Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697649164073.pdf (Bahamas)
Report of the Chief Medical Officer Dr. Merceline Dahl-Regis Commonwealth of The Bahamas 2004-2008 TABLE OF CONTENTS Foreword Executive Summary Acknowledgements Acronyms and Conventions Introduction Physical & Political Description Population Demographics Population Trends 7.1 Population Mortality Trends 7.2 Sector Policies, Plans & Supporting Systems 8.1 8.2 8.3 8.4 Policies to Guide Delivery of Services Plans, their Assessments and Evaluations Legislation in Support of Service Delivery Health Information Health Infrastructure Organizational Structure 9.1 Service Delivery 9.2 Facilities 9.3 9.3.1 Hospitals 9.3.2 Health Centres 9.4 Resources 9.4.1 Manpower 9.4.2 Health Services Financing Expanded Programme of Immunization School Health Services Infectious Disease Surveillance Health Services & Programmes 10.1 Maternal and Child Health 10.2 10.3 10.4 10.5 HIV/AIDS 10.6 Tuberculosis 10.7 Non-communicable Diseases & Injuries 10.8 Mental Health Services 10.9 Oral Health Services 10.10 Nutrition 10.11 Health Promotion & Education 10.12 Healthy Lifestyles Initiative 10.13 Prison Health Services Environmental Health Services 11.1 Water and Sewerage Management Solid Waste Management 11.2 Food Safety – Establishments Inspected and Passed; Training of Food Handlers 11.3 Vector Control – Aedes Aegypti Indices; Rodent Control Activities 11.4 Port Health – Inspections and Results 11.5 Hospital Services In-patient 12.1 12.2 Laboratory 12.2.1 Emergency Response 12.2.2 Outpatient Services General Population Population Sub-groups Infants Health Situation 13.1 13.2 13.2.1 13.2.2 Children Aged 1-4 years 13.2.3 Children, Aged 5-14 years 13.2.4 Adolescents Aged 15-24 years 13.2.5 Persons Aged 25-44 years 13.2.6 Persons Aged 45-64 years Conclusions 14.1 14.2 14.3 Summary of Achievements Future Strategic Foci Recommendations and Proposals/Plans for the Future References Tables and Figures 52 52 52 52 53 55 56 56 56 57 60 62 62 64 64 64 66 66 67 67 69 69 69 70 71 72 1 FOREWORD The Chief Medical Officer’s (CMO’s) Report 2004-2008 is the third in a series of published reports that describes the health status of the peoples of The Bahamas.
Since 1963, the Government of The Bahamas has made health care available to all citizens through the Department of Public Health.
In more recent times the revised Health Act of 1999 supported the mission of the Ministry of Health which is to “ensure that the highest quality of services for health promotion, health protection and healthcare are accessible to all residents of The Bahamas in order to achieve optimal health.” Guided by this mission The Ministry of Health continues to operate from a social model whereby improvements to health and well-being are achieved by directing efforts to- wards addressing the social and environmental determinants of health, among others.
The national healthcare system consists of three key components: the Ministry of Health, the Department of Public Health, and the Public Hospitals Authority, the latter of which was established by an act of Parliament in 1999.

Recognizing that the Ministry cannot provide health services by itself, it partners with non-governmental organizations, and other private agencies to provide a comprehensive approach to healthcare for its residents.
The status of a nation’s health, like an individual’s, is largely a matter of choices.

This report describes the health system’s perfor- mance and identifies choices and possible linkages with related programmes.

Data in this report can be used to guide design of national health services strategic plans and can provide direction to major programme priorities impacting the health outcomes of residents across the Bahamian archipelago.
The Bahamas’ health care system has seen many improvements that include expansion of specialists’ services.

This has resulted in growing health expenditures, many of which are technology driven.

It is vital that we strike a balance among preventive services, primary care services, and curative services.
During the period 2004-08, gains were made, however we were not successful in re- orienting health services, nor has there been a corresponding redistribution of resources that helps in striking such a balance.

This redistribution must include appropriate funding for the three sectors of public health (human, environmental and veterinary) which will be the key to the success of improving the social determinants of health.
Moving forward, we must integrate environmental services with health services and balance primary health services and curative services, in order to make changes on those core determinants of health that will move us toward better results, thereby improv- ing the lives of the residents of The Bahamas.
The data presented in this report underscore the necessity of accurate data to support the analysis in the overall assessment and evaluation of interventions to serve the health needs of the people of The Bahamas.

Optimal results are achieved when individuals also make healthy choices Dr. Merceline Dahl-Regis Chief Medical Officer 31 December 2010 MInistry of Health, Commonwealth of The Bahamas 1 2 ExECuTivE SuMMARy The period 2004-08 has proven to be a challenging time for the Ministry of Health (MOH).
Many changes have occurred, in the health sector nationally and globally, that have impacted the health of the Bahamian people.

Throughout this period, the MOH has transitioned through several organizational structures.

Initially, the Government directed the inclusion of the Department of Environmental Health Services (DEHS) in MOH; later it reassigned DEHS to a newly created Ministry of Environment.
The separation of public health activities in DEHS to another Ministry has been one of a series of challenges encountered by MOH in managing public health threats, emergencies and events.

The country has focused attention on social factors impacting health issues, including a rise in violence resulting from urbanization and economic problems.

Nevertheless, the level of governmental commitment to health strategies and services has remained constant, despite an economic downturn.
For its part, the MOH has worked to sustain the Bahamian people’s health in the face of these mounting challenges.

The MOH adopted the WHO guidelines for food health/food safety, assuming full responsibility for training food handlers in food safety—shifting from physical exam and stool examination-based health certification to a knowledge-based food handlers certification process, in compliance with internationally accepted guidelines for food safety.
Consequently, we have had zero outbreaks of foodborne illness in the community.

The World Health Assembly revised the International Health Regulations (IHR (2005)), and The Bahamas became a signatory at the 58th World Health Assembly.

This revision laid the solid groundwork for capacity building in surveillance—nationally, regionally, and internationally—as well as strengthening port health surveillance.
Pandemic planning incorporated a multitude of agencies; it sought to develop a national response to emerging threats posed by Influenza A (H5N1).

The IHR (2005) came into effect in June 2007; and in 2008, The Bahamas conducted an assessment of its capacity to provide surveillance, response, and control for possible public health emergencies of international scale and scope.
This established inter-sectoral, inter- ministerial, inter-departmental, and interagency networks and strengthened private-public partnerships for health promotion and prevention.

The MOH also conducted the “Chronic Noncommunicable Diseases (CNCD) Prevalence Study and Risk Factor Survey” in 2005, aimed at identifying determinants of CNCD’s that contribute to the burden of disease in The Bahamas.
The Healthy Lifestyles initiative was launched; a new MOH initiative aimed at increasing awareness—and reducing the impacts—of chronic non-communicable diseases on residents of The Bahamas.

With the prevalence of hypertension and diabetes both on the rise, the Ministry of Health sought innovative approaches to strengthen community involvement in managing these epidemics.
The MOH also resourced the scaling up of access to antiretroviral therapy (ART) for persons infected with HIV/AIDS, and it has provided medications free of charge to all persons meeting treatment criteria.

This has been beneficial in reducing both the level of hospitalizations and deaths associated with HIV/AIDS—moving it from one of the top one or two causes of death to the #4 cause of death by 2008.

Gilead began production of the antiretroviral drug Viread® (tenofovir) in Grand Bahama.
This drug has contributed to the management of AIDS locally and globally.

In addition, in 2006 The Bahamas successfully managed a malaria outbreak on the island of Great Exuma through cooperative efforts by the Department of Public Health (DPH) and DEHS with significant support from the Pan American Health Organization (PAHO).

Commendation for our management of this outbreak internationally was echoed by US Centers for Disease Control and Prevention.
We have been cited for “textbook” management of an outbreak, resulting in rapid containment of a potential public health threat of global concern.

2 Annual Report of the Chief Medical Officer The Department of Public Health began a restructuring exercise in 2006 and continued into 2007, which included the introduction of management teams in polyclinics aimed at increasing efficiency and improving patient care.
These polyclinics aligned with regionalized groups of Family Island services and each polyclinic assumed responsibility for referral services for their regional cluster and to provide support for the staff resulting in a more efficient referral system and continuity of care.

Extended hours for patient care were reintroduced in the polyclinics to meet increased patient demand for services.
In 2008, oncology services relocated to newly renovated facilities in Princess Margaret Hospital, enabling oncology care to be provided for persons with cancer in a setting that is more spacious and more appropriately equipped.
MInistry of Health, Commonwealth of The Bahamas 3 3 ACkNOWLEDgEMENTS The production of this report would not be possible without the assistance of managers of the National Programmes and their support staff , including Ms. Camille Deleveaux and staff in the Health Information and Research Unit; Ms. Margaret Daxon and staff in the Chronic Noncommunicable Disease Unit; Dr. Cherita Moxey; Ms. Amelia Collie; and many other personnel throughout the Ministry of Health, the Department of Public Health and the Department of Environmental Health Services.
Appreciation is extended to Ms. Sandra Smith and Mrs. Kathy Johnston of the Planning Unit in the Ministry of Health.

Gratitude is also extended to Ms. Sherrylee Smith for editing the report.

Special thanks are extended to the Pan American Health Organization/World Health Organization (PAHO/WHO), whose sponsorship of Ms. Yvette Holder, Consultant Epidemiologist and Biostatistician, enabled this report to come to fruition.
Particular thanks are given to Dr. Merle Lewis (PAHO) for her inspiration and continued support.
4 Annual Report of the Chief Medical Officer 4 ACRONyMS AND CONvENTiONS No cases recorded - Data not available … Arterial Blood Gas ABG AIDS Acquired Immune Deficiency Syndrome Anti-HBS Antibody to Hepatitis B Surface Antigen Acute Respiratory Infection ARI Antiretroviral Therapy ART Attenuated Tetanus Toxoid ATT BP Blood Pressure CAREC Caribbean Epidemiology Centre CCAC CDR CLAP CMO CMV CNCD CSF CVA DEHS DHSS dmft DMFT DOT DPH DPT EMS ENT EPI GBHS GC GDP G/E Gm(s) GPC HAV Hb HBsAg HBV HCV HIRU HIB HIV Community Counseling and Assessment Centre Crude Death Rate Latin American Centre for Perinatology Chief Medical Officer Cytomegalovirus Chronic Non-Communicable Diseases Cerebral Spinal Fluid Cerebro-vascular Accident Department of Environmental Health Services Dengue Haemorrhagic Shock Syndrome decayed, missing, and total deciduous teeth Decayed, Missing and Filled permanent Teeth Directly Observed Therapy Department of Public Health Diphtheria, Pertussis and Tetanus Vaccine Emergency Medical Services Ear, Nose and Throat Expanded Programme on Immunization Grand Bahama Health System Gonnococcal Gross Domestic Product Gastroenteritis Gram(s) General Practice Clinic Hepatitis A Virus Haemoglobin Hepatitis B Surface Antigen Hepatitis B Vaccine Hepatitis C Virus Health Information and Research Unit Haemophilus influenza type B vaccine Human Immunodeficiency Virus Her Majesty’s Prison Human Resource HMP HR HTLV 1 & 2 Human T-Lymphotrophic Virus 1 & 2 ICU IHR IMR L.E.
MCH MDG MOH MMR MTCT NICU OB PAHO PET PHA PHAC PKD PMTCT RTA RTI PMH PSW RMH SCBU SIP SLE SRC STD STI TB UA UHCG VDRL URTI WHO YPLL Intensive Care Unit International Health Regulations Infant Mortality Rate Life Expectancy Maternal and Child Health Millennium Development Goals Ministry of Health Measles, Mumps and Rubella vaccine Mother-to-child Transmission Neonatal Intensive Care Unit Obstretrics Pan American Health Organization Pre-Eclamptic Toxaemia Public Hospitals Authority Public Health Agency of Canada Polycystic Kidney Disease Prevention of Mother-to-child Transmission Road Traffic Accident Road Traffic Injury Princess Margaret Hospital Private Surgical Ward Rand Memorial Hospital Special Care Baby Unit Perinatal Information System Systemic Lupus Erythematous Sandilands Rehabilitation Centre Sexually Transmitted Disease Sexually Transmitted Infection Tuberculosis Urine Analysis Urine Human Chorionic Gonadotrophin Venereal Disease Research Laboratory (Test) Upper Respiratory Tract Infection World Health Organization Years of Potential Life Lost MInistry of Health, Commonwealth of The Bahamas 5 5 iNTRODuCTiON The Report of the Chief Medical Officer is intended to offer information about the performance of the health care system and the overall health of the population.
This document provides a forum for discussion of health determinants that impact residents of the country and describes the impact that programmes designed to improve the health of our residents have had on the country.

Further, it allows one to examine the relationship between health policy and the technical outputs that occur as a result of our national programmes.
The use of data in this report can help policymakers and programme managers guide their development of interventions aimed at decreasing morbidity and mortality and promoting good health.

The Chief Medical Officer’s Report also evaluates the performance of the health system, in identifying gaps in programmes and coverage, in order to improve upon currently available services.
This report paints a picture of the nation’s health status, as evidenced by the progress made toward the achievement of the Millennium Development Goals (MDGs).

Throughout the time period covered by most of this report, MOH has been challenged with major changes in its organizational structure, especially the migration and return of Environmental Health Services.
As a key member of the public health team, the Department of Environmental Health Services is an essential component of the environmental management of determinants of health; as such, whether they are organizationally included in the Ministry of Health or situated in a parallel agency, they are critical to our attainment of improved health within the nation.
6 Annual Report of the Chief Medical Officer 6 PHySiCAL AND POLiTiCAL DESCRiPTiON The Commonwealth of The Bahamas comprises an archipelago of some 700 islands situated in the Caribbean Sea.

Fewer than 40 are inhabited.

Most of our 300,000 Bahamians live on two main islands, New Providence, with the Commonwealth’s capital Nassau, and Grand Bahama.
The country’s economic mainstays are tourism and banking, both of which contribute to give the country one of the highest per capita Gross Domestic Products (GDP) in the English-speaking Caribbean.

The per capita GDP had been increasing steadily until 2008, when the country began to experience the cascading consequences of the global economic downturn, including a decrease in tourist arrivals (Table 1).
Household income declined in 2008 to pre-2007 levels, although inequality in income distribution widened slightly—a marginal decrease in the Gini coefficient demonstrating a continued trend from 2001 (Gini coefficient of 0.5745 (Bahamas Survey of Living Conditions, 2001)).

Table 1.
Socio-Economic indicators yEAR 2004 2005 2006 2007 2008 Per capita gDP1,2 H/hold income3,4, 5 gini Coeff.2 unemployment Rate%3,4 19,281.4 20,132.6 22,060.9 22,448.7 22,102.2 39, 626 38, 891 43, 421 45, 221 43, 459 … … … 0.45 0.44 10.2 10.2 7.6 7.9 8.7 1 At current market prices Sources: 2 World Statistics Pocketbook/United Nations Statistics Division (Economic Commission of Latin America and the Caribbean) 3 Department of Statistics, The Bahamas in Figures, 2007 4 5 2008 Labour Force and Household Income Survey 2009 Labour Force and Household Income Survey (in print) Idem.
Idem.

Generally, the Commonwealth of The Bahamas has an active labour force.

Participation rates have hovered around 76% for the past decade and participation continues beyond the retirement age (Table 2).

Unemployment rates had been less than 10% since 2005 and youth unemployment has decreased slightly from 18.9% to 17.6%.

Notable, too, is that 67% of the labour force is employed by the private sector.

However, public service remains the largest employer, employing 31% of all employed persons.
It is surmised that many persons, upon their retirement from public sector jobs, then are employed by the private sector.

30% of the labour force reported having no educational certificate—i.e., had passed no national examination.

As expected, this rate is higher among the unemployed than among the employed, 45.0% and 28.6% respectively (Table 3).
Men were more likely to have no educational certificate than women among both unemployed (52.0% vs. 40.2% respectively) and employed persons (35.2% vs. 21.6% respectively).

