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ANNUAL REPORT OF THE CHIEF MEDICAL OFFICER 2001 - 2003 Ministry of Health Commonwealth of The Bahamas April 2005 Annual Report of the Chief Medical Ofﬁcer 2 Annual Report of the Chief Medical Ofﬁcer TABLE OF CONTENTS APPENDICIES GENERAL APPENDICIES TABLE OF FIGURES LIST OF TABLES EXECUTIVE SUMMARY ACKNOWLEDGMENTS ACRONYMS AND ABBREVIATIONS 1 OVERVIEW 1.1 Brief Physical Description 1.2 Governance 1.3 Socio-Economic Proﬁle 1.4 Demography 2.
HEALTH SITUATION 2.1 Wellness 2.2 Morbidity 2.2.1 Non-Communicable Diseases 2.2.2 Communicable Diseases 2.2.2.1 Communicable Disease Surveillance 2.2.2.2 Childhood Immunization 2.2.2.3 HIV/AIDS by Age and Gender 2.2.2.4 Tuberculosis by Age and Gender 2.2.3 Hospital-Based Reports 2.2.4 Other 2.2.4.1 Rehabilitation Services 2.2.4.2 Oral Health 2.2.4.3 Prision Health 2.2.4.4 National Blood Programme 2.2.4.5 Holistic Health 2.3 Mortality 2.3.1 Age-Gender Distribution of Deaths 2.3.2 Proportionate Mortality by Cause of Death by Gender 2.3.3 Group Causes of Deaths by Age and Gender 2.3.4 Leading Causes of Death 2.4 Population Sub-Groups 2.4.1 Infants 2.4.2 Children (1 - 4 years) 2.4.3 Children (5 - 14 years) i iii iii iv v Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 2.4.4 Adolescents (15 - 24 years) 2.4.5 Adult Females (25 - 64 years) 2.4.6 Adult Males (25 - 64 years) 2.4.7 The Elderly 3.
POLICIES, PLANS, PROGRAMMES 3.1 The National Health Policy and Health Services Strategic Plan 3.2 Major Health Programmes 3.3 Achievements and Progress Indicators 3.4 Major Health Events and Developments 2001-2003 4.
HEALTH INFRASTRUCTURE 4.1 Organization of the Health System 4.1.1 Organization and Management 4.2 Resources 4.2.1 Manpower 4.2.2 Facilities and Technology 4.2.3 Financial 4.3 Legislation 4.4 Information Systems Development 4.4.1 Natinal Health Information and Research Unit 4.4.2 Public Health Information System 4.5 Research 4.6 Essential Public Health Functions 5.
ENVIRONMENTAL HEALTH 5.1 Water Supply and Quality 5.2 Sewage Disposal 5.3 Solid and Liquid Waste Disposal 5.4 Occupational Health 5.5 Veterinary Public Health 5.6 Food Safety 5.6.1 The Food Handlers Programme 5.7 Quality Control of Drugs 5.8 Pesticide Control 5.9 Disaster Management and Preparedness 5.10 Vector and Rodent Control 5.11 Port Health 5.12 Building Development 5.13 Bahamas Environment, Science and Technology Comission 6.
ISSUES, CONCLUSIONS AND RECOMMENDATIONS FOR THE FUTURE ii ii Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDICIES APPENDIX 1 Map of the Commonwealth of The Bahamas APPENDIX 2 Sector Contribution to GDP, 2000-2002 (‘000) APPENDIX 3 Operational Deﬁnitions For Basic Demographic Indicators APPENDIX 4 Communicable Disease Report, 2001-2003 APPENDIX 5 Summary of Cases Reported Rates for Selected Diseases, 2001-2002 APPENDIX 6 Reported Incidence Rate of HIV Infections and AIDS By Gender, 1996-2003 APPENDIX 7 Age-Gender Distribution of Population and Deaths in Bahamas, 2003 APPENDIX 8 Years of Potential Life Lost by Gender and Broad Causes of Deaths, 1999-2003 APPENDIX 9 Group Causes of Deaths by Age and Gender, 2001-2003 APPENDIX 10 Group Causes of Death by Age and Gender, 2003 APPENDIX 11 Discharge Diagnoses from Princess Margaret Hospital in Females by Age Group, 2003 APPENDIX 12 Discharge Diagnoses from Princess Margaret Hospital in Males by Age Group, 2003 APPENDIX 13 Discharge Diagnoses from Rand Memorial Hospital in Females by Age Group, 2003 APPENDIX 14 Discharge Diagnoses from Rand Memorial Hospital in Males by Age Group, 2003 GENERAL APPENDICIES Notiﬁcation Rates of Tuberculosis by Age and Gender, 2000-2003 Ten Leading Causes of Death with Rates per 100,000 Population, 1999-2003 Ten Leading Causes of Death by Years of Potential Life Lost, 1999-2003 Deaths
 & Proportional Mortality from Selected Causes by Age & Gender, 2001-2003 Visits by Adults & Children to Primary Care Clinics by Selected Causes, 1996-98 Framework of Strategic Directions and Strategic Goals Infrastructural Developments (1993-2001) Public Health Information System Design Some of the Documents Reviewed for the CMO’s Report Origanizational Structure of the Planning Unit of the Ministry of Health and Environment Organizational Chart of the Ministry of Health and Environment Reported Incidence of Non-AIDS HIV (Total and Teenage) and AIDS, 1994-2003 Reported Age-Speciﬁc Incidence Rate of Non-AIDS HIV, 1989, 1994, 1998, 2003 Reported Non-AIDS HIV in Infants and Children under 5 Years of Age, 1994-2003 TB Cases by Gender, Nationality and HIV Status, Bahamas, 2001-3002 Share of Total Population versus Share of Total Deaths, by Age Group, 2003 Proportionate Mortality by Years of Potential Life Lost (YPLL) in both Genders by Cumulative Causes of Death, 1999-3003 iii iii Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer TABLE OF FIGURES Fig.
1.1 Population of The Bahamas, and the Proportion Living in New Providence, 1970-2000 Fig.

1.2 Trends of Annual Gross Domestic Growth Rate, 1993-2003 Fig.

1.3 Health Sector Contributions to the Gross Domestic Product, 1993-2003 Fig.

1.4 Gross Domestic Product and Gross National Product Per Capita (B$), 1999-2002 Fig.

1.5 Dependency Ratio of All Bahamas, by Gender, 1999-2003 Fig.

1.6 Cumulative Distribution of Stated Household Incomes, Bahamas, 2003 Fig.
1.7 Population Pyramids for Bahamas, 1980 (above) and 2000 (below) Fig.

1.8 Age-Speciﬁc Birth Rates per 1,000 Females 15-49 Years, Bahamas, 1999, 2001, 2003 Fig.

1.9 Age Speciﬁc Birth Rates Among Females 10-19 Years, by Island, Based on Registered and Estimated Live Births, 1993-2003 Fig.

1.10 Crude Birth Rates, Death Rates and Natural Increase, 1994-2003 Fig.

1.11 Life Expectancy, by Gender, Bahamas, 1960-2001 Fig.

1.12 Maternal Mortality Ratios, 1994-2003 Fig.


2.1 Childhood Immunization Coverage in The Bahamas, 1994-2003 Fig.

2.2 Prevalence of HIV in Antinatal Women, Blood Donors and STI Clients, Bahamas, 1994-2003 Fig.

2.3 Trends in HIV MTCT Rates by Treatment Status, 1995-2003 Fig.

2.4 TB Notiﬁcation Rates per 100,000 Population 1994-2003 Fig.

2.5 Age-Gender Speciﬁc Death Rates in Both Genders, 1994 & 2003 Fig.

2.6 Annual Trends in Years of Potential Life Lost by Cause of Death, 1999-2003 Fig.
2.7 Age-Speciﬁc Death Rate of Males, 1999, 2001, 2003 Fig.

2.8 Age-Speciﬁc Death Rate of Females, 1999, 2001, 2003 Fig.

2.9 Ten Leading Causes of Death, 1996-2003 Fig.

2.10 Ten Leading Causes of Death by YPLL, 1996-2003 Fig.

2.11 Age-Speciﬁc Death Rates from Land Transport Accidents, 1999-2003 Fig.

4.1 Health Expenditure as a Proportion of National Recurrent Expenditure, 1993-2003 Fig.
4.2 Recurrent Expenditure in Health, by Department, 2003/2004 11 31 32 34 35 38 39 40 41 42 43 47 60 60 iv iv Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer LIST OF TABLES Table 1.1 Projected Population, Bahamas, 2003, by Age Group and Gender Table 1.2 Basic Demographic Information, 1999-2003 Table 2.1.
Low and High Z-Scores for Children 2-10 Years Years of Age Table 2.2 Body Mass Indices for Adolescents, Ages 11-20 Years Table 2.3 Body Mass Indices among Adults, Ages 21-60 Years, by Gender Table 2.4 Selected Abnormal Screening Results in School Health Table 2.5 Cumulative Cases of Non-AIDS HIV and AIDS as at December 2003 Table 2.6 Ten Leading Causes of Death, by Gender in 2003 Table 2.7 Reported Cases of Child Abuse, by Type and Year Table 2.8 Cases of Children Seen at SCAN Clinic 201-2003 (0-16 Years) Table 2.9 Prevalance of Substance Use among Students during the Past Month, by Grade Level Table 4.1 Number of Health Personnel in the Public & Private Sector, with Rates per 10,000 Population, 2002/2003 Box 4.1 Sources of Health Data 12 20 26 26 27 28 33 44 46 46 47 57 62 v v Annual Report of the Chief Medical Ofﬁcer vi Annual Report of the Chief Medical Ofﬁcer EXECUTIVE SUMMARY Background The Commonwealth of The Bahamas is an archipelago of some 700 islands and cays located in the Atlantic Ocean.
In 2002, the population was estimated to be 316,298.

The two major population centres are New Providence and Grand Bahama where 85% of the population resides.

The population is shifting from youthful to less youthful as a result of lower fertility rates and higher life expectancy rates.

The national per capita income increased from B$11,041 (Bahamian dollars) in 1995 to B$21,531 in 2002.

Tourism and tourism-related commerce are the most important economic activities in the country.
According to the 2002 Human Development Report, The Bahamas ranked 49 out of 174 countries with a Human Development Index of 0.815.

In 1999, the adult literacy rate was 95.7%.

After Independence in 1973, The Bahamas remained a member of the Commonwealth of Nations, with Her Majesty the Queen as Head of State.

The Bahamas is governed by a bi-cameral legislature based on the Westminster Model.

The country’s most recent elections were held in 2002.
The government is committed to protecting and promoting the health of the people of The Bahamas.

The Ministry of Health (MOH) has a mandate “to ensure that the highest quality of services for health promotion, protection and care are accessible to all persons of The Bahamas in order to achieve optimal health”, as well as a strategic plan to guide health development.
Objective The Chief Medical Ofﬁcer’s (CMO) report is a comprehensive report on health developments in the country which is presented at an annual meeting of all CMOs in the Caribbean Community.

The Pan American Health Organization (PAHO) has developed a template for standardized reports for the member states.

Each country can, of course, vary the format to meet its own needs and experiences.

This is The Bahamas’ second report which updates the ﬁrst report prepared in 2002.
This report provides baseline information as well as trend data for the ongoing evaluation of the National Health Services Strategic Plan (NHSSP) 2003-2004.

Other reports exist which, when taken together, provide an analysis of the health situation in the country.

Two such reports are PAHO’s quadrennial report Health of the Americas, Bahamas Chapter and the Caribbean Cooperation of Health II report which charts the country’s progress toward meeting a set of targets in eight priority areas.
Methodology The Planning Unit of the MOH was responsible for preparing this report.

In 2004, representatives from the MOH, its departments and agencies (Department of Public Health (DPH), Department of Environmental Health Services (DEHS), Public Hospitals Authority (PHA)), the Department of Statistics and the Ministry of Agriculture and Fisheries came together to begin work on the report.
The team reviewed reports and documents, interviewed key persons, relied on the ﬁndings of the mid-term evaluation of the NHSSP 2000-2004 and conducted research on line.

Gains in Health 1.

The Bahamas has made impressive gains over the years in the area of health: • Life expectancy at birth has increased steadily from approximately 66 years between 1969-1971 to approximately 73 years between 1999-2001.

• The infant mortality rate (IMR) has declined from 19.7 per 1,000 live births in 1994 to 15.0 in 2003.
• The number of new persons testing HIV positive annually has declined by 56.1% from its peak level of 659 in 1994 to 259 in 2003.

1 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer • The prevalence of HIV in pregnant women is on the decline, from 4.2% in 1994 to 3.1% in 2003.

• After years of mono-therapy, in 2001 triple antiretroviral (ARV) therapy was given to pregnant women.
In 2003, there was no mother-to-child transmission of HIV to newborns in mothers who received ARV therapy.

• Reported deaths from HIV/AIDS declined from 320 in 1999 to 102 in 2003, which reduced the number of years of potential life lost (YPLL) due to premature death from AIDS over the referenced period.

• The Communicable Disease Trend (Bahamas) 1994-2003 indicated that vaccine preventable diseases are becoming extinct.

The Pentavalent (DPT, Hib.


and HBV) vaccine was included in the national immunization schedule of The Bahamas.

• The government increased access to affordable quality health care for persons living with HIV/AIDS by removing cost barriers.

• Behavioural change initiatives against HIV which target adolescents have been initiated.

2.

A revised version of the 2000–2004 NHSSP was completed in 2003.
It provides indicators within a comprehensive framework to focus attention on areas of deﬁciency in the seven priority health programmes.

3.

Since 2000, the budget allocated to the health sector has increased, health outcomes have improved and legislation has been strengthened.

4.

The administrative ofﬁces of the MOH and the DPH relocated to a new, modern, multi million dollar facility in October 2002.

5.

An ultra modern primary health facility opened in the Southern District of New Providence.
It provides diagnostic services including ophthalmology, speech therapy, and preventive oral health for children, audiology, laboratory and radiology services.

6.

The DEHS and The Bahamas Environmental, Scientiﬁc and Technical Commission were incorporated into the MOH.

7.

The MOH’s Planning Unit which is responsible for coordinating standardized planning was strengthened.

Several existing programmes were improved and new ones established.

• Programme coordination was introduced in the DPH.
• The Chronic Non-Communicable Diseases (CNCD) National Programme was strengthened.

• The National Blood Programme was established.

• The National Laboratory Strengthening Project was established and phased in.

• The Public Health Information System Project Plan was completed and implemented according to schedule.
• Oral health services were expanded to provide oral prophylaxis (cleaning), sealants, ﬂuoride treatments and restorations, dental prosthesis and school-based dental education throughout The Bahamas.

2 2 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Areas of Concerns Despite the gains in health care, some problem areas remained, and new concerns arose over the period 2002 – 2004.
These are discussed under three main headings – health outcomes; health information management and research; and health policy, planning and management.

Health Outcomes • The Bahamas Living Conditions Survey, conducted in 2001, showed that 34.4% of adults 21 to 60 years of age were overweight (body index mass (BMI) of 25 – 29.9) and 30.9% were obese (BMI 30-34.9).
• CNCD (in particular, hypertension, diabetes, coronary heart disease, stroke, chronic respiratory diseases and cancers) accounted for nearly 45% of all deaths in the country in 2003 and represent the single major contributor to the total YPLL.

With increased life expectancy, lower fertility rates and lifestyle changes, CNCD have gained more importance as causes of mortality.
• The 2003 mortality data show that infants and persons 45 years old and older have a disproportionate share of deaths compared with their share of the total population.

• Over the ﬁve year period, 1999-2003, communicable diseases accounted for 30% of the total YPLL.

This is largely attributable to younger people dying from AIDS.

• Between 2001-2003, more males died from external causes than did females.

Conversely, more females died from neoplasms than did males.
• The overwhelming causes of death of infants were those originating in the perinatal period and congenital causes.

Together these accounted for 80.4% of all deaths of infants.

• Between 2001-2003, child neglect and physical abuse were the most commonly reported types of child abuse and accounted for 42% and 32% respectively of all cases.

Sexual abuse and incest accounted for an additional 23% of reported cases.

• Adolescent pregnancy is a continuing problem.


In 2003, the live birth rate per 1,000 females aged 10-19 years was 23.0.

• The morbidity proﬁle of adolescents and the results of a national youth survey showed that more attention must be paid to risk factors such as smoking, alcohol use and abuse which contribute to the high prevalence of homicides and injuries.
Health Information Management and Research • Quality information is not available system-wide but is available from some units and departments, though not on a consistent basis.

Consequently, coordination of information management remains a challenge.

• Technical problems with the automated Health Management Information System (HMIS) used in the PHA persist.

• Annual and other periodic reports need to be produced regularly.
• The quality of data, data processing and analysis and health information dissemination is weak.

3 3 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer • The surveillance system for communicable diseases is well developed but the surveillance system for non- communicable diseases is not.
Health policy, planning and management • Results of the Essential Public Health Functions evaluation indicate that the public health care system performed below average in all but two areas.

• Various units and departments (e.g.

human resource development, equipment) have not yet developed policies and operational plans within the framework of the Revised NHSSP 2003-2004.

• Procurement plans, procedures and standards are lacking.
• In keeping with the predominantly curative health delivery, tertiary care receives up to two-thirds of the national health recurrent budget.

Cost recovery is less than 3%.

Salaries and personal emoluments make up approximately 80% of institutional budgets.
• Although the morbidity and mortality proﬁle of the country indicates that lifestyle diseases are the main causes of sickness and death, funding to public health (preventive and curative) has not increased for several years and remains at 10% of the total MOH recurrent budget.

Strategic opportunities The health care system can take advantage of a number of strategic opportunities in order to help the citizens of The Bahamas achieve optimal health.
They are: • The prospect of harnessing the country’s resources for advancing promotion/prevention strategies as the most effective means of achieving optimal health status for the population at the least cost.

• The establishment of a National Health Insurance scheme to provide universal health cover and adequate funding for quality health care.
• The on-going organizational reforms in health can facilitate and improve the relationship between the public health sector and the private health sector to achieve mutual health gains for the country’s beneﬁt.

• A political commitment to the NHSSP and to reducing the IMR.

• The Public Health Information System (i-PHIS) provides a sound basis for the strengthening of the HMIS, health planning and management, and the monitoring of health services.
• Support for the philosophy of a healthy environment for healthy people and the emphasis on sustainable development are evident in the increasing budget allocation to environmental health services which will translate into health gains.
The Role of the Ministry of Health The MOH is determined to consolidate the gains that have been achieved over the past several years and to spread “best practices” throughout its programmes: this requires a willingness to be bold and innovative and to not simply maintain the status quo.

Some of the steps along the way forward are discussed as public health interventions and health management and support services.
4 4 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Public health interventions Given that the primary causes of morbidity and mortality in The Bahamas are preventable, the MOH must continue the process it has begun of reorienting health services towards primary care.

The budget and human resource implications of doing so include providing increased ﬁnancing for prevention programmes and health promotion, and for the training of relevant personnel.
Population health promotion will empower individuals and households with the knowledge and skills to avoid risky behaviour that could lead to, among other things, HIV, vehicular accidents, unwanted pregnancies and CNCD.

It is now mandatory that medical students complete a rotation with the DPH and the Ofﬁce of the CMO is actively recruiting young physicians to train for careers in public health.
Public health interventions must be disseminated widely, and necessary legislation either enacted where none exists, or enforced if it does exist, to regulate, among other things, tobacco advertising, environmental smoke, the use of seat belts, possession of ﬁre arms and the importation of quality foods.

The promotion of healthy lifestyles must include attention to proper diet, good nutrition, adequate exercise, non smoking, the judicious use of alcohol, and safe sex.
Additional surveillance and surveys on the major causes of morbidity and mortality, namely injury, homicide, diabetes and circulatory disorders, are required to better understand the risk proﬁle of patients and to guide the implementation of appropriate strategies to prevent these health problems.

Health Management and Support Services • The quality of care provided across programmes and departments should be monitored through regular audits.
Likewise, performance, process and outcome evaluations should be conducted routinely to enhance the development of the system.

• Capacity building must be strengthened in order to properly carry out policy formulation, information management, health promotion, ﬁnancial management, human resource management, procurement and quality control.

• Heads of units and departments should prepare and use periodic reports as an integral management tool.
• The i-PHIS should be nationalised and promoted as the tool for creating the data upon which policy and management decision making will be made over the course of the next several years.

• Priority must be given to regulating pharmaceuticals and vaccines in the private and public sectors in order to determine the procurement costs of these items.

• It is imperative that the resource allocation formula currently in use be revised to emphasize primary and preventive care.
As the demand for newer technologies and tertiary care increases, resources are shifted away from preventive and promotive health.

• The appraisal reports on health workers’ performance should directly relate to their compensation.

• There is a need for the health system to improve its capacity for human resource planning and management in all departments.
5 5 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer ACKNOWLEDGMENTS The Annual Report of the Chief Medical Ofﬁcer (CMO) 2001-2003 was prepared through the collaborative effort of the Ministry of Health (MOH), the National Health Information and Research Unit (HIRU), the Department of Public Health (DPH), the Public Hospitals Authority (PHA), the Department of Environmental Health Services (DEHS), Pan American Health Organization (PAHO/WHO), the Department of Statistics, the Ministry of Agriculture and Fisheries, and the Department of Social Services.
The following teams worked on preparing the report over a period of approximately ﬁve weeks: Ministry of Health Coordinating Team Mrs. Elizabeth Keju, Under Secretary, Planning Unit, MOH Ms. Sandra Smith, Planning Ofﬁcer, MOH Dr. Mohammed Imana, Medical Epidemiologist, DPH Mrs. Stephanie Dean, Nursing Coordinator, Surveillance Unit, DPH Ms. Camille Deleveaux, Epidemiologist, HIRU, MOH Mrs. Theresa Maynard, Secretary, CMO’s Ofﬁce Task Team Mrs. Elizabeth Keju, Under Secretary, Planning Unit, MOH Ms. Coralee Mackey, Supervisor, Vital Statistics, Department of Statistics Mrs. Hanna Gray, Deputy Managing Director, PHA Mrs. Philabertha Carter, Project Ofﬁcer, MOH Ms. Sandra Smith, Planning Ofﬁcer, MOH Ms. Camille Deleveaux, Epidemiologist, HIRU, MOH Dr. Mohammed Imana, Medical Epidemiologist, Surveillance Unit, DPH Ms. Stephanie Dean, Nursing Coordinator, Surveillance Unit, DPH Dr. Maurice Isaacs, Veterinary Services, Ministry of Agriculture and Fisheries Ms. Melony McKenzie, Director, DEHS Mr. Dwayne Curtis, Deputy Director, DEHS Dr. Ann Rolle, Coordinator, Chronic Non-Communicable Diseases, MOH Ms. Carmelta Barnes, Nutritionist, Nutrition Unit, DPH Mrs. Kelsie Dorsette, Deputy Director, Department of Statistics Dr. Agreta Eneas-Carey, Consultant, Geriatric Hospital Ms. Lesa Ricketts-Hall, Biostatistician, PHA Ms. Nanika Brathwaite, Statistician, HIRU, MOH Ms. Valarie Minus, Statistician, HIRU, MOH 6 6 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Ms. Deborah Fox, Manager,
 Expanded Programme on Immunization, DPH Ms. Charlene Bain, Programme Coordinator, DPH Ms. Velma Burrows, Chief Physiotherapist, PHA Editorial Team Dr. Merceline Dahl-Regis, CMO, MOH Mrs. Hannah Gray, Director of Planning, PHA Ms. Anya Symonette, Staff Nurse, Planning Unit, MOH Dr. Elsa Wilson, Planning Unit, MOH The team extends special thanks to the individuals in the various departments who provided data and technical support during the preparation of this report.
7 7 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer ACRONYMS AND ABBREVIATIONS Bahamian Dollar Acquired Immunodeﬁciency Syndrome Anti Retro Viral Bahamas Environmental, Scientiﬁc and Technology (Commission) Bahamas Living Conditions Survey Body Mass Index Blue Ribbon Commission $B AIDS ARV BEST BLCS BMI BRC CAREC Caribbean Epidemiology Centre CDR CMO Crude Death Rate Chief Medical Ofﬁcer CNCD Chronic Non-Communicable Diseases COB DALE DEHS DPH DPT EPHF EPI GDP GNP HACCP Hep.
B Hib.
HIRU HIV HMIS IMR i-PHIS KAP MMR MOH MTCT NGO NHSSP College of The Bahamas Disability Adjusted Life Expectancy Department of Environmental Health Services Department of Public Health Diptheria-Pertussis-Tetanus Essential Public Health Functions Expanded Programme on Immunization Gross Domestic Product Gross National Product Hazard Analysis and Critical Control Point Hepapitis B Haemophilus Inﬂuenza type b Health Information and Research Unit Human Immunodeﬁciency Virus Health Management Information System Infant Mortality Rate Public Health Information System Knowledge, Attitude and Practice Measles Mumps Rubella Ministry of Health Mother-to-Child Transmission Non-Governmental Organization National Health Services Strategic Plan NIMCOST National Inter-Ministerial Committee on Science and Technology PAHO Pan American Health Organization PHA Public Hospitals Authority PLWHA Persons Living With HIV/AIDS PMH PS RMH Princess Margaret Hospital Permanent Secretary Rand Memorial Hospital 8 8 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer SARS SCAN SIP SRC STI TB USA WHO YPLL Severe Acute Repertory Syndrome Suspected Child Abuse and Neglect Perinatal Information System Sandilands Rehabilitation Centre Sexually Transmitted Infection Tuberculosis United States of America World Health Organization Years of Potential Life Lost 9 9 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 10 10 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 1.0 OVERVIEW 1.1 Brief Physical Description A. Geography The Commonwealth of The Bahamas is an archipelago of some 700 islands and cays located 55 miles southeast of Florida, off the south eastern coast of the United states of America (USA) (See Appendix 1 for map of country).
Twenty-nine of these islands are inhabited.

