The
Development Planning Unit
Government of the British Virgin Islands

NATIONAL INTEGRATED DEVELOPMENT STRATEGY

Health Sector

CHAPTER 1
INTRODUCTION

Health is a dynamic state that is individually perceived. Understanding health and illness requires a careful study of both individuals and the entire population. Factors such as culture, education, economics, geographic location and healthcare availability all impact on the health of individuals, families and communities.

There is a great diversity of definitions and opinions about the meaning of health and illness. However there seems to be agreement that both terms represent interactive states between social, physical, psychological and/or environmental factors. Within this frame, there are several important points to discuss. Perhaps the most critical one is that health is not only the absence of disease, but encompasses all of man's well-being including social, psychological and spiritual dimensions as well as environmental, economic, educational and recreational factors. Health, as defined by the World Health Organization (1960), is the state of complete physical, mental and social well being and not merely the absence of disease or infirmity.

The health sector strategies essentially aim to achieve the following:

• Equity and Access: providing greater opportunities for access to a minimum level of health care on the basis of need for care and not solely on ability to pay.
• Effectiveness and Quality: establishing the basis for a well integrated health care system offering quality services at primary, secondary and tertiary levels.
• Efficiency: maximizing the use of resources and minimizing the cost through strategic planning and sound management.
• Financial Sustainability: establishing procedures to reduce the expenditure gap between increasing costs and limited resources, and to ensure ongoing feasibility of the system.
• Inter-sectoral Collaboration and Community Participation: fostering cooperation between the Ministry of Health and other public agencies and the private sector and involving communities in monitoring and implementing the reform.

The first four objectives outlined above form core elements of a reform strategy; the fifth is considered to be a critical supporting objective given the legacy of a highly compartmentalized and hierarchical public health system.

Historical Background

The Ministry was established in 1979 as a fourth Ministry taking part of its portfolio from the Chief Minister’s Office and part from what was formally the Ministry of Natural Resources, Immigration and Public Health. It was originally named the Ministry of Social Services which is representative of the subjects for which it is responsible. In 1983, the name was changed to the present Ministry of Health, Education and Welfare.

The Ministry has a wide range of distinctly different specialist responsibilities that extend across a broad spectrum, from Caribbean Studies to Prison Management. The services provided by the Ministry are particularly sensitive and attract considerable public attention as they impact on the social, educational and health needs of the territory.

The overall goal of the Health Sector is to provide an adequate and effective health service to the entire population of the BVI, and delivery of such services in an efficient manner is the main objective.

Currently the health services are administered by the Health Department which has two operational arms; Peebles Hospital and Community Health Services.

Main Developments of the Health Sector during the last thirty years

1. Peebles Hospital

The main structure of the present hospital was completed in 1926. It was described as a cottage hospital with sixteen beds (16) and six (6) cots. Five of the adult beds constituted the main ward and were housed in what was described as "a dark and gloomy room". Two of the latter were blocked throughout the year by chronically ill patients.

Since the 1940s the building has been the subject of numerous renovations and extensions, the latest of which were completed in 1982. At present, the hospital is a three-storey building with a capacity for 44 beds. In 1996 sixteen physicians service the territory, 94 nurses (seventy-two trained nurses and twenty-two assistant nurses), five laboratory technicians, two pharmacists, two radiologists, one physiotherapist, as well as a hospital administrator and many support staff.

Specialist medical services are available in general surgery, anesthesiology, pediatrics, obstetrics and gynecology, internal medicine, ophthalmology and dermatology. X-ray, ultrasound, medical laboratory, physical therapy and pharmacy services are available.

2. Public Health Services

Public Health Programmes began in 1968. This included mobile child health clinics, and counseling and advisory services for the mothers in the Road Town Area and rural districts. Antenatal, food handlers and immigration clinics were held at the Road Town Clinic and visits were made to schools. Prior to this date there was no organized immunization programme; today the territory boasts a 95% immunization coverage for under five years old against diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, measles, mumps, rubella and tuberculosis. The infant mortality rate has been substantially reduced during the past thirty years

In 1990, Public Health Department split into two fundamental units. Hospital and Community Health Services. At present, Community Health Services deliver health services on a regular basis through a comprehensive network system which include one Health Centre in Road Town and eight (8) district clinics: four (4) in Tortola, two (2) in Virgin Gorda, one (1) Jost van Dyke and one (1) Anegada. Other services provided by Community Health Services include Environmental Health, Mental Health, Health Education, Dental Health and Nutrition Services.

