- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Bermuda is a self-governing United Kingdom Overseas Territory in the Region of the Americas. It lies more than 1,300 km to the north of the Caribbean islands and 1,050 km east of the state of North Carolina in the United States. Bermuda is an archipelago of seven main islands linked by bridges and over 100 smaller islands spread over roughly 53 km2 in the Atlantic Ocean. The territory is divided into nine parishes: Devonshire, Hamilton, Paget, Pembroke, St. George’s, Sandys, Smith’s, Southampton, and Warwick. The capital city of Hamilton is located in Pembroke, which is the most densely populated parish. Bermuda’s climate is subtropical, with temperatures ranging from 18° C to 31° C, and average annual rainfall of 1,400 mm.
Bermuda is governed through the Westminster model of parliamentary democracy. Its Parliament held its first session in 1620, making it the third-oldest continuous parliament in the world. The Government consists of a governor, deputy-governor, cabinet, and legislature. The legislature is made up of the House of Assembly and the Senate ().
Bermuda’s projected population for 2016 is 61,695 with a male-to-female ratio of 91 males to 100 females. The Population Projections report for 2010-2020 forecasts a 4% decline in population for the decade, the result of emigration, which has exceeded natural increase through births and immigration every year. It is estimated that the median age will rise from 41 years in 2010 to 46 years in 2020. The proportion of seniors (65 years and older) will climb from 14% to 20% of the population, and the old-age dependency ratio is projected to increase from 19 in 2010 to 30 by 2020. Figure 1 shows the changes in the population’s structure between 1991 and 2015 ().
Figure 1. Population structure, by age and sex, Bermuda, 1991 and 2015
The Bermuda population increased 20.8% between 1991 and 2015. In 1991, the population structure had an expansive shape in the population over 30 years of age, with both regressive and stationary growth under age 30. In 2015, the expansive shape shifted to age groups above 50 years, with a regressive shape for age groups between 20 and 50 years of age. There is stationary growth in the groups under 20 years old in relation to aging and the decreases in fertility and mortality seen in the last five decades.
Source: Pan American Health Organization, based on (for 1991): the United States Census Bureau, International database (updated August 2016); (for 2015): Bermuda, Department of Statistics, Bermuda’s Population Projection 2010–2020.
In 2015, the crude birth rate was 9.4 births per 1,000 population and the total fertility rate was 1.45 children per woman. Figure 2 shows the number of births between 2004 and 2014. Fertility rates have been declining due to increased use of contraceptives, the increasing participation of women in the labor force, and changing lifestyle preferences. More women are delaying or forgoing having children as they pursue higher education and professional careers, and couples are also deciding to have fewer children due to changing economic conditions ().
Figure 2. Number of births, by sex, Bermuda, 2004-2014
Life expectancy at birth for 2016 is estimated at 81.29 years (77.51 for males and 85.13 for females). Bermuda’s population aged 65 years and older increased by 29% from 6,722 in 2000 to 8,683 in 2010. The age group that recorded the largest growth, with an increase of 57%, was those aged 80 to 84 years ().
Bermuda has one of the world’s highest per capita incomes, reported as US$ 96,018 in 2015 (). After six years of contraction, the economy began to grow that year: it is estimated that, compared to 2013, the gross domestic product (GDP) in current prices increased by 4%, and that once adjusted for inflation, GDP in constant prices increased by 0.6%. The economy is projected to further improve based on sustained growth in its main sectors: international business (which includes insurance and reinsurance), tourism, and construction.
Bermuda has one of the largest reinsurance industries in the world. It is compliant with global anti-money laundering and anti-terrorist financing standards, and does not have banking secrecy laws.
The construction sector is an important area for employment in Bermuda, and with the implementation of key projects is expected to expand. In 2014, Bermuda decided to rebuild and refocus its tourism sector to stimulate growth. In the same year, air visitors fell by 1.2% while cruise arrivals rose by 4.2% (). Inflation was 1.8% in 2013, 2.0% in 2014, and 1.5% in 2015 (). Increased price levels for services in the health and personal care sector was the most significant contributor to the level of inflation in 2015 (). Even though the economy is growing, Bermuda continues to face challenges with reducing its government debt and debt services ().