MInistry of Health, Commonwealth of The Bahamas 7 Table 2.
Labour Force by age and sex, All Bahamas, 2008 Labour Force by Age, gender and Employment Status AgE gROuP 15-19 20-24 25-34 35-44 45-54 55-64 Not Stated Total Total Labour Force Employed Labour Force unemployed Labour Force Total Women Men Total Women Men Total Women Men N % N % N % N % N % N % N % N % N % and over Table 3.
Labour Force by highest examination passed, 2008.

LABOuR FORCE By HigHEST ExAMiNATiON PASSED AND SEx:2008 ALL BAHAMAS ExAMiNATiON PASSED TOTAL % WOMEN MEN TOTAL WOMEN MEN TOTAL WOMEN MEN TOTAL LABOuR FORCE EMPLOyED uNEMPLOyED None 57,730 BJC/Pitman/RSA, Etc.
30,000 GCE O Level/BGCSE 35,770 30 16 19 21,775 35,955 50,130 18,130 32,000 7,600 3,645 3,955 14,920 15,080 27,000 13,200 13,800 3,000 1,720 1,280 20,040 15,730 32,555 18,035 14,520 3,215 2,005 1,210 GCE ‘A’ Level/Associate Degree 17,745 9 11,005 6,740 17,220 10,515 6,705 525 490 35 Degreed Persons 25,765 Professional (Non-University)/ Other Trade Certificate 22,085 Not Stated 2,500 13 12 1 14,110 11,655 25,150 13,830 11,320 615 280 335 10,485 11,600 20,835 9,895 10,940 1,250 590 660 825 1,675 2,030 480 1,550 470 345 125 Total 8 191,595 100 93,160 98,435 174,920 84,085 90,835 16,675 9,075 7,600 Annual Report of the Chief Medical Officer Male 7 POPuLATiON DEMOgRAPHiCS 20,000 15,000 10,000 5,000 0 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 7.1 POPuLATiON TRENDS Fig.
1.

Distribution of population by age and sex, 2004.

Male 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Male Female 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0 5,000 10,000 15,000 20,000 20,000 15,000 10,000 5,000 0 0 5,000 10,000 15,000 20,000 Fig.

2.

Fig.2.

Population distribution by age and sex, 2008.
80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Male Female 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Female 0 0 5,000 5,000 10,000 10,000 15,000 15,000 20,000 20,000 0 5,000 10,000 15,000 20,000 Source: Department of Statistics Population pyramids are evolving from a triangular shape to one like a barrel with a shrinking base, narrow apex and a bulging centre from which the labour force is drawn (Figs.
1-2).

Given a low dependency ratio of 0.54, each person of employable age (15-59) needs to support less than one additional person who is not employed.

Female 5,000 10,000 15,000 20,000 MInistry of Health, Commonwealth of The Bahamas 9 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0 Table 4.
Basic Demographic indicators, 2002 - 2008 indicator 2002 2003 2004 2005 2006 2007 2008 Year Estimated Mid-Interval Population 312,100 316,298 320,800 325,200 329,500 334,000 338,300 Estimated # women 15-44 age group 79,800 80,700 81,400 82,100 82,900 83,200 83,800 Total Births Live Births 5,270 5,132 5,250 5,654 5,390 5,937 5,562 5,216 5,054 5,154 5,548 5,296 5,854 5,480 Live Birth Rate (per 1,000 pop.)
16.7 16.0 16.1 17.1 16.0 17.5 16.2 Live Births (Registered*) for females 15-44 years 4,866 4,942 5,099 5,531 5,232 5,146 5,088 General Fertility Rate (live births per 1,000 females 15-49 yrs) Total Fertility Rates 58.2 1.92 56.1 1.87 55.5 1.90 50.0 2.05 55.4 1.93 61.1 2.14 56.7 2.00 Total Number of Deaths 1,827 1,666 1,736 1,824 1,730 1,798 1,862 Deaths Rate (per 1,000 pop.)
Stillbirths 5.9 54 5.3 90 5.4 96 Stillbirth Rate (per 1,000 total births) 10.4 17.8 18.6 5.6 106 19.1 5.2 94 5.4 83 5.5 82 17.7 14.2 15.0 Natural Increase 3,414 3,388 3,418 3,724 3,566 4,056 3,618 Natural Increase Rate (per 1,000 pop.)
10.9 10.8 10.6 Infant Deaths Infant Death Rate (per 1,000 live births) Perinatal Death Rate (per 1,000 total births)** *(2006, estimated occurrence) Neonatal Deaths *(2006, estimated occurrence)* Neonatal Death Rate (per 1,000 livebirths)* Maternal Deaths (Registered) Child Deaths (1-4 Years) Child Mortality Rate (per 10,000 children) 87 16.7 … … … 0 … … 87 17.2 21.2 30 5.9 2 10 3.9 89 17.3 22.3 30 5.8 2 15 6.5 Sources: Department of Statistics and Health Information & Research Unit, Ministry of Health Annual Report of the Chief Medical Officer Fig.
3.

Trends in population growth and associated factors, 1998 - 2008 s n o s r e P f o # 35,0000 34,0000 33,0000 32,0000 31,0000 30,0000 29,0000 28,0000 27,0000 Est.

Pop.

Livebirth Rate Nat.

Incr.


1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 n o i t a l u p o p 0 0 0 , 1 r e P 25 20 15 10 5 0 Source: Department of Statistics The natural increase of population varied between 10.6 and 12.1 persons per 1000, contributing to a stable average annual population growth of 1.9% for the past decade (Fig.

3).

Fig.

4.
3).

Fig.

4.

Age-specific fertility rates by age-group, 2004 - 2008 n o i t a l u p o p 0 0 0 , 1 r e P 120 100 80 60 40 20 0 1998 15-19 1999 2008 2007 2006 2005 2004 2003 30-34 2004 2005 35-39 2006 40-44 2007 2008 45-49 2000 20-24 2001 25-29 2002 Source: Health Information and Research Unit Age Group A slight increase in fertility rates was seen in all age-groups, including the 15-19 year old group (Fig.

4).
4).

This overall increase in all age groups peaked in 2007, with a decrease in 2008, however the rates never returned to the levels of 2004.

MInistry of Health, Commonwealth of The Bahamas 11 7.2 POPuLATiON MORTALiTy TRENDS As death rates stabilized, so did life expectancies, with gains becoming relatively smaller (Table 5).

Male life expectancy has steadily increased, while female life expectancy has varied slightly but remains greater than male life expectancy.

Table 5.
Table 5.

Life expectancy at birth, 1980 – 2008 ca.

1980 ca.

1990 ca.

2000 2008 L.E.

C.D.R.

L.E.

C.D.R.

L.E.

C.D.R.

L.E.

C.D.R.

Male Female 64.3 72.1 7.9 5.0 68.3 75.3 5.9 4.6 69.9 79.4 6.1 4.7 71.0 76.7 6.2 4.8 Source: Department of Statistics Fig.

5.
5.

Mortality rates – crude death rate per 100,000 pop., infant, neonatal and perinatal mortality rates per 1000 livebirths, and stillbirth rates per 1000 livebirths, 1998 - 2008 s e t a R 30 25 20 15 10 5 0 Crude Death Rate Stillbirth Rate Perinatal MR Neonatal MR IMR 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Source: HIRU Year Stillbirth rates, and hence, perinatal mortality rates show a rising trend (Fig.

5).
5).

Neonatal deaths more than doubled in 2005, from 30 to 72; although decreasing from then onwards, these remained higher than previous levels (Tables 4, 6).

Also notable was an increase in late neonatal deaths to 25 in 2005 from 8 the previous year, with no significant decline in subsequent years.

The apparent increase may be due to improved reporting.

It is remarkable that this was also the year of greatest natural increase.

12 Annual Report of the Chief Medical Officer Table 6.
Foetal and infant Deaths by age, 1999 - 2008 yEAR FOETAL DEATHS 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 75 63 51 54 90 96 86 72 83 82 REgiSTERED iNFANT DEATHS By AgE TOTAL iNFANT DEATHS <6 days 7-27 days 18 19 8 … 19 21 40 30 31 29 14 10 15 … 11 8 25 23 21 11 28 days- 11mths.

17 23 14 … 24 27 36 26 17 31 Registered Est.

Occurrences* 49 52 37 … 54 56 101 89 69 71 85 78 68 87 87 89 109 96 103 98 *Based on institutional census.

N.B.
N.B.

Differences between tables on infant deaths due to late registration.

Source: Registered Deaths, Department of Statistics and Health Information & Research Unit Table 7.

Crude deaths rates (per 100,000 pop.)

and ranks for leading causes of death, 2004 – 2008.

Condition 2004 2005 2006 2007 2008 Hypertensive Dis.

HIV/AIDS Cerebrovascular Dis.

Ischaemic Heart Dis.

Diabetes Mellitus Cancer of the Breast Cancer of the Prostate Motor Vehicle Inj.
Homicides CDR Rank CDR Rank CDR Rank CDR Rank CDR Rank These nine conditions, namely hypertensive disease, HIV/AIDS, cerebrovascular disease, ischaemic heart disease, diabetes, motor vehicle injuries, homicides, cancer of the breast in women and of the prostate in men, accounted for roughly half of all deaths each year – 53.4% in 2004, 48.1% in 2005, 54.2% in 2006 and 45.2% in 2007 (Table 7, Figs.
6, 7) .

Hypertension has remained the single leading cause of death in all years, except 2006 and 2008, when it was replaced by HIV/AIDS (2006) and ischaemic heart disease (2008).

Most noteworthy is the marked increase in homicide rates, which have almost doubled in four years, where males were nine times more likely to be murdered than females.
Also noted are decreases in the rates of deaths due to cancer of the breast in females and HIV/AIDS, although the death rates due to HIV/AIDS for males were almost one and a half times higher than that for females.

Death due to diabetes is the only rate that has remained constant over time, despite population-based interventions that have been initiated.

MInistry of Health, Commonwealth of The Bahamas 13 Fig.

6.
Leading causes of death, 2004, 2005 2004 2004 Hypertensive Diseases (I10-I15) Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) HIV Disease (AIDS) (B20-B24) Cerebrovascular Diseases (I60-I69) Cerebrovascular Diseases (I60-I69) Ischemic Heart Diseases (I20-I25) Ischemic Heart Diseases (I20-I25) Diabetes (E10- E14) Diabetes (E10- E14) Land Transport Accidents (V01-V89) Land Transport Accidents (V01-V89) Assault (homicide) (X85-Y09) Assault (homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Malignant Neoplasm of Female Breast (C50 in Women) Malignant neoplasm of prostate (C61) Malignant neoplasm of prostate (C61) Heart failure and complications and ill-deﬁned heart disease (150-151) Heart failure and complications and ill-deﬁned heart disease (150-151) Based on PAHO’s Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 02/07 2005 2005 Hypertensive Diseases (I10-I15) Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) HIV Disease (AIDS) (B20-B24) Cerebrovascular Diseases (I60-I69) Cerebrovascular Diseases (I60-I69) Ischemic Heart Diseases (I20-I25) Ischemic Heart Diseases (I20-I25) Diabetes (E10- E14) Diabetes (E10- E14) Certain Conditions Originating in the Perinatal Period (P00-P96) Certain Conditions Originating in the Perinatal Period (P00-P96) Land Transport Accidents (V01-V89) Land Transport Accidents (V01-V89) Assault (Homicide) (X85-Y09) Assault (Homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Malignant Neoplasm of Female Breast (C50 in Women) Heart failure and complications and ill-deﬁned heart disease (I50-I51) Heart failure and complications and ill-deﬁned heart disease (I50-I51) Based on PAHO’s Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 06/07 14 Annual Report of the Chief Medical Officer Fig.
7.
Leading causes of death, 2006, 2007 2006 2006 HIV Disease (AIDS) (B20-B24) HIV Disease (AIDS) (B20-B24) Hypertensive Diseases (I10-I15) Hypertensive Diseases (I10-I15) Ischemic Heart Diseases (I20-I25) Ischemic Heart Diseases (I20-I25) Cerebrovascular Diseases (I60-I69) Cerebrovascular Diseases (I60-I69) Diabetes (E10- E14) Diabetes (E10- E14) Certain Conditions Originating in the Perinatal Period (P00-P96) Certain Conditions Originating in the Perinatal Period (P00-P96) Assault (Homicide) (X85-Y09) Assault (Homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Malignant Neoplasm of Female Breast (C50 in Women) Land Transport Accidents (V01-V89) Land Transport Accidents (V01-V89) Malignant Neoplasm of Prostate (C61) Malignant Neoplasm of Prostate (C61) Based on PAHO’s Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 06/07 2007 2007 Hypertensive Diseases (I10-I15) Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) HIV Disease (AIDS) (B20-B24) Ischemic Heart Diseases (I20-I25) Ischemic Heart Diseases (I20-I25) Cerebrovascular Diseases (I60-I69) Cerebrovascular Diseases (I60-I69) Diabetes (E10- E14) Diabetes (E10- E14) Assault (Homicide) (X85-Y09) Assault (Homicide) (X85-Y09) Certain Conditions Originating in the Perinatal Period (P00-P96) Certain Conditions Originating in the Perinatal Period (P00-P96) Land Transport Accidents (V01-V89) Land Transport Accidents (V01-V89) Malignant Neoplasm of Female Breast (C50 in Women) Malignant Neoplasm of Female Breast (C50 in Women) Heart Failure and Complications and Ill-Deﬁned Heart Disease (I50-I51) Heart Failure and Complications and Ill-Deﬁned Heart Disease (I50-I51) Based on PAHO’s Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 01/2010 MInistry of Health, Commonwealth of The Bahamas 15 Fig.
8. years of potential life lost (yPLL) 2002-2006 6,000 5,000 4,000 L L P Y 3,000 2,000 1,000 0 2006 2005 2004 2003 2002 ) e d i c i m o H ( Source: HIRU Age Group & g n i n w o r D l a t n e d i c c A When mortality is measured using Years of Potential Life Lost (YPLL), HIV/AIDS outranks hypertension as the leading cause of mortality (Fig.
8), because people with hypertension generally die later in life.

For this reason, too, perinatal conditions and congenital anomalies ranked highly.

Most troubling was a four-fold increase in YPLL due to homicides, the result of more deaths at increasingly younger ages.
16 Annual Report of the Chief Medical Officer 8 SECTOR POLiCiES, PLANS & SuPPORTiNg SySTEMS 8.1 POLiCiES TO guiDE DELivERy OF SERviCES The National Food and Nutrition Policy and Agenda for Action for The Bahamas The Government of The Commonwealth of The Bahamas recognizes the correlation between the social determinants and health outcomes.

A healthy population is more productive, better able to learn and acquire skills, and more apt to engage in socially acceptable leisure and pleasure activities.
Notably, there is a close interrelationship between food, nutrition, levels of physical fitness and health status.

Good nutrition leads to proper growth and development, protects against diseases and reduces health care costs.

The health and well being of a population are dependent upon a good quality food supply system that is accessible, affordable, available, and sustainable.

These fundamental elements of food security contribute significantly to quality of life.
Low levels of physical fitness and lack of exercise are considered independent risk factors for many of the CNCDs, including hypertension, diabetes mellitus type 2, coronary heart disease, and some cancers.

The Ministry of Health and the Ministry of Agriculture and Marine Resources recognize this important relationship and the need for a comprehensive policy on food and nutrition.
In collaboration with other government ministries, a multi-sectoral committee was established to review the current food, nutrition and health situation, and set guidelines for improving food and nutrition security for all segments of the population and the many visitors to the country.

The result was the development of the Food and Nutrition Policy and Agenda for Action, which was proposed in 2008 by the Ministry of Health as a draft document, but not yet ratified.
PLANS, THEiR ASSESSMENTS AND EvALuATiONS 8.2 The National Health Service Strategic Plan 2006-2015 was drafted in 2005 but not given final approval.

While this plan was not finalized, portions of the draft document helped to guide programmes during the period of this report.

LEgiSLATiON iN SuPPORT OF SERviCE DELivERy 8.3 The following pieces of legislation have been prepared and/or enacted to facilitate delivery of quality health services to the people of the Commonwealth of The Bahamas.
Draft Revision of The Medical Act The draft Medical Act, which will repeal the existing Act, makes the Medical Council more effective by establishing it as a more autonomous body with four committees: a preliminary Proceedings Committee, an Education Committee, a Health Committee and a Professional Conduct Committee.
It is expected that the Act, once passed, will provide administrative structures to: (1) better regulate the medical profession, (2) upgrade doctors’ skills through its continuing education requirements, and (3) better safeguard the public through improved means of receiving and responding to complaints.
Amendment to The Dental Act A Bill for an Act to Regulate the Practice of Dentistry will repeal and replace the existing Dental Act, and will modernize and expand law and policy governing the practice of dentistry in The Bahamas by establishing statutory committees within the Dental Council.

