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Annual report of the Chief Medical Officer, 2004-2008

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Title:
Annual report of the Chief Medical Officer, 2004-2008
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Bahamas medical and sanitary report
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Ministry of Health
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Nassau
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Ministry of Health
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79 p. : ill. (some col.) ; 28 cm. bf

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Health -- Bahamas
Medicine -- History -- Bahamas
Public health -- Bahamas

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Report is published irregularly
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Ministry of Health

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Hilda Bowen Library
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Report of the Chief Medical Ofcer Dr. Merceline Dahl-Regis Commonwealth of The Bahamas 2004-2008

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1 Foreword 1 2 Executive Summary 2 3 Acknowledgements 4 4 Acronyms and Conventions 5 5 Introduction 6 6 Physical & Political Description 7 7 Population Demographics 9 7.1 Population Trends 9 7.2 Population Mortality Trends 12 8 Sector Policies, Plans & Supporting Systems 17 8.1 Policies to Guide Delivery of Services 17 8.2 Plans, their Assessments and Evaluations 17 8.3 Legislation in Support of Service Delivery 17 8.4 Health Information 18 9 Health Infrastructure 19 9.1 Organizational Structure 19 9.2 Service Delivery 20 9.3 Facilities 21 9.3.1 Hospitals 21 9.3.2 Health Centres 23 9.4 Resources 25 9.4.1 Manpower 25 9.4.2 Health Services Financing 26 10 Health Services & Programmes 28 10.1 Maternal and Child Health 28 10.2 Expanded Programme of Immunization 31 10.3 School Health Services 32 10.4 Infectious Disease Surveillance 35 10.5 HIV/AIDS 37 10.6 Tuberculosis 42 10.7 Non-communicable Diseases & Injuries 44 10.8 Mental Health Services 46 10.9 Oral Health Services 47 10.10 Nutrition 49 10.11 Health Promotion & Education 50 10.12 Healthy Lifestyles Initiative 50 10.13 Prison Health Services 50 TABLE OF CONTENTS

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11 Environmental Health Services 52 11.1 Water and Sewerage Management 52 11.2 Solid Waste Management 52 11.3 Food Safety Establishments Inspected and Passed; Training of Food Handlers 52 11.4 Vector Control Aedes Aegypti Indices; Rodent Control Activities 53 11.5 Port Health Inspections and Results 55 12 Hospital Services 56 12.1 In-patient 56 12.2 Laboratory 56 12.2.1 Emergency Response 57 12.2.2 Outpatient Services 60 13 Health Situation 62 13.1 General Population 62 13.2 Population Sub-groups 64 13.2.1 Infants 64 13.2.2 Children Aged 1-4 years 64 13.2.3 Children, Aged 5-14 years 66 13.2.4 Adolescents Aged 15-24 years 66 13.2.5 Persons Aged 25-44 years 67 13.2.6 Persons Aged 45-64 years 67 14 Conclusions 69 14.1 Summary of Achievements 69 14.2 Future Strategic Foci 69 14.3 Recommendations and Proposals/Plans for the Future 70 15 References 71 16 Tables and Figures 72

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MInistry of Health, Commonwealth of The Bahamas 1e Chief Medical Ocers (CMOs) Report 2004-2008 is the third in a series of published reports that describes the health status of the peoples of e Bahamas. Since 1963, the Government of e Bahamas has made health care available to all citizens through the Department of Public Health. In more recent times the revised Health Act of 1999 supported the mission of the Ministry of Health which is to ensure that the highest quality of services for health promotion, health protection and healthcare are accessible to all residents of e Bahamas in order to achieve optimal health. Guided by this mission e Ministry of Health continues to operate from a social model whereby improvements to health and well-being are achieved by directing eorts to wards addressing the social and environmental determinants of health, among others. e national healthcare system consists of three key components: the Ministry of Health, the Department of Public Health, and the Public Hospitals Authority, the latter of which was established by an act of Parliament in 1999. Recognizing that the Ministry cannot provide health services by itself, it partners with non-governmental organizations, and other private agencies to provide a comprehensive approach to healthcare for its residents. e status of a nations health, like an individuals, is largely a matter of choices. is report describes the health systems perfor mance and identies choices and possible linkages with related programmes. Data in this report can be used to guide design of national health services strategic plans and can provide direction to major programme priorities impacting the health outcomes of residents across the Bahamian archipelago. e Bahamas health care system has seen many improvements that include expansion of specialists services. is has resulted in growing health expenditures, many of which are technology driven. It is vital that we strike a balance among preventive services, primary care services, and curative services. During the period 2004-08, gains were made, however we were not successful in re orienting health services, nor has there been a corresponding redistribution of resources that helps in striking such a balance. is redistribution must include appropriate funding for the three sectors of public health (human, environmental and veterinary) which will be the key to the success of improving the social determinants of health. Moving forward, we must integrate environmental services with health services and balance primary health services and curative services, in order to make changes on those core determinants of health that will move us toward better results, thereby improv ing the lives of the residents of e Bahamas. e data presented in this report underscore the necessity of accurate data to support the analysis in the overall assessment and evaluation of interventions to serve the health needs of the people of e Bahamas. Optimal results are achieved when individuals also make healthy choices Dr. Merceline Dahl-Regis Chief Medical Ocer 31 December 2010 1FOREWORD

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2 Annual Report of the Chief Medical Ofcere period 2004-08 has proven to be a challenging time for the Ministry of Health (MOH). Many changes have occurred, in the health sector nationally and globally, that have impacted the health of the Bahamian people. roughout this period, the MOH has transitioned through several organizational structures. Initially, the Government directed the inclusion of the Department of Environmental Health Services (DEHS) in MOH; later it reassigned DEHS to a newly created Ministry of Environment. e separation of public health activities in DEHS to another Ministry has been one of a series of challenges encountered by MOH in managing public health threats, emergencies and events. e country has focused attention on social factors impacting health issues, including a rise in violence resulting from urbanization and economic problems. Nevertheless, the level of governmental commitment to health strategies and services has remained constant, despite an economic downturn. For its part, the MOH has worked to sustain the Bahamian peoples health in the face of these mounting challenges. e MOH adopted the WHO guidelines for food health/food safety, assuming full responsibility for training food handlers in food safetyshiing from physical exam and stool examination-based health certication to a knowledge-based food handlers certication process, in compliance with internationally accepted guidelines for food safety. Consequently, we have had zero outbreaks of foodborne illness in the community. e World Health Assembly revised the International Health Regulations (IHR (2005)), and e Bahamas became a signatory at the 58th World Health Assembly. is revision laid the solid groundwork for capacity building in surveillancenationally, regionally, and internationallyas well as strengthening port health surveillance. Pandemic planning incorporated a multitude of agencies; it sought to develop a national response to emerging threats posed by Inuenza A (H5N1). e IHR (2005) came into eect in June 2007; and in 2008, e Bahamas conducted an assessment of its capacity to provide surveillance, response, and control for possible public health emergencies of international scale and scope. is established inter-sectoral, interministerial, inter-departmental, and interagency networks and strengthened private-public partnerships for health promotion and prevention. e MOH also conducted the Chronic Noncommunicable Diseases (CNCD) Prevalence Study and Risk Factor Survey in 2005, aimed at identifying determinants of CNCDs that contribute to the burden of disease in e Bahamas. e Healthy Lifestyles initiative was launched; a new MOH initiative aimed at increasing awarenessand reducing the impactsof chronic non-communicable diseases on residents of e Bahamas. With the prevalence of hypertension and diabetes both on the rise, the Ministry of Health sought innovative approaches to strengthen community involvement in managing these epidemics. e MOH also resourced the scaling up of access to antiretroviral therapy (ART) for persons infected with HIV/AIDS, and it has provided medications free of charge to all persons meeting treatment criteria. is has been benecial in reducing both the level of hospitalizations and deaths associated with HIV/AIDSmoving it from one of the top one or two causes of death to the #4 cause of death by 2008. Gilead began production of the antiretroviral drug Viread (tenofovir) in Grand Bahama. is drug has contributed to the management of AIDS locally and globally. In addition, in 2006 e Bahamas successfully managed a malaria outbreak on the island of Great Exuma through cooperative eorts by the Department of Public Health (DPH) and DEHS with signicant support from the Pan American Health Organization (PAHO). Commendation for our management of this outbreak internationally was echoed by US Centers for Disease Control and Prevention. We have been cited for textbook management of an outbreak, resulting in rapid containment of a potential public health threat of global concern. 2EXECUTIVE SUMMAR Y

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MInistry of Health, Commonwealth of The Bahamas 3e Department of Public Health began a restructuring exercise in 2006 and continued into 2007, which included the introduction of management teams in polyclinics aimed at increasing eciency and improving patient care. ese polyclinics aligned with regionalized groups of Family Island services and each polyclinic assumed responsibility for referral services for their regional cluster and to provide support for the sta resulting in a more ecient referral system and continuity of care. Extended hours for patient care were reintroduced in the polyclinics to meet increased patient demand for services. In 2008, oncology services relocated to newly renovated facilities in Princess Margaret Hospital, enabling oncology care to be provided for persons with cancer in a setting that is more spacious and more appropriately equipped.

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4 Annual Report of the Chief Medical Ofcere production of this report would not be possible without the assistance of managers of the National Programmes and their support sta including Ms. Camille Deleveaux and sta in the Health Information and Research Unit; Ms. Margaret Daxon and sta in the Chronic Noncommunicable Disease Unit; Dr. Cherita Moxey; Ms. Amelia Collie; and many other personnel throughout the Ministry of Health, the Department of Public Health and the Department of Environmental Health Services. Appreciation is extended to Ms. Sandra Smith and Mrs. Kathy Johnston of the Planning Unit in the Ministry of Health. Gratitude is also extended to Ms. Sherrylee Smith for editing the report. Special thanks are extended to the Pan American Health Organization/World Health Organization (PAHO/WHO), whose sponsorship of Ms. Yvette Holder, Consultant Epidemiologist and Biostatistician, enabled this report to come to fruition. Particular thanks are given to Dr. Merle Lewis (PAHO) for her inspiration and continued support. 3ACKNOWLEDGEMENTS

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MInistry of Health, Commonwealth of The Bahamas 5No cases recorded Data not available ABG Arterial Blood Gas AIDS Acquired Immune Deciency Syndrome Anti-HBS Antibody to Hepatitis B Surface Antigen ARI Acute Respiratory Infection ART Antiretroviral erapy ATT Attenuated Tetanus Toxoid BP Blood Pressure CAREC Caribbean Epidemiology Centre CCAC Community Counseling and Assessment Centre CDR Crude Death Rate CLAP Latin American Centre for Perinatology CMO Chief Medical Ocer CMV Cytomegalovirus CNCD Chronic Non-Communicable Diseases CSF Cerebral Spinal Fluid CVA Cerebro-vascular Accident DEHS Department of Environmental Health Services DHSS Dengue Haemorrhagic Shock Syndrome dm decayed, missing, and total deciduous teeth DMFT Decayed, Missing and Filled permanent Teeth DOT Directly Observed erapy DPH Department of Public Health DPT Diphtheria, Pertussis and Tetanus Vaccine EMS Emergency Medical Services ENT Ear, Nose and roat EPI Expanded Programme on Immunization GBHS Grand Bahama Health System GC Gonnococcal GDP Gross Domestic Product G/E Gastroenteritis Gm(s) Gram(s) GPC General Practice Clinic HAV Hepatitis A Virus Hb Haemoglobin HBsAg Hepatitis B Surface Antigen HBV Hepatitis B Vaccine HCV Hepatitis C Virus HIRU Health Information and Research Unit HIB Haemophilus inuenza type B vaccine HIV Human Immunodeciency Virus HMP Her Majestys Prison HR Human Resource HTLV 1 & 2 Human T-Lymphotrophic Virus 1 & 2 ICU Intensive Care Unit IHR International Health Regulations IMR Infant Mortality Rate L.E. Life Expectancy MCH Maternal and Child Health MDG Millennium Development Goals MOH Ministry of Health MMR Measles, Mumps and Rubella vaccine MTCT Mother-to-child Transmission NICU Neonatal Intensive Care Unit OB Obstretrics PAHO Pan American Health Organization PET Pre-Eclamptic Toxaemia PHA Public Hospitals Authority PHAC Public Health Agency of Canada PKD Polycystic Kidney Disease PMTCT Prevention of Mother-to-child Transmission RTA Road Trac Accident RTI Road Trac Injury PMH Princess Margaret Hospital PSW Private Surgical Ward RMH Rand Memorial Hospital SCBU Special Care Baby Unit SIP Perinatal Information System SLE Systemic Lupus Erythematous SRC Sandilands Rehabilitation Centre STD Sexually Transmitted Disease STI Sexually Transmitted Infection TB Tuberculosis UA Urine Analysis UHCG Urine Human Chorionic Gonadotrophin VDRL Venereal Disease Research Laboratory (Test) URTI Upper Respiratory Tract Infection WHO World Health Organization YPLL Years of Potential Life Lost 4ACRONYMS AND CONVENTIONS

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6 Annual Report of the Chief Medical Ofcer e Report of the Chief Medical Ocer is intended to oer information about the performance of the health care system and the overall health of the population. is document provides a forum for discussion of health determinants that impact residents of the country and describes the impact that programmes designed to improve the health of our residents have had on the country. Further, it allows one to examine the relationship between health policy and the technical outputs that occur as a result of our national programmes. e use of data in this report can help policymakers and programme managers guide their development of interventions aimed at decreasing morbidity and mortality and promoting good health. e Chief Medical Ocers Report also evaluates the performance of the health system, in identifying gaps in programmes and coverage, in order to improve upon currently available services. is report paints a picture of the nations health status, as evidenced by the progress made toward the achievement of the Millennium Development Goals (MDGs). roughout the time period covered by most of this report, MOH has been challenged with major changes in its organizational structure, especially the migration and return of Environmental Health Services. As a key member of the public health team, the Department of Environmental Health Services is an essential component of the environmental management of determinants of health; as such, whether they are organizationally included in the Ministry of Health or situated in a parallel agency, they are critical to our attainment of improved health within the nation.5INTRODUCTION

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MInistry of Health, Commonwealth of The Bahamas 7 e Commonwealth of e Bahamas comprises an archipelago of some 700 islands situated in the Caribbean Sea. Fewer than 40 are inhabited. Most of our 300,000 Bahamians live on two main islands, New Providence, with the Commonwealths capital Nassau, and Grand Bahama. e countrys economic mainstays are tourism and banking, both of which contribute to give the country one of the highest per capita Gross Domestic Products (GDP) in the English-speaking Caribbean. e per capita GDP had been increasing steadily until 2008, when the country began to experience the cascading consequences of the global economic downturn, including a decrease in tourist arrivals (Table 1). Household income declined in 2008 to pre-2007 levels, although inequality in income distribution widened slightlya marginal decrease in the Gini coecient demonstrating a continued trend from 2001 (Gini coecient of 0.5745 (Bahamas Survey of Living Conditions, 2001)).Table 1. Socio-Economic Indicators YEAR Per capita GDP1,2H/hold Income3,4, 5Gini Coeff.2Unemployment Rate%3,42004 19,281.4 39, 626 10.2 2005 20,132.6 38, 891 10.2 2006 22,060.9 43, 421 7.6 2007 22,448.7 45, 221 0.45 7.9 2008 22,102.2 43, 459 0.44 8.7 1 At current market prices Sources: 2 World Statistics Pocketbook/United Nations Statistics Division (Economic Commission of Latin America and the Caribbean) 3 Department of Statistics, e Bahamas in Figures, 2007 4 Idem. 2008 Labour Force and Household Income Survey 5 Idem. 2009 Labour Force and Household Income Survey (in print)Generally, the Commonwealth of e Bahamas has an active labour force. Participation rates have hovered around 76% for the past decade and participation continues beyond the retirement age (Table 2). Unemployment rates had been less than 10% since 2005 and youth unemployment has decreased slightly from 18.9% to 17.6%. Notable, too, is that 67% of the labour force is employed by the private sector. However, public service remains the largest employer, employing 31% of all employed persons. It is surmised that many persons, upon their retirement from public sector jobs, then are employed by the private sector. 30% of the labour force reported having no educational certicatei.e., had passed no national examination. As expected, this rate is higher among the unemployed than among the employed, 45.0% and 28.6% respectively (Table 3). Men were more likely to have no educational certicate than women among both unemployed (52.0% vs. 40.2% respectively) and employed persons (35.2% vs. 21.6% respectively).6PHYSICAL AND POLITICAL DESCRIPTION