3. Environmental Health

Thirty years ago, the Environmental Health Unit was staffed by one Public Health Inspector and its main focus was solid waste management and investigation of nuisance complaints. The only legal instrument for enforcing public health measurements was the 1950 Public Health Ordinance.

Today, the unit is staffed with five (5) Public Health Inspectors and clerical support. A Public Health Ordinance was enacted in 1969 and revised in 1976. The 1976 Ordinance confers ample powers on the Minister responsible for health to make regulations. In 1988, steps were taken to draft new regulations and amend deficiencies of those held over under the 1976 Ordinance. Following the improvements other programmes have been developed in Food Hygiene, Vector Control, Water Quality and Institutional Hygiene.

An important area for the conservation of the environment was the decision in 1988 to dispose of solid waste through incineration rather than the traditional method of sanitary landfill. The new incinerator became fully operational in 1994, and consistent with this fact and the increased responsibilities, the unit was given full departmental status the same year. The Solid Waste Department is responsible for the following operations: solid waste collection and disposal, operation of the Pockwood Pond incinerator, street and road cleaning, roadside trimming, ghut cleaning and beautification.

4. Mental Health

Prior to 1969, the BVI was totally dependent on the goodwill of the Government of Antigua for the treatment of persons with chronic mental illnesses. After a slow start in 1969 a two-bedded unit was added to the hospital for treatment of mentally ill patients. In response to the growing need to provide care for people with mental health problems, the Community Mental Health Programme started in 1972 as follow-up service out of the hospital. It was later expanded and promoted to become the treatment module for the entire territory. Since then it has provided essential mental health care and family support free of charge to the territory.

Health Perspectives in the BVI

The overall goal of the health sector is the provision of high quality and accessible primary and secondary health care services to improve the quality of life and the standard of living of the people of the B.V.I. To accomplish this goal the Government aims to promote high quality, cost effective services, choice for the public, and as wide a scope of local services as possible within their technical and financial capability.

Health Sector development has to be viewed in the overall context of the BVI economy. The territory has experienced unprecedented economic growth within the last two decades, fuelled by the expanding and lucrative tourism and financial services industries, with concurrent improvements in communication, transportation and standards of living. This growth has also attracted a large and needed pool of immigrant labour and placed increased demands on housing, the social services, the educational system and the health services. Furthermore, as standards of living have improved, so has the average life expectancy of the population, resulting in greater incidences of chronic diseases and disabilities associated with lifestyles and longevity.

These dramatic demographic changes with the attendant shifts in disease profiles are inflicting new pressures on the health service sector. Superimposed on this picture are the health needs of a large tourist population. A successful response will require a review of both the numbers of providers and the level of skills that these providers will bring to a rationalized and forward-looking health service in the BVI. In particular, the critical care services and emergency response capability of the hospital will demand recruitment and training of several categories of specialists health care providers.

Health care delivery in the BVI involves the public and private sectors. Government is the major provider and financier of health services. Persons requiring care that is not available in the territory are assisted by referrals overseas for diagnostic and treatment services.

Primary Health Care in the territory is provided by: one (1) Hospital (Peebles Hospital), one (1) Health Center in Road Town, a network of eight (8) District Clinics (East End, Long Look, Capoons Bay, Cane Garden Bay, Anegada, Jost van Dyke, The Valley and North Sound), as well as two satellite clinics in Brewers Bay and Sea Cows Bay.

Programmes in the clinics especially target mothers and young children. They include the following: growth, nutrition, and developmental surveillance, immunization, vision and hearing screening, school health, antenatal, postnatal and family planning, family life education, home visiting and AIDS and sexual health counseling. Other services offered include community mental health, dental health, environmental health, health education and community nutrition.

In addition there are a growing number of establishments promoting healthy eating, natural remedies, physical exercise and traditional therapies such as massage.

Private medical practice is an important aspect of the health care delivery system in the BVI. All government consultant physicians and surgeons are allowed private practice on a part time basis. It is estimated that around fifty percent of the population use private practitioners in the territory and in neighboring Puerto Rico and the U.S. Virgin Islands. The Health Information System does not capture these health incidents and thus an accurate picture of the health of the country may not be obtainable. Private health care is provided by one (1) private hospital, two (2) private dental surgeries, two (2) private medical complexes and nine (9) private physicians.