The 2000 census1 reported a total population of 303,611, a 19% increase over the 1990 population ﬁgure of 255,000 (Fig.

1.1).

Over 95% of the population lives on seven of the islands.

In 2003, the projected population for The Bahamas was 316,298 (Table 1.1).
The two major population centres are Nassau, the capital, located on the island of New Providence, and Freeport, which is in Grand Bahama: at the 2000 census, 69.7% of the population lived in New Providence and 15.4% in Grand Bahama.

The other populated islands and cays are called “Family Islands”.

The proportion of the total population living on the Family Islands declined from 24.6% in 1970 to 16.5% in 1990 and even further to 14.9% in 2000.

Fig.
Fig.

1.1 Population of The Bahamas, and the Proportion Living in New Providence, 1970-2000 ��� ��� ��� ��� ��� ��� �� � �� �� �� �� �� �� �� �� �� �� 1 The Commonwealth of the Bahamas Census of the Population and Housing 2000.

Preliminary results.

Department of Statistics, 2001.
11 11 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Table 1.1 Projected Population, Bahamas, 2003, By Age Group and Gender Age Group (Years) MALES FEMALES TOTAL 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ TOTAL 15,6597 15,9701 316,298 B.
Physical Characteristics The Bahamas occupies a total land mass of 5,382 square miles scattered over 80,000 square miles of the Atlantic Ocean.

The population density per square mile increased from 47.4 in 1990 to 56.7 in 2000.

New Providence is the most densely populated island, with 2,655.4 persons per square mile.

Only three other islands or island groups have population densities greater than 100 per square mile.

The climate is tropical, moderated by the warm waters of the Gulf Stream.
The average summer (June – September) temperatures can reach as high as 90oF (29oC) and drop to 78oF (23oC) at night.

Winter (December – March) temperatures generally peak at 75oF (21oC) and seldom fall below 60oF (14oC).

The Bahamas experiences hurricanes and other tropical storms which cause extensive ﬂood and wind damage.

Hurricane Michelle struck the north western Bahamas in November 2001.
It caused extensive damage to property: few people were injured as a result of this hurricane, however, several cases of post traumatic stress syndrome were reported after the hurricane.

C. Communications Virtually all parts of the country are linked by sea, air and ground transport.

There are regular mail boats and air transport from New Providence to the Family Islands.
There are three sea ports located at Nassau, Freeport and 12 12 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Matthew Town, Great Inagua.

There are 60 airports located throughout the islands.

There are some 2,400 kilometers of highways, approximately 1,400 of which are paved.

Commercial transport in the form of buses, taxis and self- drive cars are readily available in the major centres.

There is no rail transport.


With regard to telecommunications, Bahamas Telecommunications Company, a government-owned company, provides land and cellular phone services throughout the country.

The number of telephone subscribers in 2002 was 226,513.

In some of the smaller Family Islands, residential telephone service is not available, but telephone service is available at a central point.
In 2003, the south easterly islands of Crooked Island, Acklins, Long Cay and Maygauana were supplied with telephone and internet services for the ﬁrst time.

There were 13,100 internet users in The Bahamas in 2001, and internet connectivity in major business centres is increasing.

More recently, a Wireless Fidelity Network was introduced in New Providence, Grand Bahama, Exuma and Abaco, which provides free wireless internet access for laptops and pocket personal computers.
There is universal access to radio throughout the country through three AM and six FM broadcast stations.

National television coverage is accessible in most of the Family Islands.

Many residents are able to view US television stations through cable services provided by Cable Bahamas (a privately owned cable company) or via privately owned satellite dishes.

There are four major newspapers which are circulated nationwide.
The MOH produces a weekly column called “Joining Hands for Health” in one of the local newspapers.

1.2 Governance The Commonwealth of The Bahamas gained independence from the United Kingdom on 10 July, 1973.

The country is governed by a parliamentary democracy based on the Westminster Model, with a Governor General who represents Her Majesty the Queen, a bicameral legislature including an elected Parliament, and an independent judiciary.
The government is headed by a Prime Minister who is also a member of the legislature.

Government business is carried out by government ministries – each ministry is headed by a minister (political) and permanent secretary (administrative) - and by quasi- government institutions.

There is a local government system in the Family Islands comprised of a number of locally-elected district councils and a central council.
The government administration is headed by an island administrator who is an established public ofﬁcer.

The local government system facilitates community participation in health planning and health care delivery.

After the last general elections held in 2002, the portfolio of the Ministry of Health (MOH) was revised to formally include the Department of Environmental Health Services (DEHS) and the Bahamas Environment, Science and Technology (BEST) Commission.

1.3 Socio-Economic Proﬁle A.


Gross Domestic Product (GDP) per capita Since 1972, the exchange rate of the Bahamian dollar to the US dollar has been 1:1.

The GDP per capita continued to increase, from $15,786 in 1999 to $17,315 in 2002.

Provisional data for 2003 show an increase to $17,396 in the GDP per head.

The real GDP growth rate, based on constant 1991 market prices, decreased from 1.18% in 2000 to 0.81% in 2002.

In 2003, it increased to 1.5% (Fig.


1.2).2 Inﬂation rates, which are generally comparable to those in the USA, increased in the last three years from 1.6% in 2000 to 3.0% in 2003.

2 www.bahamas.gov.bsSource: Central Bank of The Bahamas, Department of Statistics, IMF 13 13 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
1.2 Trends of Annual Gross Domestic Growth Rate, 1993-2003 � � � � � � � � � � � � � � �� � � � � � �� �� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� B.

Sector contribution to GDP The Bahamas is a stable, developing nation with an economy based primarily on tourism and offshore banking.

Other primary industries are cement, oil reﬁning and trans-shipment, salt production, rum, aragonite, pharmaceuticals, and spiral welded steel pipes.
In 2002, Industry accounted for approximately 8.8% of the GDP while agriculture accounted for 2.7% of the GDP.

The agricultural sector is dominated by small-scale producers whose principal products are citrus fruit, vegetables and poultry.

In the last decade, the health sector contribution to the GDP was consistently around 3% (Fig.

1.3).

The ratio between public and private health contributions remained at 2:1 over the period.
14 14 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
1.3 Health Sector Contributions to the Gross Domestic Product, 1993-200 ��������������� ���������������� �������������� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� � � � � � � � � � � � � � � � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� �������������������������������� Tourism and tourism related commerce remain the most important economic activities in The Bahamas, accounting for over 50% of GDP and, directly or indirectly, 60% of employment.
In 2003, 4,594,042 tourists visited The Bahamas, an increase of 9% over the 2000 ﬁgure.

The detailed sector contribution to GDP is presented in Appendix 2.

C. Consumption per capita The economy remains strong and of the countries in the region of the Americas, only the USA and Canada have a higher GNP per capita than The Bahamas.

The GNP increased from $15,447 per capita in 1999 to $16,756 in 2002.

Trends for both GDP and GNP are shown in Fig.

1.4.
1.4.

15 15 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.

1.4 GDP and GNP per capita (B$), 1999-2002 ��� ��� �������� ������� ������� ������� ������� ������� ������� ������� ������� ���� ���� ���� ���� ���� ���� ���� �������� �������� �������� �������� �������� �������� ������� �������� ������������������������������������� According to the Human Development Report of 2002, The Bahamas ranked 49 out of 175 countries with a Human Development Index of 0.815.
The Human Development Index measures achievements in terms of life expectancy, educational attainment and adjusted real income.

D. Employment data, dependency ratio and labour force by gender and age group Service industries (including the public sector), tourism, banking and insurance, ﬁshing and agriculture employ approximately 80% of the labour force.

The working population increased from 157,640 in 1999 to 173,795 in 2003.
About 50.5% of the work force is male, a decline of approximately 1.5% from 1999 ﬁgures.

Approximately 67% of the total work force was between the ages of 20-44 years, a decline of 2% from the 1999 report.

In 2003, the percentage of the work force between the ages of 55-64 increased to 8% from 7% in 1999.

Unemployment continues to be a problem in The Bahamas.

According to the Department of Statistics, the overall unemployment rate in 2003 was estimated to be 10.8%.
However, the rate was slightly higher for women (11.7%) than for men (10.0%).

The unemployment rates are slightly higher in New Providence (11.9%) than in Grand Bahama (8.7%).

In 2003, 41% of the unemployed labour force was younger than 25 years of age and 27% was between the ages of 25-34.
16 16 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer After a period of progressive decline in the dependency ratio from approximately 55% in 1995 to 52% in 2000, the ratio increased slightly to 54.9% in 2003 (Fig.

1.5).

The ratio for males is now higher than that for females.

Fig.
Fig.

1.5 Dependency Ratio of all Bahamas, by Gender, 1995-2003 � � � � � � � � � �� �� �� �� �� �� �� �� �� �� �� ��� ������ ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� E. Poverty levels The Bahamas Living Conditions Survey (BLCS), conducted by the Department of Statistics in 2001, collected information on the levels of well-being and living conditions of persons residing in randomly selected households throughout the country.

Results showed the poverty line to be an income of $2,863 per annum.
The Department of Statistics reported that 5.5% of the 96,050 households which stated their incomes earned less than $5,000 and 12.3% earned less than $10,000 per annum (Fig.

1.6).

Nearly two-thirds of all households earned less than $40,000 per annum in 2003.

17 17 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
1.6 Cumulative Distribution of Stated Household Incomes, Bahamas, 2003 � � � � � � � � � � � ��� ��� �� �� �� �� � ����� ������ ������ ������ ������ ������� ������ ������� �������� ����������� �������������������������������������������� F. Education indicators The Bahamas enjoys a high standard of living and universal access to all essential social services including health, education and housing.

Approximately 35% of the national recurrent budget is allocated to the social sectors.
Education is compulsory for children 5-16 years of age.

The adult literacy rate in The Bahamas was 95.7% in 1999.

3 During the 2003/2004 academic year, there were 220 schools in The Bahamas - 157 public schools, 52 private schools and 11 schools for children with special needs.

The total enrolment in the public primary and secondary schools was 49,456 and 48.6% of the students were females.

The teacher-to-student ratio was approximately 1:17.
Tertiary education is provided at the government owned College of The Bahamas (COB) and at a number of private institutions.

Both the government and the private institutions offer associate and bachelor degree programmes.

Selected masters degree programmes afﬁliated with American universities are also available at COB.

1.4 Demography A.

Total population by age and gender In 2003, 28.4% of the population of 316,298 was younger than 15 years of age and 5.2% was 65 years old or older.
The median age was 27 years.

Females constituted 50.5% of the population.

Women of childbearing years aged 15- 49 comprised 55.3% of the female population and 28% of the total population.

3 UNESCO 2000 literacy assessment 18 18 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer B.
Population pyramid The population pyramids based on data from the 1980 and 2000 censuses show a transition from a youthful to a less youthful population due to lower fertility and higher survival rates.

In 1980, 39.4% of the male population and 37.4% of the female population were younger than 15 years old: 3.6% of males and 4.8% of females were older than 65 years (Fig.

1.7).

In 2000, there were nearly 10% less males (30.5%) and 10% less females (28.7%) younger than 15 years old than there were in 1980.
In 2002, the percentage of males and females older than 65 years of age increased by one over the ﬁgure for 1980: 4.5% of the male population and 5.9% of the female population were 65 years or older.

Similarly, more people survived into their mid years in 2000 than did in 1980.

The population pattern for 2000 shows that The Bahamas is in demographic transition – it falls between that of a typical less developed country and a typical industrialized country.

Fig.
Fig.

1.7: Population Pyramids for Bahamas, 1980 (above) and 2000 (below) ���� ������ ��� ����� ����� ����� ����� ����� ����� ����� ��� ���� ���� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ���� ���� ���� ������ ��� ����� ����� ����� ����� ����� ����� ����� ��� ���� ���� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ���� ���� C. Total fertility rates The total fertility rate has, over the past ﬁve years, remained more or less constant at approximately 2.3 children per woman.
The general fertility rate decreased from 63.9 births per 1,000 females aged 15-49 years in 1999 to 56.1 births in 2003 (Table 1.2).

According to the Department of Statistics, the age speciﬁc rates for the 15-19 year and the 20-24 year age groups in 2003 were respectively 46.1 and 96.5 per 1,000 women (Fig.

1.8).
1.8).

This reﬂects a decrease 19 19 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer from the 1999 ﬁgures of 52.4 and 110.5 per 1,000 women for the respective age groups.

The highest age speciﬁc fertility rates are in the 20-24 and 25-29 age groups.

Although the rates among 10-19 year old females, based on registered births, were lower in Grand Bahama and in the Family Islands than in New Providence (Fig.
1.9), in the last two years there has been a rapid increase in fertility rates in Grand Bahama.

Table 1.2 Basic Demographic Information, 1999-2003 INDICATOR 1999 2000 YEAR 2001 2002 2003 Estimated mid-interval population 298,050 303,611 307,379 311,871 316,298 Estimated # women in 15-44 age group at mid-interval 75,947 77,515 77,436 78,027 78,522 Total births Live births Birth Rate (per 1,000 pop.)

Live births (Registered) for females 15 - 44 yrs.


General Fertility Rate (live births per 1,000 females 15 - 49 yrs) Total Fertility Rates Deaths occurring during the year Death Rate (per 1,000 pop.)

Still Births Still Birth Rate (per 1,000 total births) Natural Increase Natural Increase Rate (per 1,000 pop.)
Infant Death Rate (per 1,000 live births) Perinatal Death Rate (per 1,000 total births) Neonatal Deaths Neonatal Death Rate (per 1,000 live Births) Maternal Deaths Maternal Death Rate (per 100,000 live births) Child deaths (1 - 4) yrs.

Child Mortality Rate/10,000 children ... data not currently available.
... 4942 ... ... 1810 5.8 54 10.2 ... ... 16.7 ... ... ... 0 0.0 ... ... 56.1 ... 1649 5.2 78 15.4 ... ... 17.2 19.2 30 5.9 2 39.6 10 3.9 N.B.
(1) 2002 mortality data and 2003 death rate are provisional; (2) Population ﬁgures for 2001-2003 are based on the 1990 census.

Source: Department of Statistics & Health Information & Research Unit 20 20 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
1.8 Age-Speciﬁc Birth Rates per 1,000 Females 15-49 Years, Bahamas, 1999, 2001, 2003 � � � � � � � � � � � � � � � � � � ��� ��� �� �� �� �� � ���� ���� ���� ����� ����� ����� ����� ����� ����� ����� ��������������������������� Fig.
1.9 Age-Speciﬁc Birth Rates Among Females 10-19 Years, by Island, Based on Registered and Estimated Live Births, 1993-2003 ������������� ������������� ������������� �������������� ������������� � � � � � � � � � � �� �� �� �� �� �� �� �� � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� 21 21 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer D. Population growth rate The annual population growth rate has declined from 2.2% in 1980 to an estimated 1.9% in 2002.
The crude rate of natural increase declined from 16.7 per 1,000 population in 1994 to 11.7 per 1,000 population in 2001 (Fig.

1.10).

Fig.

1.10 Crude Birth Rates, Death Rates and Natural Increase, 1994-2003 ��������� ������������������ ��������� � � � � � �� �� �� �� �� �� �� �� � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� E. Transient population According to the 2000 census, Bahamians constitute 87.3% of the population and non-Bahamians the remainder.
Haitians make up approximately 52.1% of the immigrant population.

The Bahamas government remains concerned about the large number of illegal Haitian immigrants entering The Bahamas, particularly as it impacts the health care system.

In 2003, 4.6 million people visited The Bahamas - a record number.

Of these, 1.6 million were stop-over visitors.

Approximately 65% of the visitors travelled to The Bahamas by sea.
As a result of the booming tourist industry, tourist and port health programmes have been established.

Generally speaking, The Bahamas does not have a pool of migrant workers concentrated in particular industries.

However, the construction industry in the major population centres has periodically attracted migrant workers.

22 22 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer F. Indigenous population About 85% of the Bahamian population is black and 15% white.
Much of the population, black and white, emigrated from the Americas.

The main and ofﬁcial language is English although Creole is spoken by Haitian immigrants.

G. Life expectancy by gender Life expectancy at birth has increased steadily from approximately 66 years of age between 1969-1971 to approximately 73 years between 1999-2001 (69.9 years for males and 76.4 for females) (Fig.

1.11).

Fig.
1.11).

Fig.

1.11 Life Expectancy, by Gender, Bahamas, 1960-2001 ������ ���� ������� ���� ���� ���� ���� ���� ���� ���� � � � � � � � � � � �� �� �� �� �� �� ��������� ��������� ��������� ��������� ������ In its World Health Report of 2000, the World Health Organization (WHO) computed a new indicator, Disability- Adjusted Life Expectancy (DALE), to measure healthy life expectancy.4 It summarises the expected number of years to be lived in “full health” without disability.
The DALE is calculated by weighting the years of ill-health according to severity and subtracting that number from overall life expectancy to give the estimated years of healthy life.

The Bahamas ranked 109th out of 191 countries in terms of DALE – a rank lower than several other countries in the Caribbean Region.

The DALE for males at birth is 56.7 years and for females is 61.6 years.
In terms of child survival, for children under ﬁve years of age, The Bahamas scored an index of equality of survival of 0.857 on a scale of 0 to 1.

4 WHO.

World Health Report 2000.

Health systems: improving performance.

23 23 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer H. Crude birth rate In the last ﬁve years, the crude birth declined from 18.0 per 1,000 population in 1999 to 16 per 1,000 population in 2003 (Table 1.2).
The population pyramids, trends in the total and age-speciﬁc fertility rates and the crude birth rates suggest that Bahamians increasingly prefer smaller family sizes.

I.

Crude death rate Between 1999 – 2002, the crude death rate (CDR) increased from 5.3 to 5.8 per 1,000 population, and in 2003 it declined to 5.2 when 1,649 deaths were recorded (Table 1.2).

In 2003, CDRs per 1,000 population in New Providence, Grand Bahama and the Family Islands were 5.6, 4.0 and 5.2 respectively.
In the Family Islands, the CDR ranged from 2.1 in Inagua to approximately 12 per 1,000 population in Mayaguana (5 deaths) as well as Acklins (3 deaths).

The population on each of the latter two islands is less than 500.

J.

Basic demographic information The operational deﬁnitions for the basic demographic indicators are shown in Appendix 3.

A notable achievement is the decline in the infant mortality rate (IMR) from 19.7 deaths per 1,000 live births in 1994 to 15.0 in 2003.
This decrease is attributed to a reduction in mother-to-child transmission (MTCT) of the human immunodeﬁciency virus/acquired immunodeﬁciency syndrome (HIV/AIDS) and to successful immunization programmes.5 Much of the decline has been due to gains in the neonatal mortality rate.

The Neonatal Intensive Care Unit, established in 1996 at the Princess Margaret Hospital (PMH), continues to enhance the viability of newborns with special medical needs.
The stillbirth rate has ﬂuctuated widely since 1994 when the rate was 12.9 stillbirths per 1,000 live births; it increased to 15.4 in 2003.

The perinatal mortality rate has also ﬂuctuated, declining from 22.4 per 1,000 live births in 1994 to 19.2 per 1,000 live births in 2003.

The child mortality rate decreased from 4.6 per 10,000 children in 1999 to 3.9 in 2003 (Table 1.2).

The trend in the maternal mortality ratio per 100,000 live births between 1994 and 2003 shows two peaks, in 1995 and 2001 (Fig.
1.12).

The maternal mortality rate declined to 4.0 per 100,000 live births in 2003.

5 PAHO/WHO.

Health in the Americas 2002 Edition.

Bahamas Chapter.

July 2001 24 24 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
1.12 Maternal Mortality Ratios, 1994-2003 � � � � � � � � � � � � � � � � ��� ��� ��� �� � ����� ���� ���� ���� ���� ���� ���� � � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� 25 25 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 2.

HEALTH SITUATION 2.1 Wellness The BLCS conducted in 2001 showed the prevalence of under nutrition to be 6% in children 2-10 years of age.
The highest prevalence of under nutrition was in the urbanized areas of New Providence and Grand Bahama and the lowest was in the less developed Family Islands.

Overall, 14% of children 2-10 years old were overweight.

More girls (16%) than boys (13%) were overweight (Table 2.1).

Eighteen percent of adolescents between the ages 11 to 20 were underweight.

The highest prevalence of underweight was found in the less developed Family Islands.
It was found that 9% of adolescents were overweight while 14% of adolescents were at risk for becoming overweight.

Again, more females (9.4%) than males (8.4%) were overweight (Table 2.2).

Thirty-four percent of adults aged 21 to 60 years were overweight with a body mass index (BMI) of 25 – 29.9, and a further 30.9% were obese with a BMI of 30 - 34.9.

Consequently, approximately two-thirds of the adult population was overweight.
Females had a signiﬁcantly higher prevalence of obesity (37%) than did males (24%) (Table 2.3).

Table 2.1 Low and High Z-scores for Children 2-10 Years of Age Population Characteristic Gender Male Female Total Sample HAZ-score (%) WAZ-score (%) WHZ-score (%) < -2.0 > 2.0 < -2.0 > 2.0 < -2.0 > 2.0 11.2 9.9 10.7 6.7 6.2 6.5 4.2 1.7 3.3 7.4 8.2 7.7 7.6 4.4 6.4 13.0 15.8 14.0 No.

obs.
obs.

492 332 824 Table 2.2 Body Mass Indices for Adolescents, Ages 11-20 Years Population Characteristic Gender Male Female Age Group (years) 11-15 16-20 Total Sample Under-weight Normal BMI (%) At risk for over-weight Over-weight Total No.

obs.
obs.

Mean BMI Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Table 2.3 Body Mass Indices Among Adults, Ages 21-60 Years, by Gender BMI (%) Under-weight (< 18.5) Normal weight (18.5-24.9) Over-weight (25.0-29.9) Obese (30+) Total No.

obs.
Mean BMI Population characteristic Gender Male Female Age Group (years) 21-30 31-40 41-50 51-60 Total Sample 2.2 Morbidity Morbidity is discussed under four main groups: A. Non-Communicable Diseases (as reported from primary health care services) B. Communicable Diseases C. Hospital-based Reports D. Bahamas Living Conditions Survey 2.2.1 Chronic Non-Communicable Diseases Chronic non-communicable diseases (CNCD) account for nearly 45% of all deaths in the country.
Taken together, CNCD (in particular, hypertension, diabetes, coronary heart disease, stroke, chronic respiratory diseases and cancers) represent the leading cause of morbidity and disability in The Bahamas.

An analysis of hospital discharges for the period 2002-2003 showed that in the adult population, diabetes, hypertension and cancer are the leading causes of morbidity in females aged 45-64 years, and fourth and ﬁfth for men in the same age group.
CNCD accounted for 22% of all hospital admissions to PMH between 2002–2003: this ﬁgure only refers to hospital discharge data.

Data from the BLCS 2001 showed a prevalence of 3.3% for self-reported cases of diabetes, with rates slightly higher among females than males, and a general increase in reported cases of diabetes in adults between the ages of 55 and 64 years.

