GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

The Netherlands Antilles is comprised of five islands: Curaçao, Bonaire, Saba, Saint Eustatius, and Saint Martin. The first two are located near the northwestern coast of Venezuela and the others are about 900 km to the northeast. The total area of the Netherlands Antilles is 800 km2. The official language is Dutch, but Papiamento is the language commonly spoken on Curaçao and Bonaire, and English is spoken on Saint Martin, Saba, and Saint Eustatius. Curaçao, with an area of 444 km2, is the largest of the Dutch islands in the Caribbean, and its capital, Willemstad, is the seat of the central government.

The Netherlands Antilles is an autonomous territory within the Kingdom of the Netherlands. The islands are responsible for their own political affairs and administration, except for defense, foreign affairs, the legal system, and financial and administrative oversight. A parliamentary democracy exists and elections are held every four years. The cabinet of ministers is chosen by the Parliament. There are two levels of government: the central government, with a parliament on Curaçao composed of representatives of all the islands, and the local government of each island, consisting of an island council and a legislative assembly. The Governor of the Netherlands Antilles is the representative of the Kingdom of the Netherlands; the representative of the central government on each island is the Lieutenant Governor, who has executive powers.

The service sector—especially tourism—is the mainstay of the economy. Other important sectors are manufacturing and construction. In 1993, per capita income was US$ 7,800 and the gross domestic product (GDP) was US$ 2,114.8 million. The inflation rates for the years 1992–1996 were 1.4%, 2.1%, 1.8%, 2.8%, and 3.6%, respectively.

As for educational levels, 31% of the population of Curaçao aged 24 years and over has completed primary education; 39% has completed basic secondary studies; 18% has finished advanced secondary studies (high school); and 10% has attended a polytechnic institute or university. According to the population census of 1992, only 2% of the population of Curaçao aged 24 years and over had not completed the primary level of education. Higher percentages of females completed primary school, but more males attained higher levels of education. On average, levels of education are higher among males than females, and they are higher among young people than older adults and the elderly. The difference in education level between males and females is greatest in the oldest segments of the population.

The official unemployment rates in Curaçao for 1994, 1995, and 1996 was 12.8%, 13.1%, and 13.9%, respectively. In 1995, unemployment was 17% among women and 9.8% among men. As for the other islands, in 1994 the unemployment rate was 5.5% on Bonaire, 4.2% on Saba, 5.8% on Saint Eustatius, and 11.3% on Saint Martin.

In 1994 and 1995 the population growth rates for the Netherlands Antilles as a whole were 2.6% and 2.5%, respectively, and for Curaçao the rates were 1.2% and 1.8%. Net migration has been positive since 1994. In 1995, the estimated population of the Netherlands Antilles was 207,333 inhabitants, with a density of 259 inhabitants per km2; 34% of the population was less than 20 years of age, 59% was between 20 and 64, and 7% was 65 and over. In that same year, Curaçao had 151,540 inhabitants (73% of the total population of the Netherlands Antilles, with a similar age distribution). Females constituted 52.9% of the population. In 1994, Bonaire had 12,533 inhabitants; Saba, 1,197; Saint Eustatius, 1,882; and Saint Martin, 37,256. Annual population growth ranged from 1.2% on Bonaire to 4% on Saint Martin. Life expectancy at birth is 77.5 years for females and 71.8 years for males.

The crude death rate increased from 5.3 per 1,000 population in 1986 to 7.1 in 1993, and standardized mortality rates ranged from 4.7 per 1,000 population in 1986 to 5.4 per 1,000 in 1993. The standardized mortality rate for males is 1.5 times higher than the rate for females. Age-specific mortality for both males and females remained stable from 1986 to 1993. A significant increase has been noted in male mortality in the 1–4 and 25–44 age groups.

