The
Development Planning Unit
Government of the British Virgin Islands

NATIONAL INTEGRATED DEVELOPMENT STRATEGY

Health Sector
(continued)

CHAPTER 5
THE PROVISION AND UTILIZATION OF HEALTH SERVICES

Coverage

The hospital is fully subsidized by the Government with little or no cost to patients. The hospital offers acute care services on three wards (Surgical/Paediatric, Medical, Obstetric), as well as several special units:- Accident and Emergency, Operating Theater, Out-patient services, Labour and Delivery rooms, Ambulance services, Sick newborn nursery, and Psychiatric services.

Data on hospital services reveal that the total admissions to Peebles Hospital in 1996 were 1,684, representing 8,861 patient days. The hospital has a bed compliment of 44, resulting in a ratio of 2.3 beds per 1,000 population. The overall bed occupancy rate averaged 46%. The overall average length of stay was 5.4 days, although for patients on the medical unit, the average was 10 days, which could be attributed to care of the chronically ill, the mentally ill, and the elderly.

The total number of visits at Peebles Hospital outpatient clinics for 1996 was 19,842 representing a 4% increase over the 1995 figure. Of this total 9,287 visits were to the casualty department and 8,208 to the emergency room.

There are several technical support services:

• A small physiotherapy unit staffed by one physiotherapist. The unit offers therapeutic ultrasound, a range of electrical treatments including Transcutaneous Electrical Neurostimulator (TENS) and interferential therapy, moist heat and cold therapy, progressive resistive exercises, manual manipulation and myofacial release, cervical traction, whirlpool bath, gait re-education, kinetic activities and massage. In 1996, a total of 381 patients were treated, most of whom required a minimum of three treatments. Unfortunately, current constraints (staffing and space) have resulted in less than optimal quality of services being offered as the public demands grow exponentially.
  
• The pharmacy is located in Peebles Hospital and serves the hospital, health centres/clinics, and the Adina Donovan Home. It is staffed by a senior pharmacist, a pharmacist and a laboratory/pharmacy trainee. In 1996, 13,979 prescriptions were dispensed; this compares with 9,866, 9,914, and 11,671 in 1993, 1994 and 1995 respectively. Revenue from prescription drugs is less than 50% of actual cost, since under Government policy, certain persons are exempt from paying for drugs. Revenue collected in 1991 for paid prescriptions was US$16,790, and the cost of exempted prescriptions, US$58,289. There is no pharmaceutical control authority. The Hospital Pharmacy is the procuring pharmacy for all Government pharmaceutical supplies. Through the office of the Director of Health Services, pharmacy is responsible for the sale and distribution of controlled narcotic substances. There is a need of upgrading and revision of pertinent legislation.
  
• The laboratory, which is staffed by a laboratory director and four laboratory technicians, provides services to the Peebles Hospital, district clinics, and private physicians. Service is provided in the following disciplines: haematology, blood banking, biochemistry, microbiology, parasitology and serology. Tests that not offered in the above disciplines are referred to laboratories in USVI and Puerto Rico. In 1996, a total of 32,319 tests were performed in the lab, an increase of 3,638 over 1995. Technical assistance is provided by the Caribbean Epidemiology Centre (CAREC), laboratory division. There exists a need for technical support in biochemistry and haematology as these areas are not supported by CAREC. Blood banking is ambulatory. Blood is taken on a ‘needs’ basis. There is a need to upgrade the blood banking services.

There is no resident pathologist. Surgical pathology service is procurred from St. Thomas and Puerto Rico. For deaths/coroners cases requiring post-mortems, services are provided by a visiting pathologist from St. Thomas. Cytology services (pap-smears and other diagnostic services) are also provided from labs outside the territory (Puerto Rico and USA).

