The Tribune

By Neil Hartnell

Tribune Business Editor

nhartnell@tribunemedia.net

Financing for Bahamian public healthcare is “on an unsustainable track” with a $24m annual deficit predicted by the upcoming 2026-2027 fiscal year, it has been revealed, with this shortfall set to worsen due to an increasingly elderly population.

The Bahamas’ just-released National Health Strategy Report for 2026-2030, which has been obtained by Tribune Business, discloses that this widening financing gap - which is forecast despite a total $35.3m increase in the Ministry of Health and Wellness’ budget allocation for the current 2025-2026 fiscal year - threatens to expand inequality and “impoverishment” by forcing more families to fund medical care from their own funds.

The report, which noted that the Government’s annual healthcare spending is less than the 5 percent of gross domestic product (GDP) threshold viewed as essential to funding the universal health coverage targeted by The Bahamas, also warned that the “sustainability” of National Health Insurance (NHI) could be endangered from patient costs increasing by 53 percent during the five years since the COVID-19 pandemic.

The availability of NHI coverage was rated as the “best thing” about Bahamian healthcare by a survey of 1,445 persons conducted in July 2025, with 43 percent selecting this as the top item. However, the Health Strategy Report also revealed that a 2023 assessment of the public healthcare system had exposed that The Bahamas “met less than 20 percent” of transparency and participation standards.

And it added that “governance effectiveness is also affected by bureaucratic processes, limited transparency and vulnerability to political standards”, while noting that Bahamian adult obesity rates and hypertension “far exceed the Caribbean average”.

“The health system financing is on an unsustainable track, with a forecasted deficit of $24m by fiscal year 2026,” the Heath Strategy Report said. “Funding shortfalls will be exacerbated as the dependency ratio changes, and the country sees a rise in health expenditure for the elderly while the working population shrinks.

“Health expenditure shortfall results in significant reliance on private spending, leaving one-third of health costs to be met out-of-pocket. Such financial exposure creates inequities in access, particularly for catastrophic and specialised care, and increases the risk of impoverishment among vulnerable households.”

The Health Strategy Report showed that The Bahamas’ spending on healthcare hit a new peak of around $1.3bn, equal to $35,000 per capita or 7.6 percent of gross domestic product (GDP), in 2023. The Government’s share, at around 4.6 percent of GDP, is lower than internationally-accepted benchmarks for financing universal health coverage, and the funding “shortfall” prediction came despite health’s increased Budget allocation.

“Total health expenditure in The Bahamas stands at approximately 7.6 percent of GDP with only 4.6 percent derived from public funds; below the 5 percent-plus benchmark recommended for universal health coverage,” the report added.

“Recent steps signal momentum toward financial sustainability. The 2025–26 Budget increased allocations to the Ministry of Health and Wellness by $22m, alongside a $13.3m boost in capital spending. Legislative updates have expanded NHI Authority benefits, and work has begun on a sustainable financing framework. This progress represents an important foundation for stronger fiscal governance and resilience.”

Dr Duane Sands, a former minister of health and the Opposition’s chairman, told Tribune Business that the report provides “an interesting snapshot of healthcare in The Bahamas” as he challenged why - if the public funding “gap” is forecast at only $24m in the near-term - the Government has not made it a “priority” to allocate more financing and resources to closing it.

Suggesting that $24m is relatively small in the context of the Government’s $3.1bn annual spending Budget, although he suspects the true shortfall to be higher, Dr Sands said: “I think that is somewhat euphemistic at $24m, but at least it’s acknowledged there is a gap.

“If we were to write a Budget that had limited political influence, that said this is what we need to do based on healthcare demand, based on what we need, this is what we’re spending on it right now, the gap in funding is a lot more than that. But, to put it in black and white that there is a gap of many millions of dollars, it at least puts a number there.

“It raises the question that if there is that gap in a $3bn Budget, why haven’t you allocated money to close that gap in the context of a $3bn Budget where $60m is being spent on road works in one constituency and $100m on road works in another constituency. Why is this gap not a priority, why has it not been closed with $24m before any of these other items came to light?”

Dr Sands argued that this question should be directed to both the Davis administration’s Cabinet and the Ministry of Health and Wellness for “a reasonable answer as to why it’s [the Government] acknowledged this gap, why the minister has gone on record as saying there are delays with payments with NHI.

“While they acknowledge the challenges with healthcare financing across the board, they have not moved to close the gap. Why is it that health is not a priority? It [the report] gives an interesting snapshot into the state of healthcare in The Bahamas, but it also raises a number of questions that ought to be answered by this administration as to why they acknowledge there are problems that exist but they do not rise to the level of priority where they want to make it a priority.”