Results also indicated a prevalence of 9.3% in self-reported cases of hypertension.
27 27 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer As part of its more comprehensive approach to prevention, control and care of CNCD, the MOH will conduct a Disease Prevalence Study and a Risk Factor Survey to plan strategic interventions to reduce the disease burden in the country.

The MOH, in conjunction with the Ministry of Education, provides School Health Services.
The objective of the School Health Services is to ensure optimal health of school aged children in public schools.

The key feature of the School Health Services is health education which focuses on increasing students’ understanding of health principles and modifying health related risk behaviour.

The service also includes medical examination of students in grades 1, 6 and 10, immunizations, and treatment of minor ailments and dental care.
Results of the annual school health screening of students in grades 1, 6 and 10 for the period 2001-2003 in public schools (Table 2.4) show a decline in the number of students with high blood pressure, low haemoglobin, and vision and hearing defects.

Although there was a decline in the number of students with dental caries over the period, it remains a school health concern.
Table 2.4 Selected Abnormal Screening Results in School Health 2001 Grade Grade Grade 6 10 1 2002 Total Grade Grade Grade Total 1 6 10 2003 Grade Grade Grade 6 10 1 Conditions High Blood pressure Hb<= 10 Grams Vision problems Hearing defects Dental Caries Abnormal Weight for age(malnutrition) Underweight Overweight Total 34 121 587 4 111 166 214 1,029 6 196 338 121 253 2.2.2 Communicable Diseases 2.2.2.1 Communicable Disease Surveillance The Surveillance Unit of the Department of Public Health (DPH) maintains surveillance of communicable diseases and investigates disease outbreaks in The Bahamas.
Periodically, other agencies such as the DEHS, the Infection Control Unit of PMH and the Ministry of Agriculture assist with outbreak investigations, depending on the nature of the outbreaks.

The Epidemiology Unit, in conjunction with the Surveillance Unit, coordinates the activities of the Tuberculosis (TB), sexually transmitted infections (STIs) and general surveillance programmes and maintains some control over the Expanded Programme on Immunization (EPI).
The staff of the Surveillance Unit continues to provide services to the HIV/AIDS Programme by managing the weekly Infectious Disease Clinic at PMH.

28 28 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Surveillance data are obtained from the Primary Health Care Reports, Notiﬁable Disease Report Forms, Laboratory Notiﬁcation lists from PMH and private sector physicians.
These data are then analyzed and a weekly report is generated and disseminated to all stake holders including the Caribbean Epidemiology Centre (CAREC).

Data for reported cases of communicable diseases can be found in Appendices 4 and 5.

The Communicable Disease Surveillance System is currently undergoing revision at the regional level.
In anticipation of the revision, the Epidemiology Unit is to pilot the Syndromic Surveillance System which is a major addition to the revised Communicable Disease Surveillance System.

Communicable disease surveillance in The Bahamas continues to face enormous challenges such as limited human and ﬁnancial resources and inadequate training.
Despite these challenges, the unit continues to remain focused on achieving its overall goal as outlined in the Revised National Health Services Strategic Plan (NHSSP) 2003-2004.

Between 2001-2003, outbreaks included gastroenteritis (2002 and 2003) and dengue fever (2003).

In 2002, there were 165 reported cases of conch poisoning in which were related to poor handling of conch by vendors.
The dengue fever outbreak in 2003 resulted in 180 clinical and conﬁrmed cases, presenting predominantly with serotypes 2 and 3.

No deaths were reported in either outbreak.

Eight imported malaria cases were reported between 2001-2003.

Since the last major malaria outbreak in 1999 when 30 cases were reported, the incidence of malaria has reduced considerably.

Food-borne diseases and gastroenteritis continue to pose diagnostic challenges.

The incidence rate of each increased during the winter months.
Between 2001-2003, the incidence rate of food-borne diseases ranged from 318.2 to 417.2 per 100,000 population.

The number of cases reported for gastroenteritis increased steadily from 2,521 in 2001 to 4,904 in 2002, and decreased to 3,759 in 2003.

The increase can be attributed to better reporting and seasonal outbreak of gastroenteritis due to rota virus in children less than ﬁve years of age during the months of February and March.
There was an outbreak of Hepatitis A in 2001 when a total of 46 cases was reported.

Only ﬁve sporadic cases were reported in 2002 and one case in 2003.

With the exception of Hepatitis B (Hep.

B), there were no reports of vaccine preventable diseases in the last ﬁve years.

This is attributed to the high immunization coverage in the country.

Since the revision of the case deﬁnition for reportable Hep.

B, there were only ﬁve notiﬁed cases of symptomatic Hep.

B in 2002, and one in 2003.


Prior to the revision, all screened samples positive for Hep.

B Surface Antigen were classiﬁed as notiﬁed even if they were asymptomatic and no testing for Hep.

B virus antibody had been done.

In 2001-2003, surveillance data showed a minimal increase in the number of STIs which indicates a need to increase health promotion activities.
Approximately 700 cases of scabies are reported annually to the Surveillance Unit and it is estimated that as many as half of all cases that occur are not reported.

Between 2001-2003, 564 cases of ciguatera were reported.

The incidence of ciguatera poisoning in The Bahamas is one of the highest in the world due to the high consumption of barracuda by Bahamians.

Barracuda eat the dinoﬂagellates which carry the cigua toxin.
The number of salmonellosis cases increased in 2003 (there were 28 cases), but none was linked to an outbreak.

Between four to seven cases were reported in 2001 and 2002 respectively.

With respect to zoonotic diseases, there have not been many changes since the last Chief Medical Ofﬁcer (CMO) report in 2000.
It has not been possible to establish a link between veterinary and human health because of under reporting from veterinary clinics and private labs, and weak government veterinary capacity (especially with regards to diagnostic, surveillance, information management and epizoology).
29 29 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Emerging and re-emerging infectious diseases, such as the global severe acute respiratory syndrome (SARS) outbreak in 2003, are of great concern.

There was good collaborative support from all stakeholder agencies in The Bahamas during the SARS outbreak.
Not only was the public well informed about SARS, but health care providers were involved in various SARS related training activities in disease control and prevention.

The report of West Nile Virus in one of the Family Islands resulted in an integrated approach to outbreak investigation.
Although a formal survey was not conducted or research carried out, the experience gained in all the epidemiological investigations was well documented and two case reports were published in CAREC’s Communicable Diseases Surveillance Report 2003.

2.2.2.2 Childhood Immunization According to the Revised NHSSP 2003-2004, at least 98% of children entering pre-school or primary schools was immunized against Measles, Mumps and Rubella (MMR), Diptheria, Pertussis and Tetanus (DPT), Polio, Hep.
B and the Haemophilus Inﬂuenza type b vaccine (Hib.)

The EPI has the following objectives: • To protect all children under one year of age against DPT, Hib., Hep.
B and Polio (three doses) • To protect all children at age one year against MMR (1st dose) • To administer booster doses of DPT, Polio, Diptheria and MMR at speciﬁed intervals • To protect pregnant women against Tetanus in order to prevent Neonatal Tetanus (future pregnancies) • To protect postnatal women against Rubella in order to prevent Congenital Rubella Syndrome (future pregnancies).
The communicable disease trend in The Bahamas over the period 1994-2003 indicated that vaccine preventable diseases are becoming extinct.

The last cases of the diseases reported were as follows: Pertussis (1996); Measles (children) 1990 (adults) 1997; Mumps (1995); Rubella (1998); Congenital Rubella Syndrome (1998); Tetanus (excluding neonatal) (1996); Haemophilus Inﬂuenza (2001).

No cases of Polio, Diphtheria or Neonatal Tetanus were reported during this period.
The success of the EPI is credited to children being routinely immunized, immunization campaigns which target adults, and to the continuous training of all heath care providers who rotate through the EPI Unit.

A mass MMR campaign targeting persons between the ages 4 – 40 years was successfully executed in 1997.

A follow up MMR campaign was conducted in 2003 in order to increase MMR immunization coverage.
There have been no cases of indigenous measles since 1990, and no cases of congenital rubella since 1998.

The diphtheria and tetanus and Hep.

B vaccines were offered to persons presenting for MMR during the campaign.

Immunization coverage in The Bahamas for childhood preventable diseases continues to be among the highest in the Caribbean region.

Since 2000, immunization coverage for ﬁrst and third doses of all the vaccines has exceeded 90%, except for Hep.
B which was initiated in 2001 as a part of the Pentavalent Vaccine (ﬁve vaccines in one injection) (Fig.

2.1).

30 30 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
2.1 Childhood Immunization Coverage in The Bahamas, 1994-2003 ��� �� �� �� �� ��� ����� ��� ����� ��� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ��� ����� ����� ����� ��� ����� � � � � ���� ���� � � ���� ���� � � ��� ����� ���� ���� ���� ���� � � ���� ���� ���� � � ���� ���� ���� ���� � ���� ���� ���� ���� � ���� ����� ����� ����� ���� ���� ������ ���� ���� ���� ���� ��� ��� ��� ��� ��� The Pentavalent vaccine was ﬁrst administered in July 2001 and contributed signiﬁcantly to the EPI in The Bahamas.
The Pentavalent vaccine includes DPT, Hib.

and Hep.

B.

The Hib.

vaccine which was introduced in 1999 continues to contribute to the reduction in the morbidity rate.

The Hib.

immunization coverage was 77% in 1999, and 92% in 2003.

The level of antenatal diphtheria and tetanus coverage cannot be determined because this information is not routinely obtained from all clients on the ﬁrst visit to their doctors.
Some patients attending private clinics are not given the diphtheria and tetanus vaccines during pregnancy.

The antenatal tetanus immunization coverage ranged from 64% to 77% in 2003.

The last known case of infant tetanus was in 1970.

The estimated immunization target population is obtained from the number of live births recorded for the previous year minus the number of deaths of babies and the number of babies that immigrate minus the number that emigrate.
It is accepted that the number of live births is inaccurate because there is no national system in place to automatically record all infant migrants.

To help record the accuracy of immunization coverage, EPI Unit staff members have increased the frequency of supervisory visits to public and private clinics in New Providence and in the Family Islands.
31 31 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 2.2.2.3 HIV/AIDS by Age and Gender The frequency of HIV is monitored through sero-prevalence surveys in sub-population groups of persons attending antenatal clinics and sexually transmitted infection (STI) clinic, blood donors and the prison.

HIV infected persons are identiﬁed from these groups, and from volunteers and TB patients.
The value of monitoring the incidence of HIV from all of these sources in order to assess programme performance may be limited by the differences in where the selected asymptomatic sub-populations are located and when they are surveyed.

Surveillance data show that the prevalence of HIV in pregnant women declined from 4.2% in 1994 to 3.1% in 2003 (Fig.

2.2).
2.2).

The HIV prevalence among STI patients has ﬂuctuated over the past 10 years, with the highest prevalence seen in 1995 (7.2%), 1998 (6.4%) and 2002 (4.8%).

This ﬂuctuation may be due to variations in the number of clients screened from year to year and the inclusion of clients from the Skin Clinic.

In 2003, the prevalence among STI patients was 3.6%.

The prevalence of HIV among blood donors was more stable at approximately 0.4%, and was at its lowest (0.2%) in 2003.

Fig.
2.2 Prevalence of HIV in Antenatal Women, Blood Donors and STI Clients, Bahamas, 1994-2003 � � � � � � � � � � � ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��������������� ������������ ����������� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ��� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� Previous data showed 88.4% of HIV is spread through heterosexual contact, 2.5% through bisexual contact and 1.1% through homosexual contact.
Under-reporting remains a challenge, and intravenous transmission is still considered to be insigniﬁcant.

Although the prevalence of HIV in the STI population declined from 4.8% in 2002 to 3.6% in 2003, the prevalence has ﬂuctuated between a high of 7.2% in 1995 to a low of 3.3% in 2000.

The reason for this ﬂuctuation may be related to a skew in the screened population.
A Knowledge, Attitude and Practice (KAP) 32 32 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer study was conducted in 1998, but no follow-up study has been done.

It would be useful to conduct a follow up KAP study to see if there has been a shift in knowledge, attitude and practices towards HIV/AIDS.

From 1985 to 2003, a cumulative total of 4,967 persons tested positive for HIV but had no symptoms of AIDS (Table 2.5).
The female to male ratio is 1:0 but in the 10-14 and 15-19 year age groups, approximately twice as many females as males were infected.

The ratio of infected females to males was 1.5:1 and 1.1:1 respectively in the age groups 20-24 and 25-29.

In older age groups, the ratio of those infected was less than one female to one male.

This reﬂects a shift in infection patterns seen over the last ﬁve years.

Eighty-two percent of all infected persons fall in the age group of 15-49 years.
The peak age for females (25-29 years) occurs earlier than for males (30-34 years).

The younger age at which females contract AIDS may be due to their earlier sexual activity, a higher male-to-female transmission efﬁciency or the preference of older men for younger women.
Table 2.5 Cumulative Cases of Non-AIDS HIV and AIDS as at December 2003 Cumulative Reported Non-AIDS HIV Cases 1985-2003 Cumulative Reported AIDS Cases 1985-2003 Age Group Male Female Total % Total F:M ratio Male Female Total % Total F:M ratio < 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Unknown Total 2,481 2,486 4,967 100.0 1.0 2,879 1,879 4,758 100.0 0.7 “F:M” - Ratio of females to males.
33 33 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer The number of new persons testing positive annually for HIV has declined by 56.1% from its peak level of 659 in 1994 to 289 in 2003 (Appendix 6).

This translates into a decline in reported incidence rate from 240 per 100,000 population in 1994 to 91 per 100,000 in 2003.

Over the past decade a decline was seen in all age groups, with the exception of children 5-14 years old.
The age proﬁle of non-AIDS persons suggests that resources should be targeted at children less than 15 years of age in order to signiﬁcantly reduce the incidence of HIV in The Bahamas.

Children less than 15 years old comprised 6.1% of persons reported with HIV and 5.3% of those reported with AIDS.

In 1995, in an effort to reduce neonatal mortality, the government of The Bahamas introduced a policy to screen all pregnant women for the HIV virus if they voluntarily consented to the test.
In 1996, the rate of transmission of HIV from mother to infant decreased from 30% to 10%, a fact attributed to the screening which was implemented the year before.

It has been documented that the MTCT of the HIV virus can be reduced from 10% to 5% with appropriate interventions.

Available data show greater effectiveness of treatment among mothers in most years (Fig.

2.3).

In 2003, there was no vertical transmission of HIV from mothers to newborns.
From 1985 to the end of 2003, a cumulative total of 4,758 AIDS cases was reported (Table 2.5).

Of AIDS patients, 39.5% were females and 60.5% males.

Twice as many female as male adolescents 15-19 years old were reported to have AIDS.

As with HIV, most patients (78.2%) were between the ages of 15-49 years.

The annual reported incidence of AIDS rose from 115.4 cases in 1994 to 137.7 in 1995, and thereafter declined to 93.3 in 2002.

It rose to 110.0 in the following year.


At the end of 2003, there were 25 infants under one year and 20 children 1-4 years old living with AIDS.

There were also 1,449 persons living with AIDS, and 3,309 (70%) of all reported AIDS cases had died.

Of the total persons reported with AIDS in 2003, 75% were Bahamians.

Fig.
2.3 Trends in HIV MTCT Rates by Treatment Status, 1995-2003 ����� ����� ����� � � � � � � � � � �� �� �� �� �� �� �� � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ����������������������������������������������������������������������������������������������������������������������������������������������������������������������� ������������������������������������������������ 34 34 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer As at the end of December 2000, 86.1% of persons living with HIV/AIDS (PLWHA) resided in New Providence, 8.2% in Grand Bahama, 1.9% in Eleuthera (including Harbour Island and Spanish Wells), 1.3% in Abaco and the remaining 2.5% on other Family Islands.
2.2.2.4 Tuberculosis by age and gender There has been a signiﬁcant improvement in surveillance of TB in The Bahamas, and the quality of data collected has likewise improved.

In the last 10 years the notiﬁcation rates of new cases of TB have declined from 23.4 per 100,000 population in 1994 to 12.6 per 100,000 population in 2003 (Fig.

2.4).

The burden of TB has remained high in the 25- 49 age group.

The co-infection rate with HIV/AIDS remains high at 39% and 31.5% in 2002 and 2003 respectively.
The case fatality rate for TB co-infection with HIV/AIDS was 46.6% in 2002 and 71.4% in 2003.

With the introduction of anti retroviral (ARV) therapy for TB co-infected clients, it is expected that the case fatality rate will decline in the near future.

About seven out of ten TB clients are Bahamian, while one in four is Haitian.

There was a gradual shift in the gender distribution of cases in the last three years.

The male to female ratio was 2.1:1 in 2001, and 1.2:1 in 2003.

Fig.
Fig.

2.4 TB Notiﬁcation Rates per 100,000 Population 1994-2003 �� �� �� �� �� �� � � ���� ���� ���� ������ ���� ���� ���� ���� ���� ���� 2.2.3 Hospital-Based Reports The public hospitals (PMH, Rand Memorial Hospital (RMH) and Sandilands Rehabilitation Centre (SRC)) use a computerized patient retrieval system, called First Coast, to record their morbidity and mortality data.

However, data on outpatient diagnoses are not currently coded and are, therefore, not available.
35 35 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 2.2.4 Other 2.2.4.1 Rehabilitation Services In 1996, a community-based rehabilitation programme was successfully established in the islands of Abaco, Long Island and Eleuthera.

The programme has been suspended pending its evaluation.

Depending on the results of the evaluation, the programme might be extended to include Exuma and Andros.
A videotape of the community-based rehabilitation programme in Long Island was produced and was included in a documentary for international circulation by the Pan American Health Organization (PAHO).

The programme relies on trained volunteers from the community to assist individuals with various disabilities to reach their full potential.
It is supported by the MOH and the Ministry of Education and its main beneﬁciaries are young and elderly persons who may have one or more of the following disabilities – lack of mobility, sight impairment, hearing loss, speech difﬁculties, learning disabilities and mental disabilities.

A register of all disabled persons was compiled where community-based rehabilitation programmes exist.

In 2001, a pilot three year diploma programme in physiotherapy was completed.
Three students were sent to the University of Manchester for clinical placement and evaluation.

After completing their studies, they were employed as physiotherapists with the Public Hospitals Authority (PHA).

During 2001-2003, as part of an exchange programme with the University of Manchester, students from the United Kingdom, Ireland and the USA came to The Bahamas to complete their ﬁnal year of training in rehabilitative services.
In 2003, rehabilitative services in The Bahamas celebrated 50 years of existence.

2.2.4.2 Oral Health A 1999/2000 National Oral Health Survey concluded with several recommendations on oral health which have resulted in the establishment of a number of programmes.

In January 2003, the National Family Island Dental Prevention Programme was initiated.
Several dental professionals (usually two dentists, two hygienists, two assistants and a technician) travel to the Family Islands to provide primary, secondary and tertiary dental treatment.

They use the clinics in the community and take portable dental equipment with them.

Dental clinics are held on school premises during school hours for school aged children.
In 2003, 1,127 patients were seen in the Family Islands: 818 people received ﬂuoride treatment, 863 prophylaxes, 83 had their teeth ﬁlled and 5 people obtained dentures.

A National Sealant Programme was established and incorporated into the National Family Island Dental Prevention Programme.

Dental ofﬁcers and hygienists have been encouraged to place more sealants.

Abaco, Andros and Long Island were identiﬁed as islands which required speciﬁc dental attention.
A permanent dental ofﬁcer has been stationed in Abaco, and dental ofﬁcers are being recruited for Andros and Long Island.

Programme evaluation includes focus meetings with staff members on standard dental procedures and the appropriate use of dental materials and oral health aids.

Outcome evaluation assesses the effect of treatment.

To date, ﬁve of the seven recommendations for the 1999/2000 National Oral Health Survey have been addressed.
2.2.4.3 Prison Health The Prison Health Service falls under the direction of the MOH.

In October 2002, a Prison Reform Commission was established.

This commission is responsible for reviewing the government owned prison facility and its related affairs.
The commission recommended upgrading the medical facilities at the prison, hiring additional 36 36 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer nursing staff to enable the prison to provide comprehensive health care for prison staff and inmates, establishing a mental health team and improving pharmaceutical services.

Medical services at the prison are headed by a general physician, supported by nursing and allied health staff.
The medical team is responsible for overseeing the health of the prison staff and inmates.

Upon admission, all new inmates are screened for HIV, Hep.

B, TB and STIs.

Services include routine medical evaluations, management of chronic medical conditions and acute minor medical emergencies, infectious disease management, drug demand reduction and routine dental health care.

Mental and psychological health care are provided by personnel from the government owned psychiatric hospital, SRC.
In 2002, six prison ofﬁcers commenced training to become Trained Clinical Nurses or Enrolled Nurses.

Once trained, these persons will supplement the current nursing and allied health staff.

Since 2002, there have been marked improvements to the physical infrastructure of the health facilities at the prison, including the opening of a new health unit for staff.
2.2.4.4 National Blood Programme In order to ascertain the quality of the blood procurement services in the country, the government of The Bahamas requested PAHO to conduct an audit of the three blood banks operating in The Bahamas.

The blood banks were audited in April 2001.

As a result of the audit, PAHO recommended the establishment of a National Blood Programme Committee which was established in 2003.
The main goals of the committee were to establish a National Voluntary Blood Donor programme and to draft regulations and guidelines governing blood centres, blood and blood products.

The regulations have been drafted and submitted for review, and a national coordinator selected for the programme.

To enhance the functioning of the blood procurement programme, an individual is being trained in blood banking.

This person will be the country’s ﬁrst specialist in blood banking upon qualifying in late 2004.
In 2003, there was a total 4,152 blood donors from PMH and RMH, and 987 blood donors from the only private hospital, Doctors Hospital.

2.2.4.5 Holistic Health This is a new programme which is in development.

2.3 Mortality 2.3.1 Age-Gender Distribution of Deaths Appendix 7 shows the distribution of deaths by gender and age groups for 2003.

In 2003, the CDR was 5.2 per 1,000 population.

Among males, it was 5.6 per 1,000 and 4.8 per 1,000 among females.
Of the 1,649 registered deaths in 2003, 46.8% were females.

The age-speciﬁc death rates per 1,000 ranged from 0.4 in children 1-4 years old to 44.7 in elderly persons 65 years or older.

The corresponding rates for males were 0.5 and 49.6 per 1,000 population for the respective age groups.

Similarly, for females, the rates were 0.3 and 41.1 per 1,000 respectively.
Overall, the pattern of age-speciﬁc death rates by gender was J-shaped with the highest death rates at the extremes of life, particularly in the elderly.

At all ages, the age-speciﬁc death rates were higher for males than for females.

The additional burden of childbearing does not seem to impose excess mortality in females.

37 37 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer The CDR a decade earlier in 1994 was 5.6 per 1,000 population.
However, substantial gains have been made in the age- speciﬁc death rates especially at the extremes of life.

The death rate in infants in 1994 was nearly twice as much as that in 2003 (19.7 per 1,000 population versus 10.7).

With the exception of the elderly, age-speciﬁc death rates in the other age groups were comparable.

Among the elderly, the rate was 48.7 per 1,000 in 1994, but decreased to 44.7 in 2003 (Fig.

2.5).

Fig.
2.5).

Fig.

2.5 Age-Gender Speciﬁc Death Rates in Both Genders, 1994 & 2003 ���� ���� � � � � � � � � � � � � � � � � � � � � �� �� �� �� �� �� � �� ��� ���� ����� ����� ����� ��� ��������� Persons 45 years and older constituted 22% of the total population and accounted for 71.8% of total deaths.

Among males and females, those 45 years and older accounted for 69.5% and 74.3% of deaths respectively.
Certain steps could be taken to positively impact the CDR in infants and persons 45 years and older, while taking into consideration biological limitations to reducing death rates in the oldest populations.

One such step would be to focus more resources on these populations.

While considerable progress has been made in reducing the IMR, the potential to further reduce this rate exists, particularly in the post-neonatal period.
38 38 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 2.3.2 Proportionate Mortality by Causes of Death by Gender Appendix 8 shows that the years of potential life lost (YPLL) over the ﬁve year period 1999-2003 by cause: among both sexes, communicable diseases accounted for 29.5%, external causes of injury (including poisoning) for 19%, perinatal conditions 9.2%, diseases of the circulatory system 11.6% and neoplasms 8.3%.
By gender, external causes accounted for 25.5% of the total YPLL for deﬁned causes of death in males compared with 9.2% in females.

