Turks and Caicos Islands
- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
The Turks and Caicos Islands is an archipelago of approximately 40 islands and cays comprising a landmass of 417 km2, located southeast of the Bahamas and approximately 144 km north of Haiti. The islands and cays are distributed in two groups, namely the Turks Islands and the Caicos Islands. The Turks Islands group consists of two inhabited islands, Grand Turk and Salt Cay. Cockburn Town, the nation’s capital, is located on Grand Turk, which is the seat of the Turks and Caicos Islands Government. The territory includes four main, inhabited islands: South Caicos, Middle Caicos, North Caicos, and Providenciales.
The 2012 census showed an increase in the total population from 19,886 in 2001 to 31,458 in 2012. The overall increase was driven by economic and development booms that resulted in job opportunities in the construction and service industries, largely related to the tourism sector. In 2012, 51.0% (16,037) of the population were male and 49.0% (15,421) were female. In 2001, males comprised 49.7% and females 50.2% of the population. The increase in males over females during the inter-census period can be attributed to the increase in male immigrants drawn to the Turks and Caicos Islands for economic reasons. The 2012 census also showed substantial internal migration, from South Caicos to Grand Turk, and from North Caicos to Providenciales. Providenciales is home to 75% of residents; between 2001 and 2012 it saw an 82% increase in population ().
Haitians were the largest group of immigrants, comprising 35% of the total population in 2012, followed by Jamaicans at 8%, and Dominican Republic nationals at 5% (). The Constitution of the Turks and Caicos Islands assigns “Belonger” status to persons born in the Turks and Caicos Islands, to those born outside of the country but who have at least one parent born there, or to those who were granted resident status by the Governor ().
Turks and Caicos Islands is a United Kingdom Overseas Territory and an appointed Governor is the representative of Her Majesty Queen Elizabeth II. The Premier, who is elected, is appointed by the Governor to head the government. The Deputy Governor is the head of the Public Service and reports directly to the Governor. Each government ministry is led by a minister (political) and a permanent secretary (administrative). Each island, with the exception of Grand Turk and Providenciales, has a District Commissioner who is responsible for the administration of the local government.
Between 2009 and 2012, an interim government was installed by the United Kingdom in response to a Commission of Inquiry to implement various reforms and achieve specific milestones (). General elections were held in November 2012, resulting in a majority government for the Progressive National Party.
Life expectancy for males increased from 73.1 years in 2008 to 75.8 years in 2012, and remained stable for females at 77.8 years. The fertility rate was 1.74 children per woman in 2001 and 1.77 in 2012 for Belongers, and 1.48 in 2001 and 1.70 in 2012 for non-Belongers. The TCI 2012 census showed that the youth dependency ratio (0-14 years) decreased from 42.3% in 2001 to 28.4% in 2012; the old-age dependency ratio (65 years and older) decreased from 5.6% in 2001 to 4.3% in 2012. The crude birth rate was 16.9 live births per 1,000 population in the period 1990-2001 and declined to 15.9 in 2001-2012. The literacy rate was 98.0% in 2012. Figure 1 shows the territory’s population structure for 1990 and 2015.
Figure 1. Population structure, by age and sex, Turks and Caicos, 1990 and 2015
The territory’s population increased slightly more than threefold between 1990 and 2015, due in large part to a large immigration inflow. In 1990, the population structure had an expansive pyramid shape, especially in age groups older than 25 years. By 2015, most of the population was concentrated in the middle age groups, with the structure reflecting a combination of natural growth and immigration in the last two and a half decades.
Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.
The gross domestic product (GDP) at market prices was estimated at US$ 715.7 million in 2012 and US$ 762.7 million in 2015. The economy is primarily based on tourism, offshore financial services, and fishing; the “hotel and restaurants” sector is the largest contributor to the GDP (38.0%) followed by “financial intermediation” (11.3%) ().