“Health financing in The Bahamas faces structural challenges,” the Heath Strategy Report admitted. “It is often perceived as a cost rather than an investment, with a lack of dedicated funding sources for key health programmes such as NHI limiting prioritisation and constraining fiscal space for system strengthening.

“This framing undermines efforts to position health as a driver of economic resilience and social development. Reframing health as an investment in human capital will be essential for long-term sustainability. The financing landscape is fragmented, with multiple entities contributing to health funding and limited integration across streams.

“The National Health Insurance Authority (NHIA), envisioned as the primary funder for primary care, plays a constrained role due to ongoing parliamentary processes and structural limitations. Primary care funding continues to rely heavily on the [Government’s] consolidated fund, weakening the efficiency and predictability of resource allocation.”

The Health Strategy Report also conceded that there are concerns with NHI’s financial sustainability due to rising healthcare costs. Speaking to healthcare equity, and inequalities in accessing needed medical services especially in the Family Islands , the report added: “Financial barriers compound these challenges.

“Nearly half of outpatient care (45 percent) is delivered by the private sector, creating affordability concerns. While the rollout of National Health Insurance (NHI) has expanded access to primary care, sustainability issues persist with costs per beneficiary rising by 53 perceny between 2020 and 2025.

“Service gaps also affect equity. Mental health needs are increasing among adolescents and adults, yet evaluations and treatment are only available in Nassau, creating logistical and financial obstacles. Blood and transfusion services face ongoing shortages (15), and rehabilitation services are largely unavailable outside major islands.”

Dr Sands told Tribune Business last night that the NHI sustainability concerns require the Government to make tough choices about who pays for the scheme and how much, plus what benefits and medical services it is to provide and finance.

“NHI ought to be taken in hand and a determination made about how this is going to be managed, what the benefits are going to be, and who is going to pay them,” he argued. “It needs a more rigid utilisation oversight and funding that allows what we have determined to be our goals to be sustainable.

“This administration has adopted the same approach to NHI as it has the Public Hospitals Authority (PHA), which is to set these aspirational standards that it has no ability to fund and no intention of funding, but it creates public expectations there will be this be all and end all for everything knowing ful well neither NHI nor the PHA is able to meet the demand.”

Meanwhile, the Health Strategy Report also flagged up “inefficiencies” and challenges with public healthcare’s governance. “The governance structure of The Bahamas’ health system faces challenges with fragmentation, which limits stewardship and accountability,” the document added.

“Service delivery is divided between the Department of Public Health (DPH) and the Public Hospitals Authority, while the Ministry of Health and Wellness (MoHW) has limited capacity to act as system steward. This, combined with unclear mandates and overlapping responsibilities, has contributed to duplication, inconsistent strategic direction and gaps in performance oversight.

“The assignment of national programmes to the Office of the chief medical officer has added complexity to governance and created uncertainty around execution responsibilities. Separate strategic plans, varied funding models and inconsistent monitoring mechanisms further challenge system integration,” the Health Strategy Report added.

“Governance effectiveness is also affected by bureaucratic processes, limited transparency and vulnerability to political cycles. The 2023 Essential Public Health Functions assessment found The Bahamas met less than 20 percent of standards for participation and transparency. Frequent ministerial changes have made continuity and alignment with long-term priorities more difficult.

“Capacity constraints remain a concern. Resources for evidence generation, policy translation and compliance with regional obligations are limited. Monitoring and evaluation systems require strengthening, disease surveillance needs improvement and the absence of a National Medicines Directorate Bill for medicines and health technologies has been identified as a priority area for development.”

Further strain is imposed on The Bahamas’ public healthcare system by its relatively unhealthy population and the prevalence of chronic non-communicable diseases (NCDs) that are responsible for most deaths and demands for medical care.

“Hypertension affects 36.7 percent of the Bahamian population, well above the Caribbean range of 20.9 percent to 27.1 percent,” the Health Strategy Report said.

“Meanwhile, diabetes prevalence stands at 11.6 percent, slightly higher than the regional average of 11.1 percent. Cardiovascular diseases, particularly ischemic heart disease and stroke, are among the leading causes of death, alongside diabetes and cancers.

“Underlying risk factors are worsening among adolescents and adults. Obesity rates have reached 25 percent among adolescents and 76 percent among adults, far exceeding the Caribbean average of 60 percent for adults. Lifestyle behaviours compound these risks: Only 5 percent of adolescents meet recommended fruit intake, while physical inactivity is widespread,” the report added.

“Additionally, 84 percent of adolescents and 37 percent of adults are inactive. Harmful substance use is also prevalent, with a lifetime prevalence of 73.9 percent. Tobacco use affects 20.3 percent of adolescents and 17 pecent of adults. Poor dietary habits further exacerbate NCD risks, with high consumption of fried foods, sugars and salt.”