Clause 4 of the Bill establishes an Education Committee, a Health Committee, a Preliminary Proceedings Committee, and a Disciplinary Committee.
MInistry of Health, Commonwealth of The Bahamas 17 The Nurses and Midwives Act The drafted Bill aims at addressing certain gaps in the existing Nurses and Midwives Act, Chapter 225.

New provisions address the extended roles of nurses and midwives, the registration of specialty nurses and nurse practitioners, and their continuing professional education.

Further provision is made to require practicing nurses and midwives to hold a license from the Nursing Council upon prescribed conditions.
A requirement for ongoing medical education will be added as one of the criteria in the licensing of nurses and midwives.

The Health Services Act (Chapter 231) The Health (Amendment) Rules 2010 An amendment to Rule 77 of the Health Services Act was proposed to facilitate new requirements for the certification of food handlers, as opposed to previous requirements based on an examination by a medical practitioner.
The Health Services Act, Chapter 231) Public Health Emergency Rules The new Public Health Emergency Rules are proposed to bring The Bahamas into compliance with International Health Regulations (2005) of the WHO, adopted by the 58th World Health Assembly on May 23, 2005.
8.4 HEALTH iNFORMATiON iPHIS plans The Integrated Public Health Information System (i-PHIS) is an automated client health record and reporting system that supports interventions by public health providers, including tracking, follow-up, case management, and public health reporting.

The system is intended to provide access to all client records by multiple health care providers across The Bahamas.
In February 2003 the Public Health Agency of Canada’s (PHAC) i-PHIS application was presented to representatives from the Department of Public Health.

The application was found to meet most of the key requirements for the Department of Public Health in The Bahamas.

A pilot study was conducted in June 2004 and evaluated a few months later in November.

The evaluation team recommended that The Bahamas proceed in implementing i-PHIS across The Bahamas.
Implementation of i-PHIS began in March 2007 and has continued since.

Challenges remain, however, in terms of connectivity across the archipelago and for adequate computer support among the country’s 30 inhabited islands.

18 Annual Report of the Chief Medical Officer 9 HEALTH iNFRASTRuCTuRE 9.1 ORgANizATiONAL STRuCTuRE The Ministry of Health’s organizational structure has experienced four challenging years, with various agencies added to or removed from the Minister’s portfolio during this time.
Additions to the Ministry’s organizational structure diverted attention from other matters impacting the country’s health during these years.

Organizational Structure 2004-06 (February) The Ministry of Health and the Environment was re-structured, with two of the three arms of public health under its authority: the Departments of Public Health and Environmental Health Services.

Veterinary public health was placed under the authority of the Ministry of Agriculture.
Organizational Structure 2006-07 (February) Ministry of Health and National Insurance For one year, the MOH became Ministry of Health and National Insurance.

This change aligned with the Government’s initiative to provide universal health insurance (National Health Insurance).

The resulting organizational structure moved the Department of Environmental Health Services to another Ministry; however, the Public Analyst’s Laboratory remained under the Ministry of Health.
Organizational Structure 2007 (February – May) Ministry of Health, National Insurance and Public Information The Ministry of Health and National Insurance expanded for three months, to include Public Information, which included Bahamas Information Services and the Broadcasting Corporation of The Bahamas, Radio and Television Broadcasting.

Organizational Structure 2007 (May-June) Ministry of Health In May 2007, a new Government of The Bahamas was elected.
Subsequent Cabinet appointments included a Minister for Health, whose portfolio included both the Ministry of Health and the Department of Environmental Health.

Organizational Structure 2007-2008 (July) Ministry of Health and Social Development (including DEHS) The Ministry of Health, which included the Department of Environmental Health Services, expanded to include Social Development for a little over a year.
Organizational Structure 2008 (September) Ministry of Health (excluding DEHS and Social Development) In September 2008, Cabinet re-assignments resulted in the Minister with responsibility for Health retaining only the Ministry of Health.
Organizational Structure 2004-2008 Public Hospitals Authority (PHA) PHA’s organizational structure remained stable from 2004-08, maintaining responsibility for three government hospitals, the primary health care system in Grand Bahama (Grand Bahama Health System), for shared services by the Bahamas National Drug Agency and Materials Management Directorate, and for the Emergency Medical Service.
MInistry of Health, Commonwealth of The Bahamas 19 Department of Public Health The Department of Public Health was under the direction of the Director of Public Health during the period 2004-07.

DPH was placed under the Office of the Chief Medical Officer from November 2007 to March 2009, during which time MOH conducted a search to fill the position of the Director of Public Health.

9.2 SERviCE DELivERy Primary health care is the core foundation of public health care services.
This is delivered through a network of 28 health centres, 33 main clinics, and 35 satellite clinics dispersed across 30 inhabited islands.
Through these local facilities, medical and nursing staff conduct general ambulatory care clinics and chronic non-communicable disease clinics that service patients with hypertension and diabetes, as well as specialized services through antenatal, postnatal and immunization clinics provided as part of a maternal and child health (MCH) programme, as well as school health and oral health clinics.
These different types of clinics include: • Health centre: a health facility with resident medical officer and nursing staff— offers overnight beds for patients and deliveries; offers ambulatory care, X-ray facilities, MCH services, and other specialized care.

• Main clinic: a health facility with a resident and/or visiting medical officer, or with a resident nurse but no overnight bed facility—offers MCH services and minimal emergency care.
• Satellite clinic: a small facility for visiting medical and nursing staff—usually provided for people living in remote areas.
Other national programmes that support the MOH’s primary health care thrust include: • Health Education and Promotion • Prison Health • Infectious Disease Surveillance • National HIV/AIDS Programme • Chronic Non-Communicable Disease Surveillance • Healthy Lifestyles and Nutrition • Department of Environmental Health Services • Health Information and Research Unit Complementing the primary health care system are three public hospitals and their services to in-patients and out-patients: • The Princess Margaret Hospital, (PMH)—400+ bed acute care facility that is the country’s referral institution located in Nassau, New Providence.
Its services/clinics include physiotherapy, speech therapy, occupational therapy, neurodevelopment, dialysis, ophthalmology, ear, nose and throat (ENT), obstetrics, oncology, oral health, orthopaedics, paediatrics, psychiatry, dermatology, surgery, and general medicine.

• The Rand Memorial Hospital (RMH)—85-bed hospital located on Grand Bahama, offering antenatal and postnatal clinics, paediatrics, gynaecology, psychiatry, orthopaedics, ophthalmology, ENT, surgery and general medicine.
20 Annual Report of the Chief Medical Officer • The Sandilands Rehabilitation Centre (SRC)—367-bed psychiatric and geriatric hospital in New Providence, offering a variety of mental health services including detoxification and occupational therapy.

The health system also includes private hospitals, Doctors Hospital and Lyford Cay Medical Facility and a chain of walk-in clinics, private practitioners and private medical offices.

9.3 FACiLiTiES 9.3.1 HOSPiTALS Table 8a.

Hospital Statistics, 2004 – 2008.
Princess Margaret Hospital Number of Beds Number of Discharges Average Length of Stay % Occupancy 2004 423 15,212 6.8 69.6 2005 405 14,846 6.8 70.4 2006 405 14,876 7.7 81.4 2007 405 14,969 7.8 82.0 2008 405 15,874 7.2 80.2 Total Outpatient Visits 119,622 145,779 141,988 132,215 142,247 Rand Memorial Hospital Number of Beds Number of Discharges Average Length of Stay % Occupancy 86 4,861 3.2 52.6 85 4,870 3.3 51.8 85 4,961 3.3 52.8 85 4,832 3.2 50.2 85 5,184 3.2 54.6 Total Outpatient Visits 56,036 60,827 60,848 64,618 68,196 Doctors Hospital Number of Beds Number of Discharges Average Length of Stay % Occupancy 72 2,887 3.7 40.4 72 3,051 4.1 47.8 72 3,104 4.0 47.0 72 3,168 4.2 50.7 72 3,060 4.3 50.0 Total Outpatient Visits 12,976 14,826 15,155 10,039 10,155 Lyford Cay Hospital Average Outpatient Visits … … … … 7,020 Source: HIRU, Ministry of Health; Lyford Cay Hospital MInistry of Health, Commonwealth of The Bahamas 21 In-patient stays at PMH were longer than those of RMH and Doctor’s Hospital (Table 8a).
Although PMH’s in-patient mortality rate decreased during the past ten years, it remains nearly twice that of the other two institutions (Fig.

9).

PMH serves as a primary referral hospital for the country.

RMH refers severely ill patients to PMH under a transfer agreement for more specialized services.

Lyford Cay Hospital does not support inpatient services and currently only provides outpatient services to its clientele.

Fig.

9.
Fig.

9.

Hospital in-patient death rates, 1997 – 2008. n o i t a l u p o P 0 0 0 , 0 0 1 / e t a R 6 5 4 3 2 1 0 PMH RMH Doctors 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Source: HIRU, Ministry of Health Year Table 8b.

Hospital Statistics, Sandilands Rehabilitation Centre, 2004 – 2008.
Psychiatric Hospital 2004 2005 2006 2007 2008 Number of Beds Number of Discharges Average Length of Stay % Occupancy 367 1,044 108.4 84.3 367 1,099 102.0 90.1 367 1,258 92.6 90.9 367 1,231 92.7 89.3 367 1,191 95.3 88.4 Total Outpatient Visits* 22,548 21,471 20,660 20,849 21,293 geriatric Hospital Number of Beds Number of Discharges Average Length of Stay % Occupancy 128 49 610.0 88.5 128 36 767.3 88.7 128 28 867.2 83.5 128 32 672.3 82.0 128 23 829.1 77.9 * These outpatient visits are held at the Community Counseling and Assessment Centre; figures estimated for 2007 and 2008.
22 Annual Report of the Chief Medical Officer The average length of stay in the geriatric hospital is reflective of its function as primarily a custodial facility for the elderly.

This extended length of stay speaks to the need for service costing under different models.

The cost of providing services in a nurs- ing home setting, with a greater emphasis on custodial care and less utilization of skilled staff in institutions, is a more efficient financing mechanism.

9.3.2 HEALTH CENTRES Table 9.
Community Health Centre Service Statistics, BAHAMAS, 2004-2008 New Providence 2004 2005 2006 2007 2008 Antenatal Clinic Postnatal Clinic Child Health Clinic School Health Clinic Other Clinic Services Other Domiciliary Services Total Outpatient Visits 250,589 236,312 244,035 257,912 246,623 grand Bahama and the Family islands Antenatal Clinic Postnatal Clinic Child Health Clinic School Health Clinic Other Clinic Services 9,309 4,072 38,022 28,049 9,519 4,729 34,759 26,254 9,622 5,521 36,916 26,834 9,590 6,026 36,386 27,338 9,245 5,850 37,247 26,595 127,658 128,297 131,954 142,754 142,097 Other Domiciliary Services 21,174 24,028 24,271 27,988 28,593 Total Outpatient Visits 228,284 227,586 235,118 250,082 249,627 Source: HIRU MInistry of Health, Commonwealth of The Bahamas 23 Persons living in the Family Islands have made greater use of outpatient clinics.
This is evidenced by an outpatient visit ratio of 3.38 visits per person compared to 1.13 per person for New Providence and 1.57 per person for Grand Bahama.

This may be the result of greater access to and/or utilization of private facilities on New Providence.

The total number of outpatient visits (Table 9) in New Providence remained relatively stable from 2004-08, while in Grand Bahama and the Family Islands the trend appears to be increasing with time.

Fig.

10.
Fig.

10.

Clinic visits in New Providence, grand Bahama and the Family islands, 2004 - 2008 30,0000 20,0000 10,0000 0 Grand Bahama Family Islands New Providence 2004 2005 2006 2007 2008 Fig.

11.
11.

Home visits in New Providence, grand Bahama and the Family islands, 2004-2008 30,0000 20,0000 10,0000 0 Grand Bahama Family Islands New Providence 2004 2005 2006 2007 2008 24 Annual Report of the Chief Medical Officer 9.4 RESOuRCES 9.4.1 MANPOWER Statistics for the health professions’ human resource (HR) capacity for 2004-08 (Table 10) reflect an overall increase across all disciplines.
In 2003, MOH recognized the need to maintain an adequate HR capacity in the nursing profession, in light of health care worker migration; thus, they developed a Nursing Recruitment and Retention Plan that prevented further mass migration of nurses from the system.

The University of the West Indies Medical School saw an increased enrollment of Bahamian medical students, which is reflected in the increasing number of physicians in the work force, particularly from 2006-08.

Table 10.
Table 10.

Human resources per 10,000 population, 2004 – 2008.

Health Care Workers 2004 2005 2006 2007 2008 # Rate # Rate # Rate # Rate # Rate Physicians Dentists 720 22.4 756 23.2 849 25.1 907 27.2 947 28.0 76 2.4 77 2.4 78 3.1 78 2.3 79 2.4 Registered Nurses 792 24.7 812 25.0 832 24.6 1004 31.4 1029 32.1 Trained Clinical Nurses 445 13.8 480 14.8 460 13.6 502 15.7 515 16.1 Pharmacists Nutritionists & Dietitians Radiographers Med.

Lab.
Lab.

Technologists Source: Health Professions Council, Bahamas Medical Council, Bahamas Dental Council, MInistry of Health, Commonwealth of The Bahamas 25 9.4.2 HEALTH SERviCES FiNANCiNg Table 11.
Annual Health Budgets 2003/2004-2008/2009 RECuRRENT ExPENDiTuRES Department 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 Ministry of Health 9,652,124 9,911,680 9,960,913 10,852,257 18,971,627 19,202,679 Department of Environmental Health 23,084,386 25,929,089 26,042,597 28,330,522 33,187,604 1 Department of Public Health 19,323,932 20,143,494 20,626,198 23,804,235 27,597,797 29,883,366 Public Hospitals Authority 108,611,339 118,948,888 127,926,488 142,420,539 164,364,206 174,140,170 Total 160,671,781 174,933,151 184,556,196 205,407,553 242,121,234 223,226,215 Capital Expenditures Ministry of Health & Department of Public Health Public Hospitals Authority Department of Environmental Health Services … … … 1,558,415 1,736,877 1,846,000 4,086,000 3,900,000 5,535,698 6,169,618 6,467,890 6,182.739 2,000,000 148,396,480 5,332,954 5,615,186 6,958,683 2 Totals … 155,490,593 13,239,449 13,929,076 11,727,419 5,900,000 Source: finance Department, Ministry of Health: 1.
Department of Environmental Health Services was no longer under the Ministry of Health budget in 2008/2009.

2.

Department of Environmental Health Services was no longer under the Ministry of Health budget in 2008/2009.

26 Annual Report of the Chief Medical Officer Fig.

12.

Expenditure on health activities, 2006 -2008 0 0 0 , 0 0 0 $ 300 250 200 150 100 50 0 Ministry of Health Public Hospitals Authority Department of Public Health Department of Env.
Health 2006/2007 2007/2008 2008/2009 Fiscal Year Source: Planning Unit, Ministry of Health The Ministry of Health operates under a continuously increasing annual budget, which by fiscal year 2007/08 had reached roughly 242 million dollars.

The majority of that budget was allocated to recurrent expenditures, the largest portion assigned to the Public Hospitals Authority for the inpatient management of health services.
Outside of the MOH operational budget, the Department of Public Health operates the smallest portion of the health budget—while maintaining primary health care services on approximately 30 inhabited islands throughout the archipelago.

The 2008/09 budgetary decrease reflects deployment of the Department of Environmental Health Services to another Ministry (Fig.

12).

MInistry of Health, Commonwealth of The Bahamas 27 10 HEALTH SERviCES & PROgRAMMES 10.1 MATERNAL AND CHiLD HEALTH Table 12.
Summary of antenatal services, coverage and utilization, 2004 – 2008.