Social Determinants of Health
The 2013 Household Expenditure Survey () collected data on the levels and patterns of household expenditure and revealed that the average weekly household expenditure increased 18% above the 2004 level, reaching US$ 1,807 in 2013. The average household spent roughly US$ 10,300 a year on health care, and the average annual household income reached US$ 143,882 in 2015, above the $US 106,233 measured in 2004. The survey also reported that 60% of households owned a computer; 73% of households had landline telephones (compared to 91% in 2004), and 88% of households owned at least one cellular phone ().
Individuals in Bermuda do not pay personal income tax. Instead, the Government of Bermuda levies a payroll tax and all homeowners and long-term tenants are required to pay a land tax twice yearly.
In 2015, the unemployment rate was 7% (). Throughout 2012 2015, the annual rate fluctuated between 6% and 9%, with men experiencing slightly higher unemployment rates than women.
In 2000, the mean years of schooling attained by the population aged 25 years and older was 12.6. Bermuda provides free public primary and secondary education. Bermuda College, a two-year college, provides tertiary education. The overall total enrollment in both public and private schools has declined steadily since 2004, with total public school enrollment of students reported at 9,696 in 2014 ().
In 2007, 11% of the population was reported to be under a low-income threshold (). The Department of Statistics undertook extensive research to produce a low-income threshold measure for Bermuda instead of a poverty line model and identified single adults, single-parent households with children, and two-parent households with children as the most vulnerable household types (). Self-reported general health is poorer among those with lower education and lower income, according to the Bermuda health disparities report 2013 ().
The United Kingdom’s overarching objective for its engagement with the Overseas Territories on health matters is to improve global health and to meet the UK’s international obligations. The UK’s Foreign and Commonwealth Office (FCO) represents the needs and concerns of the Territories at regional and international meetings and fulfills international responsibilities, such as the International Health Regulations (IHR), the Framework Convention on Tobacco Control regulations (FCTC), and reporting on the Sustainable Development Goals (SDGs).
The Health System
The core structure of Bermuda’s health system was established by a number of statutes that include the Public Health Act of 1949 (amended in 2016), the Bermuda Hospitals Board Act of 1970 and the Health Insurance Act of 1970. Bermuda’s health care sector comprises one general hospital (the King Edward VII Memorial Hospital) that includes the Lamb Foggo Urgent Care Centre, one psychiatric hospital (the Mid-Atlantic Wellness Institute), 17 long-term care facilities, 193 ambulatory care facilities (including medical and dental practices, providers of home care services, etc.), 16 ancillary services (including patient transport, emergency rescue, medical and diagnostic laboratories), 18 retailers and providers of medical goods, and 18 providers of preventive care. Many private medical facilities offer various high technology services.
The Ministry of Health collaborates with the Bermuda Health Council, the Department of Health, the Bermuda Hospitals Board, and the Health Insurance Department. The Department of Health provides technical services related to public health. It consists of six sections that deliver primary and preventive health services to children, including the Expanded Program on Immunization; family planning and antenatal care to underinsured women of childbearing age; occupational health services to the uniformed services; and comprehensive primary health care to the island’s incarcerated population.
The Bermuda Health Council, established in 2004, is a quasi-autonomous nongovernmental organization that monitors the health system’s performance and coordinates health system stakeholders to ensure Bermuda’s residents have access to health insurance and safe, high-quality care. The Bermuda Hospitals Board, also quasi-autonomous, was established in 1970. Its Chief Executive Officer is responsible for King Edward VII Memorial Hospital, the Mid-Atlantic Wellness Institute, and the Lamb Foggo Urgent Care Centre.
Leading Health Challenges
Critical Health Problems
Bermuda has not experienced any critical health problems related to emerging and reemerging diseases, neglected diseases and other poverty-related infections, or tuberculosis. Influenza A/H1N1 continues to circulate in Bermuda. Between 21 February and 19 March 2016, 322 cases of fever and respiratory symptoms and influenza were reported compared to the five-year average of 248 reported cases ().