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8 Annual Report of the Chief Medical OfcerTable 2. Labour Force by age and sex, All Bahamas, 2008 Labour Force by Age, Gender and Employment Status AGE GROUP Total Labour Force Employed Labour Force Unemployed Labour Force Total Women Men Total Women Men Total Women Men N % N % N % N % N % N % N % N % N % 15-19 10,785 6 4,425 5 6,360 6 8,120 5 3,130 4 4,990 5 2,665 16 1,295 14 1,370 18 20-24 21,790 11 10,205 11 11,585 12 18,705 11 8,395 10 10,310 11 3,085 19 1,810 20 1,275 17 25-34 47,225 25 23,475 25 23,750 24 42,605 24 20,750 25 21,855 24 4,620 28 2,725 30 1,895 25 35-44 48,735 25 25,565 27 23,170 24 45,600 26 23,870 28 21,730 24 3,135 19 1,695 19 1,440 19 45-54 38,685 20 18,870 20 19,815 20 36,420 21 17,710 21 18,710 21 2,265 14 1,160 13 1,105 15 55-64 18,165 9 8,360 9 9,805 10 17,505 10 8,070 10 9,435 10 660 4 290 3 370 5 65 and over 5,185 3 1,675 2 3,510 4 5,020 3 1,605 2 3,415 4 165 1 70 1 95 1 Not Stated 1,025 1 585 1 440 0 945 1 555 1 390 0 80 0 30 0 50 1 Total 191,595 100 93,160 100 98,435 100 174,920 100 84,086 100 90,835 100 16,675 100 9,075 100 7,600 100Table 3. Labour Force by highest examination passed, 2008. LABOUR FORCE BY HIGHEST EXAMINATION PASSED AND SEX:2008 ALL BAHAMAS EXAMINATION PASSED TOTAL LABOUR FORCE EMPLOYED UNEMPLOYED TOTAL % WOMEN MEN TOTAL WOMEN MEN TOTAL WOMEN MEN None 57,730 30 21,775 35,955 50,130 18,130 32,000 7,600 3,645 3,955 BJC/Pitman/RSA, Etc. 30,000 16 14,920 15,080 27,000 13,200 13,800 3,000 1,720 1,280 GCE O Level/BGCSE 35,770 19 20,040 15,730 32,555 18,035 14,520 3,215 2,005 1,210 GCE A Level/Associate Degree 17,745 9 11,005 6,740 17,220 10,515 6,705 525 490 35 Degreed Persons 25,765 13 14,110 11,655 25,150 13,830 11,320 615 280 335 Professional (Non-University)/ Other Trade Certicate 22,085 12 10,485 11,600 20,835 9,895 10,940 1,250 590 660 Not Stated 2,500 1 825 1,6752,030 480 1,550 470 345 125Total191,595 100 93,160 98,435 174,920 84,085 90,835 16,675 9,075 7,600

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MInistry of Health, Commonwealth of The Bahamas 97.1 POPULATION TRENDSFig. 1. Distribution of population by age and sex, 2004. 0 5,000 10,000 15,000 20,000 Male 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0 5,000 10,000 15,000 20,000 Female 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0 5,000 10,000 15,000 20,000 Male 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0 5,000 10,000 15,000 20,000 Female 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Fig. 2. Fig.2. Population distribution by age and sex, 2008. 0 5,000 10,000 15,000 20,000 Male 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0 5,000 10,000 15,000 20,000 Female 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0 5,000 10,000 15,000 20,000 Male 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0 5,000 10,000 15,000 20,000 Female 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Source: Department of StatisticsPopulation pyramids are evolving from a triangular shape to one like a barrel with a shrinking base, narrow apex and a bulging centre from which the labour force is drawn (Figs. 1-2). Given a low dependency ratio of 0.54, each person of employable age (15-59) needs to support less than one additional person who is not employed. 7POPULATION DEMOGRAPHICS

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10 Annual Report of the Chief Medical OfcerTable 4. Basic Demographic Indicators, 2002 2008 Year Indicator 2002 2003 2004 2005 2006 2007 2008 Estimated Mid-Interval Population312,100 316,298 320,800 325,200 329,500 334,000 338,300Estimated # women 15-44 age group79,800 80,700 81,400 82,100 82,900 83,200 83,800Total Births5,270 5,1325,250 5,654 5,390 5,937 5,562 Live Births5,216 5,054 5,154 5,548 5,2965,854 5,480 Live Birth Rate (per 1,000 pop.)16.7 16.0 16.1 17.1 16.0 17.5 16.2Live Births (Registered*) for females 15-44 years,866 ,9425,099 5,531 5,232 5,146 5,088 General Fertility Rate (live births per 1,000 females 15-49 yrs).2 .1 55.5 50.0 55.4 61.156.7 Total Fertility Rates1.92 1.87 1.90 2.05 1.93 2.14 2.00Total Number of Deaths 1,827 1,666 1,7361,824 1,730 1,798 1,862 Deaths Rate (per 1,000 pop.)5.9 5.3 5.4 5.6 5.2 5.45.5 Stillbirths54 90 96 106 94 83 82Stillbirth Rate (per 1,000 total births)10.4 .8 18.619.1 17.7 14.2 15.0 Natural Increase,414 ,388 3,418 3,724 3,566 4,056 3,618Natural Increase Rate (per 1,000 pop.).9 .8 10.6 16.510.8 12.1 16.0 Infant Deaths87 87 89 10996 103 98 Infant Death Rate (per 1,000 live births).7 .2 17.3 19.6 18.1 17.6 17.9 Perinatal Death Rate (per 1,000 total births)** *(2006, estimated occurrence) .2 22.3 25.9 24.8 28.5 23.2 Neonatal Deaths *(2006, estimated occurrence)* 30 7269 81 66 Neonatal Death Rate (per 1,000 livebirths)* .9 5.8 13.0 13.0 13.8 12.0Maternal Deaths (Registered) 0 2 2 5 0 4 3 Child Deaths (1-4 Years) 10 15 18 8 6 15Child Mortality Rate (per 10,000 children) 3.9 6.5 7.8 3.42.7 6.5 Sources: Department of Statistics and Health Information & Research Unit, Ministry of Health

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MInistry of Health, Commonwealth of The Bahamas 11 Fig. 3. Trends in population growth and associated factors, 1998 2008 27,0000 28,0000 29,0000 30,0000 31,0000 32,0000 33,0000 34,0000 35,0000 Est. Pop. 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 0 5 10 15 20 25 Livebirth Rate Nat. Incr. 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 # of Persons Per 1,000 population Source: Department of Statisticse natural increase of population varied between 10.6 and 12.1 persons per 1000, contributing to a stable average annual population growth of 1.9% for the past decade (Fig. 3). Fig. 4. Age-specic fertility rates by age-group, 2004 2008 0 20 40 60 80 100 120 2008 2007 2006 2005 2004 45-49 40-44 35-39 30-34 25-29 20-24 15-19Per 1,000 populationAge Group Source: Health Information and Research UnitA slight increase in fertility rates was seen in all age-groups, including the 15-19 year old group (Fig. 4). is overall increase in all age groups peaked in 2007, with a decrease in 2008, however the rates never returned to the levels of 2004.

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12 Annual Report of the Chief Medical Ofcer7.2 POPULATION MORTALITY TRENDS As death rates stabilized, so did life expectancies, with gains becoming relatively smaller (Table 5). Male life expectancy has steadily increased, while female life expectancy has varied slightly but remains greater than male life expectancy. Table 5. Life expectancy at birth, 1980 2008 ca. 1980 ca. 1990 ca. 2000 2008 L.E. C.D.R. L.E. C.D.R. L.E. C.D.R. L.E. C.D.R. Male 64.3 7.9 68.3 5.9 69.9 6.1 71.0 6.2 Female 72.1 5.0 75.3 4.6 79.4 4.7 76.7 4.8 Source: Department of StatisticsFig. 5. Mortality rates crude death rate per 100,000 pop., infant, neonatal and perinatal mortality rates per 1000 livebirths, and stillbirth rates per 1000 livebirths, 1998 2008 0 5 10 15 20 25 30 Crude Death Rate Stillbirth Rate Perinatal MR Neonatal MR IMR 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998RatesYear Source: HIRUStillbirth rates, and hence, perinatal mortality rates show a rising trend (Fig. 5). Neonatal deaths more than doubled in 2005, from 30 to 72; although decreasing from then onwards, these remained higher than previous levels (Tables 4, 6). Also notable was an increase in late neonatal deaths to 25 in 2005 from 8 the previous year, with no signicant decline in subsequent years. e apparent increase may be due to improved reporting. It is remarkable that this was also the year of greatest natural increase.

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MInistry of Health, Commonwealth of The Bahamas 13Table 6. Foetal and infant Deaths by age, 1999 2008 YEAR FOETAL DEATHS REGISTERED INFANT DEATHS BY AGE TOTAL INFANT DEATHS <6 days 7-27 days 28 days11mths. Registered Est. Occurrences* 1999 75 18 14 17 49 85 2000 63 19 10 23 52 78 2001 51 8 15 14 37 68 2002 54 87 2003 90 19 11 24 54 87 2004 96 21 8 27 56 89 2005 86 40 25 36 101 109 2006 72 30 23 26 89 96 2007 83 31 21 17 69 103 2008 82 29 11 31 71 98 *Based on institutional census. N.B. Dierences between tables on infant deaths due to late registration. Source: Registered Deaths, Department of Statistics and Health Information & Research UnitTable 7. Crude deaths rates (per 100,000 pop.) and ranks for leading causes of death, 2004 2008. Condition 2004 2005 2006 2007 2008 CDR Rank CDR Rank CDR Rank CDR Rank CDR Rank Hypertensive Dis. 67.0 1 58.1 1 51.9 2 42.5 1 46.7 2 HIV/AIDS 49.8 2 48.6 2 56.4 1 39.8 2 34.6 4 Cerebrovascular Dis. 38.9 3 41.8 3 31.9 5 37.7 4 43.7 3 Ischaemic Heart Dis. 34.9 4 38.7 4 47.6 3 38.0 3 48.5 1 Diabetes Mellitus 27.1 5 29.2 5 29.7 6 28.1 5 24.2 5 Cancer of the Breast 24.8 6 25.1 6 32.5 4 25.6 7 25.4 10 Cancer of the Prostate 23.7 7 23.4 7 25.0 7 25.9 6 35.8 7 Motor Vehicle Inj. 15.6 8 19.1 8 14.0 9 14.7 9 13.9 8 Homicides 13.7 9 16.9 9 17.9 8 24.9 8 22.5 6ese nine conditions, namely hypertensive disease, HIV/AIDS, cerebrovascular disease, ischaemic heart disease, diabetes, motor vehicle injuries, homicides, cancer of the breast in women and of the prostate in men, accounted for roughly half of all deaths each year 53.4% in 2004, 48.1% in 2005, 54.2% in 2006 and 45.2% in 2007 (Table 7, Figs. 6, 7) Hypertension has remained the single leading cause of death in all years, except 2006 and 2008, when it was replaced by HIV/AIDS (2006) and ischaemic heart disease (2008). Most noteworthy is the marked increase in homicide rates, which have almost doubled in four years, where males were nine times more likely to be murdered than females. Also noted are decreases in the rates of deaths due to cancer of the breast in females and HIV/AIDS, although the death rates due to HIV/AIDS for males were almost one and a half times higher than that for females. Death due to diabetes is the only rate that has remained constant over time, despite population-based interventions that have been initiated.

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14 Annual Report of the Chief Medical OfcerFig. 6. Leading causes of death, 2004, 2005 Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) Cerebrovascular Diseases (I60-I69) Ischemic Heart Diseases (I20-I25) Diabetes (E10E14) Land Transport Accidents (V01-V89) Assault (homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Malignant neoplasm of prostate (C61) Heart failure and complications and ill-dened heart disease (150-151) Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) Cerebrovascular Diseases (I60-I69) Ischemic Heart Diseases (I20-I25) Diabetes (E10E14) Certain Conditions Originating in the Perinatal Period (P00-P96) Land Transport Accidents (V01-V89) Assault (Homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Heart failure and complications and ill-dened heart disease (I50-I51) 2004 2005 Based on PAHOs Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 02/07 Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) Cerebrovascular Diseases (I60-I69) Ischemic Heart Diseases (I20-I25) Diabetes (E10E14) Land Transport Accidents (V01-V89) Assault (homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Malignant neoplasm of prostate (C61) Heart failure and complications and ill-dened heart disease (150-151) Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) Cerebrovascular Diseases (I60-I69) Ischemic Heart Diseases (I20-I25) Diabetes (E10E14) Certain Conditions Originating in the Perinatal Period (P00-P96) Land Transport Accidents (V01-V89) Assault (Homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Heart failure and complications and ill-dened heart disease (I50-I51) 2004 2005 Based on PAHOs Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 06/07

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MInistry of Health, Commonwealth of The Bahamas 15Fig. 7. Leading causes of death, 2006, 2007 HIV Disease (AIDS) (B20-B24) Hypertensive Diseases (I10-I15) Ischemic Heart Diseases (I20-I25) Cerebrovascular Diseases (I60-I69) Diabetes (E10E14) Certain Conditions Originating in the Perinatal Period (P00-P96) Assault (Homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Land Transport Accidents (V01-V89) Malignant Neoplasm of Prostate (C61) Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) Ischemic Heart Diseases (I20-I25) Cerebrovascular Diseases (I60-I69) Diabetes (E10E14) Assault (Homicide) (X85-Y09) Certain Conditions Originating in the Perinatal Period (P00-P96) Land Transport Accidents (V01-V89) Malignant Neoplasm of Female Breast (C50 in Women) Heart Failure and Complications and Ill-Dened Heart Disease (I50-I51) 2006 2007 Based on PAHOs Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 06/07 HIV Disease (AIDS) (B20-B24) Hypertensive Diseases (I10-I15) Ischemic Heart Diseases (I20-I25) Cerebrovascular Diseases (I60-I69) Diabetes (E10E14) Certain Conditions Originating in the Perinatal Period (P00-P96) Assault (Homicide) (X85-Y09) Malignant Neoplasm of Female Breast (C50 in Women) Land Transport Accidents (V01-V89) Malignant Neoplasm of Prostate (C61) Hypertensive Diseases (I10-I15) HIV Disease (AIDS) (B20-B24) Ischemic Heart Diseases (I20-I25) Cerebrovascular Diseases (I60-I69) Diabetes (E10E14) Assault (Homicide) (X85-Y09) Certain Conditions Originating in the Perinatal Period (P00-P96) Land Transport Accidents (V01-V89) Malignant Neoplasm of Female Breast (C50 in Women) Heart Failure and Complications and Ill-Dened Heart Disease (I50-I51) 2006 2007 Based on PAHOs Standard List for Leading Causes of Death, 2006 (ICD10) Source: Department of Statistics Prepared By: Health Information and Research Unit, Ministry of Health 01/2010

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16 Annual Report of the Chief Medical OfcerFig. 8. Y ears of potential life lost (YPLL) 2002-2006 0 1,000 2,000 3,000 4,000 5,000 6,000 2006 2005 2004 2003 2002Cerebrovscular Diseases Accidental Drowning & Submersion Female Breast Cancer Hypertensive Diseases Congenita Malformations Ischaemic Heart Disease Land Transport Assault (Homicide) Perinatal Conditions HIV Disease YPLL Age Group Source: HIRUWhen mortality is measured using Years of Potential Life Lost (YPLL), HIV/AIDS outranks hypertension as the leading cause of mortality (Fig. 8), because people with hypertension generally die later in life. For this reason, too, perinatal conditions and congenital anomalies ranked highly. Most troubling was a four-fold increase in YPLL due to homicides, the result of more deaths at increasingly younger ages.

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MInistry of Health, Commonwealth of The Bahamas 17 8SECTOR POLICIES, PLANS & SUPPORTING SYSTEMS8.1 POLICIES TO GUIDE DELIVER Y OF SER VICES e National Food and Nutrition Policy and Agenda for Action for e Bahamas e Government of e Commonwealth of e Bahamas recognizes the correlation between the social determinants and health outcomes. A healthy population is more productive, better able to learn and acquire skills, and more apt to engage in socially acceptable leisure and pleasure activities. Notably, there is a close interrelationship between food, nutrition, levels of physical tness and health status. Good nutrition leads to proper growth and development, protects against diseases and reduces health care costs. e health and well being of a population are dependent upon a good quality food supply system that is accessible, aordable, available, and sustainable. ese fundamental elements of food security contribute signicantly to quality of life. Low levels of physical tness and lack of exercise are considered independent risk factors for many of the CNCDs, including hypertension, diabetes mellitus type 2, coronary heart disease, and some cancers. e Ministry of Health and the Ministry of Agriculture and Marine Resources recognize this important relationship and the need for a comprehensive policy on food and nutrition. In collaboration with other government ministries, a multi-sectoral committee was established to review the current food, nutrition and health situation, and set guidelines for improving food and nutrition security for all segments of the population and the many visitors to the country. e result was the development of the Food and Nutrition Policy and Agenda for Action, which was proposed in 2008 by the Ministry of Health as a dra document, but not yet ratied. 8.2 PLANS, THEIR ASSESSMENTS AND EV ALUATIONSe National Health Service Strategic Plan 2006-2015 was draed in 2005 but not given nal approval. While this plan was not nalized, portions of the dra document helped to guide programmes during the period of this report. 8.3 LEGISLATION IN SUPPORT OF SER VICE DELIVER Ye following pieces of legislation have been prepared and/or enacted to facilitate delivery of quality health services to the people of the Commonwealth of e Bahamas.Dra Revision of e Medical Act e dra Medical Act, which will repeal the existing Act, makes the Medical Council more eective by establishing it as a more autonomous body with four committees: a preliminary Proceedings Committee, an Education Committee, a Health Committee and a Professional Conduct Committee. It is expected that the Act, once passed, will provide administrative structures to: (1) better regulate the medical profession, (2) upgrade doctors skills through its continuing education requirements, and (3) better safeguard the public through improved means of receiving and responding to complaints. Amendment to e Dental Act A Bill for an Act to Regulate the Practice of Dentistry will repeal and replace the existing Dental Act, and will modernize and expand law and policy governing the practice of dentistry in e Bahamas by establishing statutory committees within the Dental Council. Clause 4 of the Bill establishes an Education Committee, a Health Committee, a Preliminary Proceedings Committee, and a Disciplinary Committee.