In 1993, diseases of the circulatory system and malignant neoplasms accounted for 36.3% and 22.1%, respectively, of deaths from defined causes. Mortality from infectious and parasitic diseases and external causes has shown a rising trend, and deaths attributed to perinatal and ill-defined causes have tended to decrease. The rest of the causes have remained stable. Only 3.6% of deaths are attributed to ill-defined causes. In 1993, the leading causes of death were cerebrovascular diseases (13.6%), followed by diseases of pulmonary circulation and other forms of heart disease (10.0%), ischemic heart disease (9.1%), and diabetes mellitus (5.1%). Ischemic heart disease was the leading cause of death among males; cerebrovascular diseases accounted for the largest share of female deaths. Malignant neoplasms cause more deaths among males. AIDS is the eighth leading cause of death (2.9%) among males.

Age-specific mortality has two distinct patterns: for the population aged 45 years and over, the leading causes of death are chronic noncommunicable diseases, including cardiovascular diseases, cerebrovascular diseases, and diabetes mellitus; for the group aged 1–44 years, AIDS and external causes are the most common. In general, there has been an increase in deaths from external causes, which numbered 49 in 1986 and 75 in 1993 and which occurred more frequently in males than in females.

On Curaçao, the methods used for routine compilation of data by health service providers are not reliable. For this reason, between November 1993 and August 1994 the Curaçao Health Survey was carried out in a random sample of the noninstitutionalized adult population of Curaçao. 

The results of a study provide information in three main areas: health status, lifestyles, and use of health services. About 10% of the adult population suffers from diabetes mellitus, and approximately half of them are unaware they have the disease; 20%–30% of the population suffers from hypertension; and 7% has glaucoma. Psychological problems are prevalent among adults and young people: 12% of the respondents in the 18–24 age group reported suffering from stress, nervousness, or depression. The elderly, women, and people in the lower socioeconomic groups are in a disadvantaged position with respect to their health. Seventeen percent of the respondents said they smoked. As for physical exercise and eating habits, 75% of all the adults do not engage in any regular physical exercise, and there are some obvious nutritional deficiencies: 37% do not eat vegetables daily and about half do not eat fruit every day. Excess weight is also a significant health problem, especially among women in lower socioeconomic groups. Only 40% of those surveyed visit a dentist every year. The elderly on Curaçao do not make greater use of the general medical services than younger individuals, nor do individuals in the lower socioeconomic groups.

Infant mortality decreased for both sexes from 17.8 per 1,000 live births in 1986 to 11 per 1,000 live births in 1993. Neonatal mortality fell from 9.9 per 1,000 live births in 1990 to 8.7 in 1993, and perinatal mortality declined from 23.6 to 17.9 per 1,000 live births in the same period. During the 1991–1993 period, conditions originating in the perinatal period (64.5%) and congenital abnormalities (23.0%) were the leading causes of death in the first year of life. Infectious diseases were responsible for 6.6% of infant mortality. Among children aged 1–4, the mortality rate increased; there were no differences by sex, and the most common causes of death were congenital abnormalities, which accounted for 20.8% (five deaths), followed by traffic accidents (16.7%) (four deaths), and intestinal infectious diseases (8.3%) (two deaths). The mortality rate in the group aged 5–14 years remained stable during the period 1986–1993, and no sex differences were noted. Nine of the deaths (50%) reported between 1991 and 1993 were due to traffic accidents.

In the group aged 15–24 years, mortality is twice as high among males and showed a slight upward trend in 1992–1993. External causes accounted for 42.8% (21 deaths); of these deaths, 20.4% were due to traffic accidents, 16.3% to homicide, and 6.1% to drowning.

During the period 1990–1991, the fertility rate remained stable at 2.4 per women of childbearing age (15–49 years of age) as did the specific fertility rate for the group aged 15–19 years (0.05 in 1981 and 0.05 in 1991).  