A multidisciplinary approach has been used to control antibiotic resistance and a recent study showed that Bermuda isolates do not exhibit the typical antimicrobial resistance patterns observed in other countries ().
Chronic conditions constitute a major burden of disease in Bermuda. This may lead to a health care system requiring greater levels of government subsidies and expansion of the current levels of long-term and complex care. In 2010, the six leading disabling conditions that affected the elderly were high blood pressure, impaired vision, arthritis, heart conditions, diabetes, and mobility difficulties. The 2000 and 2010 census data show that in the population 65 years old and older, hypertension increased from 26% to 45% and diabetes mellitus from 19% to 27% ().
The Annual Employment Survey, which provides a census of all businesses on the island, showed that over 2,000 persons were employed in health-related professions in 2014, of which 65% are Bermudian (). Within specific health professions, there is a shortage of Bermudians employed: 60% of nursing jobs, 55% of pharmacy jobs, and 49% of physician positions are filled by non-Bermudians, due to the need for specialized training abroad. To combat the nursing shortage, a nursing program was established at Bermuda College in 2012 (). Within the public sector, the Department of Health employs over 260 personnel who provide a variety of clinical and public health services. All physicians, dentists, pharmacists, nurses, and allied health professionals must be licensed and registered to practice and obtain continuing education hours.
There are efforts to broaden the scope and quality of oversight, monitoring, and regulation of health care providers and associated businesses and improve coordination of care across the health care system ().
Health Knowledge, Technology, and Information
The majority of health care providers use electronic systems to capture their data. The Bermuda Health Strategy 2014-2019 aims to develop an integrated electronic health system shared between the private and public sector, including laboratories and diagnostic facilities. The Bermuda Health Strategy also aims for greater regulatory control of health technologies, including high-cost diagnostic and therapeutic equipment, to ensure cost-efficient use.
Research in health is fully supported by the Department of Health and the Ethics Committee of the Bermuda Hospitals Board as outlined in the Research Governance Framework. All research involving the active participation of human subjects or the collection of information about human tissue needs to follow the guidelines as outlined in the Framework.
The Office of the Registrar General provides vital statistics on births and deaths. The Epidemiology and Surveillance Unit of the Ministry of Health provides information on select causes of death, communicable disease summaries, and risk factor surveys. The Bermuda Health Council provides information on health financing and regulation. The Health Information Management Services within the Bermuda Hospitals Board provides information on hospital service utilization. The Health Promotion Office is responsible for promoting health via community events and print, broadcast, and digital media.
The Environment and Human Security
In 2016, the Department of Environment and Natural Resources was established to “protect Bermuda’s environment and responsibly manage its natural resources” in order to provide for the environmental, economic, and social needs of the community (). The Environmental Health Unit provides a vigorous vector control program, regulates port health, ensures food safety in food production and importation, oversees occupational safety and health, and supervises water supplies, both in potable water storage and public bathing beaches, among other programs. Bermuda is considered 100% urban, and the entire population has access to improved sources of drinking water and to improved sanitation facilities.
Bermuda is vulnerable to hurricanes and tropical storms, sustaining significant losses from such events as wind, flooding, storm surge, and coastal wave damage. Bermuda has experienced several storms and hurricanes during the period under review, with minimal damage in general. Hurricanes Fay and Gonzalo in 2014 were the exception, striking only a week apart and together causing some US$ 204 million in damages.
In addition to hydrometeorological events, Bermuda is exposed to hazards including pandemics, major oil spills, air crashes, major cruise ship incidents, tsunamis, terrorism, and major fires (). Bermuda’s Emergency Measures Organization (EMO) prepares all government departments and nongovernment agencies for natural and human-caused disasters, and coordinates emergency response and recovery (). Strict building codes are enforced to mitigate against the destruction caused by hurricanes. The Department of Health has also developed a “Family Emergency Plan” that outlines what to do as a disaster approaches ().