• The Diagnostic Medical Imaging Unit (X-ray) is staffed by a senior radiographer and a radiographer. Services are offered in the areas of General Radiography - Chest X-ray/Extermination. Special radiographic procedures, which include HSG, Intravenous pyelogram (IVP), Fluoroscopy, Venography, Barium Studies and other Contrast Studies. Abdominal, obstetric and gynecological ultrasounds and very limited Cardiac Echo 2-D Studies are also offered. In 1996, over 4,500 radiological examinations were performed. 13 barium meals, 11 barium enemas, 46 IVP, 8 Special examinations, 24 fluoroscopic studies, 887 ultrasonographic exams. Over 150 patients were referred to centers outside the territory for Echocardiograms and Doppler studies.
  
• Inadequate expenditure on maintenance of both plant and equipment results in the decrease of useful life of essential equipment, poor quality service and frustration for staff concerned. The maintenance unit is poorly staffed and equipped, reflecting the inadequacy of resources to this area. It is staffed by a maintenance supervisor and six officers who perform regular maintenance of mechanical, electrical, plumbing, and other apparatus in health care facilities. Additionally, the space allocated to maintenance in the hospital is woefully inadequate. Servicing of the laboratory equipment has to wait for technicians from Puerto Rico, which results in delays and disruption of services.
  
• In 1996, 33 registered nurses provided continuous acute care services on three wards, each with different patient care demands as well as several special units: Accident and Emergency, Operating Theater, Specialist Clinics, Out-patient services, Labour and Delivery rooms, Ambulance services, Sick-newborn Nursery. Additionally, to these nurses provide care to an active psychiatric inpatient service. Current staff allocations cannot provide basic care for several special units. On many occasions, assistant nurses and orderlies must assume the role of qualified (registered) nurses. There is no alternate source of registered nursing staff for the hospital when demands are excessive, and it is not possible to mobilize nurses from other units or areas in the health service when sudden need arises. There is an urgent need for an increase in the compliment of registered nurses with the increase in population and demand for quality service.

• The medical records unit provides information that is vital to the effective planning and programming of health services. However, as the demand for information increases, this task has become more tedious due to the use of an antiquated information system. The promise of an HBO system for the past 10 years has still not materialized. This has hampered any effort of upgrading the current manual system.

Pregnant women are encouraged to attend clinic by the 12th week of pregnancy. All clients attending the public health clinic are seen and examined by the obstetrician, and there are established criteria for identifying high-risk clients, so that they are detected early and received prompt treatment. Hemoglobin levels are assessed and those with anemia are treated. VDRL tests are done and tetanus toxoid is given. A maternal "passport", which records the status of pregnancy, is given to clients and used to provide information to health personnel, particularly between levels of care. In 1991, 98 prenatal clinic sessions were registered, with 407 attendances of which 19 women were identified as having high-risk pregnancies.

Pregnant women attending government clinics, as well as those attending private physicians’ office, are referred to Peebles Hospital for delivery. The average yearly number of deliveries is 270; all deliveries are attended by qualified health personnel, 96.7% in hospital and 3.3% at health clinics by midwives. The total obstetric bed occupancy rate is 33% to 55%. The average length of stay for normal deliveries is 2 days. Cesarean sections accounted for an average of 18% of deliveries between 1994 to 1996.

A public health nurse visits the maternity unit at Peebles Hospital daily to collect information regarding delivery, management, and discharge of clients. Referrals are made to district clinics. Postnatal visits are made to homes on the third, fifth, seventh, and tenth day after delivery.

Mothers and babies return to clinic at 6 weeks for postnatal assessment; coverage ranges between 95% and 100%. In the Road Town area in 1990, 432 postnatal visits were made to 150 women. There were 330 mothers who attended postnatal clinics, 27 more than those delivered in a hospital or health centre; these 27 gave birth outside the territory.

Child health services include developmental assessment from 0-4 years old, monitoring of nutritional status based on age for weight, plotting and interpretation of growth chard, and immunization according to schedule.

The target population under 1 year old in 1996 was 292, and coverage in the group aged 0-11 months was 100 %. Twenty five percent of children registered at clinics in 1990 were born outside the British Virgin Islands. Many of these children are reported to be from the English-speaking Caribbean and the Dominican Republic.