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18 Annual Report of the Chief Medical Ofcere Nurses and Midwives Act e draed Bill aims at addressing certain gaps in the existing Nurses and Midwives Act, Chapter 225. New provisions address the extended roles of nurses and midwives, the registration of specialty nurses and nurse practitioners, and their continuing professional education. Further provision is made to require practicing nurses and midwives to hold a license from the Nursing Council upon prescribed conditions. A requirement for ongoing medical education will be added as one of the criteria in the licensing of nurses and midwives. e Health Services Act (Chapter 231) e Health (Amendment) Rules 2010 An amendment to Rule 77 of the Health Services Act was proposed to facilitate new requirements for the certication of food handlers, as opposed to previous requirements based on an examination by a medical practitioner. e Health Services Act, Chapter 231) Public Health Emergency Rules e new Public Health Emergency Rules are proposed to bring e Bahamas into compliance with International Health Regulations (2005) of the WHO, adopted by the 58th World Health Assembly on May 23, 2005. 8.4 HEALTH INFORMATION iPHIS plans e Integrated Public Health Information System (i-PHIS) is an automated client health record and reporting system that supports interventions by public health providers, including tracking, follow-up, case management, and public health reporting. e system is intended to provide access to all client records by multiple health care providers across e Bahamas. In February 2003 the Public Health Agency of Canadas (PHAC) i-PHIS application was presented to representatives from the Department of Public Health. e application was found to meet most of the key requirements for the Department of Public Health in e Bahamas. A pilot study was conducted in June 2004 and evaluated a few months later in November. e evaluation team recommended that e Bahamas proceed in implementing i-PHIS across e Bahamas. Implementation of i-PHIS began in March 2007 and has continued since. Challenges remain, however, in terms of connectivity across the archipelago and for adequate computer support among the countrys 30 inhabited islands.

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MInistry of Health, Commonwealth of The Bahamas 19 9HEALTH INFRASTRUCTURE9.1 ORGANIZATIONAL STRUCTURE e Ministry of Healths organizational structure has experienced four challenging years, with various agencies added to or removed from the Ministers portfolio during this time. Additions to the Ministrys organizational structure diverted attention from other matters impacting the countrys health during these years. Organizational Structure 2004-06 (February) e Ministry of Health and the Environment was re-structured, with two of the three arms of public health under its authority: the Departments of Public Health and Environmental Health Services. Veterinary public health was placed under the authority of the Ministry of Agriculture. Organizational Structure 2006-07 (February) Ministry of Health and National Insurance For one year, the MOH became Ministry of Health and National Insurance. is change aligned with the Governments initiative to provide universal health insurance (National Health Insurance). e resulting organizational structure moved the Department of Environmental Health Services to another Ministry; however, the Public Analysts Laboratory remained under the Ministry of Health. Organizational Structure 2007 (February May) Ministry of Health, National Insurance and Public Information e Ministry of Health and National Insurance expanded for three months, to include Public Information, which included Bahamas Information Services and the Broadcasting Corporation of e Bahamas, Radio and Television Broadcasting. Organizational Structure 2007 (May-June) Ministry of Health In May 2007, a new Government of e Bahamas was elected. Subsequent Cabinet appointments included a Minister for Health, whose portfolio included both the Ministry of Health and the Department of Environmental Health. Organizational Structure 2007-2008 (July) Ministry of Health and Social Development (including DEHS) e Ministry of Health, which included the Department of Environmental Health Services, expanded to include Social Development for a little over a year. Organizational Structure 2008 (September) Ministry of Health (excluding DEHS and Social Development) In September 2008, Cabinet re-assignments resulted in the Minister with responsibility for Health retaining only the Ministry of Health. Organizational Structure 2004-2008 Public Hospitals Authority (PHA) PHAs organizational structure remained stable from 2004-08, maintaining responsibility for three government hospitals, the primary health care system in Grand Bahama (Grand Bahama Health System), for shared services by the Bahamas National Drug Agency and Materials Management Directorate, and for the Emergency Medical Service.

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20 Annual Report of the Chief Medical OfcerDepartment of Public Health e Department of Public Health was under the direction of the Director of Public Health during the period 2004-07. DPH was placed under the Oce of the Chief Medical Ocer from November 2007 to March 2009, during which time MOH conducted a search to ll the position of the Director of Public Health. 9.2 SER VICE DELIVER Y Primary health care is the core foundation of public health care services. is is delivered through a network of 28 health centres, 33 main clinics, and 35 satellite clinics dispersed across 30 inhabited islands. rough these local facilities, medical and nursing sta conduct general ambulatory care clinics and chronic non-communicable disease clinics that service patients with hypertension and diabetes, as well as specialized services through antenatal, postnatal and immunization clinics provided as part of a maternal and child health (MCH) programme, as well as school health and oral health clinics. ese dierent types of clinics include: and deliveries; oers ambulatory care, X-ray facilities, MCH services, and other specialized care. overnight bed facilityoers MCH services and minimal emergency care. areas. Other national programmes that support the MOHs primary health care thrust include: Complementing the primary health care system are three public hospitals and their services to in-patients and out-patients: (PMH)+ bed acute care facility that is the countrys referral institution located in Nassau, New Providence. Its services/clinics include physiotherapy, speech therapy, occupational therapy, neurodevelopment, dialysis, ophthalmology, ear, nose and throat (ENT), obstetrics, oncology, oral health, orthopaedics, paediatrics, psychiatry, dermatology, surgery, and general medicine. (RMH)-bed hospital located on Grand Bahama, oering antenatal and postnatal clinics, paediatrics, gynaecology, psychiatry, orthopaedics, ophthalmology, ENT, surgery and general medicine.

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MInistry of Health, Commonwealth of The Bahamas 21 (SRC)-bed psychiatric and geriatric hospital in New Providence, oering a variety of mental health services including detoxication and occupational therapy. e health system also includes private hospitals, Doctors Hospital and Lyford Cay Medical Facility and a chain of walk-in clinics, private practitioners and private medical oces. 9.3 F ACILITIES 9.3.1 HOSPITALSTable 8a. Hospital Statistics, 2004 2008. Princess Margaret Hospital 2004 2005 2006 2007 2008 Number of Beds 423 405 405 405 405 Number of Discharges 15,212 14,846 14,876 14,969 15,874 Average Length of Stay 6.8 6.8 7.7 7.8 7.2 % Occupancy 69.6 70.4 81.4 82.0 80.2 Total Outpatient Visits 119,622 145,779 141,988 132,215 142,247 Rand Memorial Hospital Number of Beds 86 85 85 85 85 Number of Discharges 4,861 4,870 4,961 4,832 5,184 Average Length of Stay 3.2 3.3 3.3 3.2 3.2 % Occupancy 52.6 51.8 52.8 50.2 54.6 Total Outpatient Visits 56,036 60,827 60,848 64,618 68,196 Doctors Hospital Number of Beds 72 72 72 72 72 Number of Discharges 2,887 3,051 3,104 3,168 3,060 Average Length of Stay 3.7 4.1 4.0 4.2 4.3 % Occupancy 40.4 47.8 47.0 50.7 50.0 Total Outpatient Visits 12,976 14,826 15,155 10,039 10,155 Lyford Cay Hospital Average Outpatient Visits 7,020 Source: HIRU, Ministry of Health; Lyford Cay Hospital

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22 Annual Report of the Chief Medical OfcerIn-patient stays at PMH were longer than those of RMH and Doctors Hospital (Table 8a). Although PMHs in-patient mortality rate decreased during the past ten years, it remains nearly twice that of the other two institutions (Fig. 9). PMH serves as a primary referral hospital for the country. RMH refers severely ill patients to PMH under a transfer agreement for more specialized services. Lyford Cay Hospital does not support inpatient services and currently only provides outpatient services to its clientele. Fig. 9. Hospital in-patient death rates, 1997 2008. 0 1 2 3 4 5 6 PMH RMH Doctors 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997Rate/100,000 PopulationYear Source: HIRU, Ministry of HealthTable 8b. Hospital Statistics, Sandilands Rehabilitation Centre, 2004 2008. Psychiatric Hospital 2004 2005 2006 2007 2008 Number of Beds 367 367 367 367 367 Number of Discharges 1,044 1,099 1,258 1,231 1,191 Average Length of Stay 108.4 102.0 92.6 92.7 95.3 % Occupancy 84.3 90.1 90.9 89.3 88.4 Total Outpatient Visits* 22,548 21,471 20,660 20,849 21,293 Geriatric Hospital Number of Beds 128 128 128 128 128 Number of Discharges 49 36 28 32 23 Average Length of Stay 610.0 767.3 867.2 672.3 829.1 % Occupancy 88.5 88.7 83.5 82.0 77.9 ese outpatient visits are held at the Community Counseling and Assessment Centre; gures estimated for 2007 and 2008.

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MInistry of Health, Commonwealth of The Bahamas 23e average length of stay in the geriatric hospital is reective of its function as primarily a custodial facility for the elderly. is extended length of stay speaks to the need for service costing under dierent models. e cost of providing services in a nursing home setting, with a greater emphasis on custodial care and less utilization of skilled sta in institutions, is a more ecient nancing mechanism. 9.3.2 HEALTH CENTRESTable 9. Community Health Centre Service Statistics, BAHAMAS, 2004-2008 New Providence 2004 2005 2006 2007 2008 Antenatal Clinic 23,117 25,848 24,831 27,076 25,957 Postnatal Clinic 9.432 10,047 11,778 10,811 8,857 Child Health Clinic 61,561 59,470 61,734 65,258 63,559 School Health Clinic 31,727 24,903 36,841 37,396 35,947 Other Clinic Services 108,161 97,894 95,086 101,715 93,821 Other Domiciliary Services 16,131 18,150 13,765 15,656 18,482 Total Outpatient Visits 250,589 236,312 244,035 257,912 246,623 Grand Bahama and the Family Islands Antenatal Clinic 9,309 9,519 9,622 9,590 9,245 Postnatal Clinic 4,072 4,729 5,521 6,026 5,850 Child Health Clinic 38,022 34,759 36,916 36,386 37,247 School Health Clinic 28,049 26,254 26,834 27,338 26,595 Other Clinic Services 127,658 128,297 131,954 142,754 142,097 Other Domiciliary Services 21,174 24,028 24,271 27,988 28,593 Total Outpatient Visits 228,284 227,586 235,118 250,082 249,627 Source: HIRU

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24 Annual Report of the Chief Medical OfcerPersons living in the Family Islands have made greater use of outpatient clinics. is is evidenced by an outpatient visit ratio of 3.38 visits per person compared to 1.13 per person for New Providence and 1.57 per person for Grand Bahama. is may be the result of greater access to and/or utilization of private facilities on New Providence. e total number of outpatient visits (Table 9 ) in New Providence remained relatively stable from 2004-08, while in Grand Bahama and the Family Islands the trend appears to be increasing with time. Fig. 10. Clinic visits in New Providence, Grand Bahama and the Family Islands, 2004 2008 0 10,0000 20,0000 30,0000 Grand Bahama Family Islands New Providence 2008 2007 2006 2005 2004 Fig. 11. Home visits in New Providence, Grand Bahama and the Family Islands, 2004-2008 0 10,0000 20,0000 30,0000 Grand Bahama Family Islands New Providence 2008 2007 2006 2005 2004

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MInistry of Health, Commonwealth of The Bahamas 259.4 RESOURCES 9.4.1 MANPOWER Statistics for the health professions human resource (HR) capacity for 2004-08 (Table 10) reect an overall increase across all disciplines. In 2003, MOH recognized the need to maintain an adequate HR capacity in the nursing profession, in light of health care worker migration; thus, they developed a Nursing Recruitment and Retention Plan that prevented further mass migration of nurses from the system. e University of the West Indies Medical School saw an increased enrollment of Bahamian medical students, which is reected in the increasing number of physicians in the work force, particularly from 2006-08.Table 10. Human resources per 10,000 population, 2004 2008. Health Care Workers 2004 2005 2006 2007 2008 # Rate # Rate # Rate # Rate # Rate Physicians 720 22.4 756 23.2 849 25.1 907 27.2 947 28.0 Dentists 76 2.4 77 2.4 78 3.1 78 2.3 79 2.4 Registered Nurses 792 24.7 812 25.0 832 24.6 1004 31.4 1029 32.1 Trained Clinical Nurses 445 13.8 480 14.8 460 13.6 502 15.7 515 16.1 Pharmacists 158 4.9 140 4.3 156 4.9 142 4.4 138 4.1 Nutritionists & Dietitians 16 0.5 15 0.5 11 0.3 15 0.5 11 0.3 Radiographers 49 1.5 59 1.8 58 1.8 54 1.7 56 1.7 Med. Lab. Technologists 123 3.8 116 3.6 125 3.9 102 3.2 102 3.0 Source: Health Professions Council, Bahamas Medical Council, Bahamas Dental Council,

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26 Annual Report of the Chief Medical Ofcer9.4.2 HEALTH SER VICES FINANCING Table 11. Annual Health Budgets 2003/2004-2008/2009 RECURRENT EXPENDITURES Department 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 Ministry of Health 9,652,124 9,911,680 9,960,913 10,852,257 18,971,627 19,202,679 Department of Environmental Health 23,084,386 25,929,089 26,042,597 28,330,522 33,187,6041Department of Public Health 19,323,932 20,143,494 20,626,198 23,804,235 27,597,797 29,883,366 Public Hospitals Authority 108,611,339 118,948,888 127,926,488 142,420,539 164,364,206 174,140,170 Total 160,671,781 174,933,151 184,556,196 205,407,553 242,121,234 223,226,215 Capital Expenditures Ministry of Health & Department of Public Health 1,558,415 1,736,877 1,846,000 4,086,000 3,900,000 Public Hospitals Authority 5,535,698 6,169,618 6,467,890 6,182.739 2,000,000 Department of Environmental Health Services 148,396,480 5,332,954 5,615,186 6,958,6832Totals 155,490,593 13,239,449 13,929,076 11,727,419 5,900,000 Source: nance Department, Ministry of Health: 1. Department of Environmental Health Services was no longer under the Ministry of Health budget in 2008/2009. 2. Department of Environmental Health Services was no longer under the Ministry of Health budget in 2008/2009.

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MInistry of Health, Commonwealth of The Bahamas 27Fig. 12. Expenditure on health activities, 2006 -2008 0 50 100 150 200 250 300 Department of Env. Health Department of Public Health Public Hospitals Authority Ministry of Health 2008/2009 2007/2008 2006/2007$000,000Fiscal Year Source: Planning Unit, Ministry of Healthe Ministry of Health operates under a continuously increasing annual budget, which by scal year 2007/08 had reached roughly 242 million dollars. e majority of that budget was allocated to recurrent expenditures, the largest portion assigned to the Public Hospitals Authority for the inpatient management of health services. Outside of the MOH operational budget, the Department of Public Health operates the smallest portion of the health budgetwhile maintaining primary health care services on approximately 30 inhabited islands throughout the archipelago. e 2008/09 budgetary decrease reects deployment of the Department of Environmental Health Services to another Ministry (Fig. 12).

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28 Annual Report of the Chief Medical Ofcer10.1 MATERNAL AND CHILD HEALTHTable 12. Summary of antenatal services, coverage and utilization, 2004 2008. Service & Coverage 2004 # % 2005 # % 2006 # % 2007 # % 2008 # % # Pregnant women 4214 4330 4290 4606 4500 < 15 years 96 2.3 29 0.7 30 0.7 38 0.8 22 0.5 15-19 years 925 22.0 774 17.9 813 19.0 875 19.0 860 19.1 5+ gravid 219 5.2 208 4.8 270 6.3 244 5.3 200 4.4 Seen in <16 wks 1985 47.1 2115 48.8 2103 49.7 2098 45.6 2024 45.0 3+ visits @ 36 wks. 1457 81.6 1419 71.3 1668 89.7 1609 91.5 1689 77.8 High BP 234 5.8 219 5.2 315 8.0 315 7.1 227 5.3 Hb<10gm 460 11.5 400 9.6 389 9.7 302 7.1 290 7.2 Positive sugar 147 3.6 138 3.3 144 3.5 126 2.9 71 1.7 Positive albumin 291 7.2 379 9.1 465 11.5 432 9.7 331 7.9 GC Positive 273 8.3 239 7.0 188 5.1 390 10.4 275 7.3 VDRL positive 95 2.5 76 1.9 38 1.1 92 2.2 78 2.0 New cases of PET 139 3.3 200 4.6 144 3.4 147 3.2 135 3.0 New cases of eclampsia 4 0.1 19 0.4 25 0.6 7 0.2 3 0.1 New cases of severe anaemia 51 1.2 32 0.7 32 0.7 23 0.5 16 0.4 Source: Health Information and Research Unit 10HEALTH SER VICES & PROGRAMMES