Prenatal care is provided by general practitioners, midwives, and obstetricians/gynecologists. Only midwives use the perinatal information system, which includes information on prenatal care, childbirth, and the puerperium. In 1994 the system contained records on 1,144 women (37% of all births). From these records it can be concluded that only 25% of prenatal visits were made before the 20th week of pregnancy and that 52% of the women began prenatal care in the third trimester. As for care during childbirth, most births (99%) take place in clinics or in hospitals. Low-risk births generally occur at maternity clinics, and high-risk cases are referred to the General Hospital. As for maternal mortality, although only 13 maternal deaths occurred between 1986 and 1993, with an average of 3,000 live births per year, this number yields a maternal mortality rate of 54 per 100,000 live births. Among the causes associated with this rate are the high prevalence of sickle cell anemia and preeclampsia.

The population aged 65 and over doubled between 1960 and 1992, and in 1995, according to data from the Central Statistics Office, persons in this age group made up 8% of the total population. The main causes of death in this group are cerebrovascular disease, followed by heart disease (ischemic heart disease) and diabetes mellitus. 

In the last population and housing census, which was carried out in 1992, 41,272 homes were surveyed. The average number of occupants per household was 3.5, which represents a decrease with respect to the previous census, in which the average was 4.3. Women head 36% of all households; 71.3% of households consist of nuclear families, 19.1% consist of nonnuclear families, and 9.6% consist of two or more nuclear families.

 According to the 1992 census, 3.9% of the total population reported some type of disability. Of that percentage, 28.4% had a physical disability and 22.7% had a visual disability. Of the latter group, 3.8% (212 people) were blind and 82% of blind people were 60 years of age or older.

Dengue has been endemic on Curaçao since 1973. A surveillance system exists and activities are carried out to control vectors of the disease. An outbreak occurred in early 1993 and serotypes 2 and 4 were isolated. During that outbreak, 18% of all the cases were dengue hemorrhagic fever and one death was reported. Another outbreak occurred in 1995, and yet another was detected later the same year. This second outbreak ended in February 1996. Serotype 4 was isolated in only one case during the second outbreak. Of the cases reported in the last two outbreaks, 6.5% and 4.2%, respectively, were hemorrhagic dengue. In 1995, 555 cases of dengue were reported, which is double the number reported in 1993. Knowledge and attitude surveys conducted in 1995 and 1996 indicated that even when the population has sufficient information about controlling the dengue vector, the knowledge is generally not put into practice. Reported cases dengue are believed to be underestimated for these two years. 

No cases of poliomyelitis or acute flaccid paralysis have been reported. Between November 1996 and April 1997, seven cases of Guillain-Barré syndrome were reported, but all were negative for poliovirus. No cases of diphtheria, whooping cough, tetanus, mumps, or Haemophilus influenzae B have been reported. 

In January 1997, after an outbreak of measles on Guadeloupe, surveillance was stepped up on Curaçao. As of May 1997, 14 suspected measles cases had been reported, but were 10 ruled out.

No cases of cholera have been reported—there is no system for reporting clinical cases of infectious intestinal diseases. Laboratory reports from 1993 through 1995, which include results of studies of food-handlers, indicate that shigella, Campylobacter, and salmonella are the most commonly occurring microorganisms. The incidence of intestinal infections for the three years analyzed remained stable (3 per 1,000 population). The most susceptible age group was children under 1 year of age.

There is no record of outbreaks of meningitis, reporting of which is not mandatory. In 1993, 1994, and 1995, respectively, four, five, and six cases of tuberculosis were reported; three of these cases were resistant to isoniazid. Investigation of contacts is carried out for all diagnosed cases. In 1993, acute respiratory infections were the fifth leading cause of death for all age groups; there is no surveillance system for such infections. There were no reported cases of rabies or other zoonoses. 

