Health Systems and Services Profile for the British Virgin Islands

1. Health Systems and Services Profile for the British Virgin Islands

2. BRITISH VIRGIN ISLANDS Summary • The BVI, an overseas dependent Territory of the United Kingdom comprises 50 islands, cays and rocks, 15 of which are inhabited. The 4 largest islands are Tortola, Anegada, Virgin Gorda, and Jost Van Dyke. • It is self-governed by a democratically elective Legislative Council. • The Executive Council consists of the Governor, a Chief Minister, the Attorney General, and four other ministers. The Governor and Deputy Governor are appointed by His Majesty, the Queen. • Under the constitution, the Governor is responsible for foreign affairs, defense, and internal security.

3. BRITISH VIRGIN ISLANDS Summary (cont.)  General elections are held every four years and are constitutionally due in mid 2007. • In 2004, the estimated population of the BVI was 22,053, and the major ethnic group is black.  The BVI has one 44-bed public hospital (Peebles Hospital) and one 8-bed private hospital (the Bougainvillea Clinic), both located in Road Town.

4. BRITISH VIRGIN ISLANDS Summary (cont.) • HEALTH CONCERNS • Obesity, particularly among women. • Dengue is the most important vector borne disease in the BVI. • Since 1985, 50 cases of HIV/AIDS had been reported, with a total of 25 deaths by the end of 2004.

5. HEALTH SYSTEM • PUBLIC SECTOR • The Ministry of Health and Social Services is the agency responsible for carrying out the Government’s national health policy. • A 2006 Health policy document is currently under review and consultation. • In 2005, the BVI Health Services Act was passed establishing the BVI Health Service Authority Board, which manages all public health care delivery services. • The performance of the Authority is to be monitored and evaluated based on goals and targets as set out in a service level agreement which is currently being developed

6. HEALTH SYSTEM (cont.) • The Ministry of Health focuses on the performance of the Essential Public Health Functions, standard setting and regulation of the health sector • The Government’s health priorities are the enhancement of hospital services, the strengthening of public primary health care services, and the improvement of environment health including solid waste management.

7. HEALTH SYSTEM (cont.) • Government health services are provided free at the point of use to certain groups. These include full-time school children, nursing mothers, the elderly, the mentally ill, health workers, firefighters, the police, prisoners, and prison officers. • Patients requiring diagnostic and treatment services beyond the scope of Peebles Hospital are referred to Puerto Rico, Jamaica, Barbados, the United States, USVI and the United Kingdom.

8. HEALTH SYSTEM (cont.) • The BVI does not have a formal health plan, though incremental health sector development initiatives are undertaken as part of the budget development process.

9. HEALTH SYSTEM (cont.) • PRIVATE SECTOR • The territory has a growing private health sector, encompassing both inpatient and ambulatory care. Private sector provisions are concentrated in Tortola the most densely populated island. • There is one private hospital (Bougainvillea Clinic), which specializes in plastic surgery, two private dental surgeries, and three private medical complexes, all located in the capital. • There are 16 physicians practicing in the private sector.

10. HEALTH SYSTEM (cont.) • Many residents access services through the private sector and care abroad, mainly in the US Virgin Islands or Puerto Rico, either by choice or because they require specialized care unavailable locally.

11. HEALTH SYSTEM (cont.) • SOCIAL SECURITY • A compulsory social security scheme covers all paid employees, with employees and employers contributing equally to the premiums. Self-employed workers are also required to participate in the plan. • The social security benefits include maternity, occupational injury, unemployment, old-age pension, sickness, and survivor’s benefits, as well as a funeral grant. • Discussion on the development and implementation of a National Health Insurance scheme is ongoing.

12. HEALTH SYSTEM (cont.) • REGULATIONS • The new Medical Act, passed in 2000, provides for the registration of medical dental, and allied health practitioners, and for pharmacists. It makes provisions for enforcement of standards and ethical professional practice. • The Nursing Act, 1976 provides for the regulation of the nursing professionals. • The Ministry of Health has the mandate to regulate the health sector including registration, and licensing of facilities, but does not have effective mechanisms in place to do so.