Upper respiratory tract infections and gastroenteritis are usually managed at child health clinics through the use of protocols (oral re-hydration therapy in the case of gastroenteritis).

As part of the school health programme, a child receives three physical examinations – the first on admission to school another in middle school, and the final one before leaving school. Follow-up care is done by nurses and consists mainly of screening for nutritional, vision, hearing, and other defects. Haemoglobin testing is done and booster immunizations administered.

Family planning services are offered at the family planning clinic in Road Town and at district health clinics. There were 1,654 registered clients in 1996 of which 101 were new participants; 277 Pap smears were conducted. Of the clients using this service, approximately 79% were between 20 – 34 years old and 5.7% between 15 – 19 years old.

Regarding the battle against AIDS, in 1993 the National AIDS Committee was renamed the National AIDS and Sexual Health Committee, reflecting current emphasis on sexual health. Since 1987, all blood for transfusion is screened for HIV. Self-exclusion information for blood donors has been developed.

Community awareness and education, particularly targeting vulnerable groups, adolescents, and young adults are key components of the national AIDS Programme. Private physicians improved their AIDS and HIV-positive reporting, and there are ongoing efforts to strengthen and improve data management and epidemiologic surveillance, not only for AIDS, but also for other communicable diseases.

There are protocols for the management of persons with hypertension and diabetes, which are the two main health problems in adults, particularly among those 45 years old and older. There is one weekly hypertension and diabetic clinic each in Road Town, East End, Cappoons Bay and Virgin Gorda. Two hundred twenty-six (226) diabetics are registered island-wide and the majority of which are hypertensive. The main objective of control and management efforts is early detection, treatment and counseling to promote behaviour modification and lifestyle changes A national diabetic association lends support to its members.

Social changes have changed traditional patterns of caring for the elderly. The Adina Donovan Home offers residential care for 26 senior citizens. Those with health problems are referred to the hospital or the medical officer assigned to the facility. Public Health nurses visit the homes of the elderly in their respective districts. There were 120 elderly persons visited on a regular basis in 1991.

Immigration by other Caribbean nationals to the territory has increased, rendering the health of immigrants an issue of concern. In the process of getting settled in home or job, some new arrivals to move between districts, making it difficult for health personnel to contact them or provide follow-up care. In 1996, 50 immigrant clinic sessions were held for 1,116 attendances. In an effort to control the importation of communicable diseases, persons who immigrate to the British Virgin Islands are required to produce laboratory test results for VDRL, HIV, tuberculosis, ova and parasites.

Regarding oral health, the dental unit is located in Road Town and is staffed by a dental officer, a dental hygienist, and two dental assistants, who also visit Virgin Gorda, Jost Van Dyke, and Anegada. The specific goal of the programme is to reduce the DMF (decayed, missing and filled teeth) and periodontal disease indices. Services focus on early diagnosis and prompt treatment to prevent dental disease progression and recurrence, as well as on providing rehabilitation and limiting disability.

Oral screening of school children reveals high DMF indices. The current school-based fluoride mouth rinse programme started because of high DMF valued in school children and the proven benefits of fluoride mouth rinsing. In 1991, 15 schools were visited and oral inspections were carried out; as a result, 350 students were referred for curative treatment.

The community mental health programme focuses on the treatment of individuals in their own communities. Home visits to clients include monitoring of medication, administration of long-acting medication, family counseling, and the promotion of self-care. Visits also are made by mental health staff to the prison and geriatric home when necessary. The drug rehabilitation programme was suspended in 1991 due to financial constraints.

In 1991, 104 new clients were registered at the mental health centre, and there were 1,795 client contacts – 1,151 at the weekly clinics and 644 at home visits. The number of persons being admitted to hospital shows a decreasing trend, which could be attributed to the follow-up care in the community and the support received. The number of hospitalizations was 65 in 1990 and 41 in 1991.