For the period 1985–1996, the cumulative total of cases of individuals infected with HIV in the Netherlands Antilles was 815, of which 466 (57.2%) were male and 349 (42.8%) were female. The majority of individuals infected with HIV are between 25 and 44 years of age (68.3%), and 97.5% of infected persons live in Curaçao and Saint Martin. Among infected newborns, the virus was transmitted by the mother, and in the group aged 25–44 years transmission was through sexual relations. All pregnant women are tested for HIV. The highest incidence occurs in the age groups that
are most sexually active. The male/female ratio is 1.3:1, which suggests that transmission of the virus is predominantly heterosexual. The risk of acquiring the infection from a blood transfusion is minimal as laboratories screen all donated blood for HIV. The exact number of AIDS cases in the Netherlands Antilles is unknown; efforts are under way to establish a central registry in the Department of Public Health and Environmental Hygiene. As of October 1996, 58 people were using one or more drugs to treat HIV infection; no data are available for the rest of the islands. In Curaçao, AIDS is a leading cause of death in the age group 25–44 years and in 1991–1993 accounted for 14% of deaths in that age group.

Noncommunicable Diseases and Other Health-Related Problems 

In a sample of 981 children less than one year of age who were selected from children seen for well-child visits in public health services in 1992, 5.4% weighed less than 2,500 g at birth. According to data from the Public Health Service of Curaçao, in 1993 about 9% of all live-born children weighed less than 2,500 g. In the same year, 3% of children under one year of age who were seen for well-child visits were malnourished. In the group aged 1–4 years, the highest percentage of malnutrition (low weight for age) was found among children 2 and 3 years old (5%).  

In a food intake study in Curaçao in 1993, a sample of male and female children aged 10–14 years showed that participants met Dutch nutrient recommendations, but had lower than the recommended average nutrient intake for this age group. With respect to breast-feeding, a Curaçao Health Survey conducted in 1993–1994 among 236 women who had at least one child aged 0–4 years indicates that at 6 weeks of age, 73% of the children were being breast-fed; at 3 months, 42%; and at 16 months, 16.7%. 

According to the Curaçao Health Survey, the prevalence of Type II diabetes mellitus is 10% in the population over 18 years of age. The prevalence increases with age, and in the group aged 45 years and over, it is 30%–35%, while in the group aged 65 and older it is even higher. Diabetes mellitus is more frequent among women than men, but the difference is not great. The principal risk factor is obesity. More than 50% of women are obese; in the group aged 45–64 the prevalence of obesity reaches 60%. Diabetes is significantly more prevalent among those who are obese than among those of normal weight. Diabetes was the fourth leading cause of death in 1993, accounting for 5.1% of mortality. Among women, it is the third leading cause of death (17.4%) and among men it is eighth (2.9%). 

The results of the Curaçao Health Survey revealed that hypertension is the most frequently reported disease (11.4% of men and 16.7% of women), and it is estimated that the actual prevalence is double the amount reported. In 1995 there were 524 hospital admissions for cardiovascular disease on Curaçao, which represents 349 admissions per 100,000 population, with an average hospital stay of 11.8 days. No heart surgery or catheterization is performed in the Netherlands Antilles; these procedures therefore were the main reason for sending patients to other countries in 1994. Ischemic heart disease ranks third among the 10 leading causes of death, accounts for 9.1% of all deaths, and constitutes the leading cause of death among men. 

Between 1982 and 1987, the incidence of malignant neoplasms in the Netherlands Antilles increased from 156 to more than 200 per 100,000 population. From 1987 to 1991, the incidence ranged from 200 to 220. This increase is attributed to the aging of the population, to improvements in diagnosis, and, possibly, to a real increase. Among males, the most frequent tumor sites are the prostate, lung, and stomach, with incidences of 40.8, 22.2, and 18.5 per 100,000 population, respectively; among females, the most frequent sites are the breast 44.8 per 100,000 females, cervix and uterus, 21.5, and colon 11.4. In both sexes, 9.5% of malignant tumors are diagnosed in situ and 90.5% are diagnosed after they have progressed to an invasive stage. 