13. SYSTEM’S RESOURCES • HUMAN RESOURCES • As of 2004, a total of 45 physicians registered to practice in the BVI. Out of these 29 work in the public sector and 16 physicians in the private sector. • There are 6 dentist registered to practice in the BVI, 2 work in the public sector and 4 in the private sector. • All non-nationals coming to the territory to work require a work permit.

14. SYSTEM’S RESOURCES (cont.) • There are 121 Registered Nurses employed in the public sector; 24 of these work in Community Health Services and 97 at Peebles Hospital.

15. SYSTEM’S RESOURCES (cont.) • DRUGS & OTHER HEALTH PRODUCTS • There is no local production of drugs, vaccines or medical equipment. The Peebles Hospital Pharmacy is the central purchasing agency for the public health services. • Drugs are purchased through the Organization of Eastern Caribbean states pharmaceutical Services (OECS-PPS). Some drugs not included in the OECS-PPS formulary and are purchased directly from private suppliers. The OECS-PPS formulary is revised every two years.

16. SYSTEM’S RESOURCES (cont.) • Narcotics are not available at district clinics. • A certificate from the Ministry of Health Services is required for importation of narcotics. • All other drugs used in the private sector are purchased independently and except for antibiotics are not regulated by the government. • The Peebles Hospital Pharmacy supplies pharmaceuticals to the district health centers (primary care units).

17. SYSTEM’S RESOURCES (cont.) • The Medical Act (2000) requires that a registered pharmacist be present at both private and public pharmacies. There are privately owned pharmacies in Tortola and Virgin Gorda. • Vaccines are purchased through PAHO Revolving Fund. When urgently needed, some vaccines are purchased through a vendor in Barbados. • Some vaccines are provided at no cost to the private sector practitioners as a strategy to boost vaccination coverage. A limited number of vaccines are ordered directly by the private sector.

18. SYSTEM’S RESOURCES (cont.) • The national blood bank service is located at the Peebles Hospital medical diagnostic laboratory. The laboratory uses the Caribbean Regional Standards for blood banking. • All blood for transfusion is screened for HIV, Hepatitis B and syphilis. • There is no remuneration offered for blood donations. All donations are collected on a voluntary basis.

19. SYSTEM’S RESOURCES (cont.) • EQUIPMENT & TECHNOLOGY • Most of the equipment which includes laboratory, x-ray, ultrasound and dialysis are located at the public hospital. CT Scan and mammography are available in the private sector. • The maintenance staff at Peebles Hospital has had biomedical technology training provided by the suppliers and service contracts are maintained with some suppliers. • There are three private medical diagnostic laboratories in the private sector.

20. FUNCTIONS OF THE HEALTH SYSTEM • STEERING ROLE • The Ministry of Health and Welfare is responsible for providing public health and social services, as well as for monitoring and regulating health sector providers. • The Permanent Secretary is responsible for the administration of the Ministry headquarters and for supporting the Minister in his policy role. • The Director of Health Services is the chief technical adviser on health matters.

21. FUNCTIONS OF THE HEALTH SYSTEM (cont.) • FINANCING & EXPENDITURE • The Health Ministry of Health is responsible for exercising supervision and control of financing of the sector. • Public health services are almost entirely financed by the government • In 2000, the total Ministry of Health and Welfare expenditure was an estimated US$20.3 million, or approximately 17% of total government expenditure. • Community Services accounted for approximately US$3.53 million (17%) of the Ministry’s expenditure, and hospital services for some US$7.7 million (38%).

22. FUNCTIONS OF THE HEALTH SYSTEM (cont.) • The public health services’ overseas medical expenditure was estimated at US$700,000 in 2003. • User fee generally recover only 8% of the operating cost of primary and secondary health care services.