Service & Coverage 2004 # % 2005 # % 2006 # % 2007 # % 2008 # % # Pregnant women 4214 4330 4290 4606 4500 < 15 years 15-19 years 5+ gravid Seen in <16 wks 3+ visits @ 36 wks.
High BP Hb<10gm Positive sugar Positive albumin GC Positive VDRL positive New cases of PET 139 3.3 200 4.6 144 3.4 147 3.2 135 3.0 New cases of eclampsia 4 0.1 19 0.4 25 0.6 7 0.2 3 0.1 New cases of severe anaemia 51 1.2 32 0.7 32 0.7 23 0.5 16 0.4 Source: Health Information and Research Unit 28 Annual Report of the Chief Medical Officer Table 13a.
Summary of perinatal information (Maternal indicators) 2005 – 2008 indicator Mothers 2005 # % 2006 # % 2007 # % 2008 # % 4902 4713 5268 5021 Mothers with pathology “ “ “ - multiple pregnancies “ “ “ - previous hypertension “ “ “ - preeclampsia Prenatal visits No visits or no data Premature labour Delivery - C-section Contraceptive advice Source: PAHO/WHO CLAP Perinatal Information System (SIP) Table 13b.
Summary of perinatal information (Neonatal indicators), 2005 - 2008 indicator Births 2005 # % 4838 2006 # % 4681 2007 # % 5220 2008 # % 4965 Small for dates Large for dates Apgar score 4-6 Apgar score 0-3 Premature newborn Low birth weight (<2500 gms) Very low birth weight (<1500 gms) Extremely low birth weight (<1000 gms) Breast feeding 1102 22.8 1462 31.2 1206 23.1 1027 20.7 Source: PAHO/WHO CLAP Perinatal Information System (SIP) MInistry of Health, Commonwealth of The Bahamas 29 Coverage of pregnant women by the antenatal service was high, with over 75% of pregnant women having 4 or more visits before term (Table 12).
More than 94% of pregnant women received documented antenatal care, with an average number of visits which ranged from 7.4 per mother in 2005 to 6.5 in 2008 (Table 13A).
This coverage rate has evolved in response to the proportion of women at risk for perinatal complications: 20-25% were teenage pregnancies that included an annual average of 43 pregnancies in teens younger than 15 years of age (range 22-96), 4%-6% were highly multigravid, 5%-8% had high blood pressure and another 2%-4% had indications of diabetes or gestational diabetes .
The incidence of anaemia has decreased from one in nine pregnant women in 2004 to one in 14 in 2008, resulting in an equally marked drop in new cases of severe anaemia.

The proportion of women with gonococcal infection (range 5.1-10.4%) and women with positive syphilis serology (range 1.1-2.5%) highlights the need for greater education and contact tracing.

Given the above, 12-16% of deliveries have had the potential for adverse outcomes.
That they do not lead to such outcomes underscores the effectiveness of our integration of MCH services at all levels, from clinic to hospital.

The increasing rate of deliveries by Caesarean section, as evidenced in Table 13A, clearly indicates the need for monitoring trends and identifying determinants that contribute to these higher risk procedures which impact length of stay.

One area warranting attention is the promotion of breast-feeding.
At the Maternity Ward of PMH, over 90% of mothers breastfed, but at the RMH, less than half the mothers breastfed (36%-45%) (Table 13B).

At the Private Surgical Ward of the PMH, that percentage decreases to approximately 15%.

Table 14.
Summary of Post natal and infant Child Health Services Service & Coverage 2004 2005 2006 2007 2008 # % # % # % # % # % # Deliveries 3036 3294 4042 4438 3886 Home visit in 3 days 2056 67.7 2341 71.1 2351 58.2 2477 55.8 1503 38.7 2+ home visits in <10 days 1616 53.2 1744 52.9 2263 53.9 2270 51.1 1129 29.2 Clinic <6 wks post delivery 2466 81.2 2513 76.3 2337 55.6 2571 57.9 2711 69.8 Contraceptive use 2429 80.0 2463 74.8 2239 53.3 2295 51.7 2686 69.1 Hb <10gm High BP Positive sugar Postpartum haemorrhage.
Puerperal Sepsis 1 0.0 3 0.1 - - - - 1 0.0 2 0.1 1 0.0 17 0.4 1st postnatal home visit <10 days 2918 96.1 3126 94.9 1715 42.4 4403 99.2 2830 72.8 1st child health clinic visit < 1 month 2156 71.0 2240 68.0 1845 45.6 2730 61.5 2476 63.7 Solely breast-fed @ 4 wks 274 24.3 366 22.0 424 28.5 394 21.4 325 23.9 Solely breast-fed @ 12 wks 64 19.0 96 12.5 73 11.6 127 31.7 82 17.1 Overweight @ 1 yr. Abnormal hearing 4 0.1 - 10 0.3 4 0.1 - 32 1.1 3 0.1 36 0.9 28 0.6 14 0.4 Source: Health Information and Research Unit 30 Annual Report of the Chief Medical Officer In the years prior to 2008, more than half of all new mothers had received a home visit within 3 days of delivery and two more home visits one week later (Table 14).
The percentages of new mothers with hypertension were not insignificant, ranging between 6.5% and 13.7%.

A higher than usual number of cases of puerperal sepsis occurred in 2008.

With the exception of 2006, rates of home visits of the newborn within 10 days were very high with nurses achieving near perfect coverage in 2007.
Breast feeding rates were low: less than one-quarter of babies are solely breast fed at 4 weeks, with the exception of a surge that was seen in 2007 as a result of the return of certified lactation specialists.

Unfortunately, this increase was not sustained, and while it had not returned to previous levels, the percentage of new mothers that solely breast fed at 4 weeks had again begun to decrease.

Table 15.

Reasons for attendance (first visits only) at child health clinics, 2004 – 2008.
Condition 2004 2005 2006 2007 2008 URTIs Ear disorders G/E Injuries* Ringworm Eye disorders Scabies Thrush Acute bronchitis * Includes poisonings Source: Health Information and Research Unit.
Because it is difficult to identify new cases or measure the catchment populations to truly determine incidence of diseases leading to a child’s first visit to the clinic, the relative magnitude of first visits is used as a proxy comparator.

Notably, respiratory infections were the premier reason for first attendance at health centres by children aged less than five years (Table 15).
10.2 ExPANDED PROgRAMME OF iMMuNizATiON (EPi) The EPI programme has maintained high levels of coverage (Table 16) despite challenges such as: • Inefficient stock management • Poor maintenance of refrigerators, thus threatening the cold chain • Conflict with new child health policy requiring that all children be seen by a physician before being immunized.
The result of an efficient and effective immunization programme has been the decline or eradication of most vaccine preventable conditions over the past two decades.
“The last recorded cases of vaccine preventable diseases were: • Poliomyelitis (More than 30 years ago) • Diphtheria (1988) • Mumps (1995) • Pertussis (1996) MInistry of Health, Commonwealth of The Bahamas 31 • Measles (1997) • Rubella & Congenital Rubella Syndrome (1998) • Tetanus neonatorum (1998) • Tetanus (2007) • Haemophilus Influenza type B (2004)” (EPI Report, 2009).

The first case of tetanus in twenty years occurred in 2007 in an unvaccinated Haitian national.
In 2006, Hepatitis B vaccine was introduced to school children aged 5-19 as part of the School Health Programme (Table 16).
Table 16. immunization coverage rates, 2004 - 2008 vaccine 2004 2005 2006 2007 2008 DPT HIB Hep B Polio MMR ATT Source: Department of Public Health 10.3 SCHOOL HEALTH SERviCES The School Health Services Programme provides preventive and curative medical and dental care.
These services are available without cost to students attending government primary and secondary schools throughout The Bahamas.

The major objective of this programme is to ensure that students are physically and mentally healthy, “so they can derive maximum benefits from their education and achieve their fullest potential (Draft Food and Nutrition Policy, 2008).” Table 17.
Results of health screening of grade i students, 2004 - 2008 Service & Coverage Children screened High BP Hb<10gm Sugar positive Vision problem Hearing defect Underweight Overweight Dental caries 2004 # % 2750 43 1.6 122 4.4 10 0.4 153 5.6 3 0.1 80 2.9 131 4.8 959 34.9 2005 # % 2006 17 0.9 90 4.5 23 1.2 152 7.6 1 0.0 49 2.4 70 3.5 2006 # % 3713 43 1.2 242 6.5 29 0.8 200 5.4 34 0.9 133 3.6 233 6.3 520 25.9 807 21.7 2007 # % 3294 24 0.7 344 10.4 2 0.1 164 5 6 0.2 93 2.8 287 8.7 1020 31 2008 # % 3841 126 3.3 77 2.0 27 0.7 153 4.0 2 0.1 72 1.9 355 9.2 908 23.6 Source: Health Information & Research Unit 32 Annual Report of the Chief Medical Officer Table 18.
Results of health screening of grade 6 students, 2004 - 2008 Service & Coverage Children screened 2004 # % 3349 2005 # % 2508 2006 # % 3980 2007 # % 3850 2008 # % 4275 High BP Hb<10gm Sugar positive Vision problem Hearing defect Underweight Overweight Dental caries 36 1.1 30 1.2 101 2.5 47 1.2 164 3.8 82 2.
.7 78 2.1 46 1.1 356 10.6 238 9.5 420 10.6 703 18.3 707 16.6 637 19.0 399 15.9 765 19.2 720 18.7 633 14.8 Table 19.
Results of health screening of grade 10 students, 2004 - 2008 Service & Coverage 2004 # % 2005 # % 2006 # % 2007 # % 2008 # % Children screened 2844 1242 3009 2845 3280 High BP Hb<10gm Sugar positive Vision problem Hearing defect Underweight Overweight Dental caries - Source: Health Information & Research Unit Significant numbers of children with vision problems and dental caries, and to a lesser extent, with anaemia and hypertension, were seen at all grade levels (Tables 17 - 19).
The situation with respect to oral health will be discussed further under that section.

MInistry of Health, Commonwealth of The Bahamas 33 Fig.

13.
13.

Percentage of children screened at school health clinic who were overweight 30 20 % 10 0 Grade 10 Grade 6 Grade 1 2004 2005 2006 Year 2007 2008 Source: Health Information and Research Unit Not only is the percentage of overweight children increasing in each and every cohort of school entrants, but in general, the higher the grade, the greater percentage of overweight children.
It would appear then firstly, that with each year, increasing numbers of school entrants are overweight and secondly, as the children age and progress through the grades, more of them become overweight (Fig.

13).

The 10.6% of Grade 6 school children in 2004 who were overweight increased to 13.0% by Grade 10 four years later—inferring a 0.6% increase each year.

These data suggest that of the 2008 Grade 1 entrants, 14.6% or one in every seven children will be overweight by Grade 10.
This highlights the importance of monitoring trends and patterns in order to evaluate the impact of programmatic changes on health outcomes.

34 Annual Report of the Chief Medical Officer Fig.

14.

Percentage of children screened at school health clinic who had high blood pressure.
% 4 3 2 1 0 Grade 10 Grade 6 Grade 1 2004 2005 2006 Year Source: Health Information and Research Unit 2007 2008 Although the numbers of school children with high blood pressure are small and must be interpreted cautiously, the increase in percentages of these school children over the years as they enter Grade 1, (from 1.6% in 2004 to 3.3% in 2008) , Grade 6 (from 1.1% to 3.8%) and Grade 10 (from 1.9% to 3.1%) as well as within the same cohort (1.1% of sixth-graders in 2004 to 3.1% when these students enter Grade 10) is still cause for alarm as a portent of increased morbidity in later life (Fig.
14).

These trends underscore the need to analyze data promptly and to use that data to alter programme direction and develop interventions that will prevent further poor health outcomes and reduce the occurrence of preventable diseases such as hypertension and diabetes.

10.4 iNFECTiOuS DiSEASE SuRvEiLLANCE 19 cases of malaria occurred on the island of Great Exuma between May-June, 2006 due to Plasmodium falciparum, imported and then locally transmitted.
These cases were successfully treated by chloroquine and primaquine with no associated mortality, and other effective interventions including active case-finding, treatment of cases, and mosquito control, stopped transmission within 30 days (Surveillance Report) MInistry of Health, Commonwealth of The Bahamas 35 Table 20.
Reported cases of infectious diseases and syndromes to CAREC, 2004 - 2008 Disease/syndrome 2004 2005 2006 2007* 2008* Acute haemorrhagic conjunctivitis Ciguatera poisoning Dengue fever & DHSS Food-borne illness Gastroenteritis in <5 year olds Gonococcal infections Influenza-like disease (ARI) Leptospirosis Malaria imported (introduced) Fever with rash Fever with neurological signs Undifferentiated fever Meningitis due to H. influenzae Acute flaccid paralysis Salmonellosis Shigellosis Syphilis Tuberculosis (all forms) Typhoid fever Viral hepatitis Tetanus Chicken Pox Undifferentiated fever Pneumonia 408 214 1 876 1279 111 4143 0 1 1 … … 1 0 20 12 398 47 1 … … 1129 … … 416 199 0 907 825 99 259 1 1 4 … … 0 1 17 11 376 48 0 … … 376 … … 650 139 0 634 1418 104 2904 0 30 (19) 4 37 232 1 10 6 … 64 2 .. … 476 356 … … 23 … 4429 1640 … 1913 … … 3 14 … … 2 7 3 … 48 … 1 1 200 185 … … 70 1 .. ... … … 1 7(2) … … … … 4 2 … 49 2 2 121 … 4 Source: Surveillance Report, Public Health Department The surveillance of notifiable diseases evolved to include surveillance of syndromes and other selected conditions over the period 2004-06 .
Some discontinuity in reported cases was reflected during the transition period.

Nevertheless, reports indicated that respiratory conditions, food and water-related illness and sexually transmitted diseases were the diseases with the highest incidence (Table 20).

36 Annual Report of the Chief Medical Officer 10.5 Hiv/AiDS HIV positive rates among pregnant women have remained stable during the review period (Table 21).

Table 21.
Table 21.

Hiv positivity rates among pregnant women screened, 2004 - 2008 Year Positivity Rate 2004 3.0% 2005 2.8% 2006 3.1% 2007 2.5% 2008 2.0% Fig.

15.
15.

MTCT Rates, 1995-2008 n o i t a l u p o P 0 0 0 , 0 0 1 / e t a R 60 50 40 30 20 10 0 On ART Not on ART Total 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year The HIV screening of antenatal women and treatment of those who are positive has steadily improved so that whereas in 1995, of 79 women screened positive, only 15 were on treatment, in 2008, of 89 women screened positive, 80 were on treatment (Table 22).
Moreover, transmission rates in mothers on treatment decreased to 0.0.

The artifactual increase in 2008 transmission rates among women highlights the challenges of managing prevention of mother to child transmission (PMTCT) in a highly mobile immigrant population that travels easily between countries in the Region during the gestational period and returning to The Bahamas for delivery of their infants and thus preventing the administration of effective antiretroviral therapy (Fig.

15).
15).

MInistry of Health, Commonwealth of The Bahamas 37 Table 22.

Hiv Mother-to-Child Transmission Rates, 1995-2008 AN On Treatmenta AN Not on Treatmentb No.

No.

Total AN No.
year +ve ANs +ve infants Rate +ve ANs +ve infants Rate +ve ANs +ve infants Rate Note: Figures for 1996 and 2005 have been revised on 06/08 to include two new cases identified in June, 2008.
In addition, women who were not on treatment in 2003 and 2004 include one pregnant woman who tested negative antenatally but tested positive post-delivery.

a Antenatals on treatment refers to those on a treatment regimen for pregnant women.
b Includes mothers who: i) had no antenatal care (some of whom may have been on treatment prior to pregnancy); ii) were not located; iii) delivered prior to being treated, e.g, late attendees, premature labour; iv) had abortions, miscarriages, stillbirths or intrauterine deaths before or after treatment; v) were on treatment prior to this pregnancy and did not take the required regimen for pregnancy; vi) had no treatment before or during pregnancy; or vii) refused treatment.
38 Annual Report of the Chief Medical Officer Table 23.
Hiv Surveillance of selected populations, 2004 – 2007, Bahamas Hiv year Populations Number Screened Number Positive Percent Positive Blood Donors 2007 Antenatals All STD Patients Blood Donors 2006 Antenatals All STD Patients Blood Donors 2005 Antenatals All STD Patients Blood Donors 2004 Antenatals All STD Patients Fig.