Mortality from external causes has shown a rising trend. In the group aged 1–44 years, AIDS and external causes are the most frequent causes of death, especially for males, among whom external causes account for four times more years of potential life lost. A study of mortality from external causes carried out in Curaçao showed that from 1986 to 1993 traffic accidents (motor vehicle collisions) were the leading cause of death, accounting for 20–25 deaths per year. Accidental falls ranked second (approximately 10 per year), and drownings were third. Eight suicide deaths occur per year on average and there are an equal number of homicides, although in 1993 the number of homicides doubled.  

According to the 1992 census, 21.8% of the population aged 18 and over smoke. According to the Curaçao Health Survey (1993–1994), the prevalence of smoking among adults over the age of 18 is 17.1% (28.3% in males and 8.8% in females). The highest prevalence was found in the group aged 45–64, followed by the group aged 25–44. A 1996 study of a sample of households found that 20% of males and 9% of females smoked. The Curaçao Health Survey revealed that 20.5% of the population surveyed drinks alcohol regularly (37.9% of males and 7.5% of females) and 49.2% drinks occasionally (43.1% of males and 53.8% of females).

With regard to drug use, a 1996 study of a sample of households indicated that more males than females use illegal drugs (2% and 0.1%, respectively). The highest percentage of drug use was found in the group aged 35–49 (2%), followed by the group aged 20–34 years (1.4%). Drug use is more common among people with low and medium levels of education (1.8% and 1.4%, respectively) than among those with more education (0.3%). The highest rates of drug use were found among unemployed people seeking work (2.6%). Of the population that was not economically active, 1.3% indicated they used drugs. Among those who worked, 1% were drug users. The most frequently used drugs are marijuana and cocaine. 

Access to oral health care on Curaçao is variable. Those insured by the Government have limited access in comparison with other types of insurance. Low insurance coverage is an obstacle for preventive care. Use of dental services is especially low among the youngest members of the population. The oral health services available to the disabled are insufficient. According to the Curaçao Health Survey, 30.5% of the respondents have all their teeth, and 11% have no teeth; of the latter group, one-fifth lack false teeth. 

The Netherlands Antilles has suffered damage from hurricanes and storms, which have caused both loss of human life and material losses. Industrial accidents have been associated with oil refineries and hydrocarbon shipping centers. Explosions, fires, and oil spills have been reported. The Disaster Prevention System coordinates the activities of governmental and nongovernmental organizations in cases of emergencies and disasters.

In 1994, Curaçao initiated a process to contain rising health care costs. This process, known as the "New Policy," gave rise to a project to develop a new health insurance system. A Steering Committee for Health Sector Reform was formally established in October 1994. This Committee is composed of members of the Public Health Services of Curaçao, the Department of Finance of the Executive Council of Curaçao, the Welfare Services, and the Department of Public Health and Environmental Sanitation. Goals were established to ensure the provision of humane, effective, and efficient health care based on criteria of equality and on the real needs of the population.

The Government’s National Health Plan assigns priority to prevention and control of chronic noncommunicable diseases as well as encouraging changes in lifestyles and habits that increase the risk of cardiovascular diseases, hypertension, and diabetes mellitus. The Ministry of Health has created three multidisciplinary working groups to develop intervention programs. It has been decided to conduct surveys similar to the Curaçao Health Survey on the rest of the islands in the Netherlands Antilles to better assess the health situation of each island and design appropriate intervention programs.

Curaçao has two general hospitals and one surgical hospital, with a total of 618 beds: Saint Elizabeth’s Hospital (540 beds), the Adventist Hospital (42 beds), and the Dr. Taams Surgical Hospital (36 beds). There is also a maternity clinic with 23 beds, and the Institute Mon Verriet has a rehabilitation service with 12 beds. Curaçao has a total of 4.4 beds per 1,000 population. Saint Elizabeth’s Hospital, which provides hemodialysis, intensive care, and neonatal services, receives patients from the other islands in the Netherlands Antilles as well as Aruba.

