The
Development Planning Unit
Government of the British Virgin Islands

NATIONAL INTEGRATED DEVELOPMENT STRATEGY

Health Sector
(continued)

CHAPTER 2 
ECONOMIC AND SOCIAL INFLUENCES ON THE HEALTH SECTOR

The structure and performance of an economy are generally among the primary determinants of the effectiveness of a country’s health sector and the health status of its people. There is increasing evidence that economies greatly benefit from integrating health priorities into their development programs and allocating health expenditures, not only for consumption but also as investments in human capital. Good health enhances productivity, permits the use of natural resources that might be inaccessible due to diseases increases enrollment of children and their ability to learn, and frees up resources that would need to be spent on treatment of illnesses.

The economic development and income of the BVI, as well as its generally good public health system manifest relatively good health status. Improvements in nutrition, sanitation, access to immunization and family planning have generally contributed to lower mortality rates and increased life expectancy. The result is a country not plagued by basic health problems. However, the health system is showing signs of deterioration, therefore it is increasingly important to recognize the need to accelerate the process of health reform. However the good prospects in the economy, the current health structure and financial organization are now largely unable to adequately and sustainably respond to the ongoing and emerging challenges related to demographic and social changes with the framework of resource constraints.

Policy frameworks affect the allocation of resources to the health and other sectors. In addition, household use of health services is determined partly by income, education and fertility levels and partly by the cost of such services, which might be substantial for those with minimal levels of income. Environmental factors such as sanitary conditions, access to clean water and living conditions are largely outside the control of individuals. They are influenced by levels of investment in economic infrastructure and tend to be severely affected in times of budgetary constraints with implications for public health. Greater efficiency in the management of human, physical and financial resources are other important factors to improve access to health care. Effective management leads to improve quality of service by establishing firm agreements among different public/private sector and between health and other sectors of their respective roles.

Economic Variations and Implications for the Health Sector

The economy of the BVI is based primarily on tourism and on the financial services sector, with emphasis on international business company registration and trust services, although efforts are being made to diversify the economic base. The per capita GDP has linearly increased from US$9,492 in 1987, to US$18,875 in 1991 and to US$26,904 in 1996. The territory relies on local revenue and loans from local and international services to finance its capital and recurrent expenditures. At this time, aid represents less than 6% of its financial requirements.

For the last five years, the actual recurrent expenditure on health as well as the per capita recurrent health expenditure continued to increase. The health expenditure to GDP fluctuated between 1.31% in 1990 to 1.23% in 1993 and to 1.34% in 1996. The percentage of recurrent health expenditure to the total recurrent expenditure showed a gradual decrease from 9.22% in 1991 to 7.57% in 1996 (see appendix 1).

Epidemiological profiles explored in the Caribbean Regional Health Study (1996), shows that countries in the region with lower per capita expenditure on health generally displayed higher incidence of infant mortality and lower levels of life expectancy than those with higher per capita expenditure. The BVI shows a high per capita expenditure on health compared to other Caribbean countries. This however, does not necessarily equate to better health status, which is also influenced by other factors such as efficient allocation and management of resources and effective provision for more equitable access to health care systems. Morbidity and mortality are inextricably linked to environmental conditions and the life-style decisions of the population.

Unemployment and labour market structures are constraints for the improvement of the public sector and by extension the health sector. Unlike other Caribbean countries, especially non OECS, in which unemployment averaged as high as 15% for the past seven years, the BVI enjoyed a low rate estimated as 3.56% in 1991 and is not expected to indicate any significant change for the next years. A survey conducted by the Canadian Public Health Association in 1985 shows the extent to which unemployment is directly linked to health status (Darcey, 1986). It is manifested in several ways: Psychological distress, anxiety and depressive symptoms, disability, major activity limitations, alcoholism, and drinking-related problems. The study also documents the wider impact on marriage, family and social relations. It is increasingly recognized, especially among OECS countries, the need for programmes to deal with this issue.

Data from the 1991 census revealed that there were 11,730 persons of working age, which accounted for 72% of the total population. Of these, 77% formed the labour force, which was comprised of 8,849 employed and 242 unemployed persons. Over the period of 1980 to1991 the labour force increased by 82% with females accounting for almost 50% of the growth. Women’s participation in the labour force increased from 38.5% in 1980 to 43.6% in 1991. 76.2% of the labour force is employed in the tertiary sector. Of note is the fact that in 1991 approximately 60% of the labour force was expatriate, this is attributed to the fact of the small local population base. The BVI has no National Health Scheme and therefore a greater burden is placed on the public health system. It means there is a significant proportion of the population whose health status will face uncertainties due to lack of appropriate financing schemes. The majority of the population will tend to seek care at government establishments when they are chronically affected

Demographic Profile

The ability of the health sector to keep up with the needs of the population is limited due to unpredictable and rapid growth of the population, the highly uneven distribution of the population between the islands and the physical limitations due to geography. Population size, distribution, structure and composition is subjected to rapid change due to factors such as high rates of immigration and emigration and a high throughput of tourists.