Conversely, neoplasms accounted for 12.1% of the total YPLL in females compared with 5.8% in males.

Patterns of deaths and YPLL suggest that deaths due to external causes peak in the 25-44 age group while the diseases of the circulatory system are more likely to affect adults 45 years and older (Appendix 9).
The YPLL due to external causes of injuries and poisonings decreased from 5,761 in 2000 to 3,181 in 2002.

Although it rose to 4,463.5 in 2003, it was still below the 1999 level of 5,247.5.

There has also been a slight increase in the YPLL due to neoplasms and diseases of the circulatory system over the period 1999-2003; the increase was more rapid for the latter (Fig.

2.6).

Fig.
2.6 Annual Trends in Years of Potential Life Lost by Cause of Death, 1999-2003 ���� ���� ���� ���� � � � � ���� ���� ���� ���� ���� � �������� ��������������������� ���������������������������������� ��������������� ������������������������������������� ��������� �������������������� ������������������ ���� ���� ���� ���� ���� ���� 39 39 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 2.3.3 Group Causes of Death by Age Group and Gender Using PAHO’s six broad causes of mortality, the causes of death by age and gender between 2001–2003 are presented in Appendices 9 and 10.
A total of 5,195 cumulative deaths occurred, of which 5,122 had deﬁned causes.

Among deﬁned group causes of deaths, diseases of the circulatory system accounted for 28.8%, communicable diseases 19.1%, neoplasms 16.4%, external causes 8.3%, perinatal conditions 2.3% and all others 24.2%; unspeciﬁed illnesses comprised 1.4% of total deaths.
The major gender differences in the proportionate mortality by cause were that diseases of the circulatory system accounted for 31.8% of female deaths compared with 26.2% of male deaths.

On the other hand, external causes of injury and poisoning constituted 4% of total female deaths compared with 11.9% of total male deaths.

The peak age of death was 65 years for both males and females.
The age speciﬁc death rate per 1,000 population for males 65 years and older was lowest in 1999 and highest in 2001; for females, the highest and lowest rates were in 2001 and 2003, respectively (Fig.

2.7 and Fig.

2.8).

The age speciﬁc death rate for males 65 years and older dropped from 52.8 per 1,000 in 2001 to 49.6 per 1,000 in 2003, while for females it dropped from 46.4 per 1,000 to 41.1 per 1,000 over the same period.

Fig.
Fig.

2.7 Age Speciﬁc Death Rate of Males, 1999, 2001, 2003 ���� ���� ���� � � � � � � � � � � � � � � � � � � � � � �� �� �� �� �� �� � �� ��� ���� ����� ����� ����� ��� ��������� Between 2001-2003, males of all ages died more frequently from external causes than did females.

Conversely, females died more frequently from neoplasms than did males.
The main causes of death in infants were illnesses which originated in the perinatal period and congenital causes; together these accounted for 80.4% of all infant deaths.

External causes accounted for 30.8% of total deaths in children 5-14 years old and for 48.3% of total deaths in young adults 15-24 years old.

The male to female ratio of deaths from external causes was 1.4:1 in the 5-14 year age group and 6:1 in the 15-24 age group.
In the latter group of young adults, communicable diseases accounted for 19.2% of deaths while neoplasms had a much higher impact on mortality (56.2%).

40 40 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
2.8 Age Speciﬁc Death Rate of Females, 1999, 2001, 2003 ���� ���� ���� � � � � � � � � � � � � � � � � � � � � � �� �� �� �� �� �� � �� ��� ���� ����� ����� ����� ��� ��������� The leading group causes of death among adult males aged 25-44 years old were communicable diseases (which accounted for 42.0% of deﬁned causes of deaths), diseases of the circulatory system (13%) and external causes of injury and poisoning (21.7%).
In adult females, the three leading group causes of deaths were communicable diseases (39.9%), neoplasms (16.5%) and diseases of the circulatory system (13.8%).

The male to female ratio of deaths due to external causes in this age group was 6.5:1.

In elderly persons aged 65 years and older, the leading group causes of death among males were diseases of the circulatory system (37.4%), neoplasms (24.6%) and communicable diseases (9.1%).
In elderly females, the leading causes were the same as for males with respective percentages of 42.8%, 17.4% and 9.5%.

Over the period 2001-2003, the annual trends for these conditions ﬂuctuated.

2.3.4 Leading Causes of Death Using PAHO’s 6/67 mortality cause groupings, the mortality rates for the 10 leading causes of death in 2003 were determined.
Over the period 1999-2003, HIV/AIDS, land transport accidents and ischaemic heart diseases have shown general decreasing trends; only in 2000 did the rates deviate from downward trends.

On the other hand, hypertensive diseases showed an increasing trend between 1999 and 2002.

The mortality rate for hypertensive diseases rose from 34.5 per 100,000 population in 1999 to 80.2 in 2002 but declined to 55.6 in 2003 (Fig.

2.9).

Rates for most of the other leading causes of death showed ﬂuctuating patterns.
When a similar analysis of leading causes of death based on YPLL was conducted, HIV/AIDS ranked ﬁrst, followed by assault (homicide) and then by land transport accidents.

Other diseases ranking below the top three recurred over the period 1999-2003, but in no particular order.

The trend for YPLL and for mortality rates is similar – YPLL and mortality rates due to HIV/AIDS, land transport accidents and ischaemic heart diseases are declining, while hypertensive diseases are rising (Fig.

2.9 and Fig.
2.9 and Fig.

2.10).

Deaths from HIV/AIDS led to 4,044 YPLL in 2003, a decrease of 42.7% from 1999.

The YPLL for land transport accidents also showed a decrease of 31.5% from 1,693 in 1999 to 1,159 in 2003.

41 41 Annual Report of the Chief Medical Ofﬁ cer Annual Report of the Chief Medical Ofﬁ cer Fig.
2.9 Ten Leading Causes of Death, 1996-2003 � � � � � � � � � � � � � � � � � � � � � � � ��� �� �� �� �� �� � ���� ���� ���� ���� ���� ��� ������� ������ ��������� ������������� ������������ �������� ������� ���������� ���� ��������� ��������� ��������� ������ �������� �������� ������� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ���� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ���� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ��������� ��� ����� ������� ����� ���� ����� ����� ���� ����� �������� ����� �������� ��������� ��������� ������ ������ ����� ����� ����� ����� ����� ��� ��� ���� ���� ���� ����� 42 42 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
2.10 Ten leading Causes of Death by YPLL, 1996-2003 ���� ���� ���� ���� ���� ���� ���� ���� � � � � ���� � ��� ������� ������ ��������� ������� ����� ������������ �������� ������� ���������� ���� ��������� ��������� ��������� ������ �������� �������� ������� ������������� ������������� �������� �������� ����� �������� ��������� ��������� ������ ����� ������� ����� ������� ����� ������� ����� ������� ����� ������� ������ ������ ������ ������� ������� ������ ������ ������ ������ ������ ������� ������� ������� ������ ������� ������� ������� ������� ������� ������� ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ������ ����� ����� ����� ����� ����� ������ The leading causes of death, by gender, for the year 2003 are presented in Table 2.6.
Among males, the leading cause of death was HIV/AIDS, followed by hypertensive disease.

Other causes of death for males included ischaemic heart disease, cerebrovascular disease and malignant neoplasm of the prostate.

Of the 88 deaths due to homicides and land transport accidents in 2000, 74 (84.1%) were males.

Hypertensive diseases ranked as the leading cause of death for females followed by HIV/AIDS.
Other leading causes among females include diabetes mellitus, cerebrovascular diseases and ischaemic heart disease.
43 43 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Table 2.6 Ten Leading Causes of Death, by Gender in 2003 Rank Condition Number of Deaths % of Deﬁned Causes Rate Per 100, 000 Males MALES 102 11.8 HIV Disease (AIDS) (B20-B24) Hypertensive diseases (I10-I15) Ischemic heart diseases (I20-I25) Cerebrovascular diseases (I60-I69) Malignant neoplasm of prostate (C61) Assault (homicide) (X85-Y09) Diabetes mellitus (E10- E14) Pulmonary heart disease, diseases of pulmonary circulation and other forms of heart disease (I26-I45, I47-I49, I51) Land transport accidents (V01-V89) 10 Cirrhosis and certain other chronic diseases of liver (K70, K73, K74, K76) Total Deaths, Leading Causes Total Deaths, Deﬁned Causes * Total Deaths, All Causes FEMALES Hypertensive diseases (I10-I15) HIV Disease (AIDS) (B20-B24) Diabetes mellitus (E10- E14) Cerebrovascular diseases (I60-I69) Ischemic heart diseases (I20-I25) Pulmonary heart disease, diseases of pulmonary circulation and other forms of heart disease (I26-I45, I47-I49, I51) Malignant neoplasm of female breast (C50 in women) Malignant neoplasm of other and unspeciﬁed sites (C00-C14, C40-C47, C49, C50 in men, C58, C69-C80, C97) Septicemia, except neonatal (A40-A41) 10 Diseases of the urinary system (N00-N39) Total Deaths, Leading Causes Total Deaths, Deﬁned
 Causes * Total Deaths, All Causes Based on PAHO’s 6/67 Mortality Cause Groups (ICD10).
* “Deﬁned Causes” represent all causes of death except those classiﬁed as Signs, Symptoms, and Ill-Deﬁned Conditions (R00-R99); All rates are gender speciﬁc.
Source: Department of Statistics Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 2.4 Population Sub-Groups 2.4.1 Infants There was a continuous reduction in the IMR between 1999-2001.
The IMR decreased from 15.8 per 1,000 live births in 1999 to 12.7 per 1,000 live births in 2001; however, this reduction was not sustained, but rose to 17.2 per 1,000 live births in 2003 (Table 1.2).

The still birth rate fell from 14.0 to 9.5 per 1,000 live births over the period 1999-2001.

Just as the IMR increased in 2003, so did the still birth rate which rose to 15.4 in 2003.

In 2003, registered infant deaths accounted for 3.3% of total deaths (Appendix 7).
The combined data from the Perinatal Information System (SIP) for PMH and RMH showed that the prevalence of low birth weight (less than 2500 grams) increased steadily from 8.5% in 1999 to 11.2% in 2003.

A total of 126 infants developed AIDS between 1985 and the end of December 2003.

However, in 2003, there was no vertical transmission of HIV from mothers on treatment to their babies (see Section 2.2.2.2).
There have been no cases of vaccine-preventable diseases reported in children over the last ﬁve years.

In 2001, the Hep.

B vaccine was introduced as part of the immunization schedule and Hib.

was introduced in 1999 (see Section 2.2.2.1).

2.4.2 Children (1-4 years) A total of 10 deaths was recorded in 2003 in pre-school children aged one to four years old.

This represented a 33% decrease from 2001 when 15 one to four year olds died.
Diseases of the respiratory system (excluding acute respiratory infections) were among the leading causes of mortality in children in this age group in 2001 and 2003.

Other causes of death included accidental drowning, congenital malformations/chromosomal abnormalities and pulmonary heart disease.

The leading cause of inpatient morbidity during 2001-2003 was acute respiratory infections.
Other major causes of morbidity included injuries and poisonings, intestinal infectious diseases, slow foetal growth, low birth weight, pre-maturity and other diseases of the respiratory system.

Child abuse in this highly vulnerable age group continued to be a cause of concern despite a decrease from 612 to 526 (14%) reported cases from 2002 to 2003 (Table 2.7).
During the period 2001-2003, child neglect and physical abuse were the most commonly reported types of child abuse and accounted for 42% and 32% respectively of all cases.

Sexual abuse and incest accounted for an additional 23% of reported cases.

The Suspected Child Abuse and Neglect (SCAN) Programme which is dedicated to the prevention of child abuse and to the medical follow-up of abused children, registered a decrease in the number of ﬁrst time clients seen at its weekly clinic during 2003 (Table 2.8).
There was, however, an increase in return visits.
45 45 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Table 2.7 Reported Cases of Child Abuse, by Type and Year Type of Case 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Abandonment Neglect Physical Abuse Sexual Abuse Incest Verbal Abuse Total Source: Department of Social Services Table 2.8 Cases of Children Seen at SCAN Clinic 2001-2003 (0-16 years) Type of Case New Cases Return Cases Total 2001 115 52 167 2002 120 53 173 2003 88 69 157 Source: Department of Social Services 2.4.3 Children (5 - 14 years) In 2003, there were 23 deaths among children 5-14 years of age, resulting in a mortality rate of less than 1 (0.4) per 1,000 children in this age group.
Leading causes of mortality were primarily due to external causes such as assault or homicide, accidental drowning and submersion, exposure to smoke, ﬁre and ﬂames and land transport accidents.

Together, these comprised 43.5% of all deaths among this age group.

Diseases of the respiratory system were also a leading cause of death and accounted for 8.7% of deaths.
The mortality proﬁle for 2001 was different: HIV/AIDS was the leading cause of death and accounted for 28.6% of all deaths, and land transport accidents accounted for 14.3%.

The combined data on primary hospital discharge diagnoses for PMH and RMH in 2003 showed that the three leading causes of discharge diagnoses among children aged 5-14 years old were injuries (13.2%), acute respiratory infections (12.7%) and intestinal infectious diseases (11.5%).
Together, these conditions accounted for 37.3% of discharge diagnoses (Appendices 11-14).

Injuries and respiratory infections were also among the leading causes of morbidity in children 5-14 years old between 2001-2002.

There were eight registered HIV/AIDS deaths between 1999-2003.

Twenty-four HIV/AIDS cases have occurred between 1985-2003.

The age-speciﬁc incidence rate of non-AIDS HIV rose from 10.1 to 23.2 per 100,000 population and decreased to 6.6 per 100,000 population in 2003.
Children aged 5-9 years old suffered various forms of abuse.

Findings from the Drug Survey of Secondary Schools (2002), which examined drug use within the last 30 days, showed that alcohol was the most popular drug among students in grade 8 where the prevalence was 9.7%.

Among students in grade 8, 1.5% had used tobacco and 0.7% had used marijuana.

Marijuana use increased in students in the higher grades (Table 2.9).
46 46 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Table 2.9 Prevalence of Substance Use among Students During the Past Month, by Grade Level Drug Tobacco Alcohol Marijuana 8th Grade 10th Grade 12th Grade Prevalence (%) 1.5 9.7 0.7 3.5 27.6 6.7 1.9 33.9 7.7 2.4.4 Adolescents (15 - 24 years) Between 2001-2003, there were 172 deaths in the 15-24 year age group.
External causes (primarily land transport accidents and homicides) accounted for nearly half (48.3%) of all deaths (Appendix 9).

Land transport accidents accounted for 21.5% of all deaths in this age group and homicides for 18%.

The male to female ratios for land transport accidents and homicides were 5.2:1 and 4.2:1 respectively.
Between 1999 and 2002, there was a decline in land transport accidents and assaults among young males 15-24 years old and, despite an increase in the numbers in 2003, the rates remained below the 2001 level (Fig.

2.11).

Fig.
2.11 Age-Speciﬁc Death Rates from Land Transport Accidents, 1999-2003 � � � � � � � � � � � � � � � � ��� ��� �� �� �� �� � ���� ����� ����� ����� ����� ����� ����� � �������� � ��������� ����������� ����������� ����������� � �������� ���� ����� ���� ����� ����� ����� ������ ���� ���� ���� ����� ����� ����� ����� 47 47 ���� ���� ����� ����� ����� ����� ����� ���� ��� ���� ���� ���� ���� ���� Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Of the 552 hospital discharge diagnoses from PMH and RMH in 2003 among males aged 15-24 years, 44.2% were due to injuries.
Of the 2,827 hospital discharge diagnoses of females in the same age group, 46.7% were due to complications of pregnancy.

There were 412 abortions: 61.9% of them took place at RMH; 53.9% were due to spontaneous abortions; 29.1% to unspeciﬁed abortions; and 10% to ectopic pregnancies.

Mental disorders (including alcohol and drug abuse) accounted for 2.5% of hospital primary discharge diagnoses in males and females 15-24 years old.
The proportion of births to females aged 10-19 years declined steadily from 16.9% in 1988 to 12.6% in 2003.

In 2003, the live birth rate per 1,000 females in this age group was 23.0.

In 2003, there were nine births among girls 10-14 years old, less than half of the 20 births in this age group in 1994.

The birth rates among girls 10-14 years and 15 –19 years were 0.6 and 23 per 1,000 females respectively.
Findings from the BLCS 2001 showed the prevalence of contraceptive use to be 5.6% in girls 10-19 years.

There were three HIV/AIDS registered deaths in the 15-19 year age group over the period 1999-2003, as compared to ﬁve between 1996-2000.

Between 1985-2003, 34 AIDS cases were reported, 70.6% of which were females.

Over the same period, a total of 266 15-19 years olds were reported as having non-AIDS HIV infections; females comprised 70.7% of the total.
In this same age group, the overall ratio of females to males with non-AIDS HIV was 2.4 (Table 2.5).

Findings from the Drug Survey of Secondary Schools (2002) showed that alcohol was the most popular drug among students in grades 10 and 12.

In those grade levels, the prevalence was 27.6% and 33.9% respectively.

Among students in grade 10, 3.5% had used tobacco, compared to 1.9% in grade 12.
The prevalence of marijuana use increased with age, ranging from 6.7% among students in grade 10 to 7.7% among those in grade 12 (Table 2.9).

2.4.5 Adult Females (25 - 64 years) In 2003, there were 299 deaths in females 25-64 years old.

Forty-four percent of these deaths were among women 25-44 years old.

In 2003, the age-speciﬁc death rate for females aged 25-44 years was 2.6 per 1,000 population (Appendix 7).
Among these women, the three leading causes of death were HIV/AIDS, pulmonary heart disease and malignant neoplasm of the female breast.

Together, these accounted for 50% of all deaths in females.

Other causes of death included hypertensive diseases (3%) and cirrhosis and other diseases of the liver (3%).

In 2003, there were 167 deaths among women 45-64 years old, with an age-speciﬁc rate of 6.1 per 1,000 population.
Hypertensive diseases, HIV/AIDS and pulmonary heart disease were the leading causes of death.

They accounted for 35.5% of the total deaths among older women.

Other causes of death included diabetes mellitus (9%) and malignant neoplasm of the female breast (7.8%).

The death rate from breast cancer was highest in women aged 65 years and older.

The rate increased from 116.6 per 100,000 population in 1999, to 186.4 per 100,000 population in 2001, and decreased to 132.3 per 100,000 population in 2003.
Overall, the death rate from breast cancer in all females increased from 18 per 100,000 population in 1999 to 21.3 per 100,000 population in 2003.

Deaths from breast cancer constituted 21.9% of all female cancer deaths in 2003.

Deaths from cancer of the cervix constituted 9% of all female cancer deaths in 2003.

Hospital discharge diagnoses for PMH and RMH are shown in Appendices 11 and 13.
The combined morbidity data based upon hospital discharge diagnoses for 2003 from PMH and the RMH showed that the primary causes of inpatient morbidity in females aged 25-44 years old were obstetric complications of pregnancy, childbirth and the puerperium.

These represented 40.4% of hospital discharges in 2003.
The second 48 48 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer and third leading causes were other infectious and parasitic diseases (7.8%) and carcinoma in situ, benign neoplasms and neoplasms of uncertain or unknown behaviour (3.3%).

To a large extent, this reﬂected patterns seen over the period 2001-2003.

Mental disorders and injuries and poisonings were also among the ﬁve leading causes of morbidity seen at RMH over the same period.
In 2003, the major causes of morbidity in females 45-64 years old were hypertensive disease, which represented 8.7% of hospital discharges, followed by all other diseases of the digestive system (8.1%), injuries and poisonings (6.7%) and carcinoma in situ (6.6%).

Between 2001-2002, benign neoplasms, hypertensive diseases, diabetes mellitus and other diseases of the digestive system were also leading causes of morbidity in this age group.
Antenatal and postnatal care in the community clinics in New Providence remain centralised.

The teams of midwives were reorganized in 2003.

There are still four midwives teams but, unlike in the past, two teams rotate while the other two are stationary at two major polyclinics.

The objective of this approach is to reduce maternal and perinatal mortality.

All antenatal, delivery and postnatal services are provided free of charge.

Postnatal clinic is provided at four weeks post-delivery.
A revised Parentcraft Education Programme was launched in June 2003.

The aim of this project is to teach parentcraft skills to expectant couples.

A train-the-trainers workshop was also held for nursing staff.

The family planning programme seeks to promote responsible sexual behaviour, reproductive patterns and parenting.
Its broad objectives are to screen clients for cervical and breast cancer and STIs, to increase the availability and accessibility of family planning services and to establish a comprehensive male health programme.6 Family planning services continue to be free of charge to all women of childbearing age.

Results from the BLCS 2001 showed the prevalence of contraceptive use was 57% in women 30-39 years and was lower (33%) in women 40 years and older.
The birth control pill was found to be the most popular contraceptive method used among all females (47%), followed by female sterilization (19.7%).

The Male Reproductive Health Initiative was initiated in 1998 to encourage responsible manhood and quality reproductive health.

It continues to promote activities to foster health promoting behaviours among men and boys.

2.4.6 Adult Males (25-64 Years) In 2003, there were 446 deaths among males 25-64 years old.
Of this number, 188 (42.1%) occurred in males 25-44 years.

The age-speciﬁc mortality rate in this age group was 3.7 per 1,000 males.

The leading cause of mortality among males in this age group was HIV/AIDS, which accounted for 31.2% of all deaths.

Other leading causes of death were: assault or homicide (11.8%); pulmonary heart disease and disease of pulmonary circulation (6.5%); hypertensive disease (5.9%); and land transports accidents (4.3%).
Among males 45-64 years old, the age-speciﬁc mortality rate was 10.1 per 1,000 males.

As was the case for males aged 25-44 years old, the leading cause of death was also HIV/AIDS (14.5%), followed by hypertensive diseases (7.5%), pulmonary heart disease and diseases of pulmonary circulation (7.5%) and cerebrovascular disease (7.5%).

Hospital discharge diagnoses for PMH and RMH are shown in Appendices 12 and 14.
In terms of morbidity, in 2003, the leading hospital discharge diagnoses at PMH and RMH among males aged 25-44 years old were injuries (28.2%), mental disorders (7%), HIV/AIDS (6.7%), diseases of other parts of the digestive system (6.1%), acute respiratory infections (3.5%) and hypertensive diseases (3.2%).

Together, these conditions accounted for 54.7% of hospital discharge diagnoses among males 25-64 years old.

6 Carter P. Department of Public Health, MOH.


Hand-Over Notes Prepared for Permanent Secretary.

January 10, 2002 49 49 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer In 2003, the leading hospital discharge diagnoses in males 45-64 years old were injuries (11.5%) and hypertensive diseases (10.1%), followed by diseases of other parts of the digestive system (7.2%).

In 2001 and 2002, these were also the three leading hospital discharge diagnoses.
Other causes of morbidity for 2003 were cerebrovascular diseases (4.2%) and diseases of the urinary system (3.9%).

2.4.7 The Elderly As is the case throughout the world, the population in The Bahamas 65 years and older is growing at a phenomenal rate.

Despite this, in comparison to many countries, The Bahamas still has a fairly young population.

In the region, “elderly” is deﬁned as anyone 60 years of age and older.

In the USA, a person is deemed elderly upon attaining the age of 65 years.
The average age is expected to be 36 years by 2010.

Given the demographics of the population, attention must be focussed on both ends of the spectrum of the life cycle.

As stated by the WHO, “longer life can be a penalty as well as a prize.”7 The MOH continues to place emphasis on the health of older persons.

The majority of older persons are females and the likelihood is that this trend will continue.
Thus, the number of older women who are economically challenged will increase since many of them are unprepared to live without ﬁnancial support from a spouse or their children.

The government has a national plan for ageing contained in its National Policy for Older Persons which was presented by the National Council on Older Persons in September 2000.

That national plan is in the process of being expanded and revised.
In the Revised NHSSP 2003-2004, the objective for Older People is to reduce the disability rate among persons 65 years old and older by 50% by 2010.

Universal access to health care is available for all persons 60 years old and older.

Some persons must travel by boat or airplane to obtain the services of a physician on a neighbouring island.

Health services are provided at PMH and RMH which offer acute care, at the Geriatric Hospital which offers chronic care and at the community clinics.
There are also several private sector and non-governmental organizations (NGOs) which serve older persons.