23. HEALTH INSURANCE • There is no Health Insurance Scheme at present however a feasibility study for the development of a National Health Insurance scheme was commissioned in 2006. • A compulsory social security scheme covers all paid employees, with employees and employers contributing equally to the premiums; some persons are covered 100% by the government • The social security benefits include maternity, occupational injury, unemployment, old-age pension, sickness, and survivor’s benefits, as well as a funeral grant.

24. SERVICE DELIVERY • PRIMARY CARE LEVEL • The territory has been divided into health districts to facilitate efficient and effective deployment of resources to the various communities of the BVI. • There are 5 Zones: Zone 1 (Eastern Tortola); Zone 2 (Central Tortola), Zone 3 (Western Tortola); Zone 4 (Virgin Gorda) and Zone 5 (Anegada). • Public sector primary care services are offered at the District Health Clinics.

25. SERVICE DELIVERY (cont.) • There are a total of 12 health clinics and health posts in the BVI (10 clinics and 2 health posts) – the Road Town Health Center and 7 other clinics on Tortola, two on Virgin Gorda, and one each on Jost Van Dyke and Anegada • The Road Town Health Center serves as a referral point for the district clinics. • The clinic in The Valley, on Virgin Gorda, is staffed by two physicians’ the clinic at North Sound is staffed by a resident nurse who is supported by the Valley clinic physicians.

26. SERVICE DELIVERY (cont.) • District clinics provide a full range of child health services, including growth and nutritional monitoring, development assessment, treatment of common illnesses, counseling, school health, and screening for anemia, including sickle cell anemia.

27. SERVICE DELIVERY (cont.) • The Community Health Pharmacy Programme was established in 2002. The Community Health Pharmacist although stationed at Road Town Clinic, also provides services to Virgin Gorda and East End and West End on Tortola. • In January 2003, the post of Health Disaster Coordinator was established with responsibility for coordinating Health Disaster Management activities within the territory.

28. SERVICE DELIVERY (cont.) • The Health Promotion Unit in the Ministry of Health focuses on the promotion of health and wellness and emphasized behaviour modification and life style changes. • Programmes for the prevention and management of both communicable and non-communicable diseases are available through the Community Health Services and Peebles Hospital. • Hypertension and Diabetes clinics are conducted on Tortola at the Road Town, Iris Smith-Penn (East End), Cappoons Bay and on Virgin Gorda at North Sound and Iris O’Neal Clinics.

29. SERVICE DELIVERY (cont.) • The BVI’s Expanded Programme for Immunization (EPI) is a component of the Family Health Programme. Under the EPI, children under the age of one year receive BCG, Hep. B, DPT, Hib, OPV vaccines; at one year of age, children receive MMR vaccine, DPT Polio, and MMR booster shots are given according to the immunization schedule until 11 years of age. • The Hepatitis B and Hib vaccines were added to the immunization programme in 1999, and the pentavelant vaccine, which provides coverage for diphtheria, pertusis, tetanus, hepatitis B and Meningitis, was added in 2000.

30. SERVICE DELIVERY (cont.) • No cases or deaths of neonatal tetanus were recorded in 2004. • Adina Donovan Home for the elderly is a senior citizens home that offers care and protection to the elderly. There is a similar home in Virgin Gorda. • The Environmental Health Division is responsible for food hygiene, vector control, water quality surveillance, institutional hygiene, and investigation of complaints such as septic tank problems, rodents, and abandoned vehicles. • The Government Dental Services provide oral health services to the population. There are two Govt. employed Dentists who are based on Tortola. These officers also visit Virgin Gorda and Anegada.

31. SERVICE DELIVERY (cont.) • The Dental Service Unit monitors primary school fluoridation and dental health programmes. • The Community Mental Health Center, located in Road Town, provides mental health ambulatory care for the Territory through its outreach psychiatric services.

32. SERVICE DELIVERY (cont.) • SECONDARY CARE LEVEL • Secondary health care is delivered at Peebles Hospital. • There is an organized Accidents and Emergency Department which also offers walk-in and scheduled outpatient services. • A 8 bed unit renal dialysis unit was commissioned in May, 2000.