Regarding the operation of medical clinics, a medical officer is station at the health centre in Road Town. Clinics are held weekly at East End, Long Look, Cane Garden Bay and Anegada, twice a month in Jost Van Dyke and Capoons Bay. There is a resident doctor on Virgin Gorda, where medical clinics are held four times weekly and once weekly at North Sound. Most persons seen at medical clinics are children and older persons who have been referred by the nurse or who are self-referrals. In 1991, 294 medical sessions were held and, 642 persons were seen.

These services come under the responsibility of the Ministry of Health. The environmental health department’s main responsibilities include water quality surveillance, institutional hygiene through bacteriological sampling and analysis, inspection and surveys of commercial water treatment and processing plants, periodic chlorine testing of the municipal water supply, institutional sanitation, food sanitation, and vector control.

The municipal water supply is administered by the Water and Sewerage Authorities, which fall under the Ministry of Communication and Works. The department maintains laboratory services and monitors the bacteriological quality of the water it produces. Water samples collected from domestic systems show various levels of contamination from time to time. Samples collected by environmental health officers are analyzed by the water and sewerage technician, but a lack of lab facilities within the Public Health Department makes it difficult to carry out routine water quality surveillance. The Water and Sewerage Department also chlorinates the municipal water supply.

The Ministry of Natural Resources’ Conservation and Fisheries Department watches over marine environment. Water in several recreational bays is examined bacteriologically by a technician of the Water and Sewerage Department in collaboration with the Conservation and Fisheries Department; high bacterial counts are sometimes reported.

Because there are no requirements for holding tanks, yachts discharge into the ocean. Septic tank effluent from houses near the shoreline also often is discharged into the sea. Inadequate public health legislation allows raw sewerage to be discharged into coastal waters from Road Town sewerage, hotels, marinas and other tourists facilities, and houses build near the sea.

Groundwater pollution threatens the quality of the water supply. In East End and Long Look septic tanks that are not functioning because of poor construction and nature of the terrain, cause serious environmental pollution.

Deliberate dumping of used motor oil and animal waste also contributes to the pollution. Leachate from open dumps also is a hazard, but the extent to which groundwater and the marine environment are affected has not yet been determined. The 1991 enactment of the Coast Conservation and Management Act broadened the legal base for further control.

In 1991, the Environmental Health Department launched a water quality surveillance and institutional hygiene programme to monitor water supplies and ensure basic sanitation in public institutions. The programme involved the medical certification of water bottling company employees and others who sell drinking water, as well as periodic sanitary surveys to detect possible sources of public water contamination and the monitoring of the bacteriological quality of water in schools, water companies, the public water supply, hospitals hotels, and restaurants. In 1991, the survey found that all 29 schools inspected had satisfactory conditions, although one of the five commercial water supplies inspected was found to be deficient.

Groundwater was the main source of water supply, the construction of reserve osmosis desalination plants have substantially increase the water supply. Rainwater cisterns are the primary source of water for 80% of the population, but where domestic water storage is prevalent, the risk of dengue transmission increases. The remainder of the population relies on piped water. The absence of laboratory facilities precludes water quality surveillance by the public health department.

The Water and Sewerage Authorities are responsible for the public sewerage system, but this system serves only Road Town and its immediate environs. 94.5% of households are served by septic tanks or pit latrines and 4.6% by the public sewerage network. There is concern that sewerage does not receive adequate primary or secondary treatment before being discharged into the sea through 600-foot out-fall at Stanley Point. The only treatment is set to chlorination rate regardless of wastewater flow. Regulations on the size of septic tanks and soak-away system requirements according to the number of users are not enforced.

There are several sewerage treatment plants attached to hotels and marinas. These are mainly fabricated units, varying in capacity from 1,500 gallons to several thousand gallons. Three of the plants are activated sludge systems and their discharges to the sea are in most cases chlorinated. Some wastewater is recycled for gardening.