All government clinics provide medication free of charge to persons older than 65 years and several private pharmacies provide senior citizen discounts of 10%.

Some of the government health services available to the elderly are: • Community Nursing Services – conduct monthly visits to the elderly and provide counselling and referral services.
• District Nursing Service – administers injections, gives baths, inserts catheters and provides dressing changes and similar care to the elderly at home.

• Three Gerontology Clinics – doctors, nurses, podiatrists and social workers provide services at these clinics.

Clients can obtain medication and receive phlebotomy services.

• 130 bed Geriatric Hospital – provides care for the elderly who are too ill to be cared for at home or whose relatives are unable to afford adequate medical home care.
The hospital provides comprehensive medical care which includes recreational and occupational therapy.

7 WHO.

The World Health Report 1997: Conquering Suffering, Enriching Humanity 50 50 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer • Medical Loans – items such as wheelchairs, walkers, crutches or hospital beds are made available to the elderly, sometimes for a small fee.

PMH can procure loans for persons to cover expenses for surgery and other health needs.
A directory of services is also available at the Ministry of Housing and National Insurance (Ministry of Housing) and at the Ministry of Social Services and Community Development (Ministry of Social Development).

The Ministries of Housing and Social Development operate, as well as assist NGOs to provide, residential facilities in the community for older persons.

Residential facilities are located on ﬁve of the Family Islands.
There are two day care centres for the elderly - one is government operated while the other is privately owned.

The government also oversees the operation of the privately owned facilities.

An NGO, the Bahamas Red Cross, operates the Meals on Wheels programme and has limited transportation services for eligible elderly persons.

There are several clubs for elders, but there are no educational or literacy programmes speciﬁcally for elders.
The community needs to be better educated about the elderly and their unique needs.

Likewise, physicians and allied health personnel require training in this area.

The University of the West Indies Medical programme now includes geriatrics in its psychiatric rotation for 4th and 5th year medical students.

The Family Medicine Residency second year residents have a three month module on geriatric medicine.

In their ﬁnal year, residents spend a month at the Geriatric Hospital and in the Clinics.
The Department of Social Services has spearheaded a basic training programme for caregivers, at the Continuing Education and Extension Services of the College of The Bahamas.

Legislation for the regulation and licensing of homes for the elderly, prepared by the Ministries of Housing and Social Development in collaboration with the MOH, has been drafted.

The retirement age in The Bahamas is 65 years.


Pursuant to the National Insurance Act of 1972, retirement beneﬁts are awarded to all insured persons 65 years old and older who have retired from gainful employment.

In 1984, amendments made to the Regulations under the Act provided for insured persons to retire early, between the ages of 60 to 64 years, and receive their retirement beneﬁt at a reduced rate (75% of the total beneﬁt).
Persons who do not qualify for retirement because they have not paid sufﬁcient contributions into the National Insurance Board Scheme are entitled to receive an old age non-contributory pension from the National Insurance Board.

Older persons often suffer with multiple chronic illnesses.
The most common causes of inpatient morbidity among persons 65 and older are hypertension, injuries and poisonings, cerebrovascular disease (stroke, myocardial infarction), pneumonia, urinary tract infections, diabetes mellitus and malignancies.

These illnesses, along with arthritis, cataracts and glaucoma, dementia, depression and decreased hearing also affect the elderly.
In 2003, the leading causes of deaths in adults 65 years old and older were hypertensive disease, diabetes mellitus, cerebrovascular disease, ischemic heart disease, prostate cancer, urinary tract infections, acute respiratory infections and malignancies of other areas.

51 51 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 3.
POLICIES, PLANS, PROGRAMMES 3.1 The National Health Policy and National Health Services Strategic Plan Realizing the importance of health to social development, the philosophy of the government of The Bahamas is to provide quality health care to residents throughout all islands of the archipelago.
Consequently, the MOH’s mandate is to “to ensure that the highest quality of services for health promotion, protection and care are accessible to all persons of The Bahamas in order to achieve optimal health.” The MOH fulﬁls its mandate through a network of public health institutions which include the PHA, the DPH, and the DEHS and the BEST Commission.
Policy directions, which guide the development of NHSSPs and the operations of public health institutions, are designed to ensure that the health response is relevant to the socioeconomic realities and the regional and global interests of the country.
The MOH has renewed its commitment to the guiding principles of access, equity, affordability, quality, sustainability, accountability and efﬁciency and, based on these, resources have been allocated for: • Upgrading of facilities • Training and the development of staff in critical clinical and administrative areas • Expanding services to provide quality care to greater numbers of persons • Reorienting delivery models to achieve greater levels of efﬁciency and effectiveness • Improving capacity for planning, monitoring and evaluation • Developing an efﬁcient automated health information system • Strengthening public and private partnerships • Implementing strategies to improve staff morale • Promoting a culture of professionalism, punctuality and productivity • Investigating options for health care ﬁnancing.
The NHSSP 2000-2004, though ambitious, established markers to clearly view, analyze, evaluate and improve the country’s health care system.

In 2002, an Essential Public Health Functions (EPHF) Evaluation of the health system was conducted and a midterm evaluation of the NHSSP was carried out.

These tools were used to assess the health situation in the country, to revise the national objectives, to enhance the policy role of the MOH and to improve public health practices.
Results of the EPHF Evaluation indicated that the system performed below average in all but two areas, namely, health promotion and capacity for the development of laws and regulations.

Further analysis also revealed at all levels in the health system, an absence of formal evaluation processes, inefﬁcient and ineffective utilization of established institutional capacity, and inefﬁcient and ineffective management information systems.
In 2003, the NHSSP 2003-3004, a revised version of the NHSSP 2000 – 2004, was completed.

It contains indicators to focus attention on the areas of deﬁciency.

It provides a comprehensive framework that will achieve accountability and transparency.

It is intended to promote a stronger sense of equity into the entire health care system so that Family Islanders are given levels of care comparable to persons in New Providence and to create a stronger sense of inclusiveness by all stakeholders.
Monitoring and evaluation indicators are designed to ensure regular review of professional competence at all levels in order to consolidate and sustain previous gains while attaining new milestones.
52 52 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 3.2 Major Health Programmes To achieve the goals of the Revised NHSSP 2003-2004, 7 priority health programmes have been determined, namely: • Health promotion and protection • Scaling up HIV/AIDS care and treatment • Prevention and control of communicable diseases • Prevention and control of CNCD • Strengthening environmental protection and maintenance • Improving efﬁciency of delivery systems • Improving strategic management.
The newest initiatives which help strengthen the delivery system are the National Blood Programme and the National Laboratory Strengthening Project.

There is also an ongoing project to address the shortage of pharmacists and other allied health professionals within the government health care sector.

3.3 Achievements and Progress Indicators The midterm evaluation of the NHSSP 2000-2004 proved that substantial progress was made in most of the deﬁned areas during the period 2000 – 2002.
These years saw an increased budget allocation to the health sector, improved health outcomes and new and amended health care legislation.

As regards gains in health status, there was a reduction in the IMR, TB incidence rate, HIV mortality rate, hospital admission rates for HIV related conditions, HIV prevalence in pregnant women and MTCT of HIV.

There were no outbreaks of vaccine preventable diseases and only a few reported cases of malaria.
Gains were also realized in the performance of the health system.

Health personnel were trained extensively on Logical Framework Methodology in order to support planning; the capacity of the MOH’s Planning Unit to coordinate standardized planning was strengthened; and programme coordination was introduced in the DPH.

3.4 Major Health Events and Developments 2001 - 2003 Policy Initiatives 1.
In keeping with its policy to provide health care for all, regardless of ability to pay, and faced with the rising costs of health care, the government is seeking alternative means of ﬁnancing health care while maintaining its commitment to universal coverage.

The Prime Minister of The Bahamas appointed a Blue Ribbon Commission (BRC) in August 2002 to consider the feasibility of a National Health Insurance system.

The BRC completed its report for submission to Cabinet in the last quarter of 2003.

2.
2.

The government increased access to affordable, quality health care for persons living with HIV/AIDS by removing cost barriers.

3.

The MOH’s policy directorate determined that all institutions and agencies within the public health sector were a part of one health system.

Consequently, renewed focus was given to ensuring appropriate levels of integration at the policy, programmatic and service delivery levels.
This approach was successfully applied to maternal child health, prevention and control of communicable diseases and oral health.

However, there was limited success in incorporating this approach to planning, monitoring and evaluation.

The efforts to do so are continuing.

53 53 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 4.
Health ofﬁcials determined that health promotion and prevention strategies were the most effective methods to achieve optimal health status for the population at the least cost.

As a preliminary measure, the MOH provided direct allocations within the annual national health budget to strengthen existing national disease prevention and control programmes, to meet new and emerging primary care needs and to improve the overall quality of primary health care services.
Additionally, it is now mandatory that medical students complete a rotation with the DPH and the Ofﬁce of the CMO is actively recruiting young physicians to train for careers in public health.

5.

Urgent attention is being given to recruiting and retaining sufﬁcient numbers of appropriately trained personnel to meet the health care needs of The Bahamas and to alleviate the shortage of personnel in critical specialties.
In order to attract larger numbers of suitable candidates, Cabinet has approved a substantial increase in the stipend paid to students enrolled in the Associate of Arts Nursing programme at COB, agreed to fund training of clinical nurses at COB and approved increases in salaries for allied health professionals to bring their salaries in line with their counterparts in the private sector.

6.
6.

Government agencies have an obligation to consult and collaborate with relevant stakeholders to ensure quality decision making in order to build strong partnerships to achieve the national health goals.

The MOH consults and collaborates with other agencies in policy initiatives which impact the country’s health situation.

Examples of these include the Workers Health and Safety Act, 2002, the Mandatory Seat Belt Law and the Establishment of the National Disaster Preparedness Agency.
Programme Initiatives • The CNCD National Programme was strengthened.

• The National Blood Programme was established.

• The National Laboratory Strengthening Project was established and implemented.

• The programme, planning and monitoring functions of the Planning Unit were strengthened.

• An intersectoral and multidisciplinary Health Planning Committee was established.

• The Public Health Information System Project (i-PHIS) Plan was completed and implementation commenced according to schedule.
• A National Mental Health Committee was established to oversee the development of the National Mental Health Policy and Plan and the integration of mental health into community health services.

• All government clinics, maternity wards and units now use the new Perinatal Information System (SIP) in an efﬁcient manner.

• The Mobile Health Team was introduced in 2001 to routinely visit the Family Islands.
Workshops are conducted to strengthen surveillance of communicable diseases and vaccine preventable diseases.

• The Pentavalent vaccine was included in the national immunization schedule of The Bahamas.

• Prison health services were reviewed, a plan developed, and additional resources allocated to achieve the objectives of the plan.

• Regional and international partnerships were strengthened which resulted in the enhancement of HIV/AIDS prevention and treatment programmes.
Plans for the construction of laboratory facilities for HIV disease testing have been activated and the projected date for completion is 2005.

• The mid term evaluation of the NHSSP 2000-2004 was conducted and a revised NHSSP developed for 2003 – 2004.

54 54 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Service Delivery Initiatives • An ultra modern primary health facility was opened in the Southern District of New Providence.
It provides diagnostic services including ophthalmology, speech therapy and preventive oral health for children, and audiology, laboratory and radiology services.

• The administrative ofﬁces of the MOH and the DPH relocated to a new, modern, multi million dollar facility.

• The ﬁrst neurodevelopment clinic was established in 2001.

• Triple Therapy commenced for all persons living with HIV/AIDS who meet the criteria for ARV.
This is being facilitated by the government of The Bahamas and the Clinton Foundation.

• Signiﬁcantly more persons receive HIV/AIDS ARV treatment free of charge with the public health service.

• Access to oral prophylaxis (cleaning), sealants, ﬂuoride treatments and restorations has improved for school children in the Family Islands.

• Oral health services were expanded in the Family Island clinics to provide dental prosthesis for adult populations.
• School based dental education initiatives were implemented and continue to improve the dental knowledge of school children.

• Preventive oral health services were expanded within the community health setting and prison oral health services were strengthened.

55 55 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 4.
HEALTH INFRASTRUCTURE 4.1 Organization of the Health System 4.1.1 Organization and Management The government health sector is comprised of four main clusters of services: The Ministry of Health (MOH) Department of Public Health (DPH) Department of Environmental Health Services (DEHS) Public Hospitals Authority (PHA).
The MOH is responsible for health policy and planning, regulation and monitoring, public health services ﬁnancing, development and implementation of public health programmes, Community Health Services, and the provision and management of environmental health services.

The Minister of Health is responsible to his Cabinet colleagues for the efﬁcient and effective administration of the MOH.
The Permanent Secretary (PS) is the chief civil servant within the MOH and is responsible for the administration, supervision and control of all the resources allocated by the government for the operation of the public health services in the country (Appendix 15).
As the Minister’s advisor, and speciﬁcally with respect to the formation of policy, the PS must work closely with the professional and technical heads, namely, the CMO, the Director of Public Health, the Director of Environmental Health Services and the Director of Nursing.
The PS advises the Minister and facilitates his relationships with the PHA and the Boards and Councils for which he has responsibility, namely, the PHA, the Nursing Council of The Bahamas, the Medical Council of The Bahamas, the Dental Council of The Bahamas, the Health Professions Council and the Health Facilities Board.

The CMO is the Chief Technical Ofﬁcer in the MOH and has responsibility for all national disease prevention programmes, technical operating units, regulatory boards and councils.
The Minister of Health, the PS, the CMO, the Director of Nursing, the Director of Public Health and the Director of Environmental Health comprise the executive management.

An Undersecretary, Deputy Permanent Secretaries and Technical Directors provide administrative and technical support at the policy and planning levels.

The DEHS was reinstated within the MOH in 1998 but operates under a separate budget head.
The major sections in the DEHS are: Health Inspectorate Environmental Monitoring and Risk Assessment Waste Management.

The number of Health Inspectors posted to the Family Islands has increased, thereby allowing consistent delivery of quality services.

Organizational and management review of the DPH is continuing under the leadership of the Director of Public Health.

A proposal is in place to regionalize the public health delivery system.
To that end, between 2001-2003, 56 56 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer a pilot project was commenced in the south eastern Bahamas to improve the quality of public health services.

The project awaits evaluation.

If the proposal is implemented, Assistant Directors would function as regional coordinators responsible for all curative and preventive services in a cluster of islands.
District coordinators would be responsible for the delivery of quality health care on individual islands, for strengthening partnerships with local government ofﬁcials and for promoting community based health promotion.

The PHA has responsibility for the three government hospitals — PMH, RMH and SRC.

A Board, accountable to the Minister of Health governs the PHA.

The Minister has no involvement in the day-to-day operations of the PHA.
A Managing Director functions as Chief Operating Ofﬁcer of the PHA and reports to the Board.

Each hospital is managed by an Executive Management Team chaired by the Hospital Administrator.

The team includes the Medical Staff Coordinator, the Principal Nursing Ofﬁcer and the Financial Controller.

A joint planning committee of the MOH and the PHA provides a forum for consultation in the strategic allocation of resources, setting policies, review of issues and revision of the national health system.
The MOH has delegated responsibility to the PHA for the planning and management of shared services which include the National Emergency Medical Programme, the National Drug Agency, and the centralized Material Management Services which is responsible for bulk procurement of disposable medical and surgical supplies.

4.2 Resources 4.2.1 Manpower The number of health personnel in the public and private health sector has continued to grow.

There are now 16.2 physicians per 10,000 population.
There were 840 professional nurses within the public and private sectors over the 2002/2003 period which represented 26.6 nurses per 10,000 population.

There are more pharmacists in the private sector than in the public sector (Table 4.1).

Table 4.1 Number of Health Personnel in the Public & Private Sector, with Rates per 10,000 Population, 2002/2003 Category Total No.
Per 10,000 Pop Physicians Dentists Hospital Administrators Professional Social Workers Nutritionists/Dieticians Registered Nurses/Nurse Practitioners Enrolled Nurses/Trained Clinical Nurses Radiographers 523 79 35 128 15 840 508 43 57 57 16.

8 2.
5 1.1 4.0 0.5 26.9 16.3 1.4 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Laboratory Technologists/Technicians Pharmacists/Dispensers Pharmacy Technicians Physiotherapists Occupational Therapists Dental Assistants Public/Environmental Health Inspectors Statisticians 119 133 7 30 8 131 72 4 3.8 4.2 0.2 0.9 1.0 4.0 2.0 0.1 Source: Bahamas Medical Council, Health Professions Council Department of Social Services The shortage of nurses in the public sector continues to be a concern.
Recruitment and retention are major issues.

In 2002, the MOH decided on a three-pronged approach to address the shortage by providing certain incentives: sponsorship and stipends for nursing students were increased, opportunities for continuing education were promoted and high school students were encouraged to choose nursing as a career.

A Nursing Task Force was established which led to the development of a more comprehensive Strategic Plan for Nursing in The Bahamas.
It is expected that this plan will further the advancement of the nursing profession and nursing education.

In 2002, an additional 50 persons commenced training as Trained Clinical Nurses or Enrolled Nurses: six of them were prison ofﬁcers.

Seventeen registered nurses were trained as Health Visitors.

2001-2003 saw a total of 66 persons trained as registered nurses.

A Defence Force ofﬁcer is currently being trained as a professional nurse.
Training is also being provided in dialysis nursing and psychiatric nursing to further meet the growing needs in specialty areas.

Physicians are the second largest group of health care providers in The Bahamas.

In 2002, the University of the West Indies expanded its enrolment of students at the St. Augustine’s Campus in Trinidad and Tobago.

Medical students at the university can now complete their 4th and 5th year clinical programmes in The Bahamas.
Post graduate medical training has been established in The Bahamas in collaboration with the University of the West Indies in the disciplines of Family Medicine, Obstetrics, Gynaecology and Internal Medicine.

Most of the health care workers in the country are on the islands of New Providence and Grand Bahama where most of the population resides and where the hospitals are located.

The MOH and the DPH endeavour to ensure that each Family Island has at least one doctor.
Acklins, Crooked Island and Long Cay, islands located in the south eastern Bahamas, continue to share one doctor.

58 58 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 4.2.2 Facilities and Technology In 2003, there were ﬁve public and private hospitals in The Bahamas with a total of 1,068 beds which represented 35 hospital beds per 10,000 population.

There were 55 health centres or main clinics – nine in New Providence, ﬁve in Grand Bahama and 41 in the Family Islands.
There were 59 satellite clinics throughout the country, and 286 privately owned health care facilities that offered primary care and diagnostic services.

Certain infrastructural and technological developments have occurred within the DPH which have improved access to quality care.

In 2001, a new ultra modern health centre opened to serve south central New Providence.
It is the largest of the more than 115 Community Health Clinics, and the only public health facility that offers ophthalmology, laboratory, radiology and audiology services.

This clinic also holds a weekly nutrition clinic for at risk obese school children.

The PHA continues to develop its infrastructure.

Between 2001–2003, several initiatives were carried out to improve the delivery of health care.
SRC has undergone a number of structural upgrades and renovations: these included refurbishment and commissioning of the dental operatory, upgrades to the Centre for Special Education for children, renovations to the Occupational Therapy Department and repairs to the kitchen roof.

Technology upgrades included the installation of hardware and cabling to improve data and communication systems, security monitoring systems and a radio communication system in the transport department.
The mechanical plant, including the generators boilers and vacuum tanks, were repaired and maintained.

The Accident and Emergency Department at PMH was upgraded and renovated to alleviate the demand on the main operating theatre.

A building was speciﬁcally renovated to house the rehabilitative and some laboratory services.

Extensive renovations and upgrading were carried out to the Maternity and Gynaecological Wards, which included the Post Natal Wards and the Labour and Delivery suites.
One of the delivery rooms can now be converted easily to an Emergency Operating Theatre with provision made for piped medical gases.

It also has an emergency exit.

At RMH, infrastructural improvements included renovations to the Medical and Surgical Wards and the Special Baby Care Unit.

An off-site facility was renovated to house mammography, ultrasound and ophthalmology services.

Electrical upgrades were also carried out to the hospital.
In addition, the clinics in West End, High Rock and McClean’s Town were renovated.

4.2.3 Financial The total recurrent health expenditure increased from $84,295,460 in 1993 to $148,271,603 in the 2001/2002 ﬁscal year.

The estimates for 2002/2003 showed a budget of $155,261,671 allocated to health.
In relative terms, health expenditure as a proportion of the total actual recurrent expenditure increased from 13.4% in 1993 to 15% in 2002/2003, while 15.1% of the total budget was allocated to health in 2002/2003 (Fig.

4.1).

As shown in Fig.

4.2, the PHA received two-thirds of the recurrent expenditure for tertiary care in 2003 while DEHS received 10% for primary care services.

59 59 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Fig.
4.1 Health Expenditure as a Proportion of National Recurrent Expenditure, 1993-2003 � � � � � � � � � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ��������� ��������� ��������� ��������� ��������� ��������� ��������� ��������� ��������� ��������� ����������� Fig.
4.2 Recurrent Expenditure in Health, by Department, 2003/2004 ���� ��� ��� ��� ������ �� ��������������� ��� 60 60 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 4.3 Legislation The only health related legislation passed in The Bahamas between 2001 -2003 was the Health and Safety at Work Act, 2002.

Two statutes were passed or amended during this period which, though not entirely related to health, included health related provisions.
They were: • The labour laws amended in 2002 which now entitle women to 12 weeks maternity leave.

Unpaid paternity leave is also provided after the birth of a baby, and during the illness of the baby or the baby’s mother.

• The Employment Act, 2002 which eliminates discrimination against HIV infected persons in the work place.
4.4 Information Systems Development 4.4.1 National Health Information and Research Unit The National Health Information and Research Unit (HIRU), established in 1979, is the main agency in the MOH responsible for planning, implementing, monitoring and coordinating the collection, analysis and dissemination of statistical information relating to health services delivery and to the health situation in the country.
The areas of operation of the HIRU include biostatistics utilisation analysis and demand estimation, programme planning and evaluation, cost control and productivity enhancement, quality assurance in health delivery, education and research.8 The subsystems which comprise the national health information system are the hospital information systems, vital statistics information system, environmental health information system, the primary health care information system, surveillance system and the laboratory services system.
The various subsystems collect, process and report aggregated data to the HIRU.

The information unit is under the direct line of authority of the CMO.

Its prime function is to provide planners and administrators with the information necessary to aid them in their decision-making activities.

In line with the information subsystems, the main sources of health information are the PHA, the primary health care clinics, the Surveillance Unit, the DEHS and vital statistics (Box 4.1).
Other sources of information are surveys, other governmental sectors, the private and non-governmental sectors, civil society and the community.

The primary health care reporting form covers antenatal and postnatal services, child health, school health, other (curative) clinic services, other domiciliary services, patients requiring emergency ﬂights, new cases of notiﬁable diseases, industrial accidents, births, deaths, fees collected, summary of visits and general remarks.
8 Health Information Research Unit, MOH, Bahamas.

2001 Annual Report.

61 61 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Box 4.1 Sources of Health Data I. Morbidity A.

Hospital data Inpatient – public and private Outpatient – Accident & Emergency, General Practice Clinic B.

Community Health Services Clinic data – Primary Health Care Clinics Infectious Disease Surveillance Special Surveillance – HIV/AIDS C. Other Special Disease Registries Cancer Registry II.
Vital Statistics A.

Registered Information Births, Deaths, Marriages etc.

B.

Institutions Involved Occurrence – hospital, non-hospital HIRU Registrar General Department of Statistics III.

Environmental Health A.

Environmental Monitoring and Risk Assessment B.

Environmental Sanitation and Consumer Plan C. Solid Waste IV.

BEST Commission V. Other data sources A.

National Insurance Board Indigent, Occupational Injuries, Disabled B.
Insurance Companies C. Surveys Source: Health Information Unit Some of the activities undertaken in the area of health information systems were: • Ongoing analysis of data from the public health services • An evaluation of potential information technology solutions by the DPH and identiﬁcation of the i-PHIS as a potential technology solution.

In December 2003, the planning process for a pilot implementation of i-PHIS in four sites in New Providence was initiated.
• The provision of health information to health staff, students, researchers and to the lay public upon request.

62 62 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 4.4.2 Public Health Information System In 2000, the DPH developed a long-term strategy to strengthen the public health information system to improve the way public health data is collected and analyzed and to improve the quality of available data.
In 2001 and 2002, the DPH, with support from PAHO, documented key functional and data requirements to initiate the process.

In late 2002, the DPH identiﬁed the i-PHIS as a potential technology solution.