33. SERVICE DELIVERY (cont.) • Consultant pathology services are now provided on-island.

34. QUALITY • TECHNICAL QUALITY • Quality improvement programmes for all aspects of health care are in varying stages of development. • There is a Quality Assurance Nurse who has responsibility for quality standards in the Community and Hospital Services. • There is no research ethics committee in the territory. • There is currently no committee on Hospital Nosocomial Infections, and there is no staff assigned to deal with this.

35. QUALITY (cont.) • PERCEIVED QUALITY • There is no operational programme for improving user relations. No user satisfaction surveys are undertaken even though users are encourage to put their complaints in writing to the Director of Health Services, Ministry of Health and the Chief Executive Officer of the BVI Health services authority. • An Employee Orientation Manual and a directory of service was developed in 2003 to provide information to staff and clients on the services.

36. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM • MONITORING THE PROCESS • The BVI undertook a United Kingdom Government-funded Health Sector Adjustment Project from 1993 to 1996. • The objectives of the project were to:- implement new management structures and processes, to revise planning approaches and systems and to revise financing strategies and improved quality of care and optimized health outcomes.

37. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • The results of the project were as follows: • Agreement and partial implementation of a new management structure • A number of health sector studies (including information, health promotion, accident prevention, mental health, and environmental health), which were accepted by local health managers as giving them a sound basis for further planning.

38. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) - This project had very little success in terms of achievement of its objectives. Significant progress was only realized in the redesignation of the post of Chief Medical Officer to Director of Health Services, Chief Nursing Officer to Assistant of Director of Health Services and Hospital Administrator to Hospital General Manager. • There was no strengthening of the management systems and no activities were developed to build management capacity.

39. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • The National Health Sector Emergency and Disaster Management Plan was revised with the participation of all managers and representatives from all levels of the health sector as well as all the health related sectors in collaboration with the Department of Disaster Management. • Every year simulation exercises are held to ensure that the plan is tested and revised as necessary.

40. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • INVESTMENT IN HEALTH SERVICE INFRASTRUCTURE • The government of the BVI has committed to the building of a new hospital in 2006 to replace the present Peebles Hospital. This will result in an increase in the number of beds available from 44 to 120. • In the area of health care financing, there has been much discussion about the formation of a National Health Insurance Scheme. • A feasibility study was commissioned in 2006.

41. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • SAFEGUARDING THE QUALITY OF MEDICAL PRACTICE • A new medical act was passed in 2000. This act makes provision for the formation of a Medical and Dental Council and on Allied Health Professions Council. • These bodies which will operate independently of the Ministry of Health will seek to ensure quality practice of doctors, dentists and allied health professionals.

42. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • HUMAN RESOURCE DEVELOPMENT • In 2000, Sixteen (16) nurses were up-graded from the certificate/diploma to the bachelorate BSN level through a special initiative of the Ministry of Health and the H.L. Stoutt Community College in collaboration with the University of New York at Sunny Buffalo.

43. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • In 2005 a strategy was implemented in the Community Health services to strengthen programme planning and programme management in the areas of; • Maternal and Child Health, Family Planning, Prevention of Chronic Disease (Diabetes), School and Adolescent Health, Healthy Elderly and Workplace Health (building on the Food Handlers and Immigration Clinics) have targeted for action. • Through this programme, it is expected that the community and public health programmes, will be better focused with targeted objectives and improved monitoring and evaluation.

44. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • The territory is currently preparing to undertake a national consultation for the development of a new national strategic plan to respond to the HIV/AIDS epidemic. • It is expected that this new plan will have participation of all relevant sectors and would yield a better programme of action and response to HIV/AIDS prevention and control including protection of human rights and access to ant ratio viral therapy.

45. MONITORING & EVALUATION OF THE HEALTH SECTOR REFORM (cont.) • The Health System and Services Profile is currently updated by the Ministry of Health working closely with the PAHO/WHO Caribbean Program Coordination office in Barbados.