16.
New Cases of AiDS, by gender and year, August 1985-December 31, 2008, Bahamas r e b m u N 400 350 300 250 200 150 100 50 0 Male Female 8 8 9 1 - Year 8 0 0 2 r e b m e c e D 1 3 MInistry of Health, Commonwealth of The Bahamas 39 Source: Health Information and Research Unit From 1997, AIDS incidence has shown an overall decline, while at the same time the gender differential is decreasing towards a more even distribution of cases between the sexes (from a male to female ratio of 1.7 in 1988, to 1.9 in 1998 and 1.4 in 2007 and 1.6 in 2008), (Fig.
16).

Nevertheless, AIDS continued to predominate among males as seen in Fig.

17 while a more even gender distribution is seen among the non-AIDS cases.

This was not always the case, for at the start of the epidemic there were more male non-AIDS cases than female but by 1993, the gap had closed (Fig.

18).

The distribution of cases by age and sex revealed a gender ratio that was more inclined to females in the lower age-groups (Fig.

19).

Fig.17.
19).

Fig.17.

Cumulative Number of Reported Hiv infections, by Sex as of December 31.

2008, Bahamas 12,000 10,000 r e b m u N 8,000 6,000 4,000 2,000 0 Males Females Total AIDS Cases Non-Cases Total Infected Year Sources: Infectious Diseases Division, Public Health Dept.

and HIRU.

40 Annual Report of the Chief Medical Officer Fig.

18.
18.

Current Non-AiDS Hiv infections, by Sex and Reported year, Bahamas, 1985-2008 r e b m u N 500 450 400 350 300 250 200 150 100 50 0 Male Female Year 8 8 9 1 - 5 8 9 1 8 0 0 2 r e b m e c e D 1 3 Source: Department of Public Health – Infectious Disease Department & HIRU Fig.

19.
19.

Cumulative cases by age-group & Sex as at 31 December 2008 r e b m u N 1,400 1,200 1,000 800 600 400 200 0 Male Female <01 5-9 15-19 25-29 35-39 45-49 55-59 65+ Year Sources: Department of Public Health – Infectious Disease Department & HIRU MInistry of Health, Commonwealth of The Bahamas 41 10.6 TuBERCuLOSiS Table 24.
Status of Tuberculosis cases, BAHAMAS, 2004 – 2008 Characteristics Male Female Bahamian Non-Bahamian Culture +ve Culture -ve Culture Unk Ex-Pulmonary Pulmonary Smear +ve Smear –ve Smear Unk.
Dead Total New TB cases 2004 # % 2005 # % 36 76.7 34 70.8 14 29.8 32 68.1 16 33.3 2006 # % # % 28 58.3 20 41.7 26 54.2 22 45.8 40 83.3 0 0 8 16.7 6 12.5 42 87.5 34 81.0 5 11.9 3 7.1 7 14.6 48 45 2008 # % 36 73.5 13 26.5 32 65.3 11 34.7 47 95.9 2 4.1 0 0 5 11.1 44 89.8 34 77.3 9 20.4 1 2.3 7 8.2 49 46 Source: Department of Public Health The Tuberculosis (TB) incidence rate hovered around 15 per 100,000 population for the period under review; prevalence was estimated at between 3-8 per 100,000 population (Fig.
20).

TB cases were more likely to be male and Bahamian (Table 24).

Direct Observed Therapy Short-Course(DOTs) coverage in 2007 was 100%.

On average, 18.7% of the new smear positive cases died and 25% defaulted, so that the success rate was only 63%.

Of those smear-positive patients who were re-treated, the success rate increased to 71% but the death rate also increased to 21%.

There was one multi-drug-resistant case during the period 2004-08.
HIV prevalence in the TB population was at least 10 times higher than in the general population (Fig.

20).

During 2008, the HIV co-morbidity rate in female TB cases was less than 25%, but during the remainder of the time period co-morbid rates between the sexes differed little, ranging over the review period from 25% to 55% (Table 25).

42 Annual Report of the Chief Medical Officer Fig.
20. incidence and prevalence of TB and co-morbid Hiv, Bahamas, 1990-2008 Source: WHO Country TB database 35 35 30 30 25 25 20 20 15 15 , 0 0 0 0 0 1 r e p e t a R 40 35 30 25 20 15 10 5 , 0 0 0 0 0 1 r e p e t a R , 0 0 0 0 0 1 r e p e t a R 15 10 5 0 ) e l a c s x g o l ( t n e c r e P 101.5 101 100.5 1990 1995 2000 2005 1990 1995 2000 2005 Bahamas Incidence (all) Notiﬁed New and Relapse HIV Prevalence in TB HIV in General Population , 0 0 0 0 0 1 r e p t n e c r e P 6 5 4 3 2 1 1990 1995 2000 2005 1990 1995 2000 2005 Bahamas Prevalence (all forms) Mortality excluding PLWHA Mortality including PLWHA t n e c r e P 80 60 40 20 0 1990 1995 2000 Bahamas New ss(+) Retreatment 2005 1994 1996 1998 2000 2002 2004 2006 Bahamas Treatment Success Rate MInistry of Health, Commonwealth of The Bahamas 43 Table 25.
Distribution of Tuberculosis cases by co-morbidity with Hiv and sex, Bahamas, 2004 – 2008 year Morbid State Male Female TOTAL 2004 2005 2006 2007 2008 All TB 36 11 47 TB/Hiv 15 42% 5 45% 20 43% All TB 34 14 48 TB/Hiv 14 41% 6 43% 20 42% All TB 39 25 64 TB/Hiv 21 54% 11 44% All TB 28 20 TB/Hiv 8 29% 5 25% All TB 36 13 TB/Hiv 14 39% 3 23% 32 50% 48 13 27% 49 17 35% Source: Surveillance Unit, Department of Public Health 10.7 NON-COMMuNiCABLE DiSEASES & iNjuRiES Of all non-communicable diseases, hypertension may be the most prevalent and the condition generating the greatest need for health care.
Not only is hypertension the leading cause of mortality, it is, after injuries, also the next leading non-infectious condition responsible for hospital discharges followed by diabetes, with which it is frequently a co-morbid condition, especially among the elderly (Fig.

21).

Fig.

21.
21).

Fig.

21.

Selected conditions as percentages of total discharges (excluding deliveries) from Princess Margaret and Rand Memorial hospitals, 2004 – 2008 s e g r a h c s i D l a t o T f o % 14 12 10 8 6 4 2 0 Hypertension Ischaemic H.D.

AIDS Slow Fetal Growth Injuries and Poisonings Diabetes Stroke A.R.I.
2004 2005 2006 Year 2007 2008 Sources: Health Information & Research Unit; Statistics Unit, Public Hospitals Authority The register of 65+ year olds with hypertension and/or diabetes yielded prevalence rates of 620 and 252 per 10,000, respectively, for these two medical conditions in this age set.

Hypertension is the principal reason for a majority of new clients seeking care at health centres (Table 26).

Diabetes was the second leading diagnosis among new clients.
Significant numbers of new clients also attended the health centres for treatment of injuries, either road traffic injuries (RTI) or industrial accidents, and mental health conditions, as well as for arthritis.

44 Annual Report of the Chief Medical Officer Table 26.
New cases attending Primary Health Clinics for selected non- communicable conditions Condition Hypertension Diabetes Mellitus Arthritis RTIs Industrial Accidents Schizophrenia Epilepsy Sickle Cell Anaemia Alcohol Dependence Mental Retardation Source: Public Health Department The need for dialysis as a result of the complications associated with hypertension and diabetes is another major component of the utilization of health services.
There were 139 persons on dialysis at the Princess Margaret Hospital in 2007, the vast majority of whom were hypertensive, with and without diabetes (Fig.

22).

The other conditions present in dialysis patients were diabetes only, systemic lupus erythematous (SLE) and polycystic kidney disease (PKD).

Fig.

22.
Fig.

22.

Patients on dialysis at Princess Margarget Hospital by underlying condition, 2007 Hypertension Hypertension with Diabetes Diabetes SLE PKD Other 2007 Source: Dialysis Unit, Princess Margaret Hospital Although not reflected in hospital discharge statistics, cancers are a major cause of ill-health.

As seen earlier (Page 13), neoplasms of the prostate and breast rank among the top ten causes of mortality in males and females, respectively.
Data from the Princess Margaret Hospital show that the most common sites are indeed breast and prostate, followed by colon/rectum and uterus/ovary (Fig.

23).

MInistry of Health, Commonwealth of The Bahamas 45 Fig.

23.
Summary of cancer sites by gender, Princess Margaret Hospital, 2008 Males 152 Females 205 Oral Cavity & Pharynx-7 Lung & Bronchus-8 Pancreas-2 Kidney & Renal Pelvis-1 Urinary Bladder-1 Colon % Rectum-18 Prostate-64 Non-Hodgkin Lymphonia-6 Melanoma of the Skin-2 Leukemia-1 5% 5% 1% 1% 1% 12% 42% 4% 1% 1% Thyroid-4 Lung & Bronchus-3 Breast-92 Kidney & Renal Pelvis-3 Ovary-3 Uterine Corpus-12 Colon & Rectum-20 Non-Hodgkin Lymphonia-5 Melanoma of the Skin-0 Leukemia-0 2% 1% 45% 1% 1% 6% 10% 2% 0% 0% All Other Sites-42 28% All Other Sites-63 31% Source: Princess Margaret Hospital, New Providence 10.8 MENTAL HEALTH SERviCES Mental health services are provided under the umbrella of the Ministry of Health through both the Department of Public Health and the Public Hospitals Authority.
The Sandilands Rehabilitation Centre (SRC) provides in-patient psychiatric and mental health care, including a three hundred and sixty-seven bed inpatient unit in New Providence.

Off-site, SRC has one out- patient facility, the Community Counseling and Assessment Centre (CCAC).

The Rand Memorial Hospital in Grand Bahama also provides inpatient mental health services through the Diah Ward.
Additional programmes for mental health services in the Department of Public Health include adolescent services, the male health initiative, community health clinics, and psychiatric services offered through the Family Islands’ Community Clinics.
Discharges from the Sandilands Rehabilitation Centre and the Diah Ward of the Rand Memorial Hospital indicate a rate of 414.3 discharges per 100,000 population for mental illness, with an average length of stay of more than 90 days, varying between 92.5 days in 2004 and 95.3 days in 2008.

The most common conditions presenting for treatment were schizophrenia and disorders due to psychoactive substance abuse (Fig.

24).
24).

Males were three times more likely than females to be hospitalized for mental health conditions.

46 Annual Report of the Chief Medical Officer Fig.

24.
Patients treated in mental health facilities by diagnosis e g a t n e c r e P 100 90 80 70 60 50 40 30 20 10 0 CCAC Diah Ward SRC Other Mood Disorders Personality Disorders Neurotic Disorders Schizophrenia Substance Abuse 10.9 ORAL HEALTH SERviCES The Oral Health Services Unit within the Department of Public Health provides services through regular clinics at some community health facilities, Her Majesty’s Prison and Sandilands Rehabilitation Centre, as well as through visits to schools and some Family Islands.
The thrust of the programme is to move away from extractions and towards preventive and restorative care, especially for children.

From 2002 to 2006, there was a small but steady improvement in the percentage of children who were caries-free in Grades 1 and 6, with a concomitant reduction in the decayed, missing and filled permanent teeth (DMFT) score (Tables 27, 28).
Table 27. grade 1 Caries Prevalence Trends, 2002 - 2006 year # students Screened % caries- free # person with decayed teeth # decayed teeth 2002/3 2003/4 2004/5 2005/6 1693 2120 2106 2197 51.03 53.87 55.60 56.16 829 952 935 838 3012 3505 3251 3368 dmft 3.60 3.58 3.48 3.49 MInistry of Health, Commonwealth of The Bahamas 47 Table 28. grade 6 Caries Prevalence Trends, 2002 -2006 year # students Screened % caries- free # persons with decayed permanent teeth # decayed permanent teeth DMFT 2002/3 2003/4 2004/5 2005/6 1864 2579 2565 2071 77.20 77.08 81.95 80.61 Source: Oral Health Services, Department of Public Health 389 591 462 498 708 932 709 780 1.70 1.67 1.54 1.56 Each year, among Grade 1 students, as many as 4 children may have 10 or more decayed primary teeth.
The high percentage of children in Grade 1 with dental caries highlights the need for increased attention to preventive oral health efforts and greater use of sealants in children.

Among older children, the decayed permanent teeth score (D), consistently contributed 97% to the DMFT score.

Internationally established goals indicate that at least 50% of 5-6 year olds should be caries-free, and that the average DMFT for 11-12 year olds should be less than 3.
The Bahamas has achieved the first goal and aims to better it, while working toward the second goal.

Fig.

25.

School Dental Services-Clinical Activity Trends 2002-2006 3,000 2,500 r e b m u N 2,000 1,500 1,000 500 0 Exts Rest.

Txs Previous Txs.

# Pts.

Seen 2002 2003 2004 2005 2006 48 Annual Report of the Chief Medical Officer As can be seen from Fig.

25, there has been a decrease in the number of patients seen by the school dental services.
This may be due to the increased number of dental clinics at community centres whose proximity to home or work may make them more convenient for parents.

Nevertheless, the marked increase in preventive and restorative treatments among children from 2005-06 also has been a result of greater efforts at prevention and restoration with the operation of the several dental clinics and introduction of a surveillance programme within the school dental service.
However, medical and dental officers express concern that the clinics’ goals are not being met, due to human as well as equipment constraints.

Fig.

26 shows a breakdown of preventive care at selected dental clinics throughout The Bahamas.

Fig.

26 Preventive Dental Treatments Rendered by Clinic-New Providence & Family islands-2006 r e b m u N 700 600 500 400 300 200 100 0 Fluoride Tx Child Prophy Adult Prophy Sealants Abaco G.H.

Eleu.

Exuma So.

Eleu.


SDC EEC SBC FGC FSC 10.10 NuTRiTiON As noted earlier, the currently small but rising percentage of overweight Bahamian children is a cause for alarm.

Diabetes is a disabling medical condition and a costly one for society.

Low breast-feeding rates may be a contributing factor to increasing obesity among children, since breast-feeding often is replaced with high but “empty” caloric food choices.
School screening data (Tables 17 - 19) revealed increasing rates of obesity across the spectrum of childhood.

These data demonstrated that in Grade 1, obesity ranged from 4.8% to 9.2% of children screened.

This rate increased for Grade 6, which had fluctuating rates (low of 9.5% in 2005 to a high of 18.3% in 2007) and was demonstrated in 16.6% of the children screened in 2008.
Grade 10 screening indicated an even greater percentage of children who were overweight—as much as 23.7% of screened individuals in 2007 (range 12.5-23.7%).

Additionally, anaemia in children and pregnant women (about 5% each in the two groups), is also an indicator of food choices lacking in nutritional value.

The Nutrition Department offers counseling to those referred from clinics.

These are usually extreme cases.


The Department has taken a proactive approach, initiating a garden-based learning project that complements the education of vendors and the setting of standards for school tuck shops, while supporting the activities of other departments such as the Healthy Lifestyle Initiative and the Health-Promoting Schools Initiative.

MInistry of Health, Commonwealth of The Bahamas 49 10.11 HEALTH PROMOTiON & EDuCATiON Efforts are underway to build a national policy on health promotion.
The Department also has launched a Health-Promoting Schools Initiative, with a sensitization workshop and identifying school focal points as the basis of school-based health promotion committees.

The Department does not have in-house recording and reporting capability and utilizes resources to support their services.

This does not allow for a strategic and systematic approach to the optimal development of these services.
The Department has produced the following media presentations – “Joining Hands for Health”, “My Life, My Future”, and “Foundations for Healthy Living”, as well as a segment in the Ministry of Education’s Learning Resource Section, “A Time for Education”.

The Department also has introduced a system of identifying educational needs for wellness promotion in fundamental health priority areas of concern.
10.12 HEALTHy LiFESTyLES iNiTiATivE The Healthy Lifestyles Initiative was launched in October 2005 with the goal of reducing the levels of morbidity, disability and premature deaths associated with lifestyle-related diseases (CNCD)—diabetes, hypertension, chronic respiratory disease, heart disease, and cancer.