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MInistry of Health, Commonwealth of The Bahamas 29Table 13a. Summary of perinatal information (Maternal indicators) 2005 2008 Indicator 2005 # % 2006 # % 2007 # % 2008 # % Mothers 4902 4713 5268 5021 Mothers with pathology 202 4.1 184 3.9 265 5.0 140 2.8 multiple pregnancies 59 1.2 61 1.3 80 1.5 53 1.7 previous hypertension 13 0.3 20 0.4 29 0.6 9 0.2 preeclampsia 70 1.4 60 1.3 105 2.0 48 1.0 Prenatal visits 4616 94.2 4415 93.7 4934 93.7 4419 88.0 No visits or no data 286 5.8 298 6.3 334 6.3 302 6.0 Premature labour 788 16.1 665 14.1 724 13.7 677 13.5 Delivery C-section 1083 22.1 1139 24.2 1339 25.4 1281 25.5 Contraceptive advice 2266 46.2 1020 21.6 2888 54.8 2469 49.2 Source: PAHO/WHO CLAP Perinatal Information System (SIP)Table 13b. Summary of perinatal information (Neonatal indicators), 2005 2008 Indicator 2005 # % 2006 # % 2007 # % 2008 # % Births 4838 4681 5220 4965 Small for dates 549 11.3 490 10.5 662 12.7 611 12.3 Large for dates 358 7.4 334 7.1 295 5.7 323 6.5 Apgar score 4-6 484 10.0 467 10.0 449 8.6 354 7.1 Apgar score 0-3 92 1.9 47 1.0 49 0.9 49 1.0 Premature newborn 719 14.9 614 13.1 680 13.0 616 12.4 Low birth weight (<2500 gms) 528 10.9 505 10.8 617 11.8 576 11.6 Very low birth weight (<1500 gms) 123 2.5 110 2.3 126 2.4 126 2.5 Extremely low birth weight (<1000 gms) 53 1.1 49 1.0 53 1.0 57 1.1 Breast feeding 1102 22.8 1462 31.2 1206 23.1 1027 20.7 Source: PAHO/WHO CLAP Perinatal Information System (SIP)

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30 Annual Report of the Chief Medical OfcerCoverage of pregnant women by the antenatal service was high, with over 75% of pregnant women having 4 or more visits before term (Table 12). More than 94% of pregnant women received documented antenatal care, with an average number of visits which ranged from 7.4 per mother in 2005 to 6.5 in 2008 (Table 13A). is coverage rate has evolved in response to the proportion of women at risk for perinatal complications: 20-25% were teenage pregnancies that included an annual average of 43 pregnancies in teens younger than 15 years of age (range 22-96), 4%-6% were highly multigravid, 5%-8% had high blood pressure and another 2%-4% had indications of diabetes or gestational diabetes e incidence of anaemia has decreased from one in nine pregnant women in 2004 to one in 14 in 2008, resulting in an equally marked drop in new cases of severe anaemia. e proportion of women with gonococcal infection (range 5.1-10.4%) and women with positive syphilis serology (range 1.1-2.5%) highlights the need for greater education and contact tracing. Given the above, 12-16% of deliveries have had the potential for adverse outcomes. at they do not lead to such outcomes underscores the eectiveness of our integration of MCH services at all levels, from clinic to hospital. e increasing rate of deliveries by Caesarean section, as evidenced in Table 13A, clearly indicates the need for monitoring trends and identifying determinants that contribute to these higher risk procedures which impact length of stay. One area warranting attention is the promotion of breast-feeding. At the Maternity Ward of PMH, over 90% of mothers breastfed, but at the RMH, less than half the mothers breastfed (36%-45%) (Table 13B). At the Private Surgical Ward of the PMH, that percentage decreases to approximately 15%.Table 14. Summary of Post natal and Infant Child Health Services Service & Coverage 2004 2005 2006 2007 2008 # % # % # % # % # % # Deliveries 3036 3294 4042 4438 3886 Home visit in 3 days 2056 67.7 2341 71.1 2351 58.2 2477 55.8 1503 38.7 2+ home visits in <10 days 1616 53.2 1744 52.9 2263 53.9 2270 51.1 1129 29.2 Clinic <6 wks post delivery 2466 81.2 2513 76.3 2337 55.6 2571 57.9 2711 69.8 Contraceptive use 2429 80.0 2463 74.8 2239 53.3 2295 51.7 2686 69.1 Hb <10gm 99 4.0 195 7.7 111 4.9 160 7.5 113 2.9 High BP 250 7.1 374 10.7 215 6.5 237 6.8 332 8.5 Positive sugar 8 0.2 105 3.2 28 0.9 30 0.9 42 1.1 Postpartum haemorrhage. 1 0.0 1 0.0 2 0.1 Puerperal Sepsis 3 0.1 1 0.0 17 0.4 1st postnatal home visit <10 days 2918 96.1 3126 94.9 1715 42.4 4403 99.2 2830 72.8 1st child health clinic visit < 1 month 2156 71.0 2240 68.0 1845 45.6 2730 61.5 2476 63.7 Solely breast-fed @ 4 wks 274 24.3 366 22.0 424 28.5 394 21.4 325 23.9 Solely breast-fed @ 12 wks 64 19.0 96 12.5 73 11.6 127 31.7 82 17.1 Overweight @ 1 yr. 4 0.1 10 0.3 4 0.1 Abnormal hearing 32 1.1 3 0.1 36 0.9 28 0.6 14 0.4 Source: Health Information and Research Unit

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MInistry of Health, Commonwealth of The Bahamas 31In the years prior to 2008, more than half of all new mothers had received a home visit within 3 days of delivery and two more home visits one week later (Table 14). e percentages of new mothers with hypertension were not insignicant, ranging between 6.5% and 13.7%. A higher than usual number of cases of puerperal sepsis occurred in 2008. With the exception of 2006, rates of home visits of the newborn within 10 days were very high with nurses achieving near perfect coverage in 2007. Breast feeding rates were low: less than one-quarter of babies are solely breast fed at 4 weeks, with the exception of a surge that was seen in 2007 as a result of the return of certied lactation specialists. Unfortunately, this increase was not sustained, and while it had not returned to previous levels, the percentage of new mothers that solely breast fed at 4 weeks had again begun to decrease.Table 15. Reasons for attendance (rst visits only) at child health clinics, 2004 2008. Condition 2004 2005 2006 2007 2008 URTIs 11579 13074 13079 12537 10789 Ear disorders 1609 1339 1129 1469 1697 G/E 1053 691 885 1195 1074 Injuries* 661 654 558 747 838 Ringworm 403 516 431 491 602 Eye disorders 520 551 521 570 589 Scabies 326 205 168 170 226 rush 472 432 444 417 456 Acute bronchitis 267 294 246 382 462 Includes poisonings Source: Health Information and Research Unit.Because it is dicult to identify new cases or measure the catchment populations to truly determine incidence of diseases leading to a childs rst visit to the clinic, the relative magnitude of rst visits is used as a proxy comparator. Notably, respiratory infections were the premier reason for rst attendance at health centres by children aged less than ve years (Table 15). 10.2 EXPANDED PROGRAMME OF IMMUNIZATION (EPI) e EPI programme has maintained high levels of coverage (Table 16) despite challenges such as: e result of an ecient and eective immunization programme has been the decline or eradication of most vaccine preventable conditions over the past two decades. e last recorded cases of vaccine preventable diseases were:

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32 Annual Report of the Chief Medical Ofcer Haemophilus Inuenza type B (2004) (EPI Report, 2009).e rst case of tetanus in twenty years occurred in 2007 in an unvaccinated Haitian national. In 2006, Hepatitis B vaccine was introduced to school children aged 5-19 as part of the School Health Programme (Table 16). Table 16. Immunization coverage rates, 2004 2008 V accine 2004 2005 2006 2007 2008 DPT 93% 93% 95% 95% 94% HIB 93% 93% 95% 95% 94% Hep B 93% 93% 96% 93% 90% Polio 92% 93% 94% 95% 94% MMR 89% 84% 88% 96% 90% ATT 86% 94% 99% 94% 93% Source: Department of Public Health10.3 SCHOOL HEALTH SER VICES e School Health Services Programme provides preventive and curative medical and dental care. ese services are available without cost to students attending government primary and secondary schools throughout e Bahamas. e major objective of this programme is to ensure that students are physically and mentally healthy, so they can derive maximum benets from their education and achieve their fullest potential (Dra Food and Nutrition Policy, 2008).Table 17. Results of health screening of Grade I students, 2004 2008 Service & Coverage 2004 2005 2006 2007 2008 # % # % # % # % # % Children screened 2750 2006 3713 3294 3841 High BP 43 1.6 17 0.9 43 1.2 24 0.7 126 3.3 Hb<10gm 122 4.4 90 4.5 242 6.5 344 10.4 77 2.0 Sugar positive 10 0.4 23 1.2 29 0.8 2 0.1 27 0.7 Vision problem 153 5.6 152 7.6 200 5.4 164 5 153 4.0 Hearing defect 3 0.1 1 0.0 34 0.9 6 0.2 2 0.1 Underweight 80 2.9 49 2.4 133 3.6 93 2.8 72 1.9 Overweight 131 4.8 70 3.5 233 6.3 287 8.7 355 9.2 Dental caries 959 34.9 520 25.9 807 21.7 1020 31 908 23.6 Source: Health Information & Research Unit

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MInistry of Health, Commonwealth of The Bahamas 33Table 18. Results of health screening of Grade 6 students, 2004 2008 Service & Coverage 2004 2005 2006 2007 2008 # % # % # % # % # % Children screened 3349 2508 3980 3850 4275 High BP 36 1.1 30 1.2 101 2.5 47 1.2 164 3.8 Hb<10gm 82 2. 5 98 3.9 219 5.5 297 7.7 61 1.4 Sugar positive 9 0.3 15 0.6 20 0.5 10 0.3 11 0.3 Vision problem 590 17.6 350 14 506 12.7 527 13.7 393 9.2 Hearing defect 16 0.5 10 0.4 21 0.5 75 2.0 6 0.1 Underweight 103 3.1 44 1.8 106 2 .7 78 2.1 46 1.1 Overweight 356 10.6 238 9.5 420 10.6 703 18.3 707 16.6 Dental caries 637 19.0 399 15.9 765 19.2 720 18.7 633 14.8Table 19. Results of health screening of Grade 10 students, 2004 2008 Service & Coverage 2004 2005 2006 2007 2008 # % # % # % # % # % Children screened 2844 1242 3009 2845 3280 High BP 53 1.9 30 2.4 118 3.9 113 4.0 103 3.1 Hb<10gm 135 4.8 49 4.0 102 3.4 163 5.7 169 5.2 Sugar positive 19 0.7 5 0.4 89 3.0 6 0.2 15 0.5 Vision problem 300 10.6 18 15 372 12.4 409 14.4 325 9.9 Hearing defect 42 3.4 26 0.9 45 1.6 1 0.0 Underweight 160 5.6 75 6.0 106 3.5 185 6.5 57 1.7 Overweight 540 19 155 12.5 421 14.0 673 23.7 426 13.0 Dental caries 654 23 268 21.6 650 21.6 646 22.7 747 22.8 Source: Health Information & Research Unit Signicant numbers of children with vision problems and dental caries, and to a lesser extent, with anaemia and hypertension, were seen at all grade levels (Tables 17 19). e situation with respect to oral health will be discussed further under that section.

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34 Annual Report of the Chief Medical OfcerFig. 13. Percentage of children screened at school health clinic who were overweight 0 10 20 30 Grade 10 Grade 6 Grade 1 2008 2007 2006 2005 2004 % Year Source: Health Information and Research UnitNot only is the percentage of overweight children increasing in each and every cohort of school entrants, but in general, the higher the grade, the greater percentage of overweight children. It would appear then rstly, that with each year, increasing numbers of school entrants are overweight and secondly, as the children age and progress through the grades, more of them become overweight (Fig. 13). e 10.6% of Grade 6 school children in 2004 who were overweight increased to 13.0% by Grade 10 four years laterinferring a 0.6% increase each year. ese data suggest that of the 2008 Grade 1 entrants, 14.6% or one in every seven children will be overweight by Grade 10. is highlights the importance of monitoring trends and patterns in order to evaluate the impact of programmatic changes on health outcomes.

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MInistry of Health, Commonwealth of The Bahamas 35Fig. 14. Percentage of children screened at school health clinic who had high blood pressure. 0 1 2 3 4 Grade 10 Grade 6 Grade 1 2008 2007 2006 2005 2004 % Year Source: Health Information and Research UnitAlthough the numbers of school children with high blood pressure are small and must be interpreted cautiously, the increase in percentages of these school children over the years as they enter Grade 1, (from 1.6% in 2004 to 3.3% in 2008) Grade 6 (from 1.1% to 3.8%) and Grade 10 (from 1.9% to 3.1%) as well as within the same cohort (1.1% of sixth-graders in 2004 to 3.1% when these students enter Grade 10) is still cause for alarm as a portent of increased morbidity in later life (Fig. 14). ese trends underscore the need to analyze data promptly and to use that data to alter programme direction and develop interventions that will prevent further poor health outcomes and reduce the occurrence of preventable diseases such as hypertension and diabetes. 10.4 INFECTIOUS DISEASE SUR VEILLANCE 19 cases of malaria occurred on the island of Great Exuma between May-June, 2006 due to Plasmodium falciparum, imported and then locally transmitted. ese cases were successfully treated by chloroquine and primaquine with no associated mortality, and other eective interventions including active case-nding, treatment of cases, and mosquito control, stopped transmission within 30 days (Surveillance Report)

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36 Annual Report of the Chief Medical OfcerTable 20. Reported cases of infectious diseases and syndromes to CAREC, 2004 2008 Disease/syndrome 2004 2005 2006 2007* 2008* Acute haemorrhagic conjunctivitis 408 416 650 Ciguatera poisoning 214 199 139 23 70 Dengue fever & DHSS 1 0 0 1 Food-borne illness 876 907 634 4429 .. Gastroenteritis in <5 year olds 1279 825 1418 1640 ... Gonococcal infections 111 99 104 Inuenza-like disease (ARI) 4143 259 2904 1913 Leptospirosis 0 1 0 1 Malaria imported (introduced) 1 1 30 (19) 7(2) Fever with rash 1 4 4 3 Fever with neurological signs 37 14 Undierentiated fever 232 Meningitis due to H. inuenzae 1 0 1 Acute accid paralysis 0 1 2 Salmonellosis 20 17 10 7 4 Shigellosis 12 11 6 3 2 Syphilis 398 376 Tuberculosis (all forms) 47 48 64 48 49 Typhoid fever 1 0 2 2 Viral hepatitis .. 1 2 Tetanus 1 Chicken Pox 1129 376 476 200 121 Undierentiated fever 356 185 Pneumonia 4 Source: Surveillance Report, Public Health Departmente surveillance of notiable diseases evolved to include surveillance of syndromes and other selected conditions over the period 2004-06 Some discontinuity in reported cases was reected during the transition period. Nevertheless, reports indicated that respiratory conditions, food and water-related illness and sexually transmitted diseases were the diseases with the highest incidence (Table 20).

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MInistry of Health, Commonwealth of The Bahamas 3710.5 HIV/AIDS HIV positive rates among pregnant women have remained stable during the review period (Table 21). Table 21. HIV positivity rates among pregnant women screened, 2004 2008 Year 2004 2005 2006 2007 2008 Positivity Rate 3.0% 2.8% 3.1% 2.5% 2.0%Fig. 15. MTCT Rates, 1995-2008 0 10 20 30 40 50 60 Total Not on ART On ART 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995Rate/100,000 PopulationYear e HIV screening of antenatal women and treatment of those who are positive has steadily improved so that whereas in 1995, of 79 women screened positive, only 15 were on treatment, in 2008, of 89 women screened positive, 80 were on treatment (Table 22). Moreover, transmission rates in mothers on treatment decreased to 0.0. e artifactual increase in 2008 transmission rates among women highlights the challenges of managing prevention of mother to child transmission (PMTCT) in a highly mobile immigrant population that travels easily between countries in the Region during the gestational period and returning to e Bahamas for delivery of their infants and thus preventing the administration of eective antiretroviral therapy (Fig. 15).

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38 Annual Report of the Chief Medical OfcerTable 22. HIV Mother-to-Child Transmission Rates, 1995-2008 AN On TreatmentaAN Not on TreatmentbTotal AN Y ear No. Rate No. Rate No. Rate +ve ANs +ve Infants +ve ANs +ve Infants +ve ANs +ve Infants 1995 15 1 6.7 64 10 15.6 79 11 13.9 1996 67710.4 37 11 29.7 104 18 17.3 1997 48918.8 37 13 35.1 85 22 25.9 1998 3937.7 29 3 10.3 68 6 8.8 1999 51 2 3.9 26 4 15.4 77 6 7.8 2000 5147.8 29 6 20.7 80 10 12.5 2001 7111.4 23 1 4.3 94 2 2.1 2002 8122.5 23 4 17.4 104 6 5.8 2003 8800.0 18 3 16.7 106 3 2.8 2004 8300.0 22 1 4.5 105 1 1.0 2005 7400.0 30 1 3.3 104 1 1.0 2006 8800.0 19 1 5.3 107 1 0.9 2007 7600.0 28 3 10.7 104 3 2.9 2008 8000.0 9 5 55.6 89 5 5.6 Note: Figures for 1996 and 2005 have been revised on 06/08 to include two new cases identied in June, 2008. In addition, women who were not on treatment in 2003 and 2004 include one pregnant woman who tested negative antenatally but tested positive post-delivery. a Antenatals on treatment refers to those on a treatment regimen for pregnant women. b Includes mothers who: i) had no antenatal care (some of whom may have been on treatment prior to pregnancy); ii) were not located; iii) delivered prior to being treated, e.g, late attendees, premature labour; iv) had abortions, miscarriages, stillbirths or intrauterine deaths before or aer treatment; v) were on treatment prior to this pregnancy and did not take the required regimen for pregnancy; vi) had no treatment before or during pregnancy; or vii) refused treatment.