The economy is highly exposed to international economic fluctuations. The impact of the international financial crisis in 2008 and domestic problems in the management of the economy resulted in a 19.6% contraction of the Turks and Caicos Islands economy in 2009. The economy also contracted an estimated 2.6% in response to the 2012 crisis. Even with economic recovery between 2013 and 2016, the country has not attained the level of income per capita observed in the years 2005-2007. The unemployment rate in 2012 was estimated at 17%, compared to 10% in 2001. About 20% of the labor force worked part-time in 2012. Unemployment was 20% in the nonnational population, compared to 12% for Belongers ().
The 2012 Country Poverty Assessment found that the poverty rate was 22% for the population and 16% for households. Providenciales had a much lower rate of poverty (17% of the population and 12% of households) but because three-quarters of the territory’s population lives in Providencials, that island concentrates the majority of poor persons (60%). In the islands of Middle Caicos, North Caicos, and South Caicos, the poverty rate was over 40%. The Poverty Assessment also showed that, by nationality, Haitian nationals had the highest poverty rates, at 35%, and comprised 56% of those who are characterized as poor. The majority of undocumented immigrants in the territory are reportedly Haitian nationals. Turks and Caicos Islands nationals had an 18% poverty rate and they comprised 34% of the poor population. Nationals of the Dominican Republic and Jamaica had poverty rates of 13% and 8%, respectively, and each made up 3% of the poor population ().
In 2012, housing conditions in Turks and Caicos Islands were generally good as the vast majority of the population had access to electricity, improved water supplies, and in-house sanitation. An estimated 10% of all dwellings had two or more indicators of defective housing. The poverty rate for large households (5+ persons) was high, at 36% ().
Primary and secondary education is free and compulsory for 5-16 year olds. There are both public and private schools. Post-secondary education is provided through the Turks and Caicos Islands Community College, with campuses in Grand Turk and Providenciales (). Undergraduate, graduate, specialist, and technical studies are accessed abroad, mainly in Canada, the Caribbean, the United Kingdom, and the United States.
Turks and Caicos Islands is highly dependent on imported food, which represents over 90% of the food consumed. Imports are primarily from the United States, Haiti, and the Dominican Republic. The local agriculture sector accounts for less than 1% of GDP, due primarily to the limited availability of arable land (2.3% of the total land mass), and low annual rainfall, especially on Grand Turk, Salt Cay, and South Caicos. An Agriculture Development Plan and Policy was drafted in 2016, with a focus on increasing agriculture production, improving food security, and maintaining and safeguarding the environment. Substantive subsidies and tax exemptions for cultivating healthy food have not been implemented.
The Health System
The Turks and Caicos Islands health care system consists of both public and private health care providers. Universal health coverage has been achieved through the implementation of the National Health Insurance Plan (NHIP) in 2010, a social insurance program that provides universal coverage for basic health care to all residents; it is free at the point of care.
Primary health care is delivered through government-managed public health clinics distributed across the islands and by private primary care physicians. The Ministry of Health operates eight primary health care clinics: one in Grand Turk, two in Providenciales, two in North Caicos, and one each in South Caicos, Middle Caicos, and Salt Cay. There are six private primary care clinics, all located in Providenciales.
Secondary and tertiary care is provided at the Turks and Caicos Islands Hospital, which has two sites: one in Providenciales (Cheshire Hall Medical Center) and one in Grand Turk (Cockburn Town Medical Center). The government contracted InterHealth Canada Limited in 2008 to manage these newly constructed hospitals for a period of 25 years. Many patients continue using the Turks and Caicos Islands Hospital as the first point of care, instead of utilizing the primary care system. The Vision 2020 Health Sector Plan includes a Primary Health Care Renewal Strategy aimed at reducing the use of expensive hospital services and improving access to primary care.
The ratio of clinical personnel to the population rose for physicians from 10.8 in 2010 to 18.7 per 10,000 population in 2015, and for nurses from 30.3 in 2010 to 57.1 per 10,000 in 2015. The ratio for dentists remained unchanged at 1.8 per 10,000 population, and the ratio for allied health professionals in 2015 was 32.7 per 10,000 population.