The Healthy Lifestyles Initiative was designed to reduce the prevalence of risk factors that lead to CNCDs, specifically: smoking, physical inactivity, an unhealthy diet, and poor nutrition.
Using a population health approach and collaborative efforts with government agencies, private services, churches, schools, and other NGO’s, the Healthy Lifestyles Initiative has sought to promote health and prevent disease.

The initiative focuses on physical activity and healthy eating, and on the relationship of these activities to healthy weights.
This initiative also incorporates risk factor screening, including glucose and cholesterol screening and body mass index determinations and documentation in Healthy Lifestyle Passports.

In 2006, Healthy Lifestyles screened 5,000 persons.

That number increased to 8,360 people who were screened and counselled at 119 locations during 2007.

The Healthy Lifestyles Initiative conducted 116 health fairs or screening sessions in 2007, an increase from the 70 that were conducted in 2006.
10.13 PRiSON HEALTH SERviCES The Prison Health Initiative provides access to comprehensive health services for inmates of Her Majesty’s Prison (HMP).

These services include: routine medical evaluations, managing chronic non-communicable diseases, acute minor medical emergencies, infectious disease management, drug demand reduction, and routine dental care.
Mental and psychological health care continue to be provided by personnel from the government owned psychiatric hospital at Sandilands Rehabilitation Centre.

Daily dental care is provided by a Dentist.

HMP’s clinic is a collaborative effort staffed by people from both the Department of Public Health and National Security.
It is staffed by two full-time physicians, three part-time senior physicians, two registered nurses (one of whom is a Public Health Nurse Coordinator for Prison Health Services), as well as two trained clinical nurses (one trained in psychiatry), four trained clinical nurses (who are also Prison Officers), a part-time pharmacist, and a phlebotomist-aide.

Upon admission, all inmates are tested for the presence of communicable diseases.
On average, 2,458 persons are admitted to HMP annually; of these, 13.8% are infected with tuberculosis, 2.0% are infected with HIV, 1.8% are infected with syphilis, and 1.7% are infected with Hepatitis B.

50 Annual Report of the Chief Medical Officer Table 29.
Prison Health Screening, 2004-2008 iNDiCATORS 2004 2005 2006 2007 2008 Total admissions Male Female Average number of admissions per month Total persons <35 years of age Total persons 35+ years of age Total return visits Return visits within one year Total number persons with positive Mantoux skin test Number released before Mantoux skin test read Return visits with previously known positive Mantoux skin test Total chest X-rays completed Number of persons released before chest X-ray completed Total HIV positive Total Hepatitis B positive Total VDRL (Syphilis) Positive Total General Complaints seen Source: Prison Health Services 2549 2447 102 212 1701 848 1017 206 381 … 394 312 73 58 53 54 2633 2471 162 … 1813 820 1158 201 362 369 383 229 71 61 46 58 2356 1774 166 196 1658 698 1124 141 267 … 275 129 138 46 47 50 2284 2146 138 190 1604 680 822 135 338 … … 188 150 43 34 29 2469 2290 179 206 1792 677 1266 157 343 190 398 233 110 36 30 30 3288 4009 4227 2952 4227 MInistry of Health, Commonwealth of The Bahamas 51 11ENviRON MENTAL HEALTH SERviCES 11.1 WATER AND SEWERAgE MANAgEMENT Sewerage disposal continues to pose a challenge in the Family Islands.
Although most premises are connected to a septic tank, roughly 40% have no effluent system attached (e.g., soak away).

Pump-out systems are limited or in many instances not available, and any final sewage disposal infrastructure is practically non-existent.

The Department of Environmental Health Services (DEHS) continues to advocate for change in this regard, taking opportunities to advise owners and in a few instances to initiate legal actions.
The various responsible agencies for providing infrastructure are aware of these needs, but have indicated a financial inability to act.

Monitoring and evaluating systems are implemented for the few wastewater treatment plants that exist, which are primarily associated with hotels and related establishments.

Water quality remains a challenge and DEHS routinely tests water samples to ensure the health and safety of water for the people of The Bahamas.
One hundred and thirty-three (133) of five hundred and nineteen (519) water samples taken were found to be fully satisfactory, however, of these, 97 (18.7%) had no chlorine present.

11.2 SOLiD WASTE MANAgEMENT There has been an improvement in the management of solid waste since the introduction of modified landfills.

Transfer stations and barging now are available for the disposal of waste in some islands and settlements.
However, these resources are incomplete and still many open dumps continue to be used.

The component of waste collection and recycling has lagged behind and as a result indiscriminate dumping continues to be a problem.

While the legal framework has assigned components of general sanitation, derelict vehicle disposal, and the management of open dump sites to local government councils in the Family Islands, often financial resources are reportedly inadequate to fully implement these decisions.
One result has been that DEHS often has only partially funded work for these items.

11.3 FOOD SAFETy – ESTABLiSHMENTS iNSPECTED AND PASSED; TRAiNiNg OF FOOD HANDLERS 825 of 917 (93.5%) of food handlers were approved for vending permits.

The Health Inspectorate Division of DEHS is responsible for monitoring all food establishments and itinerant vendors.

This division is present in all the major Family islands.

The division is also involved in training food handlers.
Imported meats and meat products are inspected upon entry to ensure they meet all requirements.

The Port Health Officer in New Providence conducted the inspections.

All imported meats and meat products were deemed satisfactory.

Table 30.
Table 30.

Annual Meat Statistics, New Providence, 2004-2008 year Weight Number of cases 2004 2005 2006 2007 2008 399,537,198.8 165,556,404.7 134,996,778.0 156,481,148.3 45,787,931 2,319,168.2 11,648,929.5 2,492,223.3 2,690,142 1,035,877 Source: Department of Environmental Health Services 52 Annual Report of the Chief Medical Officer Inspections are also conducted at food stores and warehouses to ensure proper storage and refrigeration.
Challenging situations have arisen, with expired food items being offered for sale.

Five food establishments were closed temporarily due to their ineffective compliance with environmental standards.

In 2004, the Ministry of Health assumed sole responsibility for issuing food handlers’ certificates.

This was initiated in conjunction with a mandatory 4-hour safe food course for all food handlers.
The mandatory safe food course began in New Providence and by 2005 had been expanded to include Long Island, Eleuthera, Andros, Cat Island, Abaco and Exuma and the Cays.

Islands without resident trainers were supported from the Central programme in New Providence.

The training programme trained an average of three hundred (300) persons weekly and included five (5) international Serve-Safe instructors capable of training other instructors across The Bahamas.
Training for Serve-Safe instructors was expanded to Grand Bahama in 2006, when sixteen (16) trained instructors were introduced, enabling Grand Bahama to provide more consistent Serve-Safe food safety training to food handlers on that island.

In 2006, the Health Services Act, Chapter 216, Rule 77 was amended to facilitate a new legislative requirement for the certification of all food handlers, including all persons connected with the production, storage, transportation, or care of food stuffs.
It was the responsibility of the owners and operators of food establishments to ensure that all their workers had current, valid food handlers’ certificates, which must be made available upon request by an authorized Health Officer.

Food safety training is now available in most of the larger inhabited Family Islands.

Support from the Central Programme continues to provide services when any gaps in the system are recognized.

Table 31.
Food Handlers Training Sessions Fiscal year 2004 2005 2006 2007 2008 Number of Food Handlers Trained 12,042 18,771 19,481 21,243 21,670 Number of International Safe Serve Instructors … … 19 21 21 11.4 vECTOR CONTROL – AEDES AEgyPTi iNDiCES; RODENT CONTROL ACTiviTiES To increase Anopheles larval control efficiency in Exuma, DEHS implemented an aquatic weed control programme to limit or eliminate growth of aquatic weeds that provide harborage for larvae and create a physical barrier to the larvicide.
While the initial application of herbicides via airboats has been successful, the maintenance phase—with its introduction of sterilized grass carp—has suffered a setback.

This was due largely to the increased average salinity levels in the ponds, resulting in fish mortality.

The airboat has served to increase coverage of larvicidal applications and considerably reduce the time needed for chemical application.

MInistry of Health, Commonwealth of The Bahamas 53 Fig.

27.
27.

2008 Exuma Anopheles Larval Total Average x e d n I 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0. Epidemiological Week Source: DEHS Fig.

28.
Exuma Human Bait Collection Total Average, 2008 x e d n I r u o H r e p n a M r e p o t i u q s o M 18 16 14 12 10 8 6 4 2 0 R N R N R N R N R N R N R N R N R N R N R N R N Epidemiological Week Source: Department of Environmental Health Services 54 Annual Report of the Chief Medical Officer Many cleanup initiatives in New Providence and the Family Islands have resulted in a cleaner environment and in reducing the sources for breeding Aedes aegypti mosquitos.
Other efforts to be proactive include providing information to the news media, advising the public of the availability of assistance, ensuring their premises are kept free of any man-made water holding containers.

Where these containers are needed, they are managed so that they do not collect water.

Relevant educational activities such as lectures and displays have been conducted in many schools and at numerous health and career fairs.
Rodent control operations were conducted extensively in New Providence, Grand Bahama and in island settlements requiring treatment.

Surveillance measures and the application of treatment involving the placement of bait stations containing anti- coagulant rodenticide have been the method of choice.

Of special note was a rodent control and conch shell cleanup conducted on Bayshore Road and the settlement of West End, Grand Bahama.
This project offered an excellent example of a public-private partnership effort in addressing the need for remedial action.

As a result of this coalition and collaboration, rodent infestation was reduced considerably, the shoreline was cleared of piles of conch shells, and derelict boats and other debris were removed.
11.5 PORT HEALTH – iNSPECTiONS AND RESuLTS In compliance with the International Health Regulations (2005), port health has responsibility for the inspection and issuance of ship sanitation certificates and ship sanitation exemption certificates for all international vessels.
During the period January 2004 through December 2008, the Port Health Officer in New Providence inspected a total of 133 vessels (75 cruise ships, 53 freight vessels and 5 pleasure craft) and issued ship sanitation exemption certificates.

No sanitation measures were required.

MInistry of Health, Commonwealth of The Bahamas 55 12 HOSPiTAL SERviCES 12.1 iN-PATiENT Table 32.

Hospital utilization by service, PMH and RMH, 2008 Service Discharges Patient Days Ave. length of stay No.
of beds Intensive Care Unit Medical/Surgery Obstetrics/Gynaecology Paediatrics Neonatal ICU Psychiatry Source: Kurt , Salmon & Associates 115 8,690 5,671 1,619 537 - PMH RMH PMH 2895 88 RMH 804 8,436 3,750 1,752 390 - 1,841 2,662 69,329 1,645 14,222 21,017 11,485 620 35 224 PMH 25.2 8.0 2.5 13.0 21.4 - RMH PMH RMH 9.1 3.2 2.3 2.8 11.1 8.2 9 229 50 68 - 4 33 19 12 5 12 Average length of stay was consistently longer at Princess Margaret Hospital than at Rand Memorial Hospital, for all units with the exception of Obstetrics and Gynaecology which were similar in length (Table 32).
12.2 LABORATORy Table 33.
Laboratory tests at Princess Margaret Hospital by type of test, 2004-2008 Department 2004 2005 2006 2007 2008 Haematology - # Tests: Microbiology: # Tests # Specimens … 61,194 74,785 76,090 70,715 94,982 … … … … 31,834 32,079 32,264 37,367 42,233 Blood Bank - # Tests: 40,354 32,643 39,806 42,580 48,599 Transfusion Medicine - # Tests: 58,745 57,748 55,006 63,064 70,848 Cytology: # Non-Gynae # Papsmear slides 364 269 297 350 295 6,888 7,888 7,663 7,629 8,249 Histology - # Slides: 22,903 26,607 29,196 28,491 27,515 Chemistry: Serology: Stat Lab - # Tests … … … … … … … … … ... … … … … 514,274 Blood Bank tests include: Cross-match, Patient blood group, Direct coombs test, Indirect coombs test Transfusion medicine tests include: HIV, HBsAg, Corzyme,Anti HBS, HepB Conf (began February 2008), RPR, CMV (began June 2007), HTLV1/2, HCV, HAV Stat Lab tests include: WBC (Haematology), Chemistry, UA (Microbiology), UHCG (Microbiology), ABG (Chemistry), CSF (Microbiol- ogy and Chemistry) 56 Annual Report of the Chief Medical Officer The reporting of laboratory statistics has been challenged by an inadequate Laboratory Information System, which was not capable of providing statistical reports (Table 34).
Within those Departments able to provide statistics, the increasing volume of tests also reflects the increasing number of discharges seen in Princess Margaret Hospital (Table 8A).

12.2.1 EMERgENCy RESPONSE Table 34.
Accident & Emergency Department – contacts by age, sex, 2004 - 2008 FACiLiTy 2004 2005 2006 2007 2008 PRiNCESS MARgARET HOSPiTAL (PMH): 1) # Visits 2) # Registered - Gender: Male Female - Age Groups: <1 1-4 5-14 15-24 25-44 45-64 65+ RAND MEMORiAL HOSPiTAL (RMH): 1) # Visits 2) # Registered 4,886 4,541 4,303 4,162 4,209 … … … ... … Source: Keane System, Public Hospitals Authority Definition: 1) Visits - INDICATE patients seen and treated by medical staff in the A&E department.
2) Registered - INDICATE persons registered in A&E for medical care, but DOES NOT INDICATE the actual persons seen and treated by medical staff as patients may leave the department before receiving medical attention.

The volume of visits to the Accident and Emergency Department has been increasing over the previous five years.

Data from 2004-08 (Table 34) demonstrates a roughly equal distribution of males and females.
Children 0-4 years of age now account for approximately 9% of the Bahamian population, however, this age group accounts for about 15% of the Accident and Emergency population.

MInistry of Health, Commonwealth of The Bahamas 57 Table 35 – New Providence emergency Response Data, 2004 – 2008.

2004 2005 2006 2007 2008 Call Type # calls Ave.

Response Time TRAuMA Calls; 2853 # calls 3011 1 Ave.

Response Time # calls 3210 7 Ave.

Response Time # calls 3641 8 Ave.