In December 2003, planning began for a pilot project of i-PHIS at four sites in New Providence.

i-PHIS is a Canadian based information system developed through a collaborative effort by the federal, provincial and territorial governments of Canada.
It is a secure web based software system that provides frontline public health professionals and managers with case management tools to record, store, access and manage patient speciﬁc health information treatment and outcomes.

The information generated can be used to support health surveillance in The Bahamas.
The i-PHIS includes modules on immunization, high risk targeting, health assessment, communicable disease control, automated lab reporting, STI/HIV/TB case management and client services, outbreak registry and comprehensive demographic and medical record encounters.

The goal of the national health information system is to ensure that the quality of health data is high, that it is reliable and that it is readily available to health professionals.
A compatible system needs to be put in place which allows the data bases of the various health information systems to be accessible to all users.

It is essential that collaboration between the Planning Unit and the HIRU be strengthened to better facilitate the production of annual and periodic health reports.

In order to properly monitor and evaluate NHSSPs and for other purposes, health service data must be made available by geographical units (islands, districts, etc.)

and by monthly trends.


Although this is beyond the purview of the MOH, it is important to note that the quality of birth and death registration needs to be improved as this information impacts health data.

4.5 Research In the MOH, the HIRU is responsible for planning, monitoring and coordinating health research activities.

The HIRU also conducts research and provides technical advice on study design and analysis of data upon request.
Some of the research activities carried out by the HIRU between 2001-2003 included: • Designing the questionnaire on the health section for the BLCS (2001) and writing the chapter on the health section in collaboration with other health professionals; • Conducting the National Schools Drug Survey (2002); and • Assisting COB nursing students in instrument development and analysis of data.
The MOH acknowledges that its capacity for conducting and analysing research (particularly at the operational levels) needs to be strengthened considerably.

A Research Committee is being established to address this problem.

Draft terms of reference for the establishment of the committee are being reviewed and, once these terms are ratiﬁed, the Research Committee will prepare a national health research policy.

The policy will provide guidelines for all health research conducted in The Bahamas.
It is expected that the Research Committee will promote the capacity and culture for health research within the framework of the national health information system.

63 63 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Several research areas have already been identiﬁed.
They include the CNCD, maternal and child health, behaviour change, HIV/AIDS, impact of the prevention of MTCT of HIV, antibiotic susceptibility patterns of gonococcal isolates, impact of the automated health information system on quality of care at public hospitals and evaluation of projects and options for health ﬁnancing by the government.

Courses in research methodology are being planned for the future.
Monitoring and evaluation of health programmes have assisted in enhancing evidence-based decision making.

4.6 Essential Public Health Functions Ministries of Health measure EPHFs to identify factors such as human resources, management formulas and material resources when developing plans or strategies to strengthen public health infrastructure.

It is also a tool for fostering multisectoral collaboration between all stake holders involved in the business of health.
The ﬁrst EPHF evaluation was held in 2002.

The results of this exercise indicated that there were several areas that needed to be addressed in order to improve the quality and provision of health care.

The information gained was also valuable in assisting in the evaluation of the NHSSP 2000-2004, and in determining the priorities, goals and objectives for the Revised NHSSP 2003-2004.

It is proposed that the EPHF be used as a tool for monitoring and evaluating the performance of the public health system.
64 64 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 5.

ENVIRONMENTAL HEALTH 5.1 Water Supply and Quality About 96.4% of the total population has access to water supply by house connections and other acceptable piped means.

Most persons living in New Providence and Grand Bahama receive water which complies with WHO Drinking Water Guidelines.

The drinking water supply in New Providence and the Family Islands is drawn from underground source facilities.
The population not served by a piped system uses wells or rainwater tanks.

Approximately 2,000 households are serviced by private wells, the majority of which are in the Family Islands.

In these rural areas there are difﬁculties associated with providing treated water due to operational, resource and technical constraints.
The Water and Sewerage Corporation, as the body responsible for the provision of the municipal water supply, has implemented a programme for improved water supply, quality and distribution in several of the major Family Islands.

At the most basic level, the programme addresses the disinfection process through evaluation and retraining of staff.

The municipal and private systems are systematically monitored and analysed by the DEHS’ Water Quality Control Programme.
The DEHS has regulatory responsibility for monitoring the Water and Sewerage Corporation.

The Water Quality Control Programme provides analytical data relative to the bacteriological and chemical quality of water to the municipal supplier.

The data obtained are used to evaluate trends, determine potential problems in the supply and make recommendations for improvement.

A signiﬁcant number of persons consume commercially bottled water from both local and imported sources.
Local sources include producers in New Providence as well as in the Family Islands.

The DEHS monitors producers of bottled water to ensure that they are producing water under sanitary conditions and that their product is of acceptable quality.

5.2 Sewage Disposal The sewage disposal systems in use in The Bahamas are septic tanks, sewer systems and privy closets.

The Bahamas does not allow construction of new privy closets and is actively pursuing the phasing out of existing units.
Approximately 16% of the population is connected to municipal sewer systems and approximately 82% is serviced by septic tanks.

The Ministry of Works and the DEHS regulate construction of septic tanks through a permitting system.

All new projects, including renovations, are required to provide either a septic tank or a sewer system, depending on the nature and size of the project.

The Bahamas Building Code provides guidlines for architects, engineers and contractors.
The guidelines provide illustrations and design parameters to ensure that all systems meet the government’s standard.

Most hotels and island resorts have on site sewerage package treatment and disposal systems.

Additionally, all private subdivisions which contain more than 25 lots have private sewage treatment and disposal plants.

Each government subdivision in New Providence has a package sewage treatment system and a disposal plant which provides secondary treatment.
Tertiary treatment is provided at a single central facility.

Final disposal is accomplished by re-circulation for irrigation and toilet ﬂushing purposes in hotels, resorts and private communities supplemented by deep well disposal.

Sludge is removed and dried and disposed of at a landﬁll or used for agricultural purposes.

The Water and Sewerage Corporation is currently evaluating the condition of all municipal sewage treatment systems with a view to implementing improvements.
65 65 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 5.3 Solid and Liquid Waste Disposal In the last two years the New Providence Regional Landﬁll was completed and landﬁlls in San Salvador, Bimini and Eleuthera were modiﬁed.

This construction has led to a signiﬁcant improvement in waste disposal which previously consisted primarily of a modiﬁed landﬁll in New Providence and open dumping in the Family Islands.
It is proposed that over the next three years additional modiﬁed landﬁll sites will be constructed in all major Family Islands.

The improvement in waste disposal has decreased the number of ﬁres at the dump, odours from garbage and ﬂy nuisances.

The New Providence Regional Landﬁll receives in excess of 181,000 tons of solid waste per year with the largest number of loads being received on Thursdays and Fridays.

Average daily tonnage based on a seven day week is 750 tons per week.
The waste generation rate for New Providence is calculated as 5.7 pounds per person per day while the generation rate for The Bahamas is 4.0 pounds per person per day.

The average waste generation in the Family Islands is estimated at 3.0 pounds per person per day.
The high waste generation rate in The Bahamas is a result of the reliance on imports which tend to have substantial packaging, the virtual absence of recycling initiatives which results in high volumes of paper, plastic and metal components, and the large numbers of tourists who visit the country.

The three largest waste sources are commercial (30.4%), residential (27.8%) and construction and demolition (20 %), with the remaining waste stream totalling 21.8%.
It is projected that approximately 240,000 tons of waste will be generated in New Providence by the year 2006.9 The government of The Bahamas is seeking to improve the management of solid waste at the community level by providing a bulk waste collection programme and depository sites, and by implementing a national solid waste education and awareness programme.

The programme will focus on recycling and separation at the source in order to involve the adult population.
Both the bulk waste and depository site programmes were administered as pilot projects in 2001.

The signiﬁcant reduction in indiscriminate dumping in the test areas augurs well for the success of the expanded programme.

The solid waste public education and awareness initiative has been successful in making school age children aware of the importance of proper waste management.

Limited success has been noted in the adult population.
The Bahamas continues to address the problem of derelict vehicles through the DEHS’ Derelict Vehicle Removal Programme.

In 2001, approximately 7,200 derelict vehicles were removed from vacant properties, roadside garages and the roadsides in New Providence.

A total of 8,121 tons of metal, the result of crushing vehicles, was exported to the USA for recycling.

The programme will be expanded in 2002 to address the major Family Islands.

In 2002, 4,000 derelict vehicles were crushed and exported.
5.4 Occupational Health For many years, the MOH has provided basic services relating to occupational health and safety.

There is an occupational health unit located at SRC which provides assistance to eligible patients.

In many of the government’s health units, there is an Employee Assistance Ofﬁcer to offer basic advice and assistance on health and safety in the work place.
The role of the Employee Assistance Ofﬁcers has been strengthened to empower them to facilitate collaboration with supervisors and managers in the public and private sectors as they seek to assist employees in ensuring that health and safety matters are dealt with in an expedient manner.
Occupational Health and Safety has been highlighted during the past ﬁve years and the MOH is drafting a National Workers Health Plan in collaboration with the Ministry of Labour and Immigration, the trade unions and the employers’ unions.

The Health and Safety at Work Act, 2002, mandates the formation of an Advisory Council to oversee and manage all matters related to the implementation and execution of aspects of the programme.
The Advisory Council will also function as an advisory committee on health and safety in the workplace to senior policy makers.

9 Bahamas Solid Wase and Hazardous Materials Management Project 66 66 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer The MOH is committed to strengthening services related to occupational health and safety.
The risk management service within the PHA has been augmented, cooperation between health agencies and the National Insurance Board has been enhanced and collaboration between the MOH and employee and employer representatives continues.

5.5 Veterinary Public Health The Veterinary Services include the abattoir, Animal Control Unit, animal quarantine and animal health.
The work of the Veterinary Diagnostic Laboratory has been hampered since the laboratory technician resigned, particularly as regards developing a monitoring and surveillance programme.

In order to better carry out its responsibilities, the Veterinary Services must hire additional veterinary ofﬁcers, laboratory technicians, butchers, animal control wardens and support staff.
Legislation, including the Animal Contagious Diseases Act, the Veterinary Surgeons Act and the Public Market and Slaughterhouse Act, is in the process of being amended.

An Animal Control and Welfare Act, which will replace the Dog Licence Act, has also been drafted.

A contingency plan for animal health emergencies is being developed.

Recommendations have been made to join the World Organization for Animal Health (OIE), which is the agency recognized by the WTO as the expert in animal health.
The Bahamas became a member of Codex in June 2002.

Efforts continue to improve the operations and the facilities at the abattoir, animal quarantine and Animal Control Unit.

Collaborative efforts have been developed with NGOs and other parties to improve animal control efforts.

These include a neighbourhood spay/neuter/education campaign in collaboration with the Rotary Club, the Bahamas Humane Society, private veterinarians and local businesses.
5.6 Food Safety The DEHS monitors the safety of food offered to the public through meat inspections at the abattoir, sampling and testing of imported canned goods at ports of entry and sanitary inspections of food establishments.

DEHS is monitoring global trends in diseases of current interest, such as Bovine Spongiform Encephalopathy, Foot and Mouth Disease, and Avian Inﬂuenza, which can adversely impact the safety of food supplies.
In suspected cases of food borne diseases, DEHS collaborates with the Epidemiology Unit of the DPH in conducting sanitary inspections of premises that might be implicated, with a view to identifying and correcting any deﬁciencies that might have resulted in a food poisoning event.

The Codex Alimentarius, or the Food Code, contains food standards for commodities, codes of hygienic or technological practice, limits for pesticide residues and guidelines for contaminants.
The Public Market and Slaughterhouse Act has been reviewed, and a determination made that it needed no amendments.

Poultry regulations are being drafted and Hazards Analysis and Critical Control Point (HACCP) based inspection will be implemented in the poultry industry.

The DEHS plans to develop a national system of abattoirs and poultry processing facilities: these will require HACCP plans to ensure that all meat sold in The Bahamas is inspected.
There is a need to develop legislation and implement a modern inspection system with mandatory requirements for HACCP in poultry and other industries.

A Codex contact point and Codex Committee will be established in the Ministry of Agriculture and Fisheries.

Amendments have been made to the meat import regulations under the Animal Contagious Diseases Act to protect The Bahamas from the introduction of Bovine Spongiform Encephalitis and Foot-and-Mouth Disease.
The Act was amended in order to address such challenges as changing technology, country disease status and emerging diseases.

67 67 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 5.6.1 The Food Handlers Programme In 2002, permission was sought from Cabinet to amend the Food Handlers section of the Public Health Act: this section provides for training of food handlers as a prerequisite to obtaining a food handler’s certiﬁcate.
In November 2003, the MOH through the DPH began piloting the new Serve Safe Food course for all food and beverage workers in The Bahamas.

It is estimated that 30,000 workers will require this training.

The course is expected to be implemented in 2004.

5.7 Quality Control of Drugs Currently, no legislative measures exist to protect consumers against drugs that are unsafe or which contain misleading claims on labels, or from misleading advertisements made by drug companies.
The Bahamas National Drug Agency is guided by the following standards: All products shall: a. meet the requirements of the laws of The Bahamas and the conditions of the contract respecting drugs, their quality, labelling and packaging.

b. meet the requirements of the laws of the country of their origin with respect to quality, labelling and packaging.
c. be formulated and produced in accordance with Good Manufacturing Practices enforced in the country of the drug’s origin and shall meet the requirements of the ofﬁcial reference stated, and where such is not stated shall meet those of the British Pharmacopoeia, BPC., US Pharmacopoeia/National Formulary, E.U.R.P.

or any other standard approved by the Director of The Bahamas National Drug Agency.

d. meet all other speciﬁcations as identiﬁed in the Tender Document.
5.8 Pesticide Control In 2000, a ﬁnal draft of the Pesticide Control Bill was presented to the Ministry of Agriculture and Fisheries for review.

The bill has not been submitted to Cabinet.

5.9 Disaster Management and Preparedness The hurricane season in The Bahamas starts June 1 and ends November 30.

The National Hurricane and Disaster Committee is responsible for pre-disaster planning and post-disaster response.
The committee is located in the Cabinet Ofﬁce and is comprised of representatives from various government ministries.

The MOH has a Disaster Preparedness Plan which includes plans from each component department and agency within the health sector.

Since July 1996, the DPH has had a Hurricane Preparedness Plan.

The Plan was revised in 1999 and updated in 2003.


The Plan describes the various categories of hurricanes, the dangers each category presents, an explanation of meteorological terms, pre- and post-hurricane instructions and the roles of various health care personnel (such as the District Medical Ofﬁcer of Health, transport personnel and security ofﬁcers) in relation to hurricanes.

Each primary clinic maintains an emergency stock of drugs and supplies in conformity with an approved list.
In 2001, certain health centres were identiﬁed as hurricane treatment centres.

These are to be used by persons requiring medical treatment during a hurricane, as all other clinics are closed during hurricanes.

The Bahamas Red Cross Society oversees shelters and shelter management with support from the Royal Bahamas Defence Force and the Department of Social Services.

The MOH Psychiatric Services and, occasionally, churches, provide care for those who are emotionally distressed.
Expectant mothers on Family Islands who are near term and are at high risk are advised to locate closer to 68 68 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer the hospital in New Providence or Grand Bahama in case emergency care is required.

MOH, DPH and PHA personnel have been trained in the use of the Humanitarian Supply Management System (SUMA) sponsored by PAHO as well as in the Medical Management of Disasters.
A disaster preparedness workshop was conducted in August 2002 and a National Disaster Plan has been proposed.

5.10 Vector and Rodent Control The Vector Control Unit of the DEHS has responsibility for monitoring and controlling of vector levels, treatment and public education.

The Unit focuses primarily on mosquitoes and rodents.

The mosquitoes of importance in The Bahamas are Aedes aegypti, Anopheles albimanus, Anopheles crucians, Culex pipiens and Culex quinqs.
The data collected by the DEHS reﬂected signiﬁcant trap catches in the months of February, March, May and June 2001, which, with the exception of the month of February, coincided with signiﬁcant rainfall.

In 2001, the DEHS increased its use of guppies as biological controls, particularly in ponds and water storage containers.

The Pond Monitoring Programme indicated that 9% of the ponds checked were positive for Anopheles, 24% for Culex and 6 % for Aedes (non aegypti).
An Aedes aegypti survey was conducted in 2001.

It revealed that in two of the 12 areas surveyed, the Breteaux index of Aedes aegypti was above the safe level of ﬁve.

The major contributing factor to the high levels in these areas was the proliferation of the use of tubs to store water.

Aedes aegypti were found in 9.09% of the tubs checked.

Only 3 % of all containers were found positive for Aedes aegypti.
In order to decrease the level of breeding found in the two areas surveyed, the Vector Control Unit initiated an intensive house-to-house control campaign which emphasized the importance of solid waste management.

A waste depository programme was implemented to allow for the proper disposal of solid waste in these communities.

There were no cases of dengue fever reported during 2001.

There were, however, a few cases of imported malaria.
In 2001, the DEHS targeted speciﬁc areas to focus on reducing the rodent population, namely Cable Beach, Arawak Cay, Potters Cay, Bay Street and certain villages with large Haitian populations.

These areas were systematically treated for vectors and rodents and more emphasis was placed on the management of solid waste.

The DEHS provided additional trash containers, increased garbage collection and improved the monitoring of food vending operations.
As a result, the rodent catch in these areas was reduced by 50%.

The rodent control programme addressed other areas through systematic monitoring and treatment of communities.

It was determined that the major factors which inﬂuence rodent populations are overgrown properties, derelict vehicles and improper solid waste management by itinerant vendors.

These conditions were addressed via various DEHS programmes and the prosecution of violators.
5.11 Port Health Port Health includes an expansive range of services throughout the MOH.

Some of the services are administered through the Ofﬁce of the CMO, the DEHS and other agencies on behalf of the MOH.

The principal goal of providing port surveillance is to maximize control and prevention efforts, especially as it relates to surveillance for communicable diseases at ports of entry.

Health information is provided to persons stationed at ports of entry.
Health authorities continue to collaborate with public and private sector agencies to ensure that the transport of goods, inclusive of food and agricultural products, human remains and postal parcels, is not hampered or delayed inordinately in order to ensure that communicable diseases are not transmitted into or out of the country.

International Travel and Health Services may be included under ‘Port Health’ since it relates to travel into and out of the country.
This service offers yellow fever immunization and anti-malarial prophylaxis to international travellers.

Port health 69 69 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer services are also provided by the DEHS – they include inspection of aircraft and ships, and raw and processed foodstuffs.

There are plans to train junior medical ofﬁcers in port health services.
5.12 Building Development The Ministry of Works and the Ministry of Housing are the primary agencies responsible for formulating and executing policies related to building, structure, construction and screening.

The MOH’s Estates Ofﬁce is responsible for overseeing the maintenance and physical upkeep of all public health care facilities.

It ensures that all physical plants are maintained at the required building and electrical standards set by the Ministry of Works.
During the hurricane season it is responsible for ensuring that all buildings are secured in the event a hurricane should strike The Bahamas.

This ofﬁce also conducts post hurricane damage assessment.

The Chief Estates Ofﬁcer works closely with the Ministry of Works to ensure that all MOH building projects are carried out to the speciﬁcation and satisfaction of the Ministry of Works.
The DEHS’ involvement in buildings is limited to issues of lighting and ventilation, bedroom sizes, and sewage treatment and disposal.

It ensures that adequate lighting and ventilation are provided in food establishments in accordance with the requirements of the Bahamas Building Code.

Compliance with the regulations is achieved via systematic monitoring of food establishments, monitoring of building developments and building applications, and by responding to complaints.
5.13 Bahamas Environment, Science and Technology Commission The BEST Commission was designed after the National Inter-Ministerial Committee on Science and Technology (NIMCOST).

NIMCOST was created in 1989 to coordinate The Bahamas’ response to environmental, scientiﬁc and technological matters referred to the government by international organizations.

The BEST Commission was established in 1994.


It consists of a chairman and a number of board members from government agencies who have responsibility for environmental oversight in The Bahamas.

Since sustaining and protecting the environment is an important component of health, efforts have been made to revitalize the BEST Commission which now falls under the portfolio of the MOH.

The Bahamas is a contracting party to 23 international environmental agreements, treaties and conventions.
All businesses operating in The Bahamas are expected to adhere to these international agreements which have been signed and ratiﬁed and are in force.

70 70 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 6.
ISSUES, CONCLUSIONS AND RECOMMENDATIONS The health of the people of The Bahamas is not only a function of the provision of affordable and good quality health care, but is also a function of education, the physical environment (good quality air, safe water), income, nutritious diet, social cohesion and healthy behaviour.
Between 2001-2003, the main issues under discussion regarding the health of the nation included health outcomes, implementation of priority health programmes and structural reforms speciﬁed in the NHSSPs, and health resources.

Conceptually, health resources (funds, human resources, technology, information system, health policies, community knowledge) constitute the inputs; programmes and health management constitute the processes; and the health status constitutes the outcomes.
Health outcomes The health of the people of The Bahamas continues to improve.

Life expectancy has increased, the IMR rate has decreased from 15.8 per 1,000 live births in 1999 to 12.7 in 2001 and though it rose to 15 in 2003, it is still below the 1994 level of 19.7.

Likewise, the HIV seroprevalence declined and the incidence of vaccine preventable diseases remained low.

With increased life expectancy, non-communicable diseases have become important causes of mortality.
The leading causes of death between 2001-2003 were diseases of the circulatory system which accounted for 28.8% of all reported causes of death.

While communicable diseases accounted for 19.1% of deaths, they were the leading causes of premature deaths, accounting for 28.2% of the total YPLL.
Among females, hypertensive diseases, HIV/AIDS, diabetes mellitus, ischaemic heart disease, cerebrovascular diseases, pulmonary heart disease and cancer of the breast were among the leading causes of death between 2001-2003.

In males over the same period, HIV/AIDS, hypertensive diseases, ischaemic heart disease, cerebrovascular diseases, pulmonary heart disease, cancer of the prostate and assault were among leading causes of death.
Injuries from accidents and assaults were a much more common cause of admission to hospital and death in adolescent boys and young men than in women.

Adolescent girls were frequently admitted for complications of pregnancy and the puerperium.

The elderly population suffered and died most frequently from diseases of the circulatory system, hypertensive diseases, cerebrovascular diseases and diabetes.

Death rates from ischaemic heart disease decreased between 1999-2003.
Mortality due to land transport accidents and assaults has also shown general patterns of decline over the same period.

The mortality and morbidity proﬁles indicate the need to promote healthy lifestyles, target family planning at young women, intensify adolescent health services that target violent activities of teenagers, and improve the care provided to patients with ischaemic heart diseases and emergency trauma.
The need exists for periodic youth behavioural surveys to be conducted, especially as the effects of some negative behaviour (such as smoking) are manifested much later in life.

The SCAN Unit is an initiative of the MOH to address sexual abuse of children.

Although the number of abuse cases seen has decreased, child abuse issues and the need to implement interventions to decrease the incidences of abuse remain priorities.

The programmes to reduce perinatal and infant mortality should continue.
The MOH should investigate why the post- neonatal mortality rate has been increasing.

Since the last report, a large communication campaign has been launched to provide HIV/STI education via the mass media.

The HIV/AIDS Department collaborated with the Department of Education to coordinate on-going training, as well as sensitization and prevention presentations for various target groups such as school children, church leaders, work place groups and the Haitian community.
The Focus on Youth programme continues to be implemented throughout the school system.

The government continues to provide substantial ﬁnancial support for the HIV programme and has fostered partnerships with NGOs such as the Samaritan Ministries, the Clinton Foundation, the Caribbean Regional Network of PLWHA (CRN+), the Caribbean Health Research Council (CHRC) and CAREC.
71 71 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer The HIV/AIDS Department and the government will continue to give priority attention to the issue of HIV/AIDS among the 15 – 24 year age group and to focus on implementing new initiatives in moral counselling, encouraging voluntary counselling and testing and following up on PLWHA.

The prevalence of TB in HIV patients and HIV among TB patients continues to be monitored.
The MOH maintains that the direction of health services should be oriented to preventive and promotive health, with a lesser focus on curative care.