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MInistry of Health, Commonwealth of The Bahamas 39Table 23. HIV Surveillance of selected populations, 2004 2007, Bahamas HIV Y ear Populations Number Screened Number Positive Percent Positive 2007 Blood Donors 9346 41 0.4 Antenatals 3880 98 2.5 All STD Patients 1349 52 3.9 2006 Blood Donors 4846 14 0.3 Antenatals 3443 106 3.1 All STD Patients 683 36 5.3 2005 Blood Donors 5173 20 0.4 Antenatals 3597 102 2.8 All STD Patients 730 42 5.8 2004 Blood Donors 5210 12 0.2 Antenatals 3645 105 2.9 All STD Patients 879 36 4.1Fig. 16. New Cases of AIDS, by Gender and Y ear, August 1985-December 31, 2008, Bahamas 0 50 100 150 200 250 300 350 400 Female Male31 December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1985-1988 NumberYear Source: Health Information and Research Unit

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40 Annual Report of the Chief Medical OfcerF rom 1997, AIDS incidence has shown an overall decline, while at the same time the gender dierential is decreasing towards a more even distribution of cases between the sexes (from a male to female ratio of 1.7 in 1988, to 1.9 in 1998 and 1.4 in 2007 and 1.6 in 2008), (Fig. 16). Nevertheless, AIDS continued to predominate among males as seen in Fig. 17 while a more even gender distribution is seen among the non-AIDS cases. is was not always the case, for at the start of the epidemic there were more male non-AIDS cases than female but by 1993, the gap had closed (Fig. 18). e distribution of cases by age and sex revealed a gender ratio that was more inclined to females in the lower age-groups (Fig. 19).Fig.17. Cumulative Number of Reported HIV Infections, by Sex as of December 31. 2008, Bahamas 0 2,000 4,000 6,000 8,000 10,000 12,000 Total Females Males Total Infected Non-Cases AIDS CasesNumberYear Sources: Infectious Diseases Division, Public Health Dept. and HIRU.

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MInistry of Health, Commonwealth of The Bahamas 41Fig. 18. Current Non-AIDS HIV Infections, by Sex and Reported Y ear, Bahamas, 1985-2008 0 50 100 150 200 250 300 350 400 450 500 Male Female 31 December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1985-1988 NumberYear Source: Department of Public Health Infectious Disease Department & HIRUFig. 19. Cumulative cases by age-group & Sex as at 31 December 2008 0 200 400 600 800 1,000 1,200 1,400 Female Male 65+ 55-59 45-49 35-39 25-29 15-19 5-9 <01NumberYear Sources: Department of Public Health Infectious Disease Department & HIRU

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42 Annual Report of the Chief Medical Ofcer10.6 TUBERCULOSISTable 24. Status of Tuberculosis cases, BAHAMAS, 2004 2008 Characteristics 2004 # % 2005 # % 2006 # % 2007 # % 2008 # % Male 36 76.7 34 70.8 39 60.9 28 58.3 36 73.5 Female 11 23.3 14 29.8 25 39.1 20 41.7 13 26.5 Bahamian 32 68.1 32 68.1 48 75.0 26 54.2 32 65.3 Non-Bahamian 15 31.9 16 33.3 16 25.0 22 45.8 11 34.7 Culture +ve 39 83.0 41 85.4 60 93.8 40 83.3 47 95.9 Culture -ve 1 2.2 0 0 0 0 0 0 2 4.1 Culture Unk 7 14.9 7 14.6 4 6.2 8 16.7 0 0 Ex-Pulmonary 6 12.8 5 10.4 7 11.3 6 12.5 5 11.1 Pulmonary 41 87.2 43 89.6 57 89.1 42 87.5 44 89.8 Smear +ve 34 82.9 33 76.7 47 82.4 34 81.0 34 77.3 Smear ve 6 14.6 9 20.9 10 17.5 5 11.9 9 20.4 Smear Unk. 1 2.4 1 2.3 0 0.0 3 7.1 1 2.3 Dead 8 17.0 13 25.0 17 26.6 7 14.6 7 8.2 Total 47 48 64 48 49 New TB cases 47 45 60 45 46 Source: Department of Public Healthe Tuberculosis (TB) incidence rate hovered around 15 per 100,000 population for the period under review; prevalence was estimated at between 3-8 per 100,000 population (Fig. 20). TB cases were more likely to be male and Bahamian (Table 24). Direct Observed erapy Short-Course(DOTs) coverage in 2007 was 100%. On average, 18.7% of the new smear positive cases died and 25% defaulted, so that the success rate was only 63%. Of those smear-positive patients who were re-treated, the success rate increased to 71% but the death rate also increased to 21%. ere was one multi-drug-resistant case during the period 2004-08. HIV prevalence in the TB population was at least 10 times higher than in the general population (Fig. 20). During 2008, the HIV co-morbidity rate in female TB cases was less than 25%, but during the remainder of the time period co-morbid rates between the sexes diered little, ranging over the review period from 25% to 55% (Table 25).

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MInistry of Health, Commonwealth of The Bahamas 43Fig. 20. Incidence and prevalence of TB and co-morbid HIV Bahamas, 1990-2008 Source: WHO Country TB database 35 30 25 20 15 Rate per 100,000 Rate per 100,000 Percent (log xscale) Percent per 100,000 Percent Rate per 100,000Bahamas New ss(+) Retreatment 1990 1995 2000 2005 1990 1995 2000 2005 1990 1995 2000 2005 1990 1995 2000 2005 1990 1995 2000 2005 35 30 25 20 15 Bahamas Prevalence (all forms) Mortality excluding PLWHA Mortality including PLWHA 1994 1996 1998 2000 2002 2004 2006 Bahamas Treatment Success Rate HIV Prevalence in TB HIV in General Population 101.5101100.5 6 5 4 3 2 1 80 60 40 20 0 15 10 5 0 40 35 30 25 20 15 10 5Bahamas Incidence (all) Notied New and Relapse

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44 Annual Report of the Chief Medical OfcerTable 25. Distribution of Tuberculosis cases by co-morbidity with HIV and sex, Bahamas, 2004 2008 Y ear 2004 2005 2006 2007 2008 Morbid State All TB TB/HIV All TB TB/HIV All TB TB/HIV All TB TB/HIV All TB TB/HIVMale36 15 42%34 14 41% 39 21 54% 28 8 29% 36 14 39%Female11 5 45% 14 6 43% 25 11 44% 20 5 25% 13 3 23%TOTAL47 20 43% 48 20 42% 64 32 50% 48 13 27% 49 17 35% Source: Surveillance Unit, Department of Public Health10.7 NON-COMMUNICABLE DISEASES & INJURIES Of all non-communicable diseases, hypertension may be the most prevalent and the condition generating the greatest need for health care. Not only is hypertension the leading cause of mortality, it is, aer injuries, also the next leading non-infectious condition responsible for hospital discharges followed by diabetes, with which it is frequently a co-morbid condition, especially among the elderly (Fig. 21). Fig. 21. Selected conditions as percentages of total discharges (excluding deliveries) from Princess Margaret and Rand Memorial hospitals, 2004 2008 0 2 4 6 8 10 12 14 Hypertension Ischaemic H.D. AIDS Slow Fetal Growth Injuries and Poisonings Diabetes Stroke A.R.I. 2008 2007 2006 2005 2004% of Total DischargesYear Sources: Health Information & Research Unit; Statistics Unit, Public Hospitals Authority e register of 65+ year olds with hypertension and/or diabetes yielded prevalence rates of 620 and 252 per 10,000, respectively, for these two medical conditions in this age set. Hypertension is the principal reason for a majority of new clients seeking care at health centres (Table 26). Diabetes was the second leading diagnosis among new clients. Signicant numbers of new clients also attended the health centres for treatment of injuries, either road trac injuries (RTI) or industrial accidents, and mental health conditions, as well as for arthritis.

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MInistry of Health, Commonwealth of The Bahamas 45Table 26. New cases attending Primary Health Clinics for selected noncommunicable conditions Condition 2004 2005 2006 2007 2008 Hypertension 1094 792 1443 1384 1505 Diabetes Mellitus 856 530 334 815 702 Arthritis 367 308 468 647 504 RTIs 384 405 445 486 486 Industrial Accidents 198 205 212 282 213 Schizophrenia 127 120 132 121 115 Epilepsy 86 91 90 116 78 Sickle Cell Anaemia 43 55 89 47 62 Alcohol Dependence 52 46 31 64 49 Mental Retardation 22 7 17 3 8 Source: Public Health Departmente need for dialysis as a result of the complications associated with hypertension and diabetes is another major component of the utilization of health services. ere were 139 persons on dialysis at the Princess Margaret Hospital in 2007, the vast majority of whom were hypertensive, with and without diabetes (Fig. 22). e other conditions present in dialysis patients were diabetes only, systemic lupus erythematous (SLE) and polycystic kidney disease (PKD). Fig. 22. Patients on dialysis at Princess Margarget Hospital by underlying condition, 2007 Hypertension Hypertension with Diabetes Diabetes SLE PKD Other 2007 Source: Dialysis Unit, Princess Margaret HospitalAlthough not reected in hospital discharge statistics, cancers are a major cause of ill-health. As seen earlier (Page 13), neoplasms of the prostate and breast rank among the top ten causes of mortality in males and females, respectively. Data from the Princess Margaret Hospital show that the most common sites are indeed breast and prostate, followed by colon/rectum and uterus/ovary (Fig. 23).

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46 Annual Report of the Chief Medical OfcerFig. 23. Summary of cancer sites by gender, Princess Margaret Hospital, 2008 Oral Cavity & Pharynx-7 5% Lung & Bronchus-8 5% Pancreas-2 1% Kidney & Renal Pelvis-1 1% Urinary Bladder-1 1% Colon % Rectum-18 12% Prostate-64 42% Non-Hodgkin Lymphonia-6 4% Melanoma of the Skin-2 1% Leukemia-1 1% All Other Sites-42 28% Thyroid-4 2% Lung & Bronchus-3 1% Breast-92 45% Kidney & Renal Pelvis-3 1% Ovary-3 1% Uterine Corpus-12 6% Colon & Rectum-20 10% Non-Hodgkin Lymphonia-5 2% Melanoma of the Skin-0 0% Leukemia-0 0% All Other Sites-63 31% Males 152 Females 205 Source: Princess Margaret Hospital, New Providence10.8 MENTAL HEALTH SER VICES Mental health services are provided under the umbrella of the Ministry of Health through both the Department of Public Health and the Public Hospitals Authority. e Sandilands Rehabilitation Centre (SRC) provides in-patient psychiatric and mental health care, including a three hundred and sixty-seven bed inpatient unit in New Providence. O-site, SRC has one outpatient facility, the Community Counseling and Assessment Centre (CCAC). e Rand Memorial Hospital in Grand Bahama also provides inpatient mental health services through the Diah Ward. Additional programmes for mental health services in the Department of Public Health include adolescent services, the male health initiative, community health clinics, and psychiatric services oered through the Family Islands Community Clinics. Discharges from the Sandilands Rehabilitation Centre and the Diah Ward of the Rand Memorial Hospital indicate a rate of 414.3 discharges per 100,000 population for mental illness, with an average length of stay of more than 90 days, varying between 92.5 days in 2004 and 95.3 days in 2008. e most common conditions presenting for treatment were schizophrenia and disorders due to psychoactive substance abuse (Fig. 24). Males were three times more likely than females to be hospitalized for mental health conditions.

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MInistry of Health, Commonwealth of The Bahamas 47Fig. 24. Patients treated in mental health facilities by diagnosis 0 10 20 30 40 50 60 70 80 90 100 Other Mood Disorders Personality Disorders Neurotic Disorders Schizophrenia Substance Abuse SRC Diah Ward CCACPercentage 10.9 ORAL HEALTH SER VICES e Oral Health Services Unit within the Department of Public Health provides services through regular clinics at some community health facilities, Her Majestys Prison and Sandilands Rehabilitation Centre, as well as through visits to schools and some Family Islands. e thrust of the programme is to move away from extractions and towards preventive and restorative care, especially for children. From 2002 to 2006, there was a small but steady improvement in the percentage of children who were caries-free in Grades 1 and 6, with a concomitant reduction in the decayed, missing and lled permanent teeth (DMFT) score (Tables 27, 28). Table 27. Grade 1 Caries Prevalence Trends, 2002 2006 Y ear # students Screened % cariesfree # person with decayed teeth # decayed teeth dmft 2002/3 1693 51.03 829 3012 3.60 2003/4 2120 53.87 952 3505 3.58 2004/5 2106 55.60 935 3251 3.48 2005/6 2197 56.16 838 3368 3.49

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48 Annual Report of the Chief Medical OfcerTable 28. Grade 6 Caries Prevalence Trends, 2002 -2006 Y ear # students Screened % cariesfree # persons with decayed permanent teeth # decayed permanent teeth DMFT 2002/3 1864 77.20 389 708 1.70 2003/4 2579 77.08 591 932 1.67 2004/5 2565 81.95 462 709 1.54 2005/6 2071 80.61 498 780 1.56 Source: Oral Health Services, Department of Public Health Each year, among Grade 1 students, as many as 4 children may have 10 or more decayed primary teeth. e high percentage of children in Grade 1 with dental caries highlights the need for increased attention to preventive oral health eorts and greater use of sealants in children. Among older children, the decayed permanent teeth score (D), consistently contributed 97% to the DMFT score. Internationally established goals indicate that at least 50% of 5-6 year olds should be caries-free, and that the average DMFT for 11-12 year olds should be less than 3. e Bahamas has achieved the rst goal and aims to better it, while working toward the second goal.Fig. 25. School Dental Services-Clinical Activity Trends 2002-2006 0 500 1,000 1,500 2,000 2,500 3,000 Exts Rest. Txs Previous Txs. # Pts. Seen 2006 2005 2004 2003 2002Number

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MInistry of Health, Commonwealth of The Bahamas 49As can be seen from Fig. 25, there has been a decrease in the number of patients seen by the school dental services. is may be due to the increased number of dental clinics at community centres whose proximity to home or work may make them more convenient for parents. Nevertheless, the marked increase in preventive and restorative treatments among children from 2005-06 also has been a result of greater eorts at prevention and restoration with the operation of the several dental clinics and introduction of a surveillance programme within the school dental service. However, medical and dental ocers express concern that the clinics goals are not being met, due to human as well as equipment constraints. Fig. 26 shows a breakdown of preventive care at selected dental clinics throughout e Bahamas.Fig. 26 Preventive Dental Treatments Rendered by Clinic-New Providence & Family Islands-2006 0 100 200 300 400 500 600 700 Fluoride Tx Child Prophy Adult Prophy Sealants FSC FGC SBC EEC SDC So. Eleu. Exuma G.H. Eleu. AbacoNumber 10.10 NUTRITION As noted earlier, the currently small but rising percentage of overweight Bahamian children is a cause for alarm. Diabetes is a disabling medical condition and a costly one for society. Low breast-feeding rates may be a contributing factor to increasing obesity among children, since breast-feeding oen is replaced with high but empty caloric food choices. School screening data (Tables 17 19) revealed increasing rates of obesity across the spectrum of childhood. ese data demonstrated that in Grade 1, obesity ranged from 4.8% to 9.2% of children screened. is rate increased for Grade 6, which had uctuating rates (low of 9.5% in 2005 to a high of 18.3% in 2007) and was demonstrated in 16.6% of the children screened in 2008. Grade 10 screening indicated an even greater percentage of children who were overweightas much as 23.7% of screened individuals in 2007 (range 12.5-23.7%). Additionally, anaemia in children and pregnant women (about 5% each in the two groups), is also an indicator of food choices lacking in nutritional value. e Nutrition Department oers counseling to those referred from clinics. ese are usually extreme cases. e Department has taken a proactive approach, initiating a garden-based learning project that complements the education of vendors and the setting of standards for school tuck shops, while supporting the activities of other departments such as the Healthy Lifestyle Initiative and the Health-Promoting Schools Initiative.

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50 Annual Report of the Chief Medical Ofcer10.11 HEALTH PROMOTION & EDUCATION Eorts are underway to build a national policy on health promotion. e Department also has launched a Health-Promoting Schools Initiative, with a sensitization workshop and identifying school focal points as the basis of school-based health promotion committees. e Department does not have in-house recording and reporting capability and utilizes resources to support their services. is does not allow for a strategic and systematic approach to the optimal development of these services. e Department has produced the following media presentations Joining Hands for Health, My Life, My Future, and Foundations for Healthy Living, as well as a segment in the Ministry of Educations Learning Resource Section, A Time for Education. e Department also has introduced a system of identifying educational needs for wellness promotion in fundamental health priority areas of concern. 10.12 HEALTHY LIFESTYLES INITIATIVE e Healthy Lifestyles Initiative was launched in October 2005 with the goal of reducing the levels of morbidity, disability and premature deaths associated with lifestyle-related diseases (CNCD)diabetes, hypertension, chronic respiratory disease, heart disease, and cancer. e Healthy Lifestyles Initiative was designed to reduce the prevalence of risk factors that lead to CNCDs, specically: smoking, physical inactivity, an unhealthy diet, and poor nutrition. Using a population health approach and collaborative eorts with government agencies, private services, churches, schools, and other NGOs, the Healthy Lifestyles Initiative has sought to promote health and prevent disease. e initiative focuses on physical activity and healthy eating, and on the relationship of these activities to healthy weights. is initiative also incorporates risk factor screening, including glucose and cholesterol screening and body mass index determinations and documentation in Healthy Lifestyle Passports. In 2006, Healthy Lifestyles screened 5,000 persons. at number increased to 8,360 people who were screened and counselled at 119 locations during 2007. e Healthy Lifestyles Initiative conducted 116 health fairs or screening sessions in 2007, an increase from the 70 that were conducted in 2006. 10.13 PRISON HEALTH SER VICES e Prison Health Initiative provides access to comprehensive health services for inmates of Her Majestys Prison (HMP). ese services include: routine medical evaluations, managing chronic non-communicable diseases, acute minor medical emergencies, infectious disease management, drug demand reduction, and routine dental care. Mental and psychological health care continue to be provided by personnel from the government owned psychiatric hospital at Sandilands Rehabilitation Centre. Daily dental care is provided by a Dentist. HMPs clinic is a collaborative eort staed by people from both the Department of Public Health and National Security. It is staed by two full-time physicians, three part-time senior physicians, two registered nurses (one of whom is a Public Health Nurse Coordinator for Prison Health Services), as well as two trained clinical nurses (one trained in psychiatry), four trained clinical nurses (who are also Prison Ocers), a part-time pharmacist, and a phlebotomist-aide. Upon admission, all inmates are tested for the presence of communicable diseases. On average, 2,458 persons are admitted to HMP annually; of these, 13.8% are infected with tuberculosis, 2.0% are infected with HIV, 1.8% are infected with syphilis, and 1.7% are infected with Hepatitis B.