The Health Professionals Bill, passed in 2016, paves the way for the establishment of three health professions councils (nursing and midwifery, medical and dental, and allied health) to ensure that these professionals are represented and empowered to register, license, and regulate their respective professions.
Violence and Security
Turks and Caicos Islands enacted legislation that criminalizes human trafficking and mirrors the Palermo Protocol to Prevent, Suppress, and Punish Trafficking in Persons, especially Women and Children.
In the period 2015-2016, there were 352 reported cases of domestic violence. The Domestic Violence Ordinance of 2014 provides greater protection for these victims.
Leading Environmental Problems
Climate change brings the potential for an increase in the intensity of tropical storms and hurricanes. In 2011, the Turks and Caicos Islands, in collaboration with the Caribbean Community Climate Change Centre and the United Kingdom Department for International Development, developed a climate change policy, which provides a five-year mitigation strategy. A National Climate Change Committee remains active, but financial constraints and limited technical capacity have hindered successful implementation efforts ().
The Department of Agriculture and the Environmental Health Department are responsible for the inspection of all food imports. The Environmental Health Department spearheads port surveillance and the inspection of all facilities that sell food, including supermarkets and hotels. It is also responsible for food handlers’ training and certification. After a 2012 resort-centered norovirus outbreak in Providenciales, national public health surveillance systems, especially for food- and waterborne diseases, have been strengthened ().
Drinking Water and Sanitation
Eighty-two percent of households had access to safe drinking water through indoor (piped) plumbing in 2012, and 67% collected rainwater in cisterns for personal use. More than 90% of the population used bottled or filtered water for drinking purposes ().
In 2012, approximately 16% of households either used pit latrines or had no toilet facilities, which represents a reduction from the 32% reported in 2001 (). Domestic wastewater is collected primarily in septic tanks. There were 75 wastewater treatment plants, located mainly on Providenciales. Many resorts treat and recycle gray water for landscaping purposes. There are two landfills (one on Grand Turk and the other on Providenciales), and five dump sites (two on North Caicos and one each on South Caicos, Middle Caicos, and Salt Cay).
Leading Health Challenges
Critical Health Problems
During the period 2010-2016, new and emergent disease threats were largely posed by mosquito-borne diseases such as those caused by the dengue, chikungunya, and Zika viruses. During this period, dengue fever became endemic with spikes in cases after bouts of rain. Chikungunya virus was first detected in June 2014 in travelers and there was subsequent local transmission; as of September 2016, a total of 26 confirmed cases were reported. Zika virus infection was first detected in June 2016 in travelers with subsequent local transmission; as of September 2016, eight confirmed cases were reported.
Integrated vector management practices and other public health measures have been implemented to mitigate and respond to such threats.
Chronic diseases contribute substantively to morbidity, mortality, and health care costs in the Turks and Caicos Islands. In 2013, three categories of noncommunicable diseases (NCDs) accounted for most NCD-related deaths: circulatory system disorders, such as heart disease, cerebrovascular diseases, and hypertensive diseases (40%); malignant neoplasms (20%); and endocrine disorders, such as diabetes mellitus (11%). In 2015, the majority of visits to family practice clinics (excluding for pregnancy) were for the management of hypertensive diseases (59.5%), diabetes (29%), and mental disorders (5.7%). The same year, hospital admissions for NCDs presented the following distribution: heart disease (36.9%), mental disorders (23.5%), hypertensive disease (10.7%), diabetes mellitus (10.2%), and malignant neoplasms (9.6%).
To address the multi-sectoral nature of the underlying risk factors for NCDs, the National Plan of Action for the Prevention and Control of Non-Communicable Diseases and Health Promotion in Turks and Caicos Islands was developed for the period 2016-2020. The Plan’s guiding framework considers the following approaches: human rights, equity, leadership, and stewardship of the health sector; multi-sectoral action; and the empowerment of people and communities ().
