- 1 The Bahamas
- 2 Patient Access to Physiotherapy or Physical Therapy Services / Entry Point
- 3 Therapist Preparation
- 4 Professional Associations
- 5 Information about the Patient Community
- 6 Social/Cultural Influences
- 7 Delivery of Care
- 8 Type of Health System
- 9 Payment System
- 10 Resources
- 11 References
The Bahamas About 94% of the population lives on five of the islands. About 70% of the population lives in Nassau (Population Census2000, Department of Statistics).
Patient Access to Physiotherapy or Physical Therapy Services / Entry Point
Physiotherapy services in The Bahamas are delivered by licensed physiotherapists who work in both the private and public sectors. Physiotherapists in the Bahamas are few in number. Considering that The Bahamas is an archipelago of islands consisting of 700 islands, cays and rocks, 29 of which are inhabited there are fewer than 50 licensed physiotherapists to serve the needs of the population of 342,000 persons. While there are a number of small privately owned physiotherapy clinics most persons access physiotherapy services via the available hospitals. The island of New Providence on which is located the capital Nassau, is home to The Princess Margaret Hospital, the main acute care general public hospital on the island. Both In-patient and out-patient physiotherapy services are accessed through this hospital. The Sandilands Rehabilitation Centre, a geriatric and mental health institution also offers in- and out-patient physiotherapy services. Doctors Hospital, the only acute care private hospital of its kind also offers both in- and out- patient physiotherapy services. The Rand Memorial Hospital, an acute care facility located in the city of Freeport, Grand Bahama, also offers acute care and out-patient ambulatory physiotherapy services. Most of the smaller islands are equipped with community clinics which are staffed by a nurse and a travelling physician. All cases that cannot be adequately addressed at the smaller medical facilities are airlifted to the larger hospitals in Nassau or Freeport for further management. Most patients requiring physiotherapy intervention travel to Nassau or Freeport to access these services as there are only a few private clinics on some of the smaller islands. Most family islanders have no access to physiotherapy services on their island.Physiotherapy care is physician referred as the current legislature does not support direct access at this time. Patients who require physiotherapy intervention must be seen by their primary care physician first before accessing the services. At times these patients may be referred to specialists before being referred for physiotherapy services. This can lead to a fairly long wait time in some instances, between the initial complaint and actual physiotherapy intervention, especially in the public system.
Physiotherapists practicing in The Bahamas have a minimum of a Bachelors of Science in Physical Therapy. As there are no physiotherapy training programs in The Bahamas, persons interested in training for the profession are required to travel abroad to complete their training. Persons frequently travel to the University of the West Indies, Mona Campus, Kingston Jamaica to earn a three year Bachelors of Science degree in Physical Therapy at the only physiotherapy school in the English speaking Caribbean.
Others travel to various schools in the USA, Canada, England or sometimes Australia. In order to increase the numbers of physiotherapists available to serve the Bahamian population, a number of physiotherapists have been hired from The Phillipines, India, and other Caribbean islands, with either a BSc or Msc in Physical Therapy. A few PTs are presently completing or have completed t-DPT programs.
At present there are no truly developed specialty areas in The Bahamas. Most physiotherapists practice generally in either or both acute care In-patientand out-patient settings. There is however a pediatric neurodeveolpmental clinic and the PTs who work there see only infants and small children.
Information about the Patient Community
The ethnic groups in The Bahamas comprise of : Blacks or Afro-Bahamians 85%, Whites or European Bahamian 12%, Hispanic 3%, Asians or Indo-Caribbean 3% There are also large numbers of Haitian economic refugees which make up approximately 20-25% of the population. Currently about 9% of the population of The Bahamas is 60 years of age or older. However, this portion of the population is expected to increase to 18% by 2030. The portion of the population 65 years and older is expected to double from 6% at present to 12% in the same time frame. At present, about 25% of the population is 14 years old or younger, and 42% of the population is under the age of 25. While the overall portion of people under the age of 25 is projected to drop to 22%, the actual population of this group is expected to increase from about 146,000 today to 153,000 by 2030.
In 2001, 14% of children 2-10 years, and 9% of adolescents (11-20 years) were overweight (Bahamas Living Conditions Survey), predisposing them to health risks such as diabetes and hypertension as they grow into adulthood.