Bougainvillea Hospital has eight beds and mainly offers reconstructive surgery services although some general surgery also is done. The number of admissions in 1991 was 58, and the average length of stay was 3.5 days; the occupancy rate is 32.0%.

Secondary Health Care is provided at the Peebles Hospital that offers accident and emergency services, in-patient care on medical, surgical, pediatric and obstetric wards and through resident and visiting specialists.

The BVI has no facilities for Tertiary Health Care. Clients requiring this service are referred to overseas facilities at the University Hospital of the West Indies, in Jamaica, Queen Elizabeth Hospital in Barbados, hospitals in Puerto Rico, the United States of America. There is also a reciprocal agreement with the United Kingdom in which BVI nationals are able to procure tertiary care. Under this scheme, 5 children received care for the years 1996 and 1997.

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.

CHAPTER 3
TRENDS IN THE HEALTH SITUATION

The health status in the BVI can be described as generally good. This can be demonstrated by some of the usual health indicators such as life expectancy, crude death rates, and infant mortality rates (IMR). Life expectancy rates have increased over the years, while crude death rates and IMRs have decreased.

The BVI enjoys good immunization coverage when compared to ten years ago. This, together with a reasonably good public health system and initiative, has ensured the drastic reduction of many critical health problems once experienced.

The prevailing social, demographic and economic conditions previously discussed, such as an aging population, and the influence of tourism have had implications for the health status and practices of the population, as well as responses and expectations.

Community health programmes continue to make progress in the promotion of health and longevity. Immunization for pre-school and school-leavers is actively pursued and much emphasis is being placed on school and domiciliary services. Mental Health, Dental Health Care, Family Life Education and Health Education have become integral units of the Community Health Services focusing largely on preventive and promotive health.

Nutritional status of the population is also considered good, in part due to the purchasing power of the population. Availability of specific food products may become a problem if local production is not stimulated. Currently however, poor dietary habits are believed to contribute to the increasing problems of diabetes and hypertension, though no reliable statistics are available for confirmation.

The major causes of morbidity and mortality are circulatory disorders, diabetes mellitus, malignant neoplasms and mental ill health, including substance abuse. Accidents and minor infections also make considerable demands on both the private and public health sectors. These diseases/conditions account for approximately 70 % of all deaths. Possible explanations for this trend may include poor general dietary habits, poor diets before and during pregnancy and fetal development, high levels of immunization coverage, sedentary lifestyles, as well as the presence of stress-inducing factors.

Epidemiological Trends

The BVI have a health situation, which reflects that of the rest of the Caribbean region, in terms of the similarity of health problems that have emerged. These include the increasing incidence and prevalence of non-communicable chronic diseases, the resurgence of some communicable diseases and an increase in the incidence of illnesses due to external causes (violence and injury).

The territory has a relatively young population with an increasing incidence of chronic disease in adult life. The pattern of diseases has moved from communicable diseases, especially those of childhood, to chronic non-communicable diseases and conditions that can be prevented by the adoption of healthy lifestyles in early life. The major causes of morbidity and mortality are hypertensive diseases, diabetes mellitus, malignant neoplasm (particularly breast, prostate, and cervical), bronchial asthma, arthritis and mental ill health, including substance abuse. These diseases account for over 70 % of all deaths. Possible explanations for this trend may include poor general dietary habits, poor diets before and during pregnancy and fetal development, early malnutrition, high levels of immunization coverage, as well as the presence of stress-inducing factors.

Accidents and minor infections make considerable demands on both the private and public health sectors. The territory has also seen the resurgence of some communicable diseases such as dengue fever, and respiratory tract infections. Communicable diseases usually associated with poverty and poor environmental conditions (tuberculosis and gastroenteritis) are also on the rise. There is also an increase in the prevalence of sexually transmitted diseases, and particularly HIV/AIDS.

Mortality and Morbidity

Deaths that occur in hospitals are certified by a medical practitioner and reported to the National Registration Office, while those that occur at home are reported by district registrars. Given the small population size it is important to treat mortality statistics with some caution. Small variation in actual figures each year may represent large changes in rates per thousand.

The crude death rate fluctuated during the period 1991 to 1995, from low of 4.3 per 1,000 in 1991 to 5.4 and 5.5 per 1,000 in 1992 and 1994 respectively. It showed a slight decline to 4.5 in 1995. It is likely that the next few years will see some increase in death rates as the proportion of the elderly population increases. A quarter of the number of deaths occurs in persons 80 years and over.