The entire population has access to health services. At the primary care level, there are 90 general practitioners. The new general health insurance system and the new financing models are intended to improve the quality of care and enhance equity. Curaçao has 97 medical specialists, including 12 internists, 4 cardiologists, 4 neurologists, 1 gastroenterologist, 11 surgeons, 2 urologists, 5 orthopedists, 1 neurosurgeon, 2 plastic surgeons, 10 gynecologists, 3 neurologists, 3 dermatologists, 6 anesthetists, and 2 pathologists. Health professionals are trained in the Netherlands and, occasionally, in other countries.

There are five insurance modalities: the PPK ("pro-paupere kaart"), which is totally funded by the Government and is intended for the indigent and those who are not otherwise insured because of advanced age or the existence of a chronic condition; the public insurance program, which covers 100% of health care costs for blue-collar workers and 90% for personnel in higher categories of public-sector employment; the insurance fund for retired public-sector employees; private insurance plans provided by large private companies for their own personnel; and the social security fund, which covers employees of small private companies and other forms of private insurance. Given the substantial differences in coverage under the various modalities of insurance, one of the objectives of the insurance system restructuring process is to reduce differences in access and quality of medical care. 

Various health education, promotion, and protection initiatives have been implemented in the Netherlands Antilles, especially by nongovernmental organizations. The health care system remains oriented predominantly toward curative care, however. In the "Financial Review of Health Care Costs in the Netherlands Antilles, 1993" it was estimated that on Curaçao 0.8% of total health care spending was devoted to preventive care, compared with 55% for curative care. Many of the health problems that have been identified are linked to lifestyle, socioeconomic and cultural factors, and attitudes toward health and illness. Health promotion activities in the Netherlands Antilles are centered around prevention of chronic noncommunicable diseases related to lifestyle and unhealthy habits (poor diet, lack of exercise, consumption of alcohol, and smoking); prevention of drug use and rehabilitation of users; and promotion of responsible sexual behavior (AIDS prevention) and reproductive rights. The adoption of the Caribbean Charter for the Promotion of National Health in the Netherlands Antilles was a great achievement.

Since February 1995, the Department of Public Health and Environmental Sanitation has had an Environmental Section. Protection of the environment is deemed important for future plans and policies. Five main priority areas have been selected for work in the next five years: waste and wastewater; the petroleum industry and the environment; tourism, environment, and nature; environmental management; and strengthening environmental awareness. To guide efforts in these areas, a set of national regulations and basic principles for environmental management and protection of nature were developed and presented for consideration by the Parliament. Under these legal provisions, all the islands will be obligated to formulate legislation on the environment and nature. Model legislation is under study.  

Curaçao, Bonaire, and Saint Martin have good drinking water and sewerage systems. Desalinization plants produce water of excellent quality, although the process is quite costly. Only Curaçao and Saint Martin have wastewater treatment plants; on the other islands, the use of septic tanks is common. 

Most of the islands have refuse collection services operated by private companies under the supervision of local authorities. There are problems related to the safety of the final disposal sites and projects for the construction of sanitary landfills have been developed but have not been implemented because of insufficient funding. Hospitals have services for the collection and incineration of hazardous material.

Based on financial records for 1992, health sector expenditures in the Netherlands Antilles range from US$ 150-167 million. For the island of Curaçao, expenditures range from US$ 128-138 million per year.

An important objective is to improve and standardize health financing information systems. The Foundation, established in February 1993 by the Government of the Netherlands Antilles and the Executive Council of Curaçao, is responsible for processing all medical care bills for public employees and their families, patients with PPK cards, and government retirees. The Foundation also centralizes medical-financial operations to track total expenditures and exact numbers of insured individuals. 

The introduction of the General Insurance Plan for Special Medical Expenses is the first step toward a general insurance system in the Netherlands Antilles. The next step will be the introduction of a general health insurance program. The Government of the Netherlands Antilles intends to submit legislation for the establishment of national health insurance by the end of 1997. 

The current policy is also aimed at introducing the Medicine Provision System ("GVS system").