In 2015, the Tobacco Control Ordinance was enacted to protect the population and visitors from the harmful effects of tobacco.
In 2014, a total of 1,142 patients were seen at various mental health clinics throughout Turks and Caicos Islands. Approximately 32.7% of patients were seen for non-mood psychotic disorders, such as schizophrenia; 25.5% for anxiety and stress-related mental disorders; 13.9% for mood/affective disorders; and 4.9% for psychoactive substance-related conditions. Persons who require long-term mental care are generally sent to Jamaica for treatment.
In June 2016, a new Mental Health Ordinance was passed by the House of Assembly. The previous mental health legislation was enacted in 1902 (the Lunacy Ordinance Act) and last revised in 2009.
In the period 2009-2014, 119 persons tested positive for HIV. Men accounted for 58.8% of cases and females 41.2%. Four mothers tested positive for HIV in 2015, two of whom were newly diagnosed. Data from Turks and Caicos Islands are being evaluated with a view to validating the elimination of mother-to-child transmission of HIV and syphilis.
Health Knowledge, Technology, and Information
Efforts are ongoing to develop an electronic health information system to facilitate timely receipt of health and epidemiological data, as well as to strengthen public health surveillance, including by the National Epidemiology and Research Unit.
Turks and Caicos Islands is experiencing ongoing demographic changes due to the inflow of migrants. Anecdotal information suggests that since 2012, the inflow of persons, including undocumented immigrants primarily from the island of Hispaniola, is steadily increasing. Other migrants are primarily nationals from Jamaica and countries outside of the Region of the Americas, e.g., the Philippines. This inflow is fueled in part by the demand to fill construction and service-related positions in the tourism sector. It is a concern that many undocumented immigrants do not subscribe to the NHIP and may burden the health care delivery system.
Monitoring the Health System’s Organization, Provision of Care, and Performance
Most medicines in Turks and Caicos Islands are subsidized by the government through NHIP and distributed through private pharmacies. In public health care clinics, antiretroviral medicines are sourced through the Pan American Health Organization (PAHO) Strategic Fund, vaccines through the PAHO Revolving Fund, and other essential medicines from external suppliers. In 2016, a National Pharmaceutical Policy was developed to ensure equitable access to, and rational use of, efficacious, high-quality medicines and medicinal products at an affordable cost.
NHIP includes a Treatment Abroad Program that covers the costs of medical care provided abroad when not available within the territory, inclusive of travel and subsistence expenditures. The government managed to reduce the cost of this program while increasing the number of encounters by shifting an important proportion of care previously accessed in the United States to other Caribbean countries. Expenditures declined from US$ 20.4 million in 2009-2010 to US$ 10.1 million in the period 2014-2015.
Health Situation and Trends
Health of Population Groups
Children under 5 years old made up 7.1% of the population in 2012. Data for 2007-2014 showed a high of 571 live births in 2009 to a low of 424 in 2013. Hospital data for 2015 showed that 242 (11.0%) of all admissions in that year occurred in this age group. In 2011, vaccination coverage was: BCG 98.0%, oral polio 87.4%, DPT/Hep B/Hib 87.4%, and MMR1 (90.6%). The immunization report for 2012 showed coverage of 80% and greater in all antigens, with a marked increase in the pentavalent (95.3%) and oral polio (95.3%) vaccines, and MMR1 (98.2%) (). There were two neonatal deaths in 2011, one in 2012, and two each year for 2013-2015. One post-neonatal death occurred in 2014.
Health of Schoolchildren (5 to 9 Years Old)
Children 5 9 years old accounted for 6.9% of the population in 2012. Hospital data indicated that 37 (1.7%) of all admissions in 2015 occurred in this age group. Mortality data for 2011-2012 were unavailable; there were no deaths in this age group in 2013-2014.