The infant mortality rate is subject to considerable variation due to the small denominator of live births. After 1987, infant deaths have numbered from 7 in 1987 to 4 in 1996 and infant mortality ratio in 1987 was 27.0 per 1000 live births. Increases of infant mortality rates were observed in 1987 and 1989, although the general trend was downward. Infant mortality fluctuated between a high of five deaths in 1991 and a low of one death in 1995. In 1991 - 1995, of 1,512 total births, 21 were stillbirths. Of the 1,491 live births, there were 19 infant deaths, 16 (84.2 %) of which occurred in the neonatal period. In the same five-year period, there were seven deaths in children 1 – 4 years old. These data can be translated into the following average annual rates for the period: stillbirth rate per 1,000 live births, 13.8, neonatal mortality rate per 1,000 live births, 10.7 and infant mortality rate per thousand live births, 12.74. There were four infant deaths in 1996.

During 1991-1995 there were two maternal deaths, one in 1993 and one in 1994. Both of which were due to complications in ectopic pregnancies resulting in a maternal mortality rate of 13.39 per 10,000 live births for the period.

There were 405 total deaths from all causes (including ill-defined conditions) during the period 1991-1995 as shown in table

Table 2 
Demographic Indicators 1980, 1991, 1995 and 1996.

Indicator	1980	1991	1995	1996
Crude Mortality Rate	7.1	4.6	4.5	4.6
Infant Mortality Rate	44.1	23.1	3.5	13.9
Dependency Ratio	67.0	49.0	47.8	47.6
Life Expectancy	69.0	74.60	74.6	74.8
Total Fertility Rate	2.8	1.9	1.8	1.9
Source: Development Planning Unit and Health Department

Table 3 
Principal Causes of Mortality in 1991 to 1995

Cause of Death	Number	%
Heart Disease	102	25.2
Malignant Neoplasm/Cancer	87	21.5
Cerebrovascular Diseases	42	10.4
Accidents/Injuries	35	8.6
Pneumonia/Bronchopneumonia	17	4.2
Perinatal Conditions	16	4.0
Diabetes Mellitus	9	2.2
AIDS	9	2.2
Renal failure	7	1.7
Alcoholism	4	0.9
Ill-defined causes	77	19.0
TOTAL	405	100.0
Source: Hospital Medical Records

Mortality data for 1991-1995 show that Non-Communicable Chronic Diseases have been the leading cause of death accounting for approximately 60 % of all deaths. In particular heart diseases, malignant neoplasm and cerebrovascular diseases have ranked in the top three positions. Accidents and injuries are also major causes of death. The main implications for this trend is that factors such as affluence, the aging process and lifestyles may be contributing agents.

Although more than 50% of the territory’s population is estimated to seek medical care from private physicians, available data on morbidity are from public facilities, and do not show morbidity at private clinics. Morbidity data is routinely collected at Peebles Hospital and summarized according to ICD classifications. Health centre and hospital data indicate that acute respiratory infections, dermatological problems, and gastroenteritis are important causes of morbidity among children. Mental disorders and injuries stand out among adolescents and adults; and circulatory disorders (hypertension, ischaemic heart diseases, congestive heart failures), diabetes mellitus, and degenerative diseases are major causes of ill health among the elderly.

Table 4 
Principal Causes of Morbidity (Hospitalization) in 1996

There have been no major outbreaks of communicable disease in the BVI in the last eight years.

• Vaccine Preventable Diseases: The Expanded Programme of Immunization covers six diseases: diphtheria, poliomyelitis, pertussis, whooping cough, measles and tuberculosis. During the last years there have been no cases of vaccine preventable diseases. Of the target population in 1996, 292 infants (from 0-12 months), 100 % received a full course of DPT, three dozes of oral trivalent poliomyelitis vaccine and MMR (measles, mumps and rubella)vaccine. Coverage for BCG was also 100%.
  
• Vector Borne Diseases: No cases of malaria or yellow fever have been reported in the last 10 years. Sporadic cases of dengue occur. In late 1995 to the first quarter of 1996, 37 cases were reported. Since then, a few isolated cases were reported. There was no reported case of leptospirosis, plague or encephalitis.
  
• Respiratory Infections: Acute respiratory infection is a major cause of admission to hospital of children under 15 years. In 1996, 32 (71.1%) out of 45 patients were under five years. There were no deaths from bronchopneumonia in this age group.

Seven cases of tuberculosis were reported during 1992-1996. Three of these cases were reported in 1996.