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MInistry of Health, Commonwealth of The Bahamas 51Table 29. Prison Health Screening, 2004-2008 INDICATORS 2004 2005 2006 2007 2008 Total admissions 2549 2633 2356 2284 2469 Male 2447 2471 1774 2146 2290 Female 102 162 166 138 179 Average number of admissions per month 212 196 190 206 Total persons <35 years of age 1701 1813 1658 1604 1792 Total persons 35+ years of age 848 820 698 680 677 Total return visits 1017 1158 1124 822 1266 Return visits within one year 206 201 141 135 157 Total number persons with positive Mantoux skin test 381 362 267 338 343 Number released before Mantoux skin test read 369 190 Return visits with previously known positive Mantoux skin test 394 383 275 398 Total chest X-rays completed 312 229 129 188 233 Number of persons released before chest X-ray completed 73 71 138 150 110 Total HIV positive 58 61 46 43 36 Total Hepatitis B positive 53 46 47 34 30 Total VDRL (Syphilis) Positive 54 58 50 29 30 Total General Complaints seen 3288 4009 4227 2952 4227 Source: Prison Health Services

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52 Annual Report of the Chief Medical Ofcer11.1 W ATER AND SEWERAGE MANAGEMENT Sewerage disposal continues to pose a challenge in the Family Islands. Although most premises are connected to a septic tank, roughly 40% have no euent system attached (e.g., soak away). Pump-out systems are limited or in many instances not available, and any nal sewage disposal infrastructure is practically non-existent. e Department of Environmental Health Services (DEHS) continues to advocate for change in this regard, taking opportunities to advise owners and in a few instances to initiate legal actions. e various responsible agencies for providing infrastructure are aware of these needs, but have indicated a nancial inability to act. Monitoring and evaluating systems are implemented for the few wastewater treatment plants that exist, which are primarily associated with hotels and related establishments. Water quality remains a challenge and DEHS routinely tests water samples to ensure the health and safety of water for the people of e Bahamas. One hundred and thirty-three (133) of ve hundred and nineteen (519) water samples taken were found to be fully satisfactory, however, of these, 97 (18.7%) had no chlorine present. 11.2 SOLID WASTE MANAGEMENT ere has been an improvement in the management of solid waste since the introduction of modied landlls. Transfer stations and barging now are available for the disposal of waste in some islands and settlements. However, these resources are incomplete and still many open dumps continue to be used. e component of waste collection and recycling has lagged behind and as a result indiscriminate dumping continues to be a problem. While the legal framework has assigned components of general sanitation, derelict vehicle disposal, and the management of open dump sites to local government councils in the Family Islands, oen nancial resources are reportedly inadequate to fully implement these decisions. One result has been that DEHS oen has only partially funded work for these items. 11.3 FOOD SAFETY ESTABLISHMENTS INSPECTED AND PASSED; TRAINING OF FOOD HANDLERS 825 of 917 (93.5%) of food handlers were approved for vending permits. e Health Inspectorate Division of DEHS is responsible for monitoring all food establishments and itinerant vendors. is division is present in all the major Family islands. e division is also involved in training food handlers. Imported meats and meat products are inspected upon entry to ensure they meet all requirements. e Port Health Ocer in New Providence conducted the inspections. All imported meats and meat products were deemed satisfactory.Table 30. Annual Meat Statistics, New Providence, 2004-2008 Y ear Weight Number of cases 2004 399,537,198.8 2,319,168.2 2005 165,556,404.7 11,648,929.5 2006 134,996,778.0 2,492,223.3 2007 156,481,148.3 2,690,142 2008 45,787,931 1,035,877 Source: Department of Environmental Health Services 11ENVIRON MENTAL HEALTH SER VICES

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MInistry of Health, Commonwealth of The Bahamas 53Inspections are also conducted at food stores and warehouses to ensure proper storage and refrigeration. Challenging situations have arisen, with expired food items being oered for sale. Five food establishments were closed temporarily due to their ineective compliance with environmental standards. In 2004, the Ministry of Health assumed sole responsibility for issuing food handlers certicates. is was initiated in conjunction with a mandatory 4-hour safe food course for all food handlers. e mandatory safe food course began in New Providence and by 2005 had been expanded to include Long Island, Eleuthera, Andros, Cat Island, Abaco and Exuma and the Cays. Islands without resident trainers were supported from the Central programme in New Providence. e training programme trained an average of three hundred (300) persons weekly and included ve (5) international Serve-Safe instructors capable of training other instructors across e Bahamas. Training for Serve-Safe instructors was expanded to Grand Bahama in 2006, when sixteen (16) trained instructors were introduced, enabling Grand Bahama to provide more consistent Serve-Safe food safety training to food handlers on that island. In 2006, the Health Services Act, Chapter 216, Rule 77 was amended to facilitate a new legislative requirement for the certication of all food handlers, including all persons connected with the production, storage, transportation, or care of food stus. It was the responsibility of the owners and operators of food establishments to ensure that all their workers had current, valid food handlers certicates, which must be made available upon request by an authorized Health Ocer. Food safety training is now available in most of the larger inhabited Family Islands. Support from the Central Programme continues to provide services when any gaps in the system are recognized.Table 31. Food Handlers Training Sessions Fiscal Y ear 2004 2005 2006 2007 2008 Number of Food Handlers Trained 12,042 18,771 19,481 21,243 21,670 Number of International Safe Serve Instructors 19 21 2111.4 VECTOR CONTROL AEDES AEGYPTI INDICES; RODENT CONTROL ACTIVITIES To increase Anopheles larval control eciency in Exuma, DEHS implemented an aquatic weed control programme to limit or eliminate growth of aquatic weeds that provide harborage for larvae and create a physical barrier to the larvicide. While the initial application of herbicides via airboats has been successful, the maintenance phasewith its introduction of sterilized grass carphas suered a setback. is was due largely to the increased average salinity levels in the ponds, resulting in sh mortality. e airboat has served to increase coverage of larvicidal applications and considerably reduce the time needed for chemical application.

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54 Annual Report of the Chief Medical OfcerFig. 27. 2008 Exuma Anopheles Larval Total Average 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 EW52 EW50 EW48 EW46 EW44 EW42 EW40 EW38 EW36 EW34 EW32 EW30 EW28 EW26 EW24 EW22 EW20 EW19 IndexEpidemiological Week Source: DEHSFig. 28. Exuma Human Bait Collection Total Average, 2008 0 2 4 6 8 10 12 14 16 18 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18Mosquito per Man per Hour IndexEpidemiological WeekNR NR NR NR NR NR NR NR NR NR NR NR Source: Department of Environmental Health Services

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MInistry of Health, Commonwealth of The Bahamas 55Many cleanup initiatives in New Providence and the Family Islands have resulted in a cleaner environment and in reducing the sources for breeding Aedes aegypti mosquitos. Other eorts to be proactive include providing information to the news media, advising the public of the availability of assistance, ensuring their premises are kept free of any man-made water holding containers. Where these containers are needed, they are managed so that they do not collect water. Relevant educational activities such as lectures and displays have been conducted in many schools and at numerous health and career fairs. Rodent control operations were conducted extensively in New Providence, Grand Bahama and in island settlements requiring treatment. Surveillance measures and the application of treatment involving the placement of bait stations containing anticoagulant rodenticide have been the method of choice. Of special note was a rodent control and conch shell cleanup conducted on Bayshore Road and the settlement of West End, Grand Bahama. is project oered an excellent example of a public-private partnership eort in addressing the need for remedial action. As a result of this coalition and collaboration, rodent infestation was reduced considerably, the shoreline was cleared of piles of conch shells, and derelict boats and other debris were removed. 11.5 PORT HEALTH INSPECTIONS AND RESULTS In compliance with the International Health Regulations (2005), port health has responsibility for the inspection and issuance of ship sanitation certicates and ship sanitation exemption certicates for all international vessels. During the period January 2004 through December 2008, the Port Health Ocer in New Providence inspected a total of 133 vessels (75 cruise ships, 53 freight vessels and 5 pleasure cra) and issued ship sanitation exemption certicates. No sanitation measures were required.

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56 Annual Report of the Chief Medical Ofcer12.1 IN-PATIENT Table 32. Hospital utilization by service, PMH and RMH, 2008 Service Discharges Patient Days Ave. length of stay No. of beds PMH RMH PMH RMH PMH RMH PMH RMH Intensive Care Unit 115 88 2895 804 25.2 9.1 9 4 Medical/Surgery 8,690 2,662 69,329 8,436 8.0 3.2 229 33 Obstetrics/Gynaecology 5,671 1,645 14,222 3,750 2.5 2.3 50 19 Paediatrics 1,619 620 21,017 1,752 13.0 2.8 68 12 Neonatal ICU 537 35 11,485 390 21.4 11.1 5 Psychiatry 224 1,841 8.2 12 Source: Kurt Salmon & AssociatesAverage length of stay was consistently longer at Princess Margaret Hospital than at Rand Memorial Hospital, for all units with the exception of Obstetrics and Gynaecology which were similar in length (Table 32). 12.2 LABORATOR YTable 33. Laboratory tests at Princess Margaret Hospital by type of test, 2004-2008 Department 2004 2005 2006 2007 2008 Haematology # Tests: 61,194 74,785 76,090 70,715 Microbiology: # Tests 94,982 # Specimens 31,834 32,079 32,264 37,367 42,233 Blood Bank # Tests: 40,354 32,643 39,806 42,580 48,599 Transfusion Medicine # Tests: 58,745 57,748 55,006 63,064 70,848 Cytology: # Non-Gynae 364 269 297 350 295 # Papsmear slides 6,888 7,888 7,663 7,629 8,249 Histology # Slides: 22,903 26,607 29,196 28,491 27,515 Chemistry: ... Serology: Stat Lab # Tests 514,274 Blood Bank tests include: Cross-match, Patient blood group, Direct coombs test, Indirect coombs test Transfusion medicine tests include: HIV, HBsAg, Corzyme,Anti HBS, HepB Conf (began February 2008), RPR, CMV (began June 2007), HTLV1/2, HCV, HAV Stat Lab tests include: WBC (Haematology), Chemistry, UA (Microbiology), UHCG (Microbiology), ABG (Chemistry), CSF (Microbiology and Chemistry) 12HOSPITAL SER VICES

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MInistry of Health, Commonwealth of The Bahamas 57e reporting of laboratory statistics has been challenged by an inadequate Laboratory Information System, which was not capable of providing statistical reports (Table 34). Within those Departments able to provide statistics, the increasing volume of tests also reects the increasing number of discharges seen in Princess Margaret Hospital (Table 8A). 12.2.1 EMERGENCY RESPONSETable 34. Accident & Emergency Department contacts by age, sex, 2004 2008 FACILITY2004 2005 2006 2007 2008 PRINCESS MARGARET HOSPITAL (PMH): 1) # Visits 47,263 48,947 50,920 52,114 51,746 2) # Registered 57,695 59,832 60,285 61,936 66,649 Gender: Male 28,224 29,496 29,682 30,407 32,629 Female 29,469 30,334 30,601 31,528 34,018 Age Groups: <1 2,292 2,645 2,447 2,740 2,862 1-4 6,395 6,002 5,874 5,964 6,413 5-14 7,564 7,418 7,501 7,422 9,549 15-24 9,627 9,770 10,394 10,818 11,530 25-44 18,649 19,135 19,259 19,261 20,810 45-64 8,275 9,829 9,954 10,623 11,738 65+ 4,893 5,033 4,856 5,108 5,746 RAND MEMORIAL HOSPITAL (RMH): 1) # Visits 4,886 4,541 4,303 4,162 4,209 2) # Registered ... Source: Keane System, Public Hospitals Authority Denition: 1) Visits INDICATE patients seen and treated by medical sta in the A&E department. 2) Registered INDICATE persons registered in A&E for medical care, but DOES NOT INDICATE the actual persons seen and treated by medical sta as patients may leave the department before receiving medical attention.e volume of visits to the Accident and Emergency Department has been increasing over the previous ve years. Data from 2004-08 (Table 34) demonstrates a roughly equal distribution of males and females. Children 0-4 years of age now account for approximately 9% of the Bahamian population, however, this age group accounts for about 15% of the Accident and Emergency population.

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58 Annual Report of the Chief Medical OfcerTable 35 New Providence emergency Response Data, 2004 2008. Call Type 2004 2005 2006 2007 2008# calls Ave. Response Time # calls Ave. Response Time # calls Ave. Response Time # calls Ave. Response Time # calls Ave. Response TimeTRAUMA Calls;2853 3011 3210 3641 3745 Airplane Crash 4 1 7 8 5 Assaults/Rape405 0:21:05 419 0:23:31 423 0:22:23 614 0:20:15 726 0:19:56 Bomb/explosion/Major disaster 4 10 0:17:56 2 1 2 Burn victims/Explosion42 0:14:00 44 0:14:13 30 0:14:47 31 0:17:35 27 0:24:05 Electrocution 7 6 0:16:54 6 0:15:00 6 0:10:54 3 Falls/Back Injuries (Traumatic)421 0:23:28 407 0:25:14 514 0:20:55 560 0:19:59 573 0:20:56 Gunshot Wound 132 0:12:35 121 0:12:46 146 0:12:38 193 0:13:56 204 0:13:38 RTA, Traumatic Injuries (specify) 1601 0:16:38 1699 0:17:19 1781 0:17:32 1911 0:17:52 1897 0:17:05 Stabbing 237 0:19:04 304 0:16:28 301 0:19:29 317 0:19:48 308 0:15:46 Medical Calls: 2330 2352 2401 2805 2993 Carbon Monoxide/Inhalation Hazmat 0 2 1 2 3 0:10:58 Cardiac/Respiratory Arrest/Death 581 0:21:45 606 0:20:59 612 0:22:28 688 0:19:47 723 0:21:17 Near Drowning/Diving Incident 33 0:18:27 52 0:15:50 41 0:16:09 46 0:13:20 40 0:18:11 Poisoning/Overdose/Ingestion 91 0:19:55 78 0:32:07 79 0:22:59 85 0:18:19 99 0:23:22 Stroke/CVA 198 0:22:00 201 0:25:07 200 0:22:24 239 0:22:38 243 0:24:22 Unconscious/Breathing Problem 1427 0:19:27 1414 0:21:07 1468 0:20:12 1745 0:19:21 1885 0:20:11 Ordinary Problem Calls: 6469 7264 7041 7074 7298 Abdominal Pains/Problem 509 0:27:38 478 0:31:40 431 0:28:41 491 0:26:28 548 0:27:44 Allergies/Hives/Med-Reactions 14 0:21:30 23 0:19:54 35 0:18:07 25 0:12:31 46 0:17:56 Animal Bite(s)/Attack(s) 13 0:14:40 11 0:21:11 13 0:14:11 8 0:20:28 15 0:26:01 Asthmatic 306 0:19:49 401 0:19:46 286 0:20:11 327 0:17:52 390 0:21:35 Choking 10 0:16:23 9 0:14:55 11 0:14:58 10 0:10:46 14 0:19:41 Diabetic Problem(s) 377 0:19:16 469 0:21:41 450 0:22:31 445 0:21:34 856 0:22:49 Eye Problem(s)/Injuries 6 0:05:41 11 0:16:33 6 0:16:10 7 0:28:49 15 0:28:10 Fainting/Fits/Convulsions 1363 0:19:06 1646 0:19:30 1576 0:18:49 1585 0:18:35 1688 0:18:28 Fracture(s)-Lower 125 0:25:11 126 0:28:27 107 0:23:53 99 0:26:30 117 0:26:58 Fracture(s)-Upper 49 0:25:49 66 0:26:30 52 0:18:56 40 0:24:29 42 0:22:29 Lacerations/Haemorrhage 564 0:21:13 698 0:22:38 590 0:23:17 490 0:22:20 421 0:24:17 Maternity/childbirth/BBA 1012 0:20:49 1039 0:22:47 1037 0:23:00 1098 0:21:56 1037 0:23:42 Ordinary Sickness/Sick Call 1097 0:30:32 1149 0:33:14 1173 0:32:43 1207 0:29:25 1151 0:34:10 Psychiatric/Suicide Attempt 584 0:46:37 656 0:53:17 750 0:48:39 725 0:54:35 745 0:43:19 Unknown Problem (Person Down) 111 0:15:32 139 0:15:43 112 0:21:00 110 0:18:32 120 0:18:59 Vomiting/diarrhea 329 0:27:47 343 0:32:25 412 0:26:53 407 0:23:13 393 0:30:34 Transfer Patient 2563 0:47:38 2157 1:02:01 2172 0:51:30 2266 0:44:49 2640 0:49:16 Brought in Dead 218 0:15:32 281 0:17:46 284 0:19:10 247 0:18:53 301 0:16:49