Health processes and management In accordance with the mandate of the new administration, a revised Revised NHSSP 2003-2004 was published.
It updated and modiﬁed the NHSSP 2000-2004 and articulated 11 fundamental values and guiding principles for the health care sector, namely: • Respect for human rights and individual dignity • Accessible, available, affordable and appropriate health care provided • Equity (services provided on the basis of need and without discrimination based on gender, age, race, income, place of residence or immigration status) • Efﬁciency • Quality care • Accountability • Effective partnerships with relevant stakeholders • Empowerment of individuals and communities • Evidence based decision making interventions • Best practices and knowledge documented, disseminated and shared • An organizational culture that recognizes the contributions of health care providers and facilitates their continuous development.
In keeping with these values and principles, the MOH’s goal is to improve strategic management by promoting an organizational structure and culture which encourage informed decision making and facilitate improved managerial efﬁciency and accountability.

Performance indicators are also used to monitor programme efﬁciency, accountability and health indices.
The government has made a substantial investment in the development of the i-PHIS which enhances the capacity of managers to make informed decisions as a result of access to quality information.

Intersectoral collaboration and joint strategic planning between the MOH and all institutions of the government health sector have now been established as normal management procedures.
Further, there have been several successful high proﬁle projects and advancements in health which can be directly linked to strengthened partnerships with the private health sector and civil society.

These successes have led to the inclusion of indicators in the Revised NHSSP 2003-2004, the purpose of which is to further entrench these practices within the management system.
One of the Planning Unit’s primary responsibilities is to evaluate the progress made in meeting targets speciﬁed in the Revised NHSSP 2003-2004.

With technical support from an external consultant, an evaluation system has been developed with some degree of success.

However, the capacity of the system to set baselines needs to be strengthened.

This task should be less onerous since the establishment of the i-PHIS which is currently in the pilot phase.
The MOH is eagerly anticipating the positive impact of this initiative.

72 72 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer The MOH is proud of its achievements.

In the area of Maternal and Child Health, the role of midwives has been expanded to enable them to perform pelvic examinations and PAP smears.

Twenty-eight midwives have been trained thus far and the training continues.
All government clinics, maternity wards and units are using the new SIP in an efﬁcient manner and data from the system are being used in perinatal conferences, in case management and in other presentations.

Routine output reports are analyzed and distributed quarterly.

The percentage of early antenatal attendees to clinics increased from 4% to 44% in public clients and the percentage of post-partum women attending postnatal clinic ﬂuctuates between 80% and 85%, exceeding the goal set of 75%.
There have been impressive improvements with regards to neonatal care.

The neonatal facility at RMH has been upgraded and the capability of its staff to manage high risk infants has increased.

As a result, the number of infants transferred from RMH to PMH continues to decrease.
Another notable accomplishment is that more than 80% of the relevant staff within the government health sector has been trained in neonatal resuscitation and introduced to the sugar, temperature, airway, blood lab works and emotional support (STABLE) programme.

Recertiﬁcation is required every two years and there are 15 Neonatal Resuscitation Programme instructors in place to sustain this effort.

The Bahamas continues to maintain a successful EPI.
DPT-3 vaccine coverage increased from 84% in 1999 to 100% in 2001 but decreased to 91% in 2003.

MTCT of HIV/AIDS is now maintained below 3%.

The indicators of the Maternal and Child Health programme were modiﬁed in the Revised NHSSP 2003-2004 to reﬂect the reduction in infant and maternal mortality, maternal morbidity and maintenance of a zero level incidence of vaccine preventable diseases.

Modest gains have been made in strengthening child and adolescent health services.
One signiﬁcant challenge has been the inability to identify a physician trained in adolescent health or a local physician interested in being trained in the discipline: efforts to identify such a person continue.

There has been signiﬁcant progress with respect to addressing communicable diseases.

One year ahead of schedule, health promotion protocols developed for timely response have been completed for 75% of the diseases targeted in the Revised NHSSP 2003-2004.
In addition, protocols are now in place for 90% of diseases that have been identiﬁed and targeted for surveillance and control.

There were almost 50% fewer cases of TB in 2001 and 2002 than there were in 2000.

This is directly attributable to the consistent application of Directly Observed Treatment, Short-Course (DOTS) to all TB cases since 1998, and the use, since 2001, of ARV medications for persons co-infected with HIV.
The food and vector-borne programmes have improved as measured by the reduction in outbreaks of diseases.

There has also been a reduction in the incidents of dengue fever, malaria and hepatitis A.

The emergence of SARS highlighted the need to take proactive measures to counteract emerging communicable diseases that might enter the country through the port system.

In response, the MOH has developed an action plan and requested funding for it.
In accordance with the Revised NHSSP 2003-2004, key personnel have been appointed to strengthen the national CNCD prevention and control programme.

Leadership has been established and coordinators have been appointed for the areas of hypertension, diabetes, cancer and asthma.

While national action plans are being developed, short-term interventions have been undertaken.
Examples of the latter are the establishment of a specialty clinic for new diabetics, using the team approach to patient management, and the development of treatment and referral protocols for asthma patients at the primary, secondary and tertiary levels.

Indicators in the Revised NHSSP 2003-2004 focus on developing and implementing strategies to reduce the prevalence of preventable lifestyle diseases among the population.
The revised HIV/AIDS programme has been evaluated and costed and a comprehensive plan developed to accelerate access to treatment to counteract the continuing spread of this epidemic in The Bahamas.

There has already been a signiﬁcant reduction in hospital admissions as a result of the introduction of treatment with ARVs to increasing numbers of persons and the strengthening of public education.

The need for local expertise in critical areas of the health service is undeniable.
Consequently, indicators in the Revised NHSSP 2003-2004 address capacity building in nursing, medical and allied health specialties, biomedical engineering, health planning, health economics, health information systems management, biostatistics, research, monitoring and evaluation.
73 73 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer The Way Forward The main issues which require focussed attention are the status of health legislation, the regulation of professionals, health information systems, health ﬁnancing and infrastructure.
The MOH should continue to work with the relevant professional councils and regulatory bodies to ensure that appropriate standards are set and adhered to, particularly among private entities that provide health care services.

The MOH should also ensure that statutes are amended as needed, provide continuing education, maintain registers and fulﬁl any of its other statutory functions.

Mainstreaming health information into policy planning and decision making remains a challenge for the MOH.
Priority issues which require attention are the coordination of information management between various departments, the improvement of the quality of health data and the technical problems experienced with the automated HMIS in the PHA.

The MOH is determined to improve the capacity for health research, to deﬁne health problems, and to monitor and evaluate interventions and programmes.
The morbidity and mortality proﬁle suggests that The Bahamas should continue to allocate more resources to public health and environmental health services in order to reduce the burden of institutionalized care.

The government’s proposed implementation of National Health Insurance remains a viable option for reducing the burden on public funds which health care imposes.
Planning of health facilities, based on population density and need, must continue and facilities must be designed to meet the changing demographics and economic projections in the country.
74 74 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Appendix 1 Map of the Commonwealth of The Bahamas Freeport Grand Bahama Abaco Eleuthera Nassau New Providence Andros THE BAHAMAS Cat Island San Salvador Great Exuma Rum Cay Long Island Samana Cay Crooked Island Long Cay Acklins Mayaguana Little Inagua Great Inagua 75 75 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 2 Sector Contribution to GDP, 2000-2002 (‘000) (B$ thousands) Industry Agriculture & isheries: Agriculture: Fishing: Industry: Mining: Manufacturing: Electricity: Water: Construction: Wholesale & Retail Activity: Wholesale Trade: Retail Trade: Hotel & Restaurants: Hotels: Restaurants: Transport: Land Transport: Marine Transport: Air: Storage: Communication: Financial Intermediaries: Banks: Insurance: Real Estate/Rent/Business Activity Real Estate: Other Bus.
Ser: Public Administration & Defence: Education: Private: Public: Health Private: Public: Other Comm, Social & Personal Services Gross Value Added at Market Prices 5,003,699 5,131,452 5,400,064 76 76 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 3 Operational Deﬁnitions For Basic Demographic Indicators Description Of Measure Numerator (X) Denominator (Y) Expressed Per Number At Risk (K) Birth Rate Crude; speciﬁc for age of mother, sex of child, socioeconomic status, etc Number of live births reported during a given time period Estimated mid-interval population 1,000 Fertility Rate Crude; speciﬁc for age of mother, race, socioeconomic status, etc Number
 of live births reported during a given time interval from mothers aged 15-49 years Estimated number of women in age group 15-49 years at mid-interval 1,000 Death Rate Crude; speciﬁc for age, race, sex, socioeconomic area, etc Total number of deaths reported during a given time interval Still Birth Rate Crude; speciﬁc for age of mother, race, socioeconomic area, etc.
Number of fetal deaths of 28 weeks or more gestation reported during a given time period.

Estimated mid-interval population 1,000 Number of fetal deaths of 28 weeks or more gestation reported during the same time interval plus the number of live births occurring during the same time interval.
1,000 Natural Increase Rate Total live births - deaths occurring during the year Estimated mid-interval population 1,000 Infant Death Rate Crude; speciﬁc for race, sex, socioeconomic area, birth weight, cause of death, etc Perinatal Death Rate Crude; speciﬁc for age of mother, race, socioeconomic area, etc Number of deaths under 1 year of age reported during a given time period Number of live births reported during the same time interval Number of late fetal deaths (of 28 weeks or more gestation for ICD-9, or 22 weeks or more gestation for ICD-10) reported during a given time interval plus the reported number of early neonatal deaths under seven days of life during the same time period Number of fetal deaths of 28 weeks or more gestations reported during the same time interval plus the number of live births occurring during the same time period.
1,000 1,000 Neonatal Death Rate Crude; speciﬁc for race, sex, socioeconomic area, birth weight, cause of death, etc Number of deaths under 28 days of age reported during a given time period Age Speciﬁc Death Rate in children 1- 4 yrs Number of deaths in children 1 - 4 years Maternal Death Rate Crude; speciﬁc for age of mother, race, socioeconomic area, etc Number of deaths assigned to causes related to pregnancy during a given time interval Number of live births reported during the same time interval 1,000 Total population of 1-4 age group 100,000 Number of live births reported during the same time interval 100,000 77 77 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 4 Communicable Disease Report, 2001-2003 Disease & Category (International Classiﬁcation of Diseases) Disease Subject to International Health Regulation Cholera (A00) Plague (A20) Yellow Fever Diseases under International Surveillance Acquired Immunodeﬁciency Syndrome - AIDS (B20-24) Malaria (B50-54) Inﬂuenza (J10-11) Diseases under Expanded Programme on Immunization Tuberculosis (All Forms) (A17-19) Tuberculosis (Pulmonary) (A15-16) Tuberculosis (Lymphadenitis) Tuberculosis (Miliary) Tuberculosis (Pleural Efffusion) Tuberculosis (Abscess) Diphtheria (A36) Pertussis (Whooping Cough) (A37) Tetanus (excluding neonatal) (A34-35) Tetanus neonatorum (A33) Poliomyelitis, acute (A80) Acute Flacid Paralysis Measles (B05) Mumps (B26) Rubella (German Measles) (B06) Congenital Rubella Syndrome (B35.0) Other
 Diseases of Regional Interest Leprosy (Hansen’s Disease) (A30) Meningococcal Infection (due to Neisseria meningitis) (A39) Dengue Fever (A90) Sexually Transmitted Infections & Syndromes Syphilis (A51-53) Congenital Syphilis (A50) Gonococcal Infection (A54) Chlamydial Infection (A55-56) Other Diseases of Caribbean Interest Typhoid and Paratyphoid Fevers (A01) Foodbourne Illness (A05-08) Gastroenteritis <5 years (A09) Gastroenteritis >=5 years (A09) Viral Hepatitis A (Lab Conﬁrmed) (B15) Viral Hepatitis B (Lab
 Conﬁrmed) (B16) 78 78 Cumulative Total for Year 2002 2001 2003 0 0 0 288 4* 1* 577** 348 3* 857** Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Viral Hepatitis C Rabies (in humans) (A82) Leptospirosis (A27) Ciguatera Poisoning (T61.0) Other Diseases Salmonellosis (A02) Shigellosis (A03) Meningitis (due to Haemophilus Inﬂuenza) (G00.0) Conjunctivitis Chickenpox Scabies *Imported cases.
**Report based on clinical case diagnosis.

Increased number of cases in 2003 were due to an outbreak.
22 0 0 263 4 4 1 334 577 789 0 0 1 151 7 16 0 322* 139 714 4 0 0 177 28 19 0 6,387* 602 637 79 79 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Appendix 5 Summary of Cases Reported Rates for Selected Diseases, 2001-2003 Diseases Cases Reported Rates per 100,000 total population 2001 2002 2003 2001 2002 2003 Cholera Plague Diphtheria Pertussis (Whooping Cough) Tetanus (excluding neonatal) Tetanus Neonatorum Measles Mumps Rubella (German Measles) Poliomyelitis Tuberculosis Gastroenteritis <5 years (A09) Viral Hepatitis A Viral Hepatitis B Viral Hepatitis C Typhoid Fever Ciguatera Other Foodbourne Malaria Dengue Leptospirosis Inﬂuenza Meningitis (H. Inﬂuenza) Conjunctivitis Leprosy (Hansen’s Disease) Syphilis Gonococcal Infection AIDS 0 0 0 0 0 0 0 0 0 0 41 745 46 363 22 1 263 978 4* 0 0 0 0 0 0 0 0 0 0 0 0 44 1318 5 5 0 0 151 1301 1* 0 1 0 0 0 0 0 0 0 0 0 0 40 950 1 1 4 1 177 1164 3* 180 0 607** 577** 857** 1 334 0 278 71 288 0 322** 0 192 88 335 0 6,387** Population, all 307,379 311,871 316,298 Population, Children < 5 Years 30,934 30,718 30,423 80 80 Annual Report of the Chief Medical
 Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 6 Reported Incidence Rate of HIV Infections and AIDS by Gender, 1986-2003 , 0 0 1 r e p I S D A 0 0 0 , 0 0 1 r e p d e t a m i t s E n o i t a l u p o P * 3 0 0 2 - 6 8 9 1 V H S D A - n o N I I 3 0 0 2 - % M : F o i t a r l a t o T e l a M e l a m
t o t % M : F o i t a r l a t o T e l a M e l a m e F M : F o i t a r l a t o t % , 8 5 9 4 2 1 , 1 9 0 0 3 1 , % 1 6 .
9 0 .

3 5 4 3 4 2 0 1 2 7 .

0 % 5 .

3 8 6 1 9 9 - - - - - - - - - - - - 3 3 9 8 4 2 , A N - A N A N A N % 7 6 .

6 0 .

5 9 4 8 0 3 7 8 1 9 .

0 % 6 .

3 2 7 1 2 9 % 2 9 .

6 0 .

9 8 6 4 2 4 5 6 2 6 .

0 % 7 .

5 3 7 2 2 7 1 1 0 1 8 8 - , 8 4 3 7 2 1 , 6 1 2 2 3 1 , % 9 6 .

9 0 .

9 0 5 1 7 2 8 3 2 7 4 2 4 6 2 , 4 4 8 9 2 1 , 3 0 4 4 3 1 , % 8 7 .
9 0 .

9 7 5 8 9 2 1 8 2 7 7 0 9 6 2 , 7 3 4 2 3 1 , 0 4 6 6 3 1 , % 6 7 .

0 1 .

5 6 5 2 8 2 3 8 2 0 2 0 4 7 2 , 2 0 1 5 3 1 , 8 1 9 8 3 1 , % 3 1 1 .

9 0 .

 , 5 1 8 7 3 1 , 4 9 1 1 4 1 , % 7 6 .

0 1 .

 , 9 0 5 0 4 1 , 8 5 4 3 4 1 , % 8 5 .

0 1 .

 , 2 4 1 3 4 1 , 4 1 7 5 4 1 , % 8 5 .

9 0 .
9 0 .

 , 5 1 7 5 4 1 , 8 5 9 7 4 1 , % 8 4 .

1 1 .

8 5 3 1 7 1 7 8 1 1 1 4 8 9 2 , 5 2 2 8 4 1 , 6 8 1 0 5 1 , % 8 4 .

0 1 .

7 4 3 2 7 1 5 7 1 6 .

0 6 .

0 7 .

0 5 .

0 6 .

0 7 .

0 7 .

0 5 .

0 7 .

0 % 6 .

4 9 1 2 0 4 1 % 5 .

5 4 6 2 4 6 1 0 0 1 % 2 .

6 5 9 2 4 7 1 1 2 1 % 6 .

6 6 1 3 4 0 2 2 1 1 % 0 .

8 4 8 3 9 3 2 5 4 1 % 8 .

7 3 7 3 9 1 2 4 5 1 % 0 .

8 6 8 3 6 2 2 0 6 1 % 7 .


 81 81 % 7 .

 , 8 7 7 7 4 1 , 3 3 8 5 5 1 , % 5 5 .

0 1 .

8 0 4 2 0 2 6 0 2 8 .

0 % 7 .

 , 3 0 0 2 5 1 , 6 7 3 5 5 1 % 2 5 .

1 1 .

5 8 3 3 8 1 2 0 2 8 .

0 % 0 .


 , 1 1 3 4 5 1 , 0 6 5 7 5 1 % 5 4 .

0 1 .

2 3 3 3 6 1 9 6 1 6 .

0 % 0 .

 , 7 9 5 6 5 1 , 1 0 7 9 5 1 , % 9 3 .

3 1 .

9 8 2 3 2 1 6 6 1 7 .

0 % 3 .

7 8 4 3 4 0 2 4 4 1 3 0 0 2 % 6 .

2 0 1 9 .

0 9 2 4 7 8 7 8 , 3 1 5 5 , 3 7 .

0 % 0 .


0 0 1 0 8 7 , 4 3 8 8 , 2 7 9 8 1 , l a t o T Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 7 Age-Gender Distribution of Population and Deaths in Bahamas, 2003 Age Group Population % pop.
in age-group Total #Deaths % deaths in age-group Age-Speciﬁc Death Rate per 1,000 ALL (Both sexes) <1 Year 1-4 5-14 15-24 25-44 45-64 65+ Total MALES <1 Year 1-4 5-14 15-24 25-44 45-64 65+ Total FEMALES <1 Year 1-4 5-14 15-24 25-44 45-64 65+ Total Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 8 Years of Potential Life Lost by Gender and Broad Causes of Death 1999-2003 1999 2000 2001 2002 2003 1999-2003 % in 2000 % in 1999-2003 Cause MALES Communicable Dis.
5,011.5 4,233.0 4,497.5 5,593.0 2,748 22,083 Neoplasms 861.0 738.5 882.5 787 926.5 Dis.

Circulatory Sys.
Circulatory Sys.

1,341.0 1,177.0 1,591.0 2,022.0 1,975.5 Perinatal Conditions 903.0 903.0 1,161.0 1,751.0 838.5 External Causes I/P All Other Causes SSI Conditions TOTAL FEMALES Communicable Dis.
3,069.5 2,891.0 2,747.0 2,870.0 2,124.0 13,701.5 Neoplasms Dis.

Circulatory Sys.
Circulatory Sys.

Perinatal Conditions 1,083.5 1056.0 720.0 968.0 964.5 967.5 External Causes I/P 937.0 1,113.0 1,210.0 1,103.5 580.5 808.0 1,262.0 1,309.0 ,832.5 All Other Causes SSI Conditions TOTAL BOTH SEXES Communicable Dis.
8,081.0 7,124.0 7,226.5 8,463.0 4,872.0 35,766.5 Neoplasms 1,944.5 1,706.5 2,093.0 2,079.5 2,235.5 10,059 Dis.

Circulatory Sys.
2,397.0 2,141.5 2,694.5 3,260.5 3,543.0 Perinatal Conditions 1,623.0 1,870.5 1,741.5 3,888.0 1,999.5 14,036.5 11,122.5 External Causes I/P 5,247.5 5,761.0 4,396.0 3,181.0 4,463.5 23,049 All Other Causes 3,652.5 5,013.0 5,088.5 6,909.0 4,790.5 25,453.5 SSI Conditions 294.0 535.0 307.0 352.0 296.5 1,784.5 21.9 10.1 16.0 9.0 20.1 21.6 1.3 29.5 8.3 11.6 9.2 19.0 20.9 1.5 TOTAL 23,239.5 24,151.5 2,3547 2,8133 22,200.5 121,271.5 100.0 100.0 Notes: The years of potential life lost before age 65 as deﬁned by PAHO in the Health Conditions of the Americas 1990 edition, Volume 1, page 305 states: “The indicator “Years of Potential Life Lost” (YPLL) provides an estimate of the number of years of life lost prematurely, deﬁned here as the number of years of life lost by persons who die prior to 65 (between 0 and 64) years of age.
These estimates are obtained by multiplying the number of deaths in an age group by the difference between 65 and the midpoint of that age group, and adding these products across all age groups.” 83 83 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 9 Group Causes of Death by Age and Gender, 2001-2003 L L P Y 2 0 9 , 3 4 8 4 9 , 9 2 5 .

2 1 7 3 4 2 5 .

9 8 1 , 3 4 5 .

0 2 8 , 2 1 5 0 7 , 9 2 1 4 7 , 7 6 9 5 , 2 5 .

1 8 7 , 3 5 .

8 8 5 , 5 5 .

9 0 9 , 3 5 .


1 0 0 , 1 5 .

4 9 3 , 1 5 .

0 5 7 , 3 5 .

8 7 8 , 3 0 5 6 , 9 5 .
0 9 3 , 2 4 8 7 , 8 4 0 0 , 8 S R A E Y N I S P U O R G E G A t o N d e t a t S + 5 6 4 6 - 5 4 4 4 - 5 2 4 2 - 5 1 4 1 - 5 4 - 1 1 < L A T O T ) 9 - D C I ( , 1 4 5 2 , 1 5 3 0 , 1 6 2 2 , , 2 4 0 4 , 2 2 5 7 , 2 0 7 3 , .
1 s r e d r o s i D y r o t a u c r i C l 0 0 .

3 l s m s a p o e N 0 0 .

2 ) I S S ( .

4 s e s u a C l a t a n i r e P 0 0 .

4 84 84 s e s u a C l a n r e t x E 0 0 .

5 r e h t O 0 0 .

6 .
% : ) I S S ( s e s u a c d e n ﬁ e d - l l I f o s m o t p m y S , s n g i S Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 10 Group Causes of Death by Age and Gender, 2003 L L P Y 8 6 6 , 2 1 3 3 5 , 9 7 5 1 0 4 1 1 1 5 , 2 1 3 9 3 , 9 8 4 7 , 2 4 2 1 , 2 6 2 9 9 0 3 , 1 6 7 9 , 1 8 6 5 1 9 3 8 1 6 1 , 1 8 2 5 , 3 5 3 9 4 9 4 , 2 7 9 2 , 2 t o N d e t a t S 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 + - 5 6 4 6 - 5 4 4 4 - 0 2 9 1 - 0 1 9 - 5 4 - 1 1 < L A T O T ) 9 - D C I ( .
1 s r e d r o s i D y r o t a u c r i C l 0 0 .

3 l s m s a p o e N 0 0 .

2 ) I S S ( .

5 r e h t O 0 0 .

6 s e s u a C l a t a n i r e P 0 0 .