The 1991 census indicated that the total population of the BVI was 16,115 persons. The previous census in 1980 documented a total of 10, 985 persons. These figures represent an increase in population of 5,131 (46.7%) persons and an Annual Average Rate of Growth of 3.48%. Approximately 65% of this increase was attributed to the net immigration rate. Since 1980, population growth rates have increased tremendously compared to 1.41% and 2.83% per annum in 1960 and 1970 respectively. This growth reflects the increase in the migrant population that has been attracted by employment opportunities as a result of economic growth in the territory.

Recent years have seen marked changes in the distribution of population. Tortola, the largest island, accommodates approximately 82% (13,233), while Virgin Gorda the second most populated 2,437 or about 15% of the population. During the last two decades, whilst Tortola and Virgin Gorda have seen an increase in population density, Anegada and Jost Van Dyke have seen a decrease.

Over the past decades the proportion of the population under 15 years has declined, while the population of age groups 45-64 and 65 and over has remain fairly constant for the same period. On the contrary, the percentage of population between ages 15-44 increased by about 7% between 1980 and 1991 (see table 1). This drastic shift in the age composition of the population is a result of the high positive net-migration situation in the country, which has implications for the level of dependency ratios. The total dependency ratio plummeted from 115 in 1960 to a mere 49 by 1991. While the child dependency ratio drastically decreased from 103 in 1960 to 40 in 1991, that of the elderly moved from 12 to 9. The decreasing fertility levels, the massive migration in-flows, and the increasing levels of life expectancy over the decades have all contributed to this phenomenon.

The changing age structure has important implications for the kind of health needs and demands that the population is likely to present to the health care system. Non-communicable chronic and other degenerative diseases, as well as general care of the elderly will increasingly require the attention of the health system.

Table 1 
Population by Age Group in 1980 and 1991 
and Projections for the years 1996 and 2011

Both the labour force and the number of women of childbearing age are growing at a much faster rate than the entire population. In 1991, the male population accounted for 51.5% of the total population while the female population was slightly smaller with about 54.9% being of childbearing age (i.e. 15-44 years).

The General Fertility Rates showed a marked reduction since 1970 when they were 134.5 per 1000. By 1980, and 1991, rates had fallen to 107.2 and 68.01 respectively, and continue to show gradual decline. In 1996, the rate had fallen to 61.9. The Total Fertility Rate decreased from a high of 3.57 in 1970 to 1.75 in 1991, that is, below replacement level of 2.1 births per woman of childbearing age. The rate has fluctuated between 1992 to 1996. It should be noted, however, that since around the mid-seventies until present, the number of live births to native women has been underestimated by as much as 20%. This is due to the large number of women who travel to the USVI, Puerto Rico and US mainland to have their children. Between 1970 and 1991, the Age-Specific Fertility Rates have dropped. Reductions were particularly marked amongst teenagers, with a drastic fall in Age Specific Fertility Rate from 110.9 in 1970 to 45.7 in 1991. During 1980 to 1991, the per annum rate of natural increase has remained fairly stable at around 13 per 1000.

During the period from the 1970 to 1980 the birth rate has fluctuated between 25.7 and 24.8 per 1000 population, and showed no defined trend. In 1987, there were 263 recorded births, giving a crude birth rate of 19.1 per 1000. From 1991 onwards, birth rate has stabilized and shows a slightly downward trend from a high of 18.2 in 1991 to a low of 15.1 per 1000 in 1996, where 284 births were recorded.

During the decade from 1970 to 1980 life expectancy at birth remained relatively stable. Whilst life expectancy showed increases for the age groups 1-14, and for those 85 years and above, it declined for the remaining age groups. However, since 1980, the number of persons over the age of 60 years has steadily increased. In 1991, 7.8% of the population was above 60 years. In 1990, life expectancy at birth was 76.8 years for females and 73.3 for males.

e.  Migration

Migration is the single most important factor that affects the BVI population growth and structure. Not only does immigration increase population, but it also affects every aspect of social and economic life in the BVI. In the 60's and to certain extent the 70's the BVI, like many other small Caribbean Islands, had been experiencing heavy emigration, especially between the age group 20-24 years. However, since the 80’s immigration surpassed emigration resulting in a migrant population of over 49% of the total population. This significant rise in migrant population was due to the increase in economic development in the BVI, which necessitated the importation of labour. The population has undergone dynamic shifts because of high immigration and emigration rates. The net migration in 1990 was 364. Immigration by other Caribbean nationals to the territory has increased, with most immigrants coming from the English-speaking Caribbean and the Dominican Republic to work mainly in tourism and construction.

The number of tourist arrivals has steadily increased from 316,670 in 1990 to 412,032 in 1996.

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