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MInistry of Health, Commonwealth of The Bahamas 59Road trac injuries, loss of consciousness, convulsions and childbirth are the major dened reasons for use of emergency services in New Providence (Table 35). e volume of calls handled through the EMS system has increased on an annual basis. Response time, however, has not increased to any great extent, when compared over time. Table 36 Abaco Emergency Response Data, 2006-2008 Call Type 2006 (10 Months) 2007 2008# calls Ave. Response Time # calls Ave. Response Time # calls Ave. Response Time TRAUMA Calls; 39 52 72 1p1.302 1 0:05:00 Assaults/Rape 5 0:03:00 1 0:02:00 2 0:05:00 Bomb/explosion/Major disaster 1 Burn victims/Explosion 1 0:03:00 2 0:05:00 Electrocution 1 0:02:00 Falls/Back Injuries (Traumatic) 2 0:04:00 13 0:11:00 Gunshot Wound 2 0:19:00 3 0:05:00 RTA, Traumatic Injuries (specify) 31 0:12:00 47 0:07:00 46 0:10:00 Stabbing 5 0:04:00 Medical Calls: 12 26 38 Carbon Monoxide/Inhalation Hazmat Cardiac/Respiratory Arrest/Death 3 0:05:00 7 0:04:00 11 0:06:00 Near Drowning/Diving Incident 3 0:05:00 3 0:04:00 Poisoning/Overdose/Ingestion 3 0:04:00 Stroke/CVA 1 0:17:00 2 0:03:00 2 0:03:00 Unconscious/Breathing Problem 8 0:05:00 14 0:06:00 19 0:06:00 Ordinary Problem Calls: 43 56 73 Abdominal Pains/Problem 1 0:06:00 5 0:06:00 Allergies/Hives/Med-Reactions 1 0:24:00 Animal Bite(s)/Attack(s) 1 0:07:00 Asthmatic 1 0:04:00 Choking Diabetic Problem(s) 2 0:04:00 4 0:05:00 Eye Problem(s)/Injuries Fainting/Fits/Convulsions 11 0:05:00 11 0:04:00 15 0:03:00 Fracture(s)-Lower 2 0:11:00 5 0:05:00 6 0:06:00 Fracture(s)-Upper 2 0:07:00 1 0:08:00 Lacerations/Haemorrhage 9 0:06:00 7 0:04:00 8 0:07:00 Maternity/childbirth/BBA 2 0:03:00 2 0:04:00 7 0:03:00 Ordinary Sickness/Sick Call 13 0:08:00 8 0:05:00 7 0:04:00 Psychiatric/Suicide Attempt 1 0:06:00 5 0:04:00 Unknown Problem (Person Down) 5 0:04:00 9 0:05:00 16 Vomiting/diarrhea 2 0:05:00 3 0:07:00 Transfer Patient 71 96 0:06:00 120 0:06:00 Brought in Dead 1 0:04:00 1 0:04:00

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60 Annual Report of the Chief Medical Ofcere Public Hospitals Authority/Emergency Medical Services (EMS) assumed responsibility for emergency medical service in Abaco in 2006. Road trac injuries, loss of consciousness, and convulsions are the major dened reasons for use of emergency services in Abaco (Table 36). 12.2.2 OUTPATIENT SER VICES Table 37. Outpatient attendances by institution, type of service and year. FACILITY / AREA 2004 2005 2006 2007 2008 PRINCESS MARGARET HOSPITAL (PMH): Accident & Emergency 47,263 48,947 50,920 52,114 51,746 General Primary Care Clinics: 40,043 42,624 35,589 32,150 28,598 General Practice Clinic 36,910 39,629 32,362 29,471 26,063 Civil Servants Clinic 3,133 2,995 3,227 2,679 2,535 Specialty Clinics(a): 32,316 54,208 55,600 57,808 61,903 Asthma Clinic 618 559 611 643 467 Comprehensive Clinic 1,847 1,544 1,382 1,416 1,337 Dental Clinic 5,626 5,397 4,598 4,568 Dialysis Clinic 1,367 1,503 1,399 1,711 ENT Clinic 2,734 2,741 2,677 3,029 Eye Clinic 4,500 4,645 5,399 6,023 Medical Clinic 8,663 8,642 8,998 9,306 9,983 OB High Risk Clinic 1,414 Obstetric Clinic (includes OB High Risk & GYNAE clients) 4,315 4,733 4,907 5,233 Oncology Clinic 1,019 1,241 1,473 1,879 Orthopaedic Clinic 9,829 8,700 10,420 11,090 Paediatric Clinic 6,300 3,286 3,427 3,169 3,902 Skin Clinic 3,975 3,374 4,042 3,954 3,724 Surgical Clinic 9,499 5,894 6,534 6,802 7,310 Urology Clinic 1,519 1,646 1,645 1,647 Total Outpatient Attendances (PMH) 119,622 145,779 142,109 142,072 142,247 RAND MEMORIAL HOSPITAL (RMH): Accident & Emergency 4,886 4,541 4,303 4,162 4,209 General Practice Clinic 34,439 36,773 37,892 41,321 44,011 Specialty Clinics: 16,732 19,513 18,653 19,135 19,976 Surgical Clinic 2,989 3,547 2,907 3,563 3,785 Medical Clinic 4,619 5,553 4,777 5,457 5,433 Antenatal Clinic 2,937 3,432 3,394 3,374 3,102 Gynae Clinic 814 849 941 994 1,025 ENT Clinic 214 247 256 258 238 Pediatric Clinic 900 999 997 1,132 1,106

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MInistry of Health, Commonwealth of The Bahamas 61 FACILITY / AREA 2004 2005 2006 2007 2008 Postnatal Clinic 413 539 524 607 624 Psychiatric Clinic 1,021 1,013 1,239 1,299 1,490 Chest Clinic 248 244 257 309 450 Orthopedic Clinic 399 407 996 579 864 Ophthalmology Clinic 2,133 2,683 2,365 1,563 1,859 Oncology Clinic 45 Total Outpatient Attendances (RMH) 56,057 60,827 60,848 64,618 68,196 SANDILANDS REHABILITATION CENTRE (SRC): Community Counselling & Assessment Centre (CCAC) contacts 21,474 20,660 Psychiatric Clinic 1,864 1,898 2,042 2,807 2,520 Anns Town Geriatrics Clinic 908 930 978 809 794 Total Outpatient Attendances (SRC)(b) 24,302 23,680 Source: Medical Records Departments PMH, RMH and SRC, Public Hospitals Authority (a) Specialty clinic visits (PMH): In 2005, seven additional clinics began reporting: Dental, ENT, Eye, Urology, Dialysis, Oncology and Orthopaedics. (b) Total outpatient attendances (SRC) excludes: Podlewski psychiatric visits, day program attendances by adults & adolescents and outpatient child & adolescents visits.Use of clinic facilities in all three government hospitals indicates an increasing reliance on government-sponsored services. Of note, at the Princess Margaret Hospital services have increased signicantly in the Medical, Obstetrical High Risk, Oncology and Orthopaedic Specialty Clinics; at Rand Memorial, services have increased signicantly in the Gynaecology, Psychiatric, Paediatric and Orthopaedic Specialty Clinics (Table 37). e number of attendees at the General Practice Clinic (GPC) and the Civil Servants Clinic at PMH has been decreasing while the number of GPC attendees has been increasing at the Rand Memorial Hospital.

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62 Annual Report of the Chief Medical Ofcer13.1 GENERAL POPULATION Aer allowing for infant mortality, it is to be expected that mortality rates for the elderly are far higher than those for younger age groups (Fig. 29). But fewer deaths and lower mortality rates in those age groups still represent a substantial loss of potential life. e gender dierential rates, especially between 15 and 44 years, are signicant and may be attributable to vehicular and work-related injuries and HIV/AIDS.Fig. 29. Age-specic death rates, per 100,000 popn. by gender, 2007 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Female Male 65+ Years 45-64 Years 25-44 Years 15-24 Years 5-14 Years 0-4 YearsDeath RateAge Group Approximately half of all mortality was due to chronic non-communicable diseases, as well as to HIV/AIDS (which has been decreasing), cancers of the breast and prostate, injuries, and especially homicides, which have been increasing. e disparity between the populations mortality prole and that of morbidity, if measured by hospitalizations, is telling (Table 38). Whereas many hospitalizations are due to acute respiratory infections and appendicitis, hernia and intestinal obstruction, relatively fewer deaths have resulted. is stands in stark contrast to cancers of the breast and prostate, which accounted for 0.6% and 0.2% of all discharges, excluding deliveries, but which are responsible for 2-3% of deaths. 13HEALTH SITUATION

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MInistry of Health, Commonwealth of The Bahamas 63Table 38. Percentage distribution of discharge diagnoses, 2004-2007, excluding deliveries Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH ARI 6.9 4.2 6.4 4.8 7.6 5.2 5.9 4.7 Hypertensive disease 4.3 3.5 4.0 3.3 3.9 5.3 4.2 5.4 Ischaemic heart disease 0.9 2.9 1.1 2.4 1.1 1.8 1.3 3.2 Intestinal infectious diseases 3.0 3.9 1.2 2.1 2.0 2.5 1.8 1.3 Diabetes mellitus 2.8 2.6 3.6 2.6 3.3 2.3 3.8 3.1 Appendicitis, hernia, intestinal obstruction 2.7 2.4 2.9 2.1 3.0 2.1 2.8 3.4 HIV/AIDS 2.3 0.5 3.5 0.4 4.3 0.7 3.3 0.7 Cerebrovascular diseases 2.2 1.4 2.3 1.6 2.0 2.1 2.8 2.2 Slow fetal growth 1.0 0.6 2.6 0.9 2.0 0.7 1.8 1.1 Respiratory disorders, perinatal 0.7 0.9 1.6 2.2 1.3 1.6 1.0 1.4 Injuries, poisonings and other external causes* 15.8 14.4 14.0 13.6 14.8 10.7 14.2 10.8 Mental and behavioural disorders+1.0 6.2 1.0 7.7 1.0 6.5 1.0 7.0 is is a group and therefore not strictly comparable with the other conditions, but the data does not permit further breakdown into individual external causes+ Unlike RMH, there is no psychiatric ward at PMH.

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64 Annual Report of the Chief Medical Ofcer13.2 POPULATION SUB-GROUPS 131.21 INFANTS Respiratory disorders specic to the perinatal period were a leading cause of infant mortality, with cause-specic death rates at their highest for the decade. Also at their highest point for the decade were death rates for bacterial sepsis of the newborn (Fig. 30).Fig. 30. Mortality rates per 1,000 livebirths, of leading causes of infant mortality, 1996 2008, Bahamas 0.0 1.0 2.0 3.0 4.0 5.0 Respiratory Disorders Specic to the Perinatal Period Remainder other Conditions in the Perinatal Period Diseases of the Respiratory System Bacterial Sepsis of Newborn Obstetric Complications and Birth Trauma Congenital Malformations, Deformations, Abnormanlities 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996Rate/1,000 Live BirthsYear Hospital discharge data integrates infants into a 0-4 year old age group, so it is not possible to identify morbid conditions that relate specically to infants. 13.2.2 CHILDREN AGED 1-4 YEARS For the past two years of available mortality data, injuries constituted the leading cause of death among 1-4 year olds, although there seems to be a general downward trend (Fig. 31). It is heartening to note that since 2000, AIDS-related deaths among children under 5 have been near zero. Except for one infant death in 2005 and one death in the 1-4 year old group in 2000 and again in 2002, there were no AIDS deaths in this age group up until 2006.

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MInistry of Health, Commonwealth of The Bahamas 65Fig. 31. Age-specic mortality rates per 10,000 population of the leading causes of death in children aged 1-4 years, 1996-2006, Bahamas 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 External Causes AIDS Congenital Malformations, Deformations, Abnormanlities Diseases of the Respiratory System 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996Rate/10,000 Children 1-4 YearsYear Morbidity in under-5 year-olds was due mainly to respiratory infections, followed by intestinal infectious diseases and injuries (Table 39). is agrees with data from community health services. Discharges for slow foetal growth and perinatal respiratory disorders were of infants. Disparities between PMH and RMH for perinatal respiratory disorders may be related to the transfer of high risk neonates to PMH because of the availability of specialized services (i.e. NICU/SCBU) at PMH.

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66 Annual Report of the Chief Medical OfcerTable 39. Percentage distribution of hospital discharges in children aged 0-4 years by condition, 2004 2007, Princess Margaret Hospital and Rand Memorial Hospital, Bahamas Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH ARI 17.0 11/0 16.0 16.0 20.5 16.8 17.2 16.1 Intestinal infectious diseases 10.5 9.8 3.4 7.6 10.7 10.4 6.8 3.6 Slow fetal growth 5.7 11.0 13.1 6.9 10.4 6.0 10.9 9.7 Respiratory disorders, perinatal 3.6 17.2 8.1 16.9 6.8 12.7 6.1 12.5 Chronic lower respiratory disorders 3.6 3.7 2.7 5.4 1.5 1.7 4.0 Injuries, poisonings and other external causes 8.2 1.8 6.0 4.2 6.4 3.8 5.8 5.6 Congenital malformations 3.6 4.9 4.2 3.0 3.4 5.6 4.2 3.213.2.3 CHILDREN, AGED 5-14 YEARS Although mortality in this age group is the lowest in the population (33.5 per 100,000 population), data show that those few deaths that do occur are mainly due to external causes. In 2007, of 20 deaths in that age group, nine (9) were the result of injuries, ve of them road trac injuries (RTIs), and two drownings. With respect to hospitalizations, injuries accounted for 15.2% 22.3% of all discharges at PMH and RMH during the years 2004-07. Respiratory conditions, both acute and chronic, followed in importance. We point with concern to 20-25 discharges for diabetes each year from hospitals, to the 1-4 hospitalizations each year for hypertension in this age group, to290 children with abnormally high blood pressures, and 38 children with hyperglycaemia screened by school health services during 2008. 13.2.4 ADOLESCENTS AGED 15-24 YEARS Injuries were the main cause of morbidity and mortality in this age group. Strikingly, the most common cause of mortality was assaults. In 2007, 39 of the 49 male deaths were due to injuriesand of these, 24 were homicides. ere were 17 deaths among the females, four (4) of which were injuries, two (2) RTIs, and two (2) homicides. Approximately 2 of 5 discharges, excluding those related to pregnancy, are due to injuries (Table 40). e high percentage of pregnancy-related discharges speaks to the need to assess the Family Planning process in both urban areas. Among this group of adolescents, mental and behavioural disorders seen at RMH are mainly due to psychoactive substance abuse (including alcohol). is is also seen among males in the 25-44 age group.

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MInistry of Health, Commonwealth of The Bahamas 67Table 40. Percentage distribution of discharges in adolescents aged 15-24 years, 2004-2007. Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH Pregnancy, childbirth and the puerperium 75.4 43.5 70.7 57.0 62.3 64.8 75.6 67.4 Injuries 9.7 14.4 10.7 9.7 15.3 9.8 9.2 8.8 Mental and behavioural disorders 0.4 4.0 7.8 3.6 5.4 Appendicitis, hernia, intestinal obstruction 1.2 1.8 1.9 1.6 2.2 1.2 <1.0 <1.0is discharge information highlights the need to disaggregate data in order to evaluate the needs of the community. e lack of HIV/AIDS discharges in this age group reiterates the importance of evaluating the data for these patients in order to identify programmatic benets such as the eectiveness of identifying cases early and the use of ART with this population. 13.2.5 PERSONS AGED 25-44 YEARS Injuries and HIV/AIDS accounted for 84 and 45 deaths respectively among the 212 males who died in 2007. Of the 84 fatal injuries, 33 were homicides and 22 were RTIs. Injuries also accounted for a signicant proportion of hospital discharges, followed by mental disorders, especially those resulting from psychoactive substance abuse (Table 41).Table 41. Percentage distribution of discharges in persons aged 25-44 years, 2004 2007 Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH Pregnancy, childbirth and the puerperium 75.4 43.5 70.7 57.0 62.3 64.8 75.6 67.4 Injuries 9.7 14.4 10.7 9.7 15.3 9.8 9.2 8.8 Mental and behavioural disorders 0.6 8.3 7.8 3.6 5.413.2.6 PERSONS AGED 45-64 YEARS Chronic diseases (hypertension, ischaemic heart disease, cerebrovascular disease, diabetes and cancer) and HIV/AIDS are the leading causes of mortality and morbidity in this age group (Table 42). e presence of HIV/AIDS as a cause of death in this age group may be reective of deferred death due to the eectiveness of antiretroviral therapy (ART) in earlier years resulting in increased survival rates.