Response Time # calls 3745 5 Ave.
Response Time 0:21:05 419 0:23:31 423 0:22:23 614 0:20:15 726 0:19:56 Airplane Crash Assaults/Rape Bomb/explosion/Major disaster Burn victims/Explosion Electrocution Falls/Back Injuries (Traumatic) Gunshot Wound RTA, Traumatic Injuries (specify) Stabbing 4 405 4 42 7 421 132 1601 237 Medical Calls: 2330 Carbon Monoxide/Inhalation Hazmat Cardiac/Respiratory Arrest/Death Near Drowning/Diving Incident Poisoning/Overdose/Ingestion Stroke/CVA Unconscious/Breathing Problem Ordinary Problem Calls: Abdominal Pains/Problem Allergies/Hives/Med-Reactions Animal Bite(s)/Attack(s) Asthmatic Choking Diabetic Problem(s) Eye Problem(s)/Injuries 0 581 33 91 198 1427 6469 509 14 13 306 10 377 6 10 44 6 407 121 0:17:56 0:14:13 0:16:54 0:25:14 0:12:46 2 30 6 514 146 0:14:00 0:23:28 0:12:35 1 31 6 560 193 0:14:47 0:15:00 0:20:55 0:12:38 2 27 3 573 204 0:17:35 0:10:54 0:19:59 0:13:56 0:16:38 1699 0:17:19 1781 0:17:32 1911 0:17:52 1897 0:19:04 304 0:16:28 301 0:19:29 317 0:19:48 308 2352 2 2401 1 2805 2 2993 3 0:21:45 606 0:20:59 612 0:22:28 688 0:19:47 723 0:18:27 0:19:55 52 78 0:15:50 0:32:07 41 79 0:16:09 0:22:59 46 85 0:13:20 0:18:19 40 99 0:22:00 201 0:25:07 200 0:22:24 239 0:22:38 243 0:19:27 1414 0:21:07 1468 0:20:12 1745 0:19:21 1885 7264 7041 7074 7298 0:27:38 478 0:31:40 431 0:28:41 491 0:26:28 548 0:21:30 0:14:40 23 11 0:19:49 401 0:16:23 0:19:16 0:05:41 9 469 11 0:19:54 0:21:11 0:19:46 0:14:55 0:21:41 0:16:33 35 13 286 11 450 6 0:18:07 0:14:11 0:20:11 0:14:58 0:22:31 0:16:10 25 8 327 10 445 7 0:12:31 0:20:28 0:17:52 0:10:46 0:21:34 0:28:49 46 15 390 14 856 15 Fainting/Fits/Convulsions 1363 0:19:06 1646 0:19:30 1576 0:18:49 1585 0:18:35 1688 Fracture(s)-Lower Fracture(s)-Upper Lacerations/Haemorrhage Maternity/childbirth/BBA Ordinary Sickness/Sick Call Psychiatric/Suicide Attempt Unknown Problem (Person Down) Vomiting/diarrhea 125 49 564 1012 1097 584 111 329 0:25:11 0:25:49 0:21:13 126 66 698 0:28:27 0:26:30 0:22:38 107 52 590 0:23:53 0:18:56 99 40 0:23:17 490 0:26:30 0:24:29 0:22:20 117 42 421 0:20:49 1039 0:22:47 1037 0:23:00 1098 0:21:56 1037 0:30:32 1149 0:33:14 1173 0:32:43 1207 0:29:25 1151 0:46:37 0:15:32 0:27:47 656 139 343 0:53:17 0:15:43 0:32:25 750 112 412 0:48:39 0:21:00 0:26:53 725 110 407 0:54:35 0:18:32 0:23:13 745 120 393 Transfer Patient 2563 0:47:38 2157 1:02:01 2172 0:51:30 2266 0:44:49 2640 0:49:16 Brought in Dead 218 0:15:32 281 0:17:46 284 0:19:10 247 0:18:53 301 0:16:49 58 Annual Report of the Chief Medical Officer 0:24:05 0:20:56 0:13:38 0:17:05 0:15:46 0:10:58 0:21:17 0:18:11 0:23:22 0:24:22 0:20:11 0:27:44 0:17:56 0:26:01 0:21:35 0:19:41 0:22:49 0:28:10 0:18:28 0:26:58 0:22:29 0:24:17 0:23:42 0:34:10 0:43:19 0:18:59 0:30:34 Road traffic injuries, loss of consciousness, convulsions and childbirth are the major defined reasons for use of emergency services in New Providence (Table 35).
The volume of calls handled through the EMS system has increased on an annual basis.

Response time, however, has not increased to any great extent, when compared over time.
Table 36 – Abaco Emergency Response Data, 2006-2008 Call Type TRAuMA Calls; 1p1.302 Assaults/Rape Bomb/explosion/Major disaster Burn victims/Explosion Electrocution Falls/Back Injuries (Traumatic) Gunshot Wound RTA, Traumatic Injuries (specify) Stabbing Medical Calls: Carbon Monoxide/Inhalation Hazmat Cardiac/Respiratory Arrest/Death Near Drowning/Diving Incident Poisoning/Overdose/Ingestion Stroke/CVA Unconscious/Breathing Problem Ordinary Problem Calls: Abdominal Pains/Problem Allergies/Hives/Med-Reactions Animal Bite(s)/Attack(s) Asthmatic Choking Diabetic Problem(s) Eye Problem(s)/Injuries Fainting/Fits/Convulsions Fracture(s)-Lower Fracture(s)-Upper Lacerations/Haemorrhage Maternity/childbirth/BBA Ordinary Sickness/Sick Call Psychiatric/Suicide Attempt Unknown Problem (Person Down) Vomiting/diarrhea Transfer Patient Brought in Dead MInistry of Health, Commonwealth of The Bahamas 2006 (10 Months) 2007 2008 # calls Ave.
Response Time # calls Ave.

Response Time # calls Ave.
Response Time 39 1 5 2 31 12 0:05:00 0:03:00 0:04:00 0:12:00 3 0:05:00 0:17:00 0:05:00 0:06:00 0:05:00 0:11:00 0:06:00 0:03:00 0:08:00 0:04: 0:02:00 0:03:00 0:02:00 0:19:00 0:07:00 0:04:00 0:05:00 0:03:00 0:06:00 0:06:00 0:24:00 0:07:00 0:04:00 0:04:00 0:05:00 0:07:00 0:04:00 0:04:00 0:05:00 0:06:00 0:05:00 0:05:00 0:06:00 0:04:00 0:05:00 0:05:00 0:11:00 0:05:00 0:10:00 0:04:00 0:06:00 0:04:00 0:04:00 0:03:00 0:06:00 0:04:00 0:05:00 0:03:00 0:06:00 0:08:00 0:07:00 0:03:00 0:04:00 0:04:00 0:07:00 0:06:00 0:04:00 59 The Public Hospitals Authority/Emergency Medical Services (EMS) assumed responsibility for emergency medical service in Abaco in 2006.
Road traffic injuries, loss of consciousness, and convulsions are the major defined reasons for use of emergency services in Abaco (Table 36).

12.2.2 OuTPATiENT SERviCES Table 37.

Outpatient attendances by institution, type of service and year.
FACiLiTy / AREA 2004 2005 2006 2007 2008 PRINCESS MARGARET HOSPITAL (PMH): Accident & Emergency General Primary Care Clinics: General Practice Clinic Civil Servants Clinic Specialty Clinics(a): Asthma Clinic Comprehensive Clinic Dental Clinic Dialysis Clinic ENT Clinic Eye Clinic Medical Clinic OB High Risk Clinic Obstetric Clinic (includes OB High Risk & GYNAE clients) Oncology Clinic Orthopaedic Clinic Paediatric Clinic Skin Clinic Surgical Clinic Urology Clinic Total Outpatient Attendances (PMH) RAND MEMORIAL HOSPITAL (RMH): Accident & Emergency General Practice Clinic Specialty Clinics: Surgical Clinic Medical Clinic Antenatal Clinic Gynae Clinic ENT Clinic Pediatric Clinic 47,263 40,043 36,910 3,133 32,316 618 1,847 - - - - 8,663 1,414 - - - 6,300 3,975 9,499 - 48,947 42,624 39,629 2,995 54,208 559 1,544 5,626 1,367 2,734 4,500 8,642 - 4,315 1,019 9,829 3,286 3,374 5,894 1,519 50,920 35,589 32,362 3,227 55,600 611 1,382 5,397 1,503 2,741 4,645 8,998 - 4,733 1,241 8,700 3,427 4,042 6,534 1,646 52,114 32,150 29,471 2,679 57,808 643 1,416 4,598 1,399 2,677 5,399 9,306 - 4,907 1,473 51,746 28,598 26,063 2,535 61,903 467 1,337 4,568 1,711 3,029 6,023 9,983 - Annual Report of the Chief Medical Officer FACiLiTy / AREA 2004 2005 2006 2007 2008 Postnatal Clinic Psychiatric Clinic Chest Clinic Orthopedic Clinic Ophthalmology Clinic Oncology Clinic 413 1,021 248 399 2,133 45 539 1,013 244 407 524 1,239 257 996 607 1,299 309 579 624 1,490 450 864 2,683 2,365 1,563 1,859 - - - - Total Outpatient Attendances (RMH) 56,057 60,827 60,848 64,618 68,196 SANDiLANDS REHABiLiTATiON CENTRE (SRC): Community Counselling & Assessment Centre (CCAC) - contacts … 21,474 20,660 … … Psychiatric Clinic Ann’s Town Geriatrics Clinic Total Outpatient Attendances (SRC)(b) 1,864 908 … 1,898 930 2,042 978 24,302 23,680 2,807 2,520 809 … 794 … Source: Medical Records Departments - PMH, RMH and SRC, Public Hospitals Authority (a) Specialty clinic visits (PMH): In 2005, seven additional clinics began reporting: Dental, ENT, Eye, Urology, Dialysis, Oncology and Orthopaedics.
(b) Total outpatient attendances (SRC) excludes: Podlewski psychiatric visits, day program attendances by adults & adolescents and outpatient child & adolescents visits.

Use of clinic facilities in all three government hospitals indicates an increasing reliance on government-sponsored services.
Of note, at the Princess Margaret Hospital services have increased significantly in the Medical, Obstetrical High Risk, Oncology and Orthopaedic Specialty Clinics; at Rand Memorial, services have increased significantly in the Gynaecology, Psychiatric, Paediatric and Orthopaedic Specialty Clinics (Table 37).
The number of attendees at the General Practice Clinic (GPC) and the Civil Servants Clinic at PMH has been decreasing while the number of GPC attendees has been increasing at the Rand Memorial Hospital.

MInistry of Health, Commonwealth of The Bahamas 61 13 HEALTH SiTuATiON 13.1 gENERAL POPuLATiON After allowing for infant mortality, it is to be expected that mortality rates for the elderly are far higher than those for younger age groups (Fig.

29).
29).

But fewer deaths and lower mortality rates in those age groups still represent a substantial loss of potential life.

The gender differential rates, especially between 15 and 44 years, are significant and may be attributable to vehicular and work-related injuries and HIV/AIDS.

Fig.

29.

Age-specific death rates, per 100,000 popn.


by gender, 2007 e t a R h t a e D 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Male Female 0-4 Years 5-14 Years 15-24 Years 25-44 Years 45-64 Years 65+ Years Age Group Approximately half of all mortality was due to chronic non-communicable diseases, as well as to HIV/AIDS (which has been decreasing), cancers of the breast and prostate, injuries, and especially homicides, which have been increasing.
The disparity between the population’s mortality profile and that of morbidity, if measured by hospitalizations, is telling (Table 38).

Whereas many hospitalizations are due to acute respiratory infections and appendicitis, hernia and intestinal obstruction, relatively fewer deaths have resulted.

This stands in stark contrast to cancers of the breast and prostate, which accounted for 0.6% and 0.2% of all discharges, excluding deliveries, but which are responsible for 2-3% of deaths.
62 Annual Report of the Chief Medical Officer Table 38.
Percentage distribution of discharge diagnoses, 2004-2007, excluding deliveries Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH ARI Hypertensive disease Ischaemic heart disease Intestinal infectious diseases Diabetes mellitus Appendicitis, hernia, intestinal obstruction HIV/AIDS Cerebrovascular diseases Slow fetal growth Respiratory disorders, perinatal Injuries, poisonings and other external causes* 15.8 14.4 14.0 13.6 14.8 10.7 14.2 10.8 Mental and behavioural disorders+ 1.0 6.2 1.0 7.7 1.0 6.5 1.0 7.0 * This is a group and therefore not strictly comparable with the other conditions, but the data does not permit further breakdown into individual external causes + Unlike RMH, there is no psychiatric ward at PMH.
MInistry of Health, Commonwealth of The Bahamas 63 13.2 POPuLATiON SuB-gROuPS 131.21 iNFANTS Respiratory disorders specific to the perinatal period were a leading cause of infant mortality, with cause-specific death rates at their highest for the decade.

Also at their highest point for the decade were death rates for bacterial sepsis of the newborn (Fig.

30).

Fig.

30.
Mortality rates per 1,000 livebirths, of leading causes of infant mortality, 1996 – 2008, Bahamas Respiratory Disorders Speciﬁc to the Perinatal Period Remainder other Conditions in the Perinatal Period Diseases of the Respiratory System Bacterial Sepsis of Newborn Obstetric Complications and Birth Trauma Congenital Malformations, Deformations, Abnormanlities s h t r i B e v i L 0 0 0 , 1 / e t a R 5.0 4.0 3.0 2.0 1.0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Hospital discharge data integrates infants into a 0-4 year old age group, so it is not possible to identify morbid conditions that relate specifically to infants.
13.2.2 CHiLDREN AgED 1-4 yEARS For the past two years of available mortality data, injuries constituted the leading cause of death among 1-4 year olds, although there seems to be a general downward trend (Fig.

31).

It is heartening to note that since 2000, AIDS-related deaths among children under 5 have been near zero.

Except for one infant death in 2005 and one death in the 1-4 year old group in 2000 and again in 2002, there were no AIDS deaths in this age group up until 2006.
64 Annual Report of the Chief Medical Officer Fig.

31.
Age-specific mortality rates per 10,000 population of the leading causes of death in children aged 1-4 years, 1996-2006, Bahamas s r a e Y 4 - 1 n e r d l i h C 0 0 0 , 0 1 / e t a R 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Diseases of the Respiratory System Congenital Malformations, Deformations, Abnormanlities AIDS External Causes 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Morbidity in under-5 year-olds was due mainly to respiratory infections, followed by intestinal infectious diseases and injuries (Table 39).
This agrees with data from community health services.

Discharges for slow foetal growth and perinatal respiratory disorders were of infants.

Disparities between PMH and RMH for perinatal respiratory disorders may be related to the transfer of high risk neonates to PMH because of the availability of specialized services (i.e.

NICU/SCBU) at PMH.

MInistry of Health, Commonwealth of The Bahamas 65 Table 39.
Percentage distribution of hospital discharges in children aged 0-4 years by condition, 2004 – 2007, Princess Margaret Hospital and Rand Memorial Hospital, Bahamas Discharge diagnosis ARI Intestinal infectious diseases Slow fetal growth Respiratory disorders, perinatal Chronic lower respiratory disorders Injuries, poisonings and other external causes Congenital malformations 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH 17.0 10.5 5.7 3.6 3.6 8.2 3.6 11/ … 3.8 5.6 17.2 6.8 10.9 6.1 1.7 5.8 4.2 16.1 3.6 9.7 12.5 4.0 5.6 3.2 13.2.3 CHiLDREN, AgED 5-14 yEARS Although mortality in this age group is the lowest in the population (33.5 per 100,000 population), data show that those few deaths that do occur are mainly due to external causes.
In 2007, of 20 deaths in that age group, nine (9) were the result of injuries, five of them road traffic injuries (RTIs), and two drownings.

With respect to hospitalizations, injuries accounted for 15.2% - 22.3% of all discharges at PMH and RMH during the years 2004-07.

Respiratory conditions, both acute and chronic, followed in importance.
We point with concern to 20-25 discharges for diabetes each year from hospitals, to the 1-4 hospitalizations each year for hypertension in this age group, to290 children with abnormally high blood pressures, and 38 children with hyperglycaemia screened by school health services during 2008.

13.2.4 ADOLESCENTS AgED 15-24 yEARS Injuries were the main cause of morbidity and mortality in this age group.

Strikingly, the most common cause of mortality was assaults.
In 2007, 39 of the 49 male deaths were due to injuries—and of these, 24 were homicides.

There were 17 deaths among the females, four (4) of which were injuries, two (2) RTIs, and two (2) homicides.

Approximately 2 of 5 discharges, excluding those related to pregnancy, are due to injuries (Table 40).

The high percentage of pregnancy-related discharges speaks to the need to assess the Family Planning process in both urban areas.
Among this group of adolescents, mental and behavioural disorders seen at RMH are mainly due to psychoactive substance abuse (including alcohol).

This is also seen among males in the 25-44 age group.

66 Annual Report of the Chief Medical Officer Table 40.

Percentage distribution of discharges in adolescents aged 15-24 years, 2004-2007.
Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH Pregnancy, childbirth and the puerperium Injuries Mental and behavioural disorders Appendicitis, hernia, intestinal obstruction 75.4 9.7 0.4 1.2 43.5 14.4 4.0 1.8 70.7 10.7 … 1.9 57.0 9.7 7.8 1.6 62.3 15.3 … 2.2 64.8 75.6 67.4 9.8 3.6 1.2 9.2 … 8.8 5.4 <1.0 <1.0 This discharge information highlights the need to disaggregate data in order to evaluate the needs of the community.
The lack of HIV/AIDS discharges in this age group reiterates the importance of evaluating the data for these patients in order to identify programmatic benefits such as the effectiveness of identifying cases early and the use of ART with this population.

13.2.5 PERSONS AgED 25-44 yEARS Injuries and HIV/AIDS accounted for 84 and 45 deaths respectively among the 212 males who died in 2007.

Of the 84 fatal injuries, 33 were homicides and 22 were RTIs.
Injuries also accounted for a significant proportion of hospital discharges, followed by mental disorders, especially those resulting from psychoactive substance abuse (Table 41).