4 85 85 . )
2 1 x i d n e p p A e e S ( % : ) I S S ( s e s u a c d e n ﬁ e d - l l I f o s m o t p m y S , s n g S i Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 11 Discharge Diagnoses From Princess Margaret Hospital in Females by Age Group, 2003 Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ 0 Pregnancy, childbirth and the puerperium Other infectious and parasitic diseases Injuries & poisonings Acute respiratory infections All other diseases of the digestive system Carcinoma in situ, benign neoplasms and neoplasm of uncertain or unknown behaviour Hypertensive diseases Intestinal infectious diseases Remainder diseases of the respiratory system Diseases of urinary system Cerebrovascular diseases Appendicitis, hernia of abdominal cavity and intestinal obstruction Diabetes mellitus HIV disease Pulmonary heart disease, diseases of pulmonary circulation and other forms of heart disease Septicemia, except neonatal Dis.
nervous system, except meningitis All other diseases of the circulatory system Malignant neoplasm of female breast Slow fetal growth, fetal malnutrition, short gestation, low birth weight Ischemic heart diseases Remainder of other conditions originating in perinatal period Malignant neoplasm of other and unspeciﬁed sites Congenital malformations, deformations and chromosomal abnormalities Heart failure Mental and behavioral disorders Chronic lower respiratory diseases Nutritional deﬁciencies and nutritional anaemia Respiratory disorders speciﬁc to the perinatal period Malignant neoplasm of colon and rectosigmoid junction Not Stated Total Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ Not Stated Total Malignant neoplasm of stomach Malignant neoplasm of cervix uteri Malignant neoplasm of lymphoid, other hematopoieic and related tissue Cirrhosis and certain other chronic diseases of liver Tuberculosis Certain vector-borne diseases
 and rabies Malignant neoplasm of uterus, part unspeciﬁed Bacterial sepsis of newborn Malignant neoplasm of digestive organs & peritoneum, except stomach and colon Malignant neoplasm of corpus uteri Malignant neoplasm of other genitourinary organs Fetus & newborn-obstetric affected by obstetric complications, birth trauma Meningitis Leukemia Cardiac arrest Certain diseases preventable by immunization Land transport accidents Acute rheumatic fever and chronic rheumatic heart diseases Atherosclerosis Fetus and
 newborn affected by certain maternal conditions Malignant neoplasm of respiratory and intrathoracic organs, except trachea, bronchus and lung Malignant neoplasm of trachea, bronchus and lung Remainder of all other diseases 35 Factors Inﬂuencing Health Status and contact 2 1,708 with health services Symptoms, Signs, and ill-deﬁned conditions *Total 2 2,178 470 2,268 4,018 888 728 2 9,206* Total excludes normal deliveries (Groupings are based on PAHO’s 6/67 listing for ICD-10.)
87 87 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 12 Discharge Diagnoses from Princess Margaret Hospital in Males by Age Group, 2003 Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ Injuries & Poisonings Acute respiratory infections All other diseases of the digestive system Intestinal infectious diseases Hypertensive diseases Remainder diseases of the respiratory system HIV disease (AIDS) Appendicitis, hernia of abdominal cavity and intestinal obstruction Diseases of urinary system Other infectious and parasitic diseases Cerebrovascular diseases Certain vector-borne diseases and rabies Dis.
nervous system, except meningitis Pulmonary heart disease, diseases of pulmonary circulation, and other forms of heart disease Diabetes mellitus All other diseases of the circulatory system Slow fetal growth, fetal malnutrition, short gestation, low birth weight Septicemia, except neonatal Congenital malformations, deformations and chromosomal abnormalities Mental and behavioral disorders Remainder other conditions originating in perinatal period Heart failure Tuberculosis Chronic lower respiratory diseases Malignant neoplasm of prostate Ischemic heart diseases 0 63 109 17 78 48 2 7 7 15 2 8 1 1 3 46 1 24 21 1 2 8 Malignant neoplasm of other and unspeciﬁed sites Cirrhosis and certain other chronic diseases of liver Malignant neoplasm of digestive organs & peritoneum, except stomach and colon Respiratory disorders speciﬁc to the perinatal period Not Stated 0 Total Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ Not Stated Total Carcinoma in situ, benign neoplasm and neoplasms r 1 of uncertain or
 unknown behaviou Malignant neoplasm of stomach Malignant neoplasm of trachea, bronchus and lung Bacterial sepsis of newborn Malignant neoplasm of lymphoid, other hematopoieic and related tissue Nutritional deﬁciencies and nutritional anaemia Fetus & newborn affected by obstetric complications, birth trauma Malignant neoplasm of other genitourinary organs Leukemia Certain diseases preventable by immunization Malignant neoplasm of respiratory and intrathoracic organs, except trachea, bronchus and lung Meningitis
 Malignant neoplasm of colon and rectosigmoid junction 2 1 1 6 6 1 1 2 Acute rheumatic fever and chronic rheumatic 2 heart diseases Land transport accidents Cardiac arrest Atherosclerosis Remainder of all other diseases 20 Factors inﬂuencing health status and contact 6 1,656 with health services Symptoms, Signs, and ill-deﬁned conditions 88 53 26 57 43 *Total 6 2,261 531 399 971 714 *Total excludes normal deliveries.
(Groupings are based on PAHO’s 6/67 listing for ICD-10.)
Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 13 Discharge Diagnoses from Rand Memorial Hospital in Females by Age, 2003 Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ Pregnancy, childbirth and the puerperium Injuries & Poisonings 0 All other diseases of the digestive system Intestinal infectious diseases Acute respiratory infections Other infectious and parasitic diseases Mental and behavioral disorders Carcinoma in situ, benign neoplasms and neoplasms of uncertain or unknown behaviour Hypertensive diseases Diabetes mellitus Appendicitis, hernia of abdominal cavity and intestinal obstructionDiseases of urinary system Chronic lower respiratory diseases Remainder diseases of the respiratory system Malignant neoplasm of female breast Pulmonary heart disease, diseases of pulmonary circulation and other forms of heart disease Cerebrovascular diseases Heart failure Ischemic heart diseases Septicemia, except neonatal Dis.
nervous system, except meningitis All other diseases of the circulatory system Respiratory disorders speciﬁc to the perinatal period 3 Slow fetal growth, fetal malnutrition, short gestation, low birth weight HIV disease Congenital malformations, deformations and chromosomal abnormalities Not Stated Total 1 552 136 101 99 98 83 66 66 63 49 41 38 29 24 22 20 20 18 18 17 17 12 12 8 7 7 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ Not Stated Total Bacterial sepsis of newborn 7 Remainder other conditions originating in the perinatal period 6 6 Tuberculosis Cirrhosis and certain other chronic diseases of liver Malignant neoplasm of other genitourinary organs Malignant neoplasm of cervix uteri Acute rheumatic fever and chronic rheumatic heart diseases Fetus & newborn affected by obstetric complications, birth trauma 1 Leukemia Meningitis Malignant neoplasm of colon and rectosigmoid junction Malignant neoplasm of digestive organs & peritoneum, except stomach and colon Malignant neoplasm of other and unspeciﬁed sites Malignant neoplasm of stomach Malignant neoplasm of trachea, bronchus and lung Nutritional deﬁciencies and nutritional anaemia 2 2 1 2 2 2 1 1 1
 1 1 1 1 1 Remainder of all other diseases 5 Factors inﬂuencing health status and contact 50 285 with health services 37 6 32 77 114 105 70 4 Symptoms, Signs, and ill-deﬁned conditions 16 28 21 71 32 *Total 53 483 195 617 1,114 361 *The total excludes normal deliveries (Groupings are based on PAHO’s 6/67 listing for ICD-10.)
Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer APPENDIX 14 Discharge Diagnoses from Rand Memorial Hospital in Males by Age Group, 2003 Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ Injuries & Poisonings 0 9 Mental and behavioral disorders Intestinal infectious diseases All other diseases of the digestive system Acute respiratory infections Appendicitis, hernia of abdominal cavity and intestinal obstruction Hypertensive diseases 53 4 31 11 26 2 28 4 26 15 Chronic lower respiratory diseases 16 19 Diabetes mellitus Diseases of urinary system Cerebrovascular diseases Other infectious and parasitic diseases Remainder diseases of the respiratory system 1 Certain vector-borne diseases and rabies Ischemic heart diseases Pulmonary heart disease, diseases of pulmonary circulation and other forms of heart disease Carcinoma in situ, benign neoplasms and neoplasms of uncertain or unknown behaviour All other diseases of the circulatory system Diseases of the nervous system, except meningitis 6 8 15 1 1 2 2 7 13 7 1 2 2 Respiratory disorders speciﬁc to the perinatal period 2 13 HIV disease (AIDS) Congenital malformations, deformations and 3 6 chromosomal abnormalities Heart failure Tuberculosis Septicemia, except neonatal Nutritional deﬁciencies and nutritional anaemia 10
Not Stated Total 0 220 137 95 88 79 67 55 45 43 40 35 34 31 25 23 23 22 22 18 16 11 11 10 9 7 7 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Discharge Diagnosis < 1 1-4 5-14 15-24 25-44 45-64 65+ Not Stated Total Malignant neoplasm of prostate Slow fetal growth, fetal malnutrition, short 7 gestation, low birth weight Malignant neoplasm of other and unspeciﬁed sites 2 1 Remainder other conditions
 originating in 4 1 perinatal period Cirrhosis and certain other chronic diseases of liver Malignant neoplasm of lymphoid, other hematopoieic and related tissue Malignant neoplasm of digestive organs & peritoneum, except stomach and colon Malignant neoplasm of trachea, bronchus and lung Malignant neoplasm of colon and rectosigmoid junction Bacterial sepsis of newborn Malignant neoplasm of stomach Fetus & newborn affected by obstetric complications, birth trauma Meningitis Remainder of all other diseases 2 1 7 Factors influencing health status and contact 50 310 with health services 1 2 2 1 2 2 1 1 19 4 18 37 6 47 6 Symptoms, signs, and ill-deﬁned conditions 25 23 15 43 38 Total* 53 527 210 194 362 357 *The total excludes normal deliveries (Groupings are based on PAHO’s 6/67 listing for ICD-10.)
7 2 1 1 24 5 26 214 5 7 5 3 3 2 2 2 2 1 1 1 152 3 8 1 170 1,917 93 93 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 94 94 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Notiﬁcation Rates of Tuberculosis by Age and Gender, 2000-2003 Age Group Cases Population Estimates Notiﬁcation per 100,000 Males Females Total Males Females Total Males Females Total 50-59 60+ Unknown Total 50-59 60+ Unknown Total 20-49 50-59 60+ Total 20-49 50-59 60+ Total Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Ten Leading Causes of Death with Rates per 100,000 Population, 1999-2003 e t a R 3 0 0 2 .
o N 6 .

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 .

o N k n a R e t a R 1 0 0 2 .

o N k n a R e t a R 0 0 0 2 .

o N k n a R e t a R 9 9 9 1 .

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.

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1 2 5 6 5 5 , 1 s e s u a C d e n ﬁ e D , s h t a e D l a t o T 3 .

1 2 5 9 4 6 , 1 4 .

0 8 5 0 1 8 , 1 7 .

7 6 5 5 4 7 , 1 1 .

3 3 5 5 2 6 , 1 8 .


7 2 5 5 7 5 , 1 s e s u a C l l A , Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Ten Leading Causes of Deaths by Years of Potential Life Lost, 1999-2003 L L P Y 4 4 0 4 5 .

8 5 1 , 1 5 .

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8 8 3 0 .

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7 3 2 5 .

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6 9 2 5 .

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0 9 3 3 8 3 1 1 7 2 5 .

9 1 8 , 3 1 0 4 2 3 2 0 .

7 0 3 7 4 5 , 3 2 1 7 9 4 2 3 1 8 3 4 1 5 5 1 8 1 0 1 .

0 0 7 8 5 , .

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0 0 1 2 , .

0 2 1 3 , .

5 6 7 1 5 .

9 6 2 , 4 1 5 .

6 1 6 3 2 0 .

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5 2 6 0 , 7 .

0 3 9 6 , 1 .

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0 6 5 4 .

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9 6 0 , 5 1 5 .

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4 9 2 1 3 2 8 4 3 1 7 5 0 1 9 6 2 1 4 1 * * * ) e d i c i m o h ( & .
s i d , e s a e s i d t r a e h y r a n o m u P l * * * ) 1 5 I , 9 4 I - 7 4 I , 5 4 I - 6 2 I ( 97 97 ) S D A I ( e s a e s i d V H I n a h t r e h t o , , L L P Y l a t o T - l l I & s m o t p m y S , s n g i S , .
1 5 1 , 4 2 5 .

9 3 2 , 3 2 s e s u a C l l A , L L P Y l a t o T Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Deaths & Proportional Mortality from Selected Causes by Age & Gender, 2001-2003 ) ( s p u o r G e g A d e t a t S t o N + 5 6 4 6 - 5 4 4 4 - 5 2 4 2 - 5 1 4 1 - 5 4 - 1 1 < l a t o T % .

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o N l l A % .


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0 5 .

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 .

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 , 5 4 I - 6 2 I ( ) 1 5 I , 9 4 I - 7 4 I , e s a e s i d t r a e h y r a n o m u P l * * * d e n ﬁ e d - l l I & s m o t p m y S , s n g i S s e s u a C d e n ﬁ e D , s h t a e D l a t o T s n o i t i d n o C ) s h t a e D l l A % ( l a t o T 0 0 0 1 0 0 1 0 0 4 4 0 0 .

9 5 8 5 3 1 5 .

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3 5 1 8 5 0 1 3 1 4 .

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8 9 8 8 9 6 1 5 .

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7 9 5 .

2 7 5 0 .

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1 7 1 7 .

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2 6 2 8 7 2 9 .

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7 9 8 1 1 4 .

6 9 7 0 1 5 .

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3 4 9 .

1 9 9 0 .

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0 0 , 1 1 1 1 0 .
0 0 1 5 9 1 , 5 s e s u a C l l A , s h t a e D l a t o T Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Visits by Adults & Children to Primary Care Clinics by Selected Causes, 1996-98 New 1996 Return Total 1997 New Return Total 1998 New Return Total Condition ADULTS Hypertension 590 19,696 20,286 1,283 19,247 20,530 743 23,988 24,731 Diabetes Arthritis Diseases of the skin and subcutaneous tissue* 429 369 0 5,504 5,933 400 6,993 7,393 494 7,861 8,355 2,057 2,426 553 2,612 3,165 380 2,731 3,111 0 0 0 0 0 0 0 0 Injuries 177 50 227 384 103 487 309 183 492 Mental Disorders Neoplasms 0 0 Eye Diseases 1,188 0 0 0 0 0 1,188 0 0 0 0 0 0 0 0 1 0 0 184 0 59 60 0 59 244 Ear Diseases 1,306 270 1,576 1,305 224 1,529 1,592 291 1883 0 0 0 1,686 362 2,124 1,625 490 2115 Symptoms, Signs and Ill-deﬁned Conditions CHILDREN Acute Gastroenteritis 2,012 151 2,163 1,234 Intestinal Parasitism Scabies Ringworm Eye Diseases Ear Diseases Injuries Poisonings 637 151 599 771 1,943 877 43 18 2 26 15 126 326 7 655 153 625 786 2,069 1,203 50 * (excluding scabies and ringworm) **New and return visits may not have been speciﬁed in all instances.
R = REPEAT visits N = NEW visits (First visit associated with health problem for that year Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Framework of Strategic Directions and Strategic Goals � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �������������������� ������������������������� ������������������������ ������������������������� ����������������������������� ����������������������������� � � � � � � � � � � � � � � � ����������������������������� ������������������������� ���������������������������������� ���������������������������������� ������������������������ ������������������������� ������������������������� 100 100 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Infrastructural Developments (1993-2001) (Physical upgrades, upgrade of existing technology and services and introduction of new technology and services).
1.

Princess Margaret Hospital • Refurbishment of Private Wards, Labour and Delivery Units and Surgical Suites (partnership with Physicians Alliance Ltd.) • Neonatal Intensive Care Unit (NICU) • Trauma Unit • Refurbishment of Public Wards • Laboratory Remodeling and expansion of onsite Laboratories (histology lab, morgue etc.
New Site (General Hardware Building) • Rehabilitation therapy (new site GH building) • Physical Plant Refurbishments: Water, Sewerage, Electrical, Medical Gases systems • New Dialysis unit • Ambulance Bay • MMD warehouse • X-Ray (introduced technology upgrades and new services) • Emergency Room Chest Pain room Privacy for sexual abuse cases Pediatrics room Operating Theatre Stat Laboratory • Pharmacy Introduction of pharmacy management information system (improvements in outpatients dispensary) 2.
Sandilands Rehabilitation Centre • Geriatrics • Sandilands • Child and Adolescent Unit • Community Counseling and Assessment Centre (Relocation and expansion) 3.

Grand Bahama Health System • Rand Memorial Hospital Accident and Emergency Upgrade The Morgue Ophthalmology Services 101 101 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer • Community Clinics in Grand Bahama New Eight Mile Rock Clinic 4.
Public Health Department • Community Clinics in New Providence Refurbishment of Gambier Clinic Repairs to Ann’s Town, Coconut Grove and Balliou Hill Road Clinic New South Beach Clinic 5.

Community Clinics in Family Islands • Major Renovations of Family Island facilities examples: Wheymss Bight, Eleuthera, Governor’s Harbour, Old Bight Cat Island, Smith’s Bay Cat Island, Forbes Hill, Exuma Clarence Town, Long Island Deadman’s Cay, Long Island Moore’s Island Abaco etc.
102 102 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Public Health Information System Design 103 103 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Some of the Documents Reviewed for the CMO’s Report PAHO/WHO.

Health of the Americas, Bahamas Chapter, 2002 edition PAHO/WHO.

Health Services System Proﬁle, January 2002 Commonwealth of the Bahamas.
National Health Services Strategic Plan 2000-2004 The Commonwealth of the Bahamas Census of the Population and Housing 2000.

Preliminary results.

Department of Statistics, 2001 Dept.

of Statistics.

Statistical Abstract 1999.

September 1999 Dept.

of Statistics.

Mortality Rates by Age and Sex, Based on Registered Deaths, Bahamas 1990-2000.

July 17, 2001 Dept.

of Statistics.

Socioeconomic proﬁle, The Bahamas 1995-1999.

Sector contribution to the GDP 1995-2000.


Feb 2002 The Central Bank of The Bahamas.

Quarterly Statistical Digest.

Vol.

10 (4), November 2001 Health Information and Research Unit, Ministry of Health, Bahamas.

2001 Annual Report 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

PAHO/WHO.

Health Situation in the Americas.

Basic indicators 2001 11.

PAHO/WHO.

PAHO Special Program for Health Analysis: List 6/67 for ICD-10 Mortality Tabulation.

7 July 1999 12.

PAHO/WHO.


PAHO Special Program for Health Analysis: List 6/61 for ICD-9 Mortality Tabulation.

Undated 13.

Ministry of Health, Bahamas (in collaboration with Caribbean Food & Nutrition Institute, PAHO/WHO).

National health and nutrition survey 1988-89.

1991 14.

Ministry of Health, Bahamas.

Adolescent Health Survey, Bahamas.

Undated report 15.

Ministry of Health, Bahamas.

The Commonwealth of the Bahamas HIV/AIDS Programme: A model for success.

June 2001 16.
June 2001 16.

Planning Unit, Ministry of Health, Bahamas.

Building Health Planning Capacity in the Bahamas: Draft Plan of Action for Feb 2001 to 30 June 2002 17.

Gomez MP, Bain RM, Major C, Gray H, Read SE.

Characteristics of HIV-infected women in the Bahamas.

J AIDS Hum Retrov 1996; 12 (4): 400-5 18.

Baez RJ.

Oral health status of school children in the Commonwealth of the Bahamas.

Results of a national survey 1999-2000 19.

Khetan S, Maharaj R, Davis GK.


Management of acute myocardial infarction in the public sector in the Bahamas.

West Indian Medical Journal 2000; 49 (2): 115-7 20.

The National Council on Older Persons.

Report on a National Policy for Older Persons.

September 2000 21.

Del Riego A.

Rapid Assessment Report.

National Health Information System, Bahamas.

August 2000 22.

Ministry of Health, Commonwealth of the Bahamas.

Primary Health Care Monthly Report 23.


Ministry of Health, Commonwealth of the Bahamas.

Primary Health Care Services Tally Sheets 24.

Fountain T. Revision of the Primary Health Care Reporting System.

1993 25.

Fountain T. Reliability of mortality statistics: a comparison of ICD-9 codes applied by the Princess Margaret Hospital and the Department of Statistics.

September 1996 26.

Fountain T. Proposal for the Reorganisation of the Health Information and Research Unit, MOH.

Undated 27.
Undated 27.

Fountain T. A Brief on Health Information.

Undated 28.

Fountain T. A Brief on the Development of a National Health Information Network.

Undated 104 104 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer 29.

Health Information and Research Unit, MOH, Bahamas.

Basic Health Information.

March 1996 30.

Health Information and Research Unit, MOH, Bahamas.

Health Information Brochure, 1995-2000.

31.

Health Information and Research Unit, MOH, Bahamas.
Deaths from cancers 1994-1998.

Oct 2001 32.

Health Information and Research Unit, MOH, Bahamas.

Estimates of births among teenagers by age group with percents and rates per 1,000 females, Bahamas 1986-1999.

Aug 2001 33.

Health Information and Research Unit, MOH, Bahamas.

Number, percent and rate of Deaths due to Road Trafﬁc Accidents 1996- 2000.

July 2001 34.

Health Information and Research Unit, MOH, Bahamas.

Registered live births among females aged 10-19 years by Island, Bahamas 1990-1998.
July 2000 35.

Sands A.

Public Health Information System Design Existing, 2001.

36.

Surveillance Unit.

Form for Annual Operational Plan Communicable Disease 2001 37.

McPhee E. Surveillance, prevention and control of selected communicable diseases: malaria, dengue and foodborne diseases.

Draft report.

Dec 17, 2001 38.

Fox D. Expanded Programme on Immunization.

17 December 2001 39.

Fox D. Expanded Programme on Immunization, Bahamas.

Annual Report 2000 40.

Clarke A. Maternal and Child Health.


Trends in Infant Mortality Rates 1997-2001.

28 Jan 2002 41.

Clarke A. Maternal and Child Health.

Preliminary Infant Mortality Rate, 2001.

21 Jan 2002 42.

Government of the Bahamas.

Summary of Recurrent Expenditure 1999/2000 43.

Carter P. Programme Planning Unit, Dept.

of Public Health, MOH.

Hand-over Notes for Permanent Secretary.

Jan 10, 2002 44.

Department of Social Services.

Child Welfare Division, New Providence.


Statistical Data on Reported Cases for 2000 45.

Brown M. Review of the Project to Reduce Infant Mortality in the Bahamas.

March 2000 46.

Johnson M, Clarke A. Midwives Clinic Manned by Dept.

of Public Health Midwives Team.

17 December 2001 47.

Gray H. Script for interview on the structural and service improvements at the Princess Margaret Hospital by the Deputy Managing Director, Public Hospitals Authority with the counsellors on Jan 18, 2002.

Feb 11, 2002 48.
Feb 11, 2002 48.

Registrar-General’s Department.

Schedule Form E: Commonwealth of the Bahamas – Medical Certiﬁcate of Deaths/Stillbirth.

49.

PriceWaterhouseCoopers.

Public Sector Health Services Information Management/Information Technology Strategic Plan.

Final Report Prepared for the MOH and PHA, Nassau, Bahamas.

Nov 26, 2001 Other (General) Texts 50.

UNICEF/EAPRO.

Prevention of mother-to-child transmission of HIV.

HIV/AIDS Antiretroviral Newsletter 1999; Nov Issue No.

2 51. WHO.
2 51. WHO.

World Health Report 2000.

Health systems: improving performance 52. WHO.

World Health Report 1997.

Conquering suffering, enriching humanity.

53.

Food and Agricultural Organisation of the UN, WHO.

Understanding the Codex Alimentarius.
Rome, 1999 105 105 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Organizational Structure of the Planning Unit of the Ministry of Health and Environment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 106 106 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Organizational Chart of the Ministry of Health and Environment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 107
 107 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Reported Incidence of Non-AIDS HIV (Total and Teenage) and AIDS, 1994-2003 ����� ���� ������������ � � � � � � � � � � � � � � � � � � � � � � � � � � � ��� ��� ��� ��� ��� �� � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� 108 108 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Reported Age-Speciﬁc Incidence Rate of Non-AIDS HIV, 1989, 1994, 1998, 2003 ���� ���� ���� ���� ��� ��� ��� ��� ��� ��� ��� ��� � ������� ��� ��� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ����� ���� ����� ����� ����� ����� ���� ���� ���� ���� ����� ����� ����� ���� ���� ���� ����� ���� ���� ����� �����
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 �� �� �� �� � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� 110 110 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer TB Cases by Gender, Nationality & HIV Status, Bahamas, 2001-2003 ���� ���� ���� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� ��� �� �� �� �� �� � � � � � � � � � �� �� �� �� �� �� �� � ����� �������� ������ ������ ������ �������� 111 111 Annual Report of the Chief Medical Ofﬁ cer Annual Report of the Chief Medical Ofﬁ cer Share of Total Population versus Share of Total Deaths, by Age Group, 2003 ������������� �������� �� �� �� � � � � � � � � � � � �� �� �� � �� ��� ���� ����� ��������� ����� ����� ��� 112 112 Annual Report of the Chief Medical Ofﬁcer Annual Report of the Chief Medical Ofﬁcer Proportionate Mortality by Years of Potential Life Lost (YPLL) in both Genders by Cumulative Causes of Death, 1999-2003 ������������������ ��������������� �������������������� � � � � � � � � ���������������������������������� ��������� �������������������� ������������������������������������� ������ ������� � � �� �� �� �� �� �� ������� 113 113