Health of Adolescents (10-14 and 15-19 Years Old)
Adolescents 10 14 and 15 19 years old represented 13.9% of the population in 2012. Of all hospital admissions in 2015, 126 (5.7%) were in this age group. In the period 2008-2013, approximately 40.0% of children transitioning from primary school to high school who participated in school health surveys were classified as either overweight or obese (). In the 10-14-year age group, there were no deaths in 2013 and one death in 2014. For the 15-19-year age group, there were no deaths in 2013 and two (males) in 2014.
Health of Adults
Adults 20 29 years old comprised 61.2% of the population in 2012. Of all hospital admissions in 2015, 67.6% (1,486) were in this age group. In 2013, there were 25 deaths (14 females and 11 males) in this age group, representing 30.9% of all (81) deaths that year.
Health of the Elderly
Persons 60 years old and older comprised 11.0% of the Turks and Caicos Islands population in 2012. The group’s greatest concern was accessibility of medicines, which were no longer dispensed by government clinics but by private pharmacies subsidized by the NHIP. In 2015, 14.0% of hospital admissions were in this group. In 2013, there were 53 deaths (28 females and 25 males), representing 66.1% of all deaths that year.
In 2014, a total of 78 deaths were recorded; 26 were females and 52 males. The leading causes of death were diseases of the circulatory system (40.0%), which included ischemic heart disease (55.2%), cerebrovascular disease (13.8%), and other circulatory system disorders (31.0%). This was followed by external causes (13.0%), neoplasms (11.7%), diabetes mellitus (6.5%), and diseases of the respiratory system (6.5%). No maternal deaths were recorded between 2011 and 2015.
Available data show a reduction in the number of visits to public health clinics in 2015 (9,354) compared to 2014 (14,922). Women predominantly sought attention in public primary care (61.0%). Of the 460 pregnant women who accessed antenatal care in these facilities in 2012, Haitian nationals accounted for the largest portion (38.3%) followed by Turks and Caicos Islands nationals (28.0%) ().
In the two-year period between January 2013 and December 2014, a total of 3,514 hospital admissions were recorded at Turks and Caicos Islands hospital facilities; 18.2% were in Grand Turk and 81.8% in Providenciales. Females accounted for 64.0% of these admissions. The mean age of admission was 37.4 years (including obstetrics). The majority of admissions (21.0%) were in the 30-40-year age group. The services most often provided during admission were internal medicine (21.0%), family practice (21.0%), surgery (19.0%), and gynecology (18.0%). Other conditions commonly related to admission were diseases of the digestive system, diseases of the circulatory system, and external causes. In November 2013, a total of 35 persons were receiving renal dialysis at the two centers located on Grand Turk and Providenciales.
A number of initiatives are on-stream to ensure principles of equity, human rights, and fiscal responsibility, which are at the core of an improved health care delivery system in Turks and Caicos Islands. In 2015, the Ministry of Health adopted the following six strategic directions to address gaps and challenges in the period 2016-2020:
- Strengthen the capacity of the health workforce;
- Strengthen the delivery of services based on the principles of primary health care;
- Strengthen response to identified priority diseases and/or conditions, and improve programs;
- Strengthen the provision of high-quality health services through the established and enforced health policies, regulations, and standards;
- Ensure the financial affordability and sustainability of health care delivery;
- Strengthen inter-sectoral coordination to address priority health problems.
A gap analysis of the International Health Regulations regarding core capacity compliance in Turks and Caicos Islands was conducted by the United Kingdom in 2013. Based on this analysis, an action plan was developed to address the deficiencies in the areas of: legislation, finance, human resources, laboratory diagnostic capacity, port health, surveillance, and capacity to respond to chemical and radiological incidents ().
The Turks and Caicos Islands takes the health of residents and visitors seriously and, to that end, pursues various efforts and initiatives (Box 1). Further, in 2016, Turks and Caicos Islands, in collaboration with the Caribbean Public Health Agency (CARPHA), launched the Tourism Health and Safety initiative. Turks and Caicos Islands was the first country in the Caribbean to launch such a multi-sectoral program that seeks to ensure the health and safety of tourists in recognition of the importance of the tourism sector to the economy. The program is also a part of the ongoing initiative to enhance public health surveillance.