Table 41.
Percentage distribution of discharges in persons aged 25-44 years, 2004 - 2007 Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH Pregnancy, childbirth and the puerperium 75.4 43.5 70.7 57.0 62.3 64.8 75.6 67.4 Injuries Mental and behavioural disorders 9.7 0.6 14.4 10.7 8.3 … 9.7 7.8 15.3 … 9.8 3.6 9.2 … 8.8 5.4 13.2.6 PERSONS AgED 45-64 yEARS Chronic diseases (hypertension, ischaemic heart disease, cerebrovascular disease, diabetes and cancer) and HIV/AIDS are the leading causes of mortality and morbidity in this age group (Table 42).
The presence of HIV/AIDS as a cause of death in this age group may be reflective of deferred death due to the effectiveness of antiretroviral therapy (ART) in earlier years resulting in increased survival rates.

MInistry of Health, Commonwealth of The Bahamas 67 Table 42.

Proportionate mortality of leading causes of death in persons aged 45-64 years, 2007-2008.
Cause of death HIV/AIDS Hypertension Ischaemic heart disease Cerebrovascular disease Diabetes Cancer of the breast TOTAL 2007 2008 % 9.8 8.1 7.5 6.7 5.5 4.5 # 52 46 40 40 22 17 % 10.3 9.1 7.9 7.9 4.4 3.4 # 50 41 38 34 28 23 509 100% 217 100% A similar profile is seen when hospital discharges are considered (Table 43).

Table 43.

Percentage distribution of discharges of persons aged 45 – 64 years from PMH and RMH, 2004 – 2007.
Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH Hypertension Diabetes mellitus HIV/AIDS Cerebrovascular disease ARI Ischaemic heart disease Cancer of the breast Injuries Mental disorders 7.7 4.5 3.0 3.0 3.3 1.7 1.4 10.8 … 7.7 4.5 <1.0 2.9 2.8 6.4 2.0 10.6 4.9 7.3 6.6 5.0 3.4 2.4 2.2 1.5 9.7 1.9 7.5 4.7 <1.0 2.9 3.3 5.3 … 8.8 5.2 7.4 4.7 6.7 3.5 2.8 2.1 … 11.0 1.3 8.6 3.5 <1.0 3.2 3.7 3.2 … 9.8 5.3 6.8 5.4 4.4 5.1 2.6 2.8 1.8 8.3 1.9 8.8 4.6 1.2 2.9 3.8 5.6 <1.0 6.7 5.2 68 Annual Report of the Chief Medical Officer 14CONCLuSiONS 14.1 SuMMARy OF ACHiEvEMENTS The Bahamas is advancing well towards achieving some of the Millennium Development Goals (MDG) health-related targets.
EPI coverage is near 100% and continues to expand, controlling more conditions.

All births are attended by skilled personnel.

Antenatal care coverage is now over 80%.

Maternal mortality, for the most part, varied between 0-2 deaths during the last five years.

The MCH programme continues to be a success, despite severe staffing limits and other challenges.

Other effective programmes include the HIV/AIDS programme, which has succeeded in changing AIDS mortality and reducing MTCT to near zero.
The national TB Programme has intensified the surveillance and management of TB, so that DOTS coverage remains 100%.

The Infectious Disease Surveillance Programme has demonstrated effective surveillance and prompt control measures that have contained malaria and dengue outbreaks.

Much of the work of the public health services has been provided effectively, in a strategically focused manner.
The Government of The Bahamas has provided invaluable support for persons with chronic diseases, as evidenced by the provision of free medications for HIV/AIDS (antiretroviral therapy) and CNCD’s (antihypertensives, chemotherapy, insulin and other anti-diabetic agents, etc.).
Statistics from school health clinics, with their Grades 1 and 6 entry screenings, have been able to identify and address early health problems including vision and hearing loss, abnormal weights, hypertension and oral health abnormalities.

Although the latter has achieved the minimum standards set for oral health status of children, there is room for improvement.

14.2 FuTuRE STRATEgiC FOCi Despite these achievements, challenges remain.
Every one in 12 admissions of children under age five is for an injury.

RTIs and other unintentional injuries tend to afflict those in the lower age groups; assaults, homicides, and industrial accidents prevail in our older youth.

Data from the Emergency Medical Service requires analysis to determine where response times in New Providence can be improved.

No new antigens were added to the paediatric immunization schedule despite recent advances in vaccine-preventable diseases.
In addressing the social determinants of health, issues such as single parent and teenage pregnancies, the impacts of urbanization and overcrowding in New Providence as people move toward commerce centers in search of employment, and other social determinants of health—all play a significant role in the health and longevity of Bahamians.

Safety and injury prevention are priority areas to be addressed.
The prevalence of chronic non-communicable diseases, and the appearance of risk factors such as obesity and elevated blood pressure early in life—all speak to the need for the early inculcation of healthy lifestyle habits.

Proper nutrition from birth, including exclusive breastfeeding for at least the first 12 weeks, and regular exercise—all must be promoted.

Reproductive health is another area of concern.

Teen pregnancies are not insignificant.

Neither is the incidence of STIs such as gonorrhea.
Both indicate the need for continued promotion of the practices of safe sex or abstinence.

The prominence of breast and prostate cancer as causes of mortality argues for aggressive screening for these increasingly common types of cancer.

Finally, the data in this report point to persons at increased risk for the use and misuse of psychoactive substances, including alcohol, as a major factor negatively affecting mental health—mainly among young males.
This issue, like the other health issues mentioned above, may be addressed by the promotion of healthy lifestyle habits.

Indeed, the Healthy Lifestyle Initiative launched by the Ministry of Health, is a central key to strengthening the health of the people of the Commonwealth of The Bahamas.

Underpinning these recommendations should be a strong information system to guide decision-making and to assess the effectiveness and efficient focus of programmes and interventions as they are executed.
The iPHIS holds the potential to do this when completed.

We believe its completion is imminent and that MOH staff will be able and enthusiastic to explore its potentials.

MInistry of Health, Commonwealth of The Bahamas 69 14.3 RECOMMENDATiONS AND PROPOSALS/PLANS FOR THE FuTuRE This report highlights the need for the continued, timely collection and analysis of data, in order to document the health status of the nation and to focus health policy and programmes.
Gaps identified in this report underscore the need to conduct more surveys and intensive studies, including those that monitor the attainment of the Millennium Development Goals.

The Ministry of Health must work toward costing the programmes that are currently in place and to insist on doing this in any future programmes.

The MOH needs to build its capacity—to act and respond, to assess and refine—especially in the area of project management skills.

We have studied the health patterns of Bahamians.


We know much of what needs to be done to foster our people’s health and longevity.

The ability of MOH to significantly bring down the rates of HIV/AIDS and its mortality has been a major achievement, one not achieved by many larger nations.

We know our people.

We have studied their patterns—both those that lead to health and those that lead toward illness and early death.
As noted earlier, for a nation as for an individual, health is largely a matter of making and maintaining the right choices.

At the Ministry of Health, we believe our choices are fundamentally already defined.

We need to keep getting better at managing the challenges we have examined and outlined in this report.

We do not need to re-invent the wheel.

We need to put axles between those we already have.

70 Annual Report of the Chief Medical Officer 15REFERENCES Bahamas Department of Statistics.
Bahamas Survey of Living Conditions, 2001 Bahamas Department of Statistics.

2008 Labour Force and Households Income Survey Bahamas Department of Statistics.

2009 Labour Force and Household Income Survey.

(in print).. Bahamas Department of Statistics.

The Bahamas in Figures, 2007.

Economic Commission of Latin America and the Caribbean.

World Statistics Pocketbook.


Bahamas Country TB Reports, accessed at http://www.who.int/tb/publications/global_report/2009/update/a-1_amr.pdf Department of Public Health – Oral Health Services Annual Report, 2006 Department of Public Health: EPI Report, 2009.
Draft Food and Nutrition Policy, 2008 Surveillance Report Prison Health Report, 2004 Prison Health Report, 2005 Prison Health Report, 2006 Prison Health Report, 2007 MInistry of Health, Commonwealth of The Bahamas 71 16TABLES AND FiguRES 16.1 TABLES Table 1.

Socio-Economic Indicators Table 2.

Labour Force by age and sex, all Bahamas, 2008 Table 3.

Labour Force by highest examination passed, 2008 Table 4.

Basic Demographic Indicators, 2002 - 2008 Table 5.

Life expectancy at birth, 1980 – 2008 Table 6.


Foetal and infant Deaths by age, 1999 – 2008 Table 7.

Crude deaths rates (per 100,000 pop.)

and ranks for leading causes of death, 2004 – 2008.

Table 8a.

Hospital Statistics, 2004 – 2008.

Table 8b.

Hospital Statistics, Sandilands Rehabilitation Centre, 2004 – 2008.

Table 9.

Community Health Centre Service Statistics, BAHAMAS, 2004-2008 Table 10.

Human resources per 10,000 population, 2004 – 2008.

Table 11.
Table 11.

Annual Health Budgets 2003/2004-2008/2009 Table 12.

Summary of antenatal services, coverage and utilization, 2004 – 2008.

Table 13a.

Summary of perinatal information (Maternal indicators) 2005 – 2008 Table 13b.

Summary of perinatal information (Neonatal indicators), 2005 - 2008 Table 14.

Summary of Post natal and Infant Child Health Services Table 15.

Reasons for attendance (first visits only) at child health clinics, 2004 – 2008.

Table 16.
Table 16.

Immunization coverage rates, 2004 - 2008 Table 17.

Results of health screening of Grade I students, 2004 - 2008 Table 18.

Results of health screening of Grade 6 students, 2004 – 2008 Table 19.

Results of health screening of Grade 10 students, 2004 - 2008 Table 20.

Reported cases of infectious diseases and syndromes to carec, 2004 - 2008 Table 21.

HIV positive rates among pregnant women screened, 2004-2008 Table 22.

HIV Mother-to-Child Transmission Rates, 1995-2008 Table 23.
HIV Surveillance of selected populations, 2004 – 2007, Bahamas Table 24.

Status of Tuberculosis cases, BAHAMAS, 2004 – 2008 Table 25.

Distribution of Tuberculosis cases by co-morbidity with HIV and sex, Bahamas, 2004 – 2008 Table 26.

New cases attending Primary Health Clinics for selected non- communicable conditions Table 27.

Grade 1 Caries Prevalence Trends, 2002 - 2006 72 Annual Report of the Chief Medical Officer Table 28.

Grade 6 Caries Prevalence Trends, 2002 -2006 Table 29.
Prison Health Screening 2004-2008 Table 30.

Annual Meat Statistics, New Providence, 2004-2008 Table 31.

Food Handlers Training Sessions, 2004-2008 Table 32.

Hospital utilization by service, PMH and RMH, 2008 Table 33.

Laboratory tests at Princess Margaret Hospital by type of test, 2004-2008 Table 34.

Accident and Emergency Visits by Age and Sex, 2004-2008 Table 35.

New Providence emergency Response Data, 2004 – 2008 Table 36.

Abaco Emergency Response Data, 2006-2008 Table 37.


Hospital Outpatient Visits by Institution and Service, 2004-2008 Table 38.

Percentage distribution of discharge diagnoses, 2004-2007, excluding deliveries Table 39.

Percentage distribution of hospital discharges in children aged 0-4 years by condition, 2004 – 2007, Princess Marga- ret Hospital and Rand Memorial Hospital, Bahamas Table 40.

Percentage distribution of discharges in adolescents aged 15-24 years, 2004-2007.

Table 41.
Table 41.

Percentage distribution of discharges in persons aged 25-44 years, 2004 – 2007 Table 42.

Proportionate mortality of leading causes of death in persons aged 45-64 years, 2007-2008.

Table 43.

Percentage distribution of discharges of persons aged 45 – 64 years from PMH and RMH, 2004 – 2007.

16.2 FiguRES Fig.

1.

Distribution of population by age and sex, 2004.

Fig.

2.

Population distribution by age and sex, 2008.

Fig.

3.

Trends in population growth and associated factors, 1998 – 2008 Fig.
4.

Age-specific fertility rates by age-group, 2004-2008 Fig.

5.

Mortality rates – crude death rate per 100,000 pop., infant, neonatal and perinatal mortality rates per 1000 live- births, and stillbirth rates per 1000 livebirths, 1998 – 2008 Fig.

6.

Leading causes of death, 2004 , 2005 Fig.

7.

Leading causes of death, 2006, 2007 Fig.

8.

Years of potential life lost (YPLL) 2002-2006 Fig.

9.

Hospital in-patient death rates , 1997 – 2007 Fig.

10.
10.

Clinic visits in New Providence, Grand Bahama and the Family Islands, 2004-2008 Fig.

11.

Home Visits in New Providence, Grand Bahama and the Family Islands, 2004-2008 Fig.

12.

Expenditure on health activities, 2006 -2008 MInistry of Health, Commonwealth of The Bahamas 73 Fig.

13.

Percentage of children screened at school health clinic who were overweight Fig.14.

Percentage of children screened at school health clinic who had high blood pressure Fig.

15.

MTCT Rates, 1995-2008 Fig.

16.


New Cases of AIDS, by Sex and Year, 1985-2008.

Fig.

17.

Cumulative Number of Reported HIV Infections, by Sex, 2008.

Fig.

18.

Current Non-AIDS HIV infections, by Sex and Reported Year, 1985-2008 Fig.

19.

Cumulative cases by age-group & Sex as at 31.12.2008 Fig.

20.

Incidence and prevalence of TB and co-morbid HIV, Bahamas, 1990 – 2008 Fig.

21.
21.

Selected conditions as percentages of total discharges (excluding deliveries) from princess Margaret and Rand Memorial hospitals, 2004 – 2008 Fig.

22.

Patients on dialysis at princess margarget hospital by underlying condition, 2007 Fig.

23.

Summary of cancer sites by gender, Princess Margaret Hospital, 2008 Fig 24.

Patients treated in Mental Health Facilities by Diagnosis Fig.

25.

School Dental Services-Clinical Activity Trends 2002-2006 Fig.

26.
26.

Preventive Dental Treatments Rendered by clinic-New Providence & Family Islands-2006 Figure 27:.

Exuma Anopheles Larval Total Average-2008 Figure 28.

2008 Exuma Human Bait Collection Total Average Fig.

29.

Age-specific death rates, per 100,000 popn.

by gender, 2007 Fig.

30.

Mortality rates per 1,000 livebirths, of leading causes of infant mortality, 1996 – 2006, Bahamas Fig.

31.
Age-specific mortality rates per 10,000 population of the leading causes of death in children aged 1-4 years, 1996-2006, Bahamas 74 Annual Report of the Chief Medical Officer M i n i s t r y o f H e a l t h 2 0 0 4 – ANNExES , c
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’ s ( H e a l t h R e l a t e d ) / MInistry of Health, Commonwealth of The Bahamas 77 Functional Organizational Chart—Public Hospitals Authority Minister of Health Internal Auditor Board of Directors Chairman Managing Director Deputy Managing Director Director of Projects Director of Shared Services Director of Human Resources Financial Controller Medical Advisor Nursing Services Advisor Legal Advisor/Board Secretary Princess Margaret Hospital BNDA MMD Capital Development Unit Plant, Equipment & Furniture Procurement Oversight Project Management Information Technology Management & Development Quality Management Oversight Public Relations Planning & Business Development Information Monitoring Evaluation & Analysis Recruitment & Retention Budgeting & Reporting Quality Standards Development Monitoring Quality Standards Development Monitoring Career Pathways/ Succession Planning Accounts Payable Medical Services Oversight Nursing Services Oversight Sandilands Rehabilitation Centre Grand Bahamas Health Services Training & Development Payrolls Performance Management Assets Management Medical Internship & Special Programmes Oversight Technical Oversight Allied Health Services Litigation Management NEMS Policy & Statutory Provisions Ofﬁce
 Management Employee Relations Compensation & Salary Administration Registry Legend: BNDA MMD NEMS Bahamas National Drug Agency Materials Management Directorate National Emergency Medical Services 78 Annual Report of the Chief Medical Officer – / S u p p l i e s C l i n c i T e a m s i i T r a n n g / D e v e o p m e n t l Q A / R e s e a r c h M o n i t o r i n g & MInistry of Health, Commonwealth of The Bahamas 79 Ministry of Health The government of the Bahamas Meeting and Delancy Nassau, Bahamas 82 Annual Report of the Chief Medical Officer