Reported cases of child abuse in youth under the age of 18 showed a 24% increase from 545 in 2007 to 719 in 2008. In both years, child neglect and physical abuse were the most commonly reported types of abuse and together accounted for 62% of cases in 2008. Sexual abuse and incest together accounted for 22% of cases in 2008 (Department of Social Services). Young people are also at risk from violent crime and other injuries as reflected in morbidity and mortality trends and this appears to be escalating. Injuries and poisonings were the leading cause of hospitalization for males 15 to 24 years (Public Hospitals Authority), while homicide and traffic accidents accounted for just over half of all deaths in this age group, males most at risk (Department of Statistics).Over the years there has been an increase in the incidence and progression of chronic noncommunicable diseases, including hypertension, diabetes, coronary heart disease, stroke, chronic respiratory diseases and some cancers. These diseases are highly affected by lifestyle choices such as diet, lack of exercise, stress, smoking and alcohol consumption. More than 70% of the bahamian population is overweight and 38% engage in little or no physical activity. 50% of the population report eating less than one serving a day of fruits and vegetables. An estimated 37% of the population has hypertension, and 10% has type 2 diabetes. (CNCD Survey, MOH, 2005). Chronic non-communicable diseases account for nearly 45% of all deaths in The Bahamas (Health in The Americas, 2007, PAHO), and represent five of the ten leading causes of death among individuals aged 45 years and older (Department of Statistics). Approximately half of all public hospital beds are occupied with persons suffering from chronic non-communicable diseases.3
Mortality and Morbidity
The tables below depict the leading causes of death in The Bahamas for various age groups. These statistics were retrieved from the Health information and Research Unit, Ministry of Health.
Source: Health Information and Research Unit, Ministry of Health, The Bahamas.
Most Bahamian families consist of large extended families. Many of those who live in New Providence can most often trace their roots of origin to settlements on some of the inhabited family islands. Families tend to be fairly close knit and supportive, especially on the family islands, where persons report experiencing a greater sense of community, than in the capital of Nassau. However, present at most social gatherings are large quantities of food. The typical “soul food” found in the southern United States is common place along with traditional items such as peas and rice, pea soup, steamed fish, steamed, stewed and cracked conch and side dished such as coleslaw, potato salad, canned beets and corn. Grits figures prominently in the Bahamian breakfast diet along with souse (a clear, light meat soup) and Jonny cake. As a result of a fatty diet, traditional and fast foods, and large portion sizes, obesity tends to take on a familial trend. These trends are also seen in familial incidences of the chronic non-communicable diseases such as diabetes and high blood pressure.
Persons who live on the Family Islands have more restricted access to fast foods and may not have as many modern conveniences as those in the more densely populated capitals. Persons are less sedentary and there are larger numbers of persons involved in physical labor such as fishing and farming. Swimming, walking, diving and “rushing”(marching around the church singing) are also common. As a result, there is a tendency towards a healthier lifestyle.
Generally Bahamian families are supportive of ill family members, participating in their care and rehabilitation. It is not rare to see a “cook out” or “grill out” being held by a patient’s family, community or church, to sell food, the proceeds of which go towards the medical bills of their loved one.
However, as a result of the rise of chronic non communicable diseases the Government of The Bahamas has initiated The Healthy Lifestyle Initiative, to influence the families and society at large towards healthier lifestyle habits and choices.
The cultural festival of Junkanoo, features prominently on the Bahamian calendar and is traditionally held in Nassau on December 26th and January 1st at 3 am weather permitting. It also takes place across the family of islands on a much smaller scale on various dates. Junkanoo is a street parade or African origin, with live music and large colorful costumes, during which various groups compete for the overall first place prize after being judged in various categories. Persons can be seen practicing and preparing for Junkanoo during the latter half of the year. Men are typically responsible for making and designing the large costumes although most participants are encouraged to make their own costume. Various marching bands can also be heard practicing, as brass instruments and goat-skin drums are played during the parade.
Traditionally Bahamians practice the Christian religion and there are large numbers of churches to be found throughout the islands. Persons can also be found to practice “bush Medicine”, a carryover from the African Culture. Although English is the official language of The Bahamas an English dialect (or broken English) is widely spoken. Haitian creole can also be heard due to the large numbers of Haitian economic refugees. These refugees tend to live in poorer conditions and place an additional burden on the public health system. Many times a language barrier is encountered by physiotherapists when treating such persons and an interpreter is needed in order for rehabilitation to be effective.
Delivery of Care
Physiotherapy services are delivered by registered physiotherapists in both the private and public settings. In 2008 there were 41 registered physiotherapists working in The Bahamas which represents a rate of 1.2 per 10,000 population. The numbers of physiotherapists are well below the numbers necessary to adequately serve the population in the areas of treatment and prevention. This contributes to bottle necks in the system, especially in the public health care system by which the majority of the bahamian population accesses health care. The lack of adequate numbers of physiotherapy personnel provides a barrier to timely access to physiotherapy intervention and services.3 As a result there are limitations to the scope of health promotion and prevention that can be performed by the physiotherapy community as a result of the overwhelming numbers of persons who require prompt care as a result of injury and/or dysfunction. At present there are long wait lists at the two main hospitals in Nassau, for persons who require physiotherapy assessment and treatment. For example, persons who require out-patient physiotherapy services at the Princess Margaret Hospital are faced with an approximately four month wait period. However special considerations are give to persons who require continued care after hospitalization and who live on one of the family islands and are required to remain in Nassau for rehabilitation. Thses individuals are given priority and seen within a week of referral.