Monitoring the Health System’s Organization, Provision of Care, and Performance
Bermuda’s health system has served the island well over many years, but dramatic changes in technology and demographics have created gaps in coverage and increasing health care costs. In 2008, it was reported that 11% of households were below the low-income threshold of US$ 36,605 (); for these households the current per capita health expenditure represents a substantial financial challenge. In 2013, well-off households spent 3% of their income on health care, while less well-off households spent nearly 20% ().
The health system in Bermuda tends to be complex with a fragmented financing structure. The health care delivery system for patient services is funded by four main sources: public and private health insurance plans (60%), government subsidies and grants (29%), out-of-pocket payments (10%), and charitable donations (1%) (). These sources provide coverage for two sets of benefits: the Standard Health Benefit (SHB) and Supplemental Benefits. The SHB is a predefined set of services that must be included in all health insurance plans in Bermuda and are provided in the hospital or by an SHB-approved provider in the community. The same services are covered under government subsidies for seniors, youth, and the indigent. Services included under SHB are covered at 100% with no co-pay or balance billing. For services that are not available on-island, there are provisions for private or public coverage of those services overseas at international health centers.
All services not paid by a health insurer or Government subsidies are covered by out-of-pocket payments. Under certain circumstances, health charities will provide care to patients at no cost to the patient. Government funding also supports programs that ensure that vulnerable populations have access to health care either through grant funding, community outreach events, or operation of public clinics.
The 2015 National Health Accounts Report indicated that Bermuda spent 12.4% of its GDP on health care (US$ 11,188 per capita). Public sector expenditure is allocated partly to the Ministry of Health for the promotion of health and prevention of diseases, but mainly to the provision of clinical services delivered through patient subsidies, grants, and Standard Health Benefit (SHB) reimbursement at Bermuda’s single hospital system. The Bermuda Hospitals Board is the leading organizational provider of acute health care services and represents the principal component of total health expenditure. The largest individual component of private health expenditure is overseas care. The remainder of the expenditure is on local practitioners, mainly physicians and dentists, local diagnostic imaging and laboratory services, and the professional services of a wide range of local health care providers (including dieticians, specialized disease management counselors, physiotherapists, optometrists, podiatrists, and psychologists), immunizations, prescription drugs, home health care, and health care administration ().
The “Well Bermuda” National Health Promotion Strategy, developed in 2008, was Bermuda’s first concerted effort to create a joint approach to health promotion and a shared vision for health promoters across all sectors. The vision of the Bermuda Health Strategy for 2014-2019 is “Healthy People in Healthy Communities.” The aim of this strategy is to provide a framework to restructure the health system to improve the quality of health care, increase access, and contain health costs.
In July 2016, the Tobacco Control Act of 2015 replaced the Tobacco Products (Public Health) Act of 1987. The Act is intended to protect children from tobacco products, strengthen provisions controlling smoking, and control the sale and use of e-cigarettes and cigarette rolling papers in order to reduce exposure to chronic disease risk factors. Smoking inside all Government premises, including government vehicles, has been banned for a decade.
The Mental Health Plan 2010 focuses on patient-centered care in the community. It includes three main segments, each with supporting strategies: expanding the community-based care model, implementing service improvements, and reforming forensic mental health services.
Health Situation and Trends
The total number of deaths of residents recorded in 2015 was 466, resulting in a mortality rate of 663.86 per 100,000. In 2015, the infant mortality rate was 3.4 per 1,000 live births (two infant deaths); in 2014 one infant death was recorded. There were two stillbirths recorded in 2014 and three in 2013 (). Women exceeded men in the distribution of deaths in the age groups 70-74 years as well as all age groups above 85 years.