• Enteric Diseases: Gastroenteritis is identified as a major cause of morbidity in children. This condition was a major cause for persons seeking care in the emergency room in 1996. There was one death from gastroenteritis in 1996 and no deaths from this cause in the previous two years. Hospital admissions for gastroenteritis show a general increase from 1990 to 1996. There were no cases from 1990 to 1994, 3 in 1995 and 47 in 1996. There has been no case of typhoid since before 1981. One case of viral hepatitis was reported in 1995. Food poisoning is uncommon except for illness of ciguatera, of which there was an average of 22 admissions over the last three years. The food handler’s and immigration clinics revealed thirty-six positive tests for helminths from an attendance in 1996 of 1,412 and 1,116 respectively. No cases of cholera have been reported
  
• Sexually Transmitted Diseases: Data relating to sexually transmitted diseases gives an inaccurate picture of STD situation as many infected persons are treated by private practitioners who are reluctant to report cases. The ready access and utilization of service in the US Virgin Islands and other places to preserve anonymity further exacerbates the problem. Between 1985 and December 1997, 47 persons were reported as being HIV-positive. Of this number, 19 were reported as having full-blown AIDS; 15 of whom have since died. The male to female ratio among the 19 AIDS case was 2.1:1. Heterosexual transmission was the major route of infection with 16 (84%) cases assigned to this category. A recent HIV sero-prevalence study conducted in February 1996 to August 1997 revealed no positive HIV cases among the 408 pregnant women tested. Recent data on other STDs are not readily available.

The following statistics are based on data over three years 1994-1996:

After mental illness, diseases of the cardiovascular system and diabetes mellitus are the most common causes of hospitalization in the BVI. Cardiovascular disease, including ischemic heart disease, acute myocardial infarction, cerebrovascular accident (stroke) is the most frequent cause of death. The leading causes of death, all ages are: acute myocardial infarction, other diseases of the circulatory system, malignant neoplasm, cerebrovascular disease, pneumonia other diseases of the respiratory system.

Hospital morbidity statistics reinforce the conclusion that cardiovascular disease, cancer and diabetes mellitus are important health problems in the territory. Cardiovascular disease encompasses several different diseases of the circulatory system, including ischaemic heart disease, cerebrovascular disease, hypertensive disease, chronic rheumatic heart disease, and other forms of heart disease. Since 1993, admissions for cardiovascular diseases have gradually increased from 102 in 1993 to 113 in 1994 and 159 in 1996 accounting for 10% of admissions in 1996 ; while cancer accounted for 3% of admissions and diabetes mellitus 5%.

There were 77 admissions for diabetes mellitus in 1993, 59 in 1994, 68 in 1995 and 60 in 1996. The percentage of admissions during this period was 3.5% to 7%. In 1996 there were approximately 350 registered diabetics attending government clinics.

• Mental Health: Mental ill health is a cause of considerable morbidity in the BVI. The number of active patients attending the mental health clinic in 1996 was 200. Adult male accounted for 79 and female 105. There was a total of 16 children. In 1996, fifty- six of sixty- two hospital admissions for psychotic conditions were classified as drug induced (marijuana and crack cocaine) psychoses. 44 or 78.5% were between the ages 15-44, 38 were males and 6 were females. Admissions for other mental conditions were: schizophrenia 15, dementia 5, personality disorders and anxiety and stress reaction disorders 24. Alcohol abuse resulted in 55 admissions, 47 males and 7 females.
  
• Accidents and Trauma: Accidents contribute considerably to both mortality and morbidity in the British Virgin Islands. In particular, a toll is taken on active men aged 15-64 years. Of the 38 deaths analyzed in 1991-1995, 33(86.8%) were males of which twenty were under the age of 40. Eighteen deaths were due to drowning, seven to motor vehicle accidents, and gunshot (homicide) 6 from among the 38 deaths analyzed. Hospital statistics also revealed 17 admissions due to motor vehicle accidents in 1996.

Table 5 
Accidents and Trauma 1991 to 1995

Specific Health Problems

Analysis by Population Groups

1. Maternal and Child Health

The delivery of prenatal care forms a considerable part of private medical practice. About 25% of pregnant women receive antenatal care at the Government clinics. Most pregnant women make their first attendance during the second trimester. The vast majority of deliveries (about 98%) take place in hospital. Hospital delivery is actively encouraged and mothers from the out islands come into the hospital at Road Town.