Home health physiotherapy services are only available through private services at present and there are a number of physiotherapists who are available to offer these services, in many instances after their usual work hours.
Type of Health System
The Government of The Bahamas subscribes to the internationally accepted principle that health is a fundamental human right, not a privilege, and to the view that quality health care must be universally available. There is full commitment to the global goal of "health for all," and community participation is accepted as a vital element of the health strategy. The people of The Bahamas enjoy universal access to health care. However, the production of health services is inconsistent with the level of per capita government expenditure on health. As a result, there is much attention paid to the development of human resources, establishment of norms and standards, and the strengthening of not only information systems but also the capacity to make effective use of them for planning, evaluation, and monitoring.1
The public sector operates three hospitals, under the umbrella of the Public Hospitals Authority or PHA. PHA is a quasi government estabilshment that is responsible for managing and developing the public hospitals in The Bahamas The Princess Margaret Hospital (PMH), a tertiary care facility, has approximately 436 beds and provides general acute and specialized in-patient services including intensive care, hemodialysis, cardiology, and urology. There is also a large out-patient service which includes Accident and Emergency, General Practice and Specialty Clinics. The Sandilands Rehabilitation Center provides both psychiatric/mental health care on an inpatient and outpatient basis (352 beds) and geriatric care (130 beds). The Sandilands Rehabilitation Centre also provides in and out-patient physical rehabilitative services including physiotherapy services with a compliment of three (3) physiotherapists and two (2) physiotherapist assistants. It also has a Community Counselling and Assessment Centre which provides psychiatric, psychological and social services including substance abuse treatment and rehabilitation.The third institution, the Rand Memorial Hospital, is in the nation’s second largest city, Freeport, on Grand Bahama. It provides general acute care as well as basic levels of specialized services, and has a bed complement of 82. It houses a physiotherapy department with a complement of three (3) physiotherapists.
Public Health Services
Delivered through a network of 57 community clinics and 54 satellite clinics in New Providence and the Family Islands and come under the management of the Department of Public Health. This is the main agency other than the Public Hospitals Authority, that offers preventative and curative services. It also encompasses community-based programs such as home and district nursing and disease surveillance. This system of polyclinics and satellite clinics is linked, through phone consultation and referral services, to the more sophisticated tertiary care services at the Princess Margaret Hospital (PMH), on New Providence, and the Rand Memorial Hospital (RMH), on Grand Bahama. Individuals may be asked to contribute towards the costs of care and transportation, but no one is denied care due to inability to pay. Public health services include general practice, maternal and child health, and dental health There are no physiotherapists employed by the department of public health at present.
The private sector provides primary care services, emergency services, secondary inpatient care, and specialized clinical, diagnostic, and treatment services in both the medical and dental fields. There are two private hospitals providing secondary care. Doctor’s Hospital has 72 beds and its services include emergency care, specialized medical care (including rheumatology and nephrology), surgery (including cardiovascular and neurosurgery), obstetrics, and diagnostic services (including nuclear medicine). This hospital offers both in and out-patient physiotherapy services. The other private hospital, Lyford Cay, has 12 beds. It provides specialty services in cardiology, plastic surgery, urology, and podiatry. There is a small physiotherapy department attached to the Lyford Cay Hospital. A number of small independently owned physiotherapy clinics are present offering general out-patient services. Orthopedic cases make up the bulk of the physiotherapy referrals to these clinics.
Specialized ambulatory services
are available in the areas of cardiology and nephrology. The Bahamas Heart Center offers a full range of cardiac evaluation techniques, including nuclear stress testing and cardiac catheterization. Pacemaker implantation is also available. Renal House offers kidney dialysis
The cost of health care in the publc sector is heavily subsidized by the government. Persons accessing health services are usually required to pay nominal fees for health services and medications. Persons usually pay out of pocket or via private medical insurance for most health care services. Several options for health and dental insurance are available through the private insurance system. There is no national health insurance scheme in The Bahamas, but the National Insurance Board provides medical benefits for job-related injuries and during illness, provided that you qualify through monthly contributions. Partial salary replacement is provided during illness to those who qualify, as well as paid medical care for industrial injuries. Other benefit types include maternity, disability, and death. In addition, provision is made for invalidity, retirement, and survivor’s benefits. The out-of-pocket expenditures of families for physician’s fees, medications, diagnostic services, and private health insurance contribute to private sector resources. The IDB has estimated that private health expenditure amounts to 2.2% of GDP and 45.6% of the total health expenditure in the country.