Since the second evaluation of the Health for All 2000 (HFA), Suriname has witnessed some important changes in political structure, which have had their bearing on the health situation in the country. In 1991 the second general democratic elections took place again since the military regime of 1980. The elected coalition government soon after its intstallation implemented a structural economic adjustment program, which resulted in much hardship mainly in years 1993 through 1995. The adjustment program was based on lowering or stopping subsidies, unification of a multiplicity of exchange rates among others. After some years of hyperinflation and increased poverty some practical improvement in the general economic situation was observed as demonstrated by the stabilization of the foreign exchange rate. In 1996, the new administration elected to power disapproved all adjustment policies and adopted a different strategy towards economic growth based on increasing public revenues, productivity and export stimulation. Many policy areas of the government include improved social well-being -housing, education and relief for the poor. Concrete projects and programs to finance these intentions are realized through re-mobilization of national resources -taxes, and bi- and multilateral development aid. Some of these concrete project include the plan to build 2000 houses per year for the population and the building of 21 policlinics in the interior. The main constraint for implementing such intentions are financial and the difference in opinions regarding the implementation of some of the plans within the group of policy makers Steps are being taken to increase the population's participation in the process of health improvement to ensure ownership by the people.

2.1 Economic trends. The country has gone through an economic structural adjustment program which caused many of the socio-economic indicators to decline drastically in a relatively short period. Presently there is clear improvement in these indicators as the adjustment