Box 1. Turks and Caicos Islands Addresses Health of Residents and Visitors
- Issues related to the health of migrant populations;
- Barriers to accessing health care services for the general population;
- The need to engage other sectors, beyond the health care sector, to improve health of the general population, in particular to reduce risk factors for NCDs. In so doing, emphasis must be placed on initiating healthy lifestyles/behaviors during childhood and continuing through the life-course to prevent NCDs in adulthood.
Initiatives to address these challenges include:
- The establishment of NHIP as the funding mechanism and model for universal access to health. The government is currently working on removing cost barriers to achieve universal access and universal health coverage, including for migrant populations.
- A Human Resources for Health Strategy that aims to strengthen the health care workforce and ensure that the population has access to appropriate care at the right level, with a focus on primary care.
- Development of the necessary technical knowledge and infrastructure to support efficient management of health resources, including a health information system, improved costing/funding modalities, and improved disease surveillance and planning.
- A National Nutritional Policy with consultation across sectors (80% complete).
- Advancing the Health in All Policy Agenda and promoting discussions across different sectors of government and society.
Major recent achievements in health legislation in the Turks and Caicos Islands include:
- In 2015, the Ministry of Health and Human Services was restructured by adding the portfolio of the Department of Agriculture to highlight this sector’s impact on health.
- The Strategic Health Plan Vision 2020 charts the way forward for the health sector in keeping with the evolving health care needs of the population and visitors.
- In 2016, the Mental Health Ordinance repealed the outdated Lunacy Ordinance, and ensures that Turks and Caicos Islands conforms to international human rights laws in this matter.
- The Tobacco Control Ordinance was enacted in 2015.
- The Health Regulations Bill, passed in 2016, aims to enforce compliance with health sector regulations and standard operating procedures for health care facilities and quality of care.
1. Department of Economic Planning and Statistics (Turks and Caicos Islands). Social statistics: population [Internet]. Grand Turk: DEPS; 2017. Available from: http://www.sppdtci.com/population.
2. Government of the Turks and Caicos Islands. Statutory Instruments 2011 No. 1681– Caribbean and North Atlantic Territories: Turks and Caicos Islands Constitution Order 2011. Grand Turk: GOTCI; 2011. Available from: https://www.integritycommission.tc/sites/default/files/pictures/Constitution%20New%202011.pdf.
3. Foreign & Commonwealth Office (United Kingdom). Turks and Caicos Islands Commission of Inquiry 2008–2009: Report of the Commissioner The Right Honourable Sir Robin Auld. London: FCO; 2009. Available from: https://www.gov.uk/government/publications/turks-and-caicos-islands-commission-of-inquiry-2008-2009.
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6. CARIBSAVE Partnership. CARIBSAVE climate change risk profile for the Turks and Caicos Islands: summary document. Christ Church, Barbados: CARIBSAVE Partnership; 2012. Available from: http://taskmediator.com/out/out.ViewDocument.php?documentid=2443&showtree=1.
7. Handfield S, Malcolm S, Ramkallowan S, Neeley K, Astwood N, Maitland TE. Norovirus outbreak: an emerging public health threat in the Caribbean with implications for small tourist dependent economies such as the Turks and Caicos Islands. West Indian Medical Journal 2013;62(Suppl 2):28.
8. Ministry of Health, Agriculture and Human Services (Turks and Caicos Islands). National Health Sector Strategic Plan 2016–2020: Turks and Caicos Islands 2020 Vision for Health Care. Grand Turk: MHAHS; 2015.
9. Maitland TE, Malcolm S, Handfield S, Malcolm K. Trends in obesity and other cardiovascular diseases risk factors among school children in the Turks and Caicos Islands (2008mong schWest Indian Medical Journal 2014:63(Suppl 2):48.
10. Ministry of Health, Agriculture and Human Services, Primary Health Care Department (Turks and Caicos Islands). Annual Reports 2011–2015. Grand Turk: MHAHS.