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68 Annual Report of the Chief Medical OfcerTable 42. Proportionate mortality of leading causes of death in persons aged 45-64 years, 2007-2008. 2007 2008 Cause of death # % # % HIV/AIDS 50 9.8 52 10.3 Hypertension 41 8.1 46 9.1 Ischaemic heart disease 38 7.5 40 7.9 Cerebrovascular disease 34 6.7 40 7.9 Diabetes 28 5.5 22 4.4 Cancer of the breast 23 4.5 17 3.4 TOTAL 509 100% 217 100%A similar prole is seen when hospital discharges are considered (Table 43).Table 43. Percentage distribution of discharges of persons aged 45 64 years from PMH and RMH, 2004 2007. Discharge diagnosis 2004 2005 2006 2007 PMH RMH PMH RMH PMH RMH PMH RMH Hypertension 7.7 7.7 7.3 7.5 7.4 8.6 6.8 8.8 Diabetes mellitus 4.5 4.5 6.6 4.7 4.7 3.5 5.4 4.6 HIV/AIDS 3.0 <1.0 5.0 <1.0 6.7 <1.0 4.4 1.2 Cerebrovascular disease 3.0 2.9 3.4 2.9 3.5 3.2 5.1 2.9 ARI 3.3 2.8 2.4 3.3 2.8 3.7 2.6 3.8 Ischaemic heart disease 1.7 6.4 2.2 5.3 2.1 3.2 2.8 5.6 Cancer of the breast 1.4 2.0 1.5 1.8 <1.0 Injuries 10.8 10.6 9.7 8.8 11.0 9.8 8.3 6.7 Mental disorders 4.9 1.9 5.2 1.3 5.3 1.9 5.2

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MInistry of Health, Commonwealth of The Bahamas 6914.1 SUMMAR Y OF ACHIEVEMENTS e Bahamas is advancing well towards achieving some of the Millennium Development Goals (MDG) health-related targets. EPI coverage is near 100% and continues to expand, controlling more conditions. All births are attended by skilled personnel. Antenatal care coverage is now over 80%. Maternal mortality, for the most part, varied between 0-2 deaths during the last ve years. e MCH programme continues to be a success, despite severe stang limits and other challenges. Other eective programmes include the HIV/AIDS programme, which has succeeded in changing AIDS mortality and reducing MTCT to near zero. e national TB Programme has intensied the surveillance and management of TB, so that DOTS coverage remains 100%. e Infectious Disease Surveillance Programme has demonstrated eective surveillance and prompt control measures that have contained malaria and dengue outbreaks. Much of the work of the public health services has been provided eectively, in a strategically focused manner. e Government of e Bahamas has provided invaluable support for persons with chronic diseases, as evidenced by the provision of free medications for HIV/AIDS (antiretroviral therapy) and CNCDs (antihypertensives, chemotherapy, insulin and other anti-diabetic agents, etc.). Statistics from school health clinics, with their Grades 1 and 6 entry screenings, have been able to identify and address early health problems including vision and hearing loss, abnormal weights, hypertension and oral health abnormalities. Although the latter has achieved the minimum standards set for oral health status of children, there is room for improvement. 14.2 FUTURE STRATEGIC FOCI Despite these achievements, challenges remain. Every one in 12 admissions of children under age ve is for an injury. RTIs and other unintentional injuries tend to aict those in the lower age groups; assaults, homicides, and industrial accidents prevail in our older youth. Data from the Emergency Medical Service requires analysis to determine where response times in New Providence can be improved. No new antigens were added to the paediatric immunization schedule despite recent advances in vaccine-preventable diseases. In addressing the social determinants of health, issues such as single parent and teenage pregnancies, the impacts of urbanization and overcrowding in New Providence as people move toward commerce centers in search of employment, and other social determinants of healthall play a signicant role in the health and longevity of Bahamians. Safety and injury prevention are priority areas to be addressed. e prevalence of chronic non-communicable diseases, and the appearance of risk factors such as obesity and elevated blood pressure early in lifeall speak to the need for the early inculcation of healthy lifestyle habits. Proper nutrition from birth, including exclusive breastfeeding for at least the rst 12 weeks, and regular exerciseall must be promoted. Reproductive health is another area of concern. Teen pregnancies are not insignicant. Neither is the incidence of STIs such as gonorrhea. Both indicate the need for continued promotion of the practices of safe sex or abstinence. e prominence of breast and prostate cancer as causes of mortality argues for aggressive screening for these increasingly common types of cancer. Finally, the data in this report point to persons at increased risk for the use and misuse of psychoactive substances, including alcohol, as a major factor negatively aecting mental healthmainly among young males. is issue, like the other health issues mentioned above, may be addressed by the promotion of healthy lifestyle habits. Indeed, the Healthy Lifestyle Initiative launched by the Ministry of Health, is a central key to strengthening the health of the people of the Commonwealth of e Bahamas. Underpinning these recommendations should be a strong information system to guide decision-making and to assess the eectiveness and ecient focus of programmes and interventions as they are executed. e iPHIS holds the potential to do this when completed. We believe its completion is imminent and that MOH sta will be able and enthusiastic to explore its potentials. 14CONCLUSIONS

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70 Annual Report of the Chief Medical Ofcer14.3 RECOMMENDATIONS AND PROPOSALS/PLANS FOR THE FUTURE is report highlights the need for the continued, timely collection and analysis of data, in order to document the health status of the nation and to focus health policy and programmes. Gaps identied in this report underscore the need to conduct more surveys and intensive studies, including those that monitor the attainment of the Millennium Development Goals. e Ministry of Health must work toward costing the programmes that are currently in place and to insist on doing this in any future programmes. e MOH needs to build its capacityto act and respond, to assess and reneespecially in the area of project management skills. We have studied the health patterns of Bahamians. We know much of what needs to be done to foster our peoples health and longevity. e ability of MOH to signicantly bring down the rates of HIV/AIDS and its mortality has been a major achievement, one not achieved by many larger nations. We know our people. We have studied their patternsboth those that lead to health and those that lead toward illness and early death. As noted earlier, for a nation as for an individual, health is largely a matter of making and maintaining the right choices. At the Ministry of Health, we believe our choices are fundamentally already dened. We need to keep getting better at managing the challenges we have examined and outlined in this report. We do not need to re-invent the wheel. We need to put axles between those we already have.

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MInistry of Health, Commonwealth of The Bahamas 71Bahamas Department of Statistics. Bahamas Survey of Living Conditions, 2001 Bahamas Department of Statistics. 2008 Labour Force and Households Income Survey Bahamas Department of Statistics. 2009 Labour Force and Household Income Survey. (in print).. Bahamas Department of Statistics. e Bahamas in Figures, 2007. Economic Commission of Latin America and the Caribbean. World Statistics Pocketbook. Bahamas Country TB Reports, accessed at http://www.who.int/tb/publications/global_report/2009/update/a-1_amr.pdf Department of Public Health Oral Health Services Annual Report, 2006 Department of Public Health: EPI Report, 2009. Dra Food and Nutrition Policy, 2008 Surveillance Report Prison Health Report, 2004 Prison Health Report, 2005 Prison Health Report, 2006 Prison Health Report, 2007 15REFERENCES

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72 Annual Report of the Chief Medical Ofcer16.1 T ABLES Table 1. Socio-Economic Indicators Table 2. Labour Force by age and sex, all Bahamas, 2008 Table 3. Labour Force by highest examination passed, 2008 Table 4. Basic Demographic Indicators, 2002 2008 Table 5. Life expectancy at birth, 1980 2008 Table 6. Foetal and infant Deaths by age, 1999 2008 Table 7. Crude deaths rates (per 100,000 pop.) and ranks for leading causes of death, 2004 2008. Table 8a. Hospital Statistics, 2004 2008. Table 8b. Hospital Statistics, Sandilands Rehabilitation Centre, 2004 2008. Table 9. Community Health Centre Service Statistics, BAHAMAS, 2004-2008 Table 10. Human resources per 10,000 population, 2004 2008. Table 11. Annual Health Budgets 2003/2004-2008/2009 Table 12. Summary of antenatal services, coverage and utilization, 2004 2008. Table 13a. Summary of perinatal information (Maternal indicators) 2005 2008 Table 13b. Summary of perinatal information (Neonatal indicators), 2005 2008 Table 14. Summary of Post natal and Infant Child Health Services Table 15. Reasons for attendance (rst visits only) at child health clinics, 2004 2008. Table 16. Immunization coverage rates, 2004 2008 Table 17. Results of health screening of Grade I students, 2004 2008 Table 18. Results of health screening of Grade 6 students, 2004 2008 Table 19. Results of health screening of Grade 10 students, 2004 2008 Table 20. Reported cases of infectious diseases and syndromes to carec, 2004 2008 Table 21. HIV positive rates among pregnant women screened, 2004-2008 Table 22. HIV Mother-to-Child Transmission Rates, 1995-2008 Table 23. HIV Surveillance of selected populations, 2004 2007, Bahamas Table 24. Status of Tuberculosis cases, BAHAMAS, 2004 2008 Table 25. Distribution of Tuberculosis cases by co-morbidity with HIV and sex, Bahamas, 2004 2008 Table 26. New cases attending Primary Health Clinics for selected noncommunicable conditions Table 27. Grade 1 Caries Prevalence Trends, 2002 2006 16TABLES AND FIGURES

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MInistry of Health, Commonwealth of The Bahamas 73Table 28. Grade 6 Caries Prevalence Trends, 2002 -2006 Table 29. Prison Health Screening 2004-2008 Table 30. Annual Meat Statistics, New Providence, 2004-2008 Table 31. Food Handlers Training Sessions, 2004-2008 Table 32. Hospital utilization by service, PMH and RMH, 2008 Table 33. Laboratory tests at Princess Margaret Hospital by type of test, 2004-2008 Table 34. Accident and Emergency Visits by Age and Sex, 2004-2008 Table 35. New Providence emergency Response Data, 2004 2008 Table 36. Abaco Emergency Response Data, 2006-2008 Table 37. Hospital Outpatient Visits by Institution and Service, 2004-2008 Table 38. Percentage distribution of discharge diagnoses, 2004-2007, excluding deliveries Table 39. Percentage distribution of hospital discharges in children aged 0-4 years by condition, 2004 2007, Princess Marga ret Hospital and Rand Memorial Hospital, Bahamas Table 40. Percentage distribution of discharges in adolescents aged 15-24 years, 2004-2007. Table 41. Percentage distribution of discharges in persons aged 25-44 years, 2004 2007 Table 42. Proportionate mortality of leading causes of death in persons aged 45-64 years, 2007-2008. Table 43. Percentage distribution of discharges of persons aged 45 64 years from PMH and RMH, 2004 2007. 16.2 FIGURES Fig. 1. Distribution of population by age and sex, 2004. Fig. 2. Population distribution by age and sex, 2008. Fig. 3. Trends in population growth and associated factors, 1998 2008 Fig. 4. Age-specic fertility rates by age-group, 2004-2008 Fig. 5. Mortality rates crude death rate per 100,000 pop., infant, neonatal and perinatal mortality rates per 1000 live births, and stillbirth rates per 1000 livebirths, 1998 2008 Fig. 6. Leading causes of death, 2004 2005 Fig. 7. Leading causes of death, 2006, 2007 Fig. 8. Years of potential life lost (YPLL) 2002-2006 Fig. 9. Hospital in-patient death rates 1997 2007 Fig. 10. Clinic visits in New Providence, Grand Bahama and the Family Islands, 2004-2008 Fig. 11. Home Visits in New Providence, Grand Bahama and the Family Islands, 2004-2008 Fig. 12. Expenditure on health activities, 2006 -2008

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74 Annual Report of the Chief Medical OfcerFig. 13. Percentage of children screened at school health clinic who were overweight Fig.14. Percentage of children screened at school health clinic who had high blood pressure Fig. 15. MTCT Rates, 1995-2008 Fig. 16. New Cases of AIDS, by Sex and Year, 1985-2008. Fig. 17. Cumulative Number of Reported HIV Infections, by Sex, 2008. Fig. 18. Current Non-AIDS HIV infections, by Sex and Reported Year, 1985-2008 Fig. 19. Cumulative cases by age-group & Sex as at 31.12.2008 Fig. 20. Incidence and prevalence of TB and co-morbid HIV, Bahamas, 1990 2008 Fig. 21. Selected conditions as percentages of total discharges (excluding deliveries) from princess Margaret and Rand Memorial hospitals, 2004 2008 Fig. 22. Patients on dialysis at princess margarget hospital by underlying condition, 2007 Fig. 23. Summary of cancer sites by gender, Princess Margaret Hospital, 2008 Fig 24. Patients treated in Mental Health Facilities by Diagnosis Fig. 25. School Dental Services-Clinical Activity Trends 2002-2006 Fig. 26. Preventive Dental Treatments Rendered by clinic-New Providence & Family Islands-2006 Figure 27:. Exuma Anopheles Larval Total Average-2008 Figure 28. 2008 Exuma Human Bait Collection Total Average Fig. 29. Age-specic death rates, per 100,000 popn. by gender, 2007 Fig. 30. Mortality rates per 1,000 livebirths, of leading causes of infant mortality, 1996 2006, Bahamas Fig. 31. Age-specic mortality rates per 10,000 population of the leading causes of death in children aged 1-4 years, 1996-2006, Bahamas

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MInistry of Health, Commonwealth of The Bahamas 75Ministry of Health 2004 February 2006 Minister of Health Parliamentary Secretary Chairman Best Commission Director BEST Environmental Protection Unit Director Department of Public Health Director Department of Environmental Health Administration Administration Oral Health Health Inspectorate Community Nursing Services Waste Management Programmes Coordination Environmental Monitoring and Risk Assessment Clinic and Community Services Roads and Parks Directory of Nursing Ofce of DoN Regulatory Bodies Medical Council Dental Council Council for Regulation of Health Professions Hospital and Health Care Facilities Licensing Board Technical and Advisory Units Health Education Health Information Unit AIDS Secretariat National Drug Council NGO Organization Desk Public Relations and Communications Finances and Materials Management Human Resource Management Policy, Planning and Development Clinical Pastoral Program and Health Care Chaplaincy Permanent Secretary Minister of Health HQ Chairman of the PHA Board Chief Medical Ofcer Ofce of CMO Public Hospitals Under Secretary ANNEXES

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76 Annual Report of the Chief Medical OfcerDepartment of Environmental Health Services under the Ministry of Health May 2007 September 2008 Director ASSISTANT DIRECTOR HEALTH INSPECTORATE PRESS LIAISON CHI (1) Administrative Responsibility HEALTH INSPECTORATE CHI SPECIAL PROJECTS Family Islands Nighttime Survellance DCHI Env. Court Building Contro; Special Projects/Env. Quarterly DCHI Port Health Main Street Meat Inspection DCHI Licensing Complaints Licensing/Special Projects Chief Public Analyst Public Analyst Deputy Public Analyst Assistant Analyst Night Survelliance Team Derelict Vehicle Site Derelict Vehicle Program Special Env. Maintenance ASSISTANT DIRECTOR WASTE DISPOSAL SITE FAMILY IS. WASTE OPERATIONS Disposal Site Manager(s) Daily Management Site CHI Collections Administration Collections Sr. Tractor Operator Tractor Operator Spotter(s) Sr. Superintendents Daily Management of Operations ASSISTANT DIRECTOR EMRA BASEL CONVENTION CHI Administration R&P Estates Management Garage (CARS) Chief Works Controller Daily Management of R&P Superintendent Assist with Daily Management Sr. Field Support ASSISTANT DIRECTOR PEU R&P Field Supervisors Sr. Field Supervisors Supervision Monitoring of Routes Field Supervisors Check of Field Work Group Leaders SHI H.I 1 H.I 2

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MInistry of Health, Commonwealth of The Bahamas 77 Minister Permanent Secretary Finance Ofcer Accounts Ofcer Under Secretary Director of Nursing Consultant Communication DPS Planing DPS (General Admin.) DPS H.R.D. Senior Assistant Secretary Chief Estates Ofcer FAS Medical Matters First Assistant Secretary DPS Medical Matters General Administration Chief Medical OfcerDepartment of Public Health Public Hospitals Authority Dental Council Medical Council National Drug Council Health Professional Council Health Facilities Council PAHO Health Information Health Education Maternal/Child Health Adolescent Health NBC Initiative NGos (Health Related) Internal Relations IDB CARICOM OAS Comm, Secretary UNFPA Physical Plant Transportation Security Maintenance Environment Disaster Preparedness Payrolls Computers Purchases & Supplies Revenue PHA DPH DEHS PAHO Health Prof. Council; Drug Council Dental Council Nursing Council AIDS Secretariat InService Training Ofce Management Personnel Registry Employee Assistance Janitorial Staff Support Staff Ministry of Health and Social Development June 2007 July 2008

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78 Annual Report of the Chief Medical Ofcer Minister of Health Managing Director Internal Auditor Board of Directors Chairman Director of Projects Project Management BNDA MMD Capital Development Unit Plant, Equipment & Furniture Procurement Oversight Information Technology Management & Development Quality Management Oversight Public Relations Planning & Business Development Information Monitoring Evaluation & Analysis Recruitment & Retention Career Pathways/ Succession Planning Training & Development Performance Management Budgeting & Reporting Accounts Payable Payrolls Assets Management Medical Services Oversight Medical Internship & Special Programmes Oversight Technical Oversight Allied Health Services Quality Standards Development Monitoring Quality Standards Development Monitoring Nursing Services Oversight Litigation Management Policy & Statutory Provisions Employee Relations Compensation & Salary Administration Registry Director of Shared Services Director of Human Resources Financial Controller Nursing Services Advisor Legal Advisor/Board Secretary Princess Margaret Hospital Sandilands Rehabilitation Centre Grand Bahamas Health Services NEMS Ofce Management Medical Advisor Deputy Managing Director Legend: BNDA Bahamas National Drug Agency MMD Materials Management Directorate NEMS National Emergency Medical Services Functional Organizational ChartPublic Hospitals Authority

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MInistry of Health, Commonwealth of The Bahamas 79 Director EMC General Administration Medical Coordinator Principal Nursing Ofcer Director of Planning Human Resources Finance Transport/Supplies Estates Management Projects Surveillance Health Information iPHIS Monitoring & Evaluation QA/Research Dental Services Allied Health Services Clinic Teams Family Island Services New Providence Training/Development Department of Public Health Proposed Organizational Structure 2005

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82 Annual Report of the Chief Medical Ofcer Ministry of Health The Government of the Bahamas Meeting and Delancy Nassau, Bahamas