1,693 persons 65 years and older. A study on the situation of the elderly in the British Virgin Islands in 2011-2012 highlighted the need for more care for the elderly suffering from chronic diseases and better access to care. There is no state-run residential housing for the elderly.

Mortality

Noncommunicable diseases dominate the territory’s mortality profile. In 2014, there were 111 deaths. Men continue to experience a higher mortality rate. Hypertension continues to be the leading cause of death in the population 12.6%, with malignant neoplasms accounting for 10.8% of all deaths; the incidence of deaths related to cardiovascular illnesses is 9.9%. The overall average age of death in 2014 was 63.8 years; the average age of death for persons with heart disease was 72. Figure 2A and B shows the percentage distribution of causes of death for males and females.

Figure 2 A and B. Percentage distribution of causes of death, by sex, British Virgin Islands, 2014

Source: British Virgin Islands, Civil Registry-Electronic Notification of Mortality Information System, 2014

Hypertension was the leading cause of death (14%) in 2014. The 2009 STEPS survey study revealed that a large percentage of the population age 25 64 years is overweight and presented with raised blood pressure; 46% of those surveyed had three or more risk factors for chronic disease. The projection is that more persons will acquire chronic noncommunicable diseases and become ill in their productive years (4).

Diseases of the lungs ranked as the second leading cause of death in 2014, and fourth in 2011; these diseases included pulmonary edema, pulmonary infarction, bacterial pneumonia, and obstructive lung disease.

Malignant neoplasms including cancer of the prostate, breast, lung, stomach, uterus, and colon ranked as the third leading cause of death in 2014. Malignant neoplasms affect more men than women.

Cardiovascular disease, including congestive health failure, arteriosclerosis, ischemic heart disease, coronary artery disease, hypertensive cardiovascular disease, myocardial infarction, and congestive heart failure, remains the leading cause of death for the population; more men than women died as a result of heart disease in 2014. In 2014, most cardiac deaths occurred in persons older than 60 years, 12.5% occurred among those under 50 years old, and 2.5% occurred among persons 50 59 years old.

In 2014, stroke ranked as the fifth leading cause of death. Among males who died of stroke in that year, the average age was 45.8 years; the average age for females was 63.8 years. There were two deaths due to stroke in children 11 years old.

Morbidity

Communicable Diseases

Vector-borne diseases remain endemic in the territory, with dengue fever and chikungunya being the most important such diseases in the territory. In 2016 there were 108 cases of dengue and 14 cases of chikungunya.

Regarding vaccine-preventable diseases, there were eight reported cases of chicken pox (varicella) in 2013 2015, all in unvaccinated persons. The territory’s immunization schedule contemplates administering varicella vaccine to children under 5 years old. No other cases of vaccine-preventable diseases were diagnosed.

There were no cases of zoonoses during the reporting period.

As of December 2016, cumulatively since the beginning of the epidemic in 1983, 127 cases of HIV/AIDS had been reported (58 females and 69 males), and there were 40 AIDS-related deaths. In 2015, nine new cases of the disease were reported. Those most at risk for acquiring HIV/AIDS continue to be heterosexual males and females, homosexual males, young persons 24 44 years of age, and persons older than 50 years. The average age of persons being diagnosed with the disease is 35 years of age. In 2013, 30% of newly reported cases were among persons older than 60 years.

There were no reported cases of tuberculosis in 2013 2015.

Chronic, noncommunicable diseases

Chronic diseases continue to be a major cause of morbidity and mortality. In 2015, such diseases accounted for four of the five leading causes of death.

Accidents and Violence

In 2016 there were five murders in the British Virgin Islands, and three in 2015.

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Prospects

The territory advanced significantly towards universal health coverage and universal health access by establishing the National Health Insurance System in 2016. That said, the development of a universal health coverage road map is considered necessary to ensure that this goal will be attained. Recommendations in the road map include a focus on the renewal of primary health care and ensuring that additional resources are available and dedicated to address the social determinants of health. Reversing the findings of the STEPS survey will require the full commitment of the Government and society to this end. Further, additional resources must be made available to the chronic, noncommunicable disease strategy, and there is a clear need to develop an e-health policy and plan and the enacting of supporting legislation to cover the handling of personal information.

The territory continues to be at risk for vector-borne diseases, particularly those transmitted by Aedes aegypti. Outbreaks of such diseases lead to illness and loss of productivity, and they erode the economy, which is highly dependent on tourism.

The National Health Insurance is a new system that has provided health care coverage to the entire population and reduced the impact of price as a barrier to care to a significant number of persons for whom previously this would have been an important deterrent. It is projected that the total health care expenditures in the program will rise in the short term and later stabilize, as unmet demand for health care in the population is met. This will necessitate constant surveillance of these trends and modifications to the system as necessary.

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References

1. Bureau of the Census (United States). International data base (IDB) [Internet]. Suitland, MD: USCB; 2015 [updated August 2016]. Available from: https://www.census.gov/population/international/data/idb/informationGateway.php Accessed February 2017.

2. Central Statistics Office (British Virgin Islands). Statistics [Internet]. Tortola: BVI-CSO; 2016. Available from: http://www.bvi.gov.vg/statistics. Accessed September 2016.

3. Ministry of Health and Social Development (British Virgin Islands). BVI health systems and services profile, 2016 [Internet]. Tortola: MHSD; 2016.4.

4. Ministry of Health and Social Development (British Virgin Islands); Caribbean Public Health Agency. STEPS risk factor survey report. Tortola: MHSD; 2010. Available from: http://www.who.int/chp/steps/2009_BVI_STEPS_Report-VI.pdf?ua=1. Accessed November 2015.

5. Ministry of Health and Social Development, Office of Gender Affairs (British Virgin Islands). Annual report 2012. Tortola: MHSD; 2013.

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