To cope with the increasing solid waste management problem, a unit with a manager who is a qualified environmental health officer was established in 1988. Approximately 7,500 tons of solid waste is collected per year in Tortola; in the much smaller islands of Virgin Gorda, which has much tourism, approximately 1,500 tons are collected per year.

Collection of all types of solid waste from residential, business, and commercial locations is practiced. Approximately 99% of the population in Tortola is covered by the Government service. A modular incinerator at Pockwood Pond began to operate in 1994. In Virgin Gorda, there is a single disposal site where spontaneous open burning of solid waste takes place; in Anegada, a new disposal site is urgently needed; and on Jost Van Dyke, an open dump is used for disposal.

The Environmental Health Division runs a food hygiene programme that includes registration and licensing of food establishments, regular inspections, medical examination of food handlers, and weekly educational sessions conducted by environmental health officers: 229 food establishments are registered. All food handlers are required to have a physical examination and laboratory tests, including tests for tuberculosis, VDRL, and stool examinations for ova and parasites, to ensure the absence of communicable diseases. A total of 767 food handlers are registered in Tortola, Jost Van Dyke, and Anegada; Virgin Gorda has 305 registered food handlers.

Food suspected of contamination is sent to the laboratory in Saint Thomas for bacteriological examination. The Department of Agriculture is responsible for the management of the abattoir and meat inspection.

The Animal Importation and Disease Ordinance, 1978, allows for the regulation of the importation of animals and animal products into the territory. This quarantine legislation is directed at reducing the possibility of introduction of exotic diseases of both animal and human health concerns. Unfortunately, there has never been the regulation of animal products into the BVI. The Veterinary Authority has no legal support for carrying out a food protection program, the Public Health Ordinance, 1969/ Regulation (Food Hygiene), 1972 empowers the public Health Inspectors and Medical Officer of Health to do so. Some attempt was made to change this in 1985, however there remains only a draft copy of this document. No zoonoses have been reported during the past fifteen years. The territory is considered free of Rabies and Venezuelan equine encephalomyelitis. The Aedes aegypti control programme, which has been in existence since 1973, is the only functioning vector-control programme.

An average of four cycles of control activities is complete each year for all premises in the territory. Abate 1% is used in drums and cisterns, and guppies, a well-known predator of mosquito larvae, also are used in drums and cisterns, and wells as part of an integrated control approach. Community education and participation are key elements in this programme. The house index, which was higher than 60% in 1973, held at 5.0% in 1992.

Environmental management is a joint effort among several government entities, including town and country planning, water and sewerage authorities, and departments charged with Environmental Health, Conservation and Fisheries, Agriculture, and Solid Waste. An inter-sectoral committee integrates the community-based Aedes aegypti programme.

The territory has no major manufacturing industries. The most potentially hazardous activities are construction, boating and marinas, agriculture, fiberglass, and the electrical trade. There are no comprehensive regulations governing these work-sites.

Non-Government Organizations

This non-profit sector has expanded in the last 10 years to include several agencies. These include Diabetic Association, Red Cross, the Virgin Gorda Health Promotion Council, East End/Long Look Action Committee (ELAC), Sea Cow’s Bay Action Committee, Family Support Network and Council on Alcohol and Drug Abuse (CADA). This sector compliments Government and Private for-profit services mostly through promotional health activities such as awareness, countering substance abuse, public education and some screening activities. Service clubs such as Rotary and Lion’s Club also offer considerable support.

Drug Supply

Drug supply is essential for adequate treatment, and cure of many health problems, as well as prevention. The high cost of drugs makes efficient procurement and distribution important. It is estimated that drugs have become the largest component in direct out-of-pocket health expenditures. Approximately 4% of health budget is spent on procurement, and management of pharmaceutical.

The BVI is a member of the Eastern Caribbean Drug Service (ECDS). This organization offers assistance with procurement services such as improvement of inventory control and stock management, development of computerized information systems, and accurate forecasting pharmaceutical needs. Quality assurance services as well as a mechanism for strengthening professional networks and improvement of the professional competence of health workers are also provided.

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