Table 1. Ten leading causes of death, in rank order and by sex, Bermuda, 2014.
|Rank||Cause of death||Females||Males||Total|
|1||Diseases of the circulatory system||42.2%||33.9%||38.0%|
|3||Diseases of the nervous system||10.3%||7.0%||8.9%|
|5||Endocrine nutritional and metabolic diseases (incl. diabetes)||5.2%||4.5%||4.9%|
|7||Diseases of the respiratory system||3.9%||5.0%||4.4%|
|8||Diseases of the genitourinary system||1.7%||2.5%||2.1%|
|9||Diseases of the digestive system||2.2%||1.7%||1.9%|
|10||Certain infectious and parasitic diseases||1.3%||1.7%||1.5%|
Source: Government of Bermuda, Ministry of Health, Department of Statistics.
Chronic diseases, including diseases of the circulatory system, cancer, diabetes, and diseases of the respiratory system accounted for approximately 80% of deaths in 2012 (). Table 1 shows the leading causes of death in 2014 in Bermuda and Figure 3 shows the number of deaths by selected age groups.
Figure 3. Deaths, by selected age groups and by sex, Bermuda, 2014
A report on sexually transmitted infections (STIs) showed that in 2015, the highest number of STI cases was reported in the 20-24-year age group. Chlamydia accounted for nearly three-quarters of all STIs. Although, the number of STIs has decreased overall, the proportion of reported genital herpes cases increased between 2011 and 2015 ().
Following the first reported AIDS case in Bermuda in 1982, 767 persons had been diagnosed with HIV on the island as of the end of 2015. Of these, 565 persons received a diagnosis of AIDS and 464 had died. There were 303 persons known to be living with HIV infection in Bermuda, giving an overall prevalence of 0.49% at the end of 2015 ().There has been a general decline in cases, with less than 10 new HIV infections reported per year from 2011 to 2015. Bermuda completed its validation process for the elimination of mother-to-child transmission and congenital syphilis in 2016. Bermuda has low incidence of tuberculosis.
In regards to vector-borne diseases, Bermuda does not have the species of mosquito (Aedes aegypti) capable of carrying the dengue and Zika viruses. In 2016, Bermuda reported the first confirmed imported (travel-related) case of the Zika virus. All cases of malaria and dengue have been sporadic, and all of them imported. The Department of Health’s Vector Control Program continues to monitor the mosquito population and eliminates mosquito-breeding sites to reduce the risk of mosquito-borne diseases.
Chronic, Noncommunicable Diseases
According to the results of the 2014 STEPS survey, more than 95% of the population has at least one risk factor for a noncommunicable disease. The survey indicated that the leading risk factors were: inadequate consumption of fruits and vegetables (82%), overweight and obesity (75%), and alcohol consumption (64%). Raised cholesterol (34%), high blood pressure (33%), and physical inactivity (27%) were also of concern (). Tobacco use was reported by 14% of survey respondents.
Injuries and poisoning were the leading causes of hospitalization (26.8%), followed by diseases of the respiratory system (12.6%).
Accidents and Violence
The number of traffic accidents in 2014 was less than half the number in 2007. Private cars, motorcycles, and trucks continued to be the primary vehicles involved in these accidents, with the main cause identified as “inattention”(). In the Bermuda Police Service Strategic Plan for 2016-2018, priorities include tackling crime and antisocial behavior, engaging the community, making the roads safer, and optimizing technology in order to respond quickly and protect vulnerable people ().
In 2010, Bermuda’s elderly population increased to 14%, and by 2020 it is anticipated to represent 20% of the total population. As life expectancy increases, more persons will reach retirement age, and a greater proportion of elderly dependents will need to be supported by the working population. The aging population and burden of noncommunicable diseases will place more demands on the health care system and issues such as quality of life, access to health care, and health care costs will become increasingly critical.
The economy is projected to further improve based on sustained growth in international business, dominated by insurance and reinsurance, and tourism and higher investment in construction. Additionally, the global economy is expected to expand, which will impact Bermuda’s economic outlook. These opportunities could be used to expand the investment in health in line with the Bermuda Health Action Plan 2014-2019 that prioritizes prevention of noncommunicable diseases.
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1. The STEPwise approach to surveillance: This survey is a simple, standardized method for collecting, analyzing, and disseminating data in World Health Organization (WHO) member countries. Available from: http://www.who.int/chp/steps/en/