Based on hospital statistics for 1995-1996, 8% of deliveries is to mothers aged 15-19 years. Within this group, the majority of births were to mothers over 18 years. Pregnancy under 15 years is infrequent. There were two maternal deaths due to ruptured ectopic pregnancies. One occurred in 1993 and one in 1994.

Admissions to the hospital for spontaneous abortions account for 2-3%, a gradually increasing trend. The number in 1995 was 39 compared to 55 in 1996. Pelvic inflammatory diseases and other gynecological conditions are important causes of morbidity resulting in 4-5% of total admissions annually.

During the period 1990 to 1995 approximately 28% of infants born were considered high risk births because of low Apgar score, multiple births, cesarean sections, low birth weight, and prematurity.

Of the 19 total infant deaths in 1991-1995, 84.2% (16) occurred during the neonatal period. The leading cause of morbidity for children under 5 years was perinatal conditions with 42 admissions, acute respiratory infection ranked second with 38 admissions. These were followed by drowsiness (35), bronchopneumonia (31), diarrhoea and gastroenteritis (27), asthma (25), convulsions and head injuries (25) and inguinal hernia (18).

The main health problems in children under 5 years old at health centres/clinics were skin rashes and skin infections, allergic reactions, gastroenteritis, obesity, and acute respiratory tract infection.

The nutrition status (Caribbean standard) among children under 5 years old attending child health clinics in 1991-1995 were: severe malnutrition 0%; mild to moderate malnutrition 2%; normal 77%; obesity 21%. As is shown in this profile, although there are no cases of severe malnutrition, there is the tendency to overfeed children resulting in obesity.

The school-age population (5 - 16 years old) including pre-primary, primary and secondary schools was 3,681 in 1990. The main health problems among pre-primary and primary students are dental caries, skin rashes and/or infections, allergic reactions, and minor injuries. Problems affecting high school students are injuries, fevers, coughs and colds, allergic reactions, and dysmenorrhea.

Data from the 1991 census revealed that 4.4% (716) of the population had one form of disability or another. Of this proportion, 4.6% reported mental retardation, 12.6%, 3.1% and 2.9% indicated sight, hearing and speech impediments respectively. "Other impairments were reported by 62.2%".

In 1996, there were 2,230 visits at Family Planning Clinics by 1654 clients (32.4 % of the female population aged 15-44 years). Approximately 47% were on oral contraceptive pills and just over 25% on injectable contraceptives. Twenty-six thousand (26,000) condoms were issued, 6.5% of clients were aged 15-18 years. During this period, 277 Pap smears were taken 17 were abnormal, of these 5 required further medical intervention.

2. Adolescent and Adult Health

Mental disorders occurring among adolescents and adults are mainly related to substance abuse psychoses, and account for a high percent of hospital admissions. Injuries related to falls, boat and motor vehicle traffic accidents are also common.

Mental disorders, particularly among those aged 25- 44 years old, ranked highest for hospital admissions from 1991 to 1995. Diabetes, hypertension, injury, heart disease, and complications related to pregnancy are other leading causes of morbidity. In 1991, mental disorders were the leading cause of hospitalization in Peebles Hospital, with 129 admissions. Pregnancy complications ranked second with 74 admissions, followed by diabetes mellitus with 69, heart diseases with 61, hypertension with 52, and fractures/open wounds with 47 admissions. Asthma and concussion also were important with 25 and 21 admissions respectively. It should be noted that patients of all ages are included in these numbers.

Over the period 1990 to 1996, of the total live births, births to teenage mothers ranged from a low of 6.25% in 1990 to a high of 11.38% in 1992. The average age of teenage girls giving birth has been 18 years from 1990 to 1996 inclusive. The average age of women aged 15 - 44 years old giving birth over this period was 27.3 years. Family life education and family planning services are available to teenage girls.

Hypertension and diabetes continue to be the main causes of morbidity, particularly in the age group 45 years old and older: 72% of persons with hypertension admitted to hospital and 80% of persons with diabetes were 45 years old and older. Cerebrovascular disease associated with hypertension is a leading cause of mortality. The main reasons for hospitalization of diabetes are for stabilization and for treatment of infections, especially those of the upper respiratory tract.

The rise in deaths from accidents and injury mainly affects the young and economically active population. The rates peak in the 20-40 age group, but remain constant thereafter. For the age group 15-44, injury was the leading cause of death during 1991 to 1995.

Data on communicable diseases and sexually transmitted diseases show that the highest mortality rates for the former are among the very young and the very old, whilst for the latter, the highest rates are borne in the 15-29 age-group

3. Health of the Elderly

There is a close correlation between age and the non-communicable diseases previously discussed. Mortality rates for circulatory disorders (especially heart diseases) and neoplasms in particular, drastically increase by age 45, and in the age-group 45-64 the rates are 6 to 12 times the preceding age group. By age 65 and over they are 26-70 times the rate of the 25-44 age group. It is necessary, however, to examine and separate the effect of aging from the consequences of exposure to a range of other risk factors.

The main causes of mortality and chronic ill health in this group are cardiovascular and cerebrovascular diseases and malignant neoplasms. Arthritis and osteoarthritis are common causes of hospitalization. 

CHAPTER 4 
POLICY, ORGANIZATION AND LEGAL CHALLENGES

Management

The Ministry of Health and Welfare bears responsibility for the planning and development of public and private health care services. Specifically, the Ministry's role in this regard is to formulate and coordinate policies relevant to planning and monitoring of the performance of health care providers. The Permanent Secretary is responsible for the administration of the Ministry and for supporting the Minister's policy role. The overall management of Health Services lies with the Director of Health Services, who is the chief technical advisor on health and health care issues. Currently the Health Services are administered by the Health Department, which has two operational arms: Peebles Hospital and the Community Health Services. These arms are headed by a Hospital General Manager and a Director of Primary Health Care, to whom the day-to-day management of health services is delegated.

The Public Health Act provides the statutory means of promoting and preserving the population’s health, and grants the Minister Responsible for Health duties, powers, and functions. This legislation covers areas such as disease prevention, treatment, and control; health education; environmental health; and the appointment of advisory boards and public health officers. There remains a need for significant review and updating of all current legislation. The BVI have not amended health legislation within the last two decades. There have been several redrafts of the BVI Medical Act and Allied Health professionals Act since 1988, but without any finalization and tabling to bring these amended acts into law. The absence of updated medical legislation has significant implications for the standard of practice both in the public and private sector and precludes the setting up of an impartial Medical Council. This is a matter that deserves the highest priority.

Planning and Development

This area is coordinated through the office of the Director of Health Services. Programs are developed for submission through the budget process in keeping within government policies. There is no Health Plan within the Health Sector. The last attempt to develop a Plan was undertaken in 1983 with support from the Pan American Health Organization.

The overall goal of the health sector is the provision of high quality and accessible primary and secondary health care services to improve the quality of life and the standard of living of the people of the B.V.I. To accomplish this goal the Government aims to promote high quality, cost effective services, choice for the public, and as wide a scope of local services as possible within their technical and financial capability.

The peculiar geography and population distribution in the territory lends itself well to a system of geographical zoning and equity-based care. Such a system promotes equal access to care from divergent points within the territory and emphasizes levels of care and appropriate referral linkages based on individual need.

The model envisaged calls for two hospital units: a multi-care facility on Tortola and a Community Hospital on Virgin Gorda. These hospital facilities would then be linked to Primary Care Polyclinics in each administrative zone. Other clinics would then feed into these via a comprehensive referral system.

The referral system will retain its two present components; local and overseas referral, both of which depend on a strong emergency medical response and evacuation capability. This capability would have to be expanded and developed with clear guidelines fore the diverse scenarios that may obtain from time to time.

Health Promotion and Disease Prevention will be the central focus in the future health services and an ongoing need for upgrading the knowledge and skills of all levels of staff in this area is envisioned. In particular, the nursing cadre will have to be singled out for special attention because of their ubiquitous role throughout the territory. The Health Education Division of the Department of Health will also play a central role in the development and monitoring of promotional and preventive activities of all units within the department.

Strategic Issues

• Public health strategy

• Legal frame work

• Primary health care provisions facilities/ services

• Hospital facilities

• Health financing mechanisms

Challenges

• To move from actions determined exclusively by demand to areas determined by situational analysis.

• To combine promotional and preventive approaches along with treatment and recovery, as the objective of services provided to the individual.

• To emphasize the economic value of life rather than health care as a right.

Strategic Goals

• To ensure that all programmes reflect a health promotion orientation.
• To institute the necessary regulatory mechanism to ensure accessible quality health care.
• To provide comprehensive health care delivery services at the primary and secondary levels for all citizens.
• To ensure access to appropriate tertiary care for all citizens.
• To develop effective management to facilitate delivery of efficient and effective health care.
• To develop programmes appropriate to the health care needs of the population.
• To mobilize adequate resources: financial, manpower, material and logistical to meet the health care needs of the population.

Health Reform

The British Virgin Islands have an overlay of health systems inherited from periods of colonialism, which are increasingly unable to provide affordable, effective and efficient service as well as respond to ongoing demands. For this reason, the territory, in 1993, attempted to carry out a health reform initiative. Health reform has been described as a process aimed at introducing substantive changes into the different agencies of the health sector, their relationships, and the roles they perform, with a view to increasing equity in benefits, efficiency in management, and effectiveness in satisfying the health needs of the population. This process is dynamic, complex, and deliberate; it takes place within a given time frame and is based on conditions that make it necessary and workable. It is ideally a continuous process responding to dynamic demographic, medical, and economic changes.

The BVI Government agreed to undertake United Kingdom Government-funded Health Sector Adjustment Project from 1993 to 1996. A wide range of consultancy assignments were undertaken to examine the health sector with regards to health status, epidemiology, policy, finance and planning and human resources. The objectives of the Project were:

• To implement a new management structure and process
• To revise planning approaches and systems
• To revise financing strategies and improved quality of care and optimized health outcomes.

The results of the project were as follows:

• Agreement and partial implementation of a new management structure

• Undertaking of a number of health sector studies (including information, health promotion, accident prevention, mental health, and environmental health), which were accepted by local health managers as giving them a sound basis for further forward planning.

The Government’s stated policy is to provide both public and private comprehensive health care, with special focus on women, children, the elderly, the mentally ill, and the handicapped. The government is the main provider of acute medical and surgical services to the population. Government health activities and policies place strong emphasis on health promotion. The BVI does not have a formulated health plan. However, the main priorities are:

• Enhancement of hospital services
• Strengthening government primary health care services
• Improving all aspects of environmental health.

Free medical and hospital care is extended to pregnant women, children, the police, indigents, firemen, the elderly, diabetics, and the mentally ill. In an effort to strengthen services at the community level, the Community Health Services Department was established in 1990. The social services unit of the health department was established and became operational in July 1991; it is headed by a social worker, whose primary responsibilities include providing social services support for the Department, particularly regarding mental health and AIDS prevention and control programmes.

Health Promotion

Many of the territory’s health problems relate to the environment and to lifestyle practices, issues that respond especially well to health promotion. The health care system has begun to focus on disease prevention, health promotion and community-based care. The health sector has utilized mainly three health promotion approaches:

1. Medical approach, such as screening for breast, cervical and prostate cancer, immunization and medically managed behavioural changes (such as substance abuse).
2. Behavioural approach, including health education, social marketing and public policy to support life-style changes (speed limits)
3. Socio-economic approach, that is housing and employment.

Other strategies include education, the use of mass media, policy and legislation development. Intersectoral action has led to improvement in water supply and quality, an improved housing stock, levels of income and actions to encourage balanced eating and exercise. Other issues that still require considerable action include:

• Urban planning and development including housing design.
• Modes of transportation and transportation routes.
• Traffic accident reduction.
• Development of safe playing areas.
• Workplace safety.
• Consumer involvement in social and cultural change.

If maximum health benefits are to be realized, the structure of Government and Management should be designed in a way that enables health agencies to comment on the health impact of proposed policies. Furthermore, Government sectors concerned with topics such as education, income security, housing, employment, transportation and communication, and all other controllers of resource used to take account of health as an essential factor when formulating policy.

The Health Education Unit has expanded from one health educator in 1988 to one Senior Health Education Officer responsible for management, one Health Education Officer, one communications specialist, one audiovisual technician, and two clerical officers.

This division is responsible for the education component of health promotion, and for communication and information, it also provides services to other health department divisions and collaborates with the Department of Education and Culture on school health matters and with the Government Information Service in disseminating information to the public. Priority areas have been identified and health promotion programmes were developed for multi-age groups to provide education/information on such issued as heart diseases, AIDS and other sexually transmitted diseases, nutrition, cholera, and environmental health. Multi-media health promotion is targeted to all community groups, but especially to vulnerable groups like adolescents and young adults.

Because it lies within the hurricane belt, the British Virgin Islands has a national emergency organization that coordinates activities related to disaster management. Community awareness and information programmes are used to make people aware of the importance of preparedness. There is an operational hospital response plan in the event of a natural disaster, and key personnel have been trained in emergency procedures. There are basic emergency supplies in each district clinic, and district emergency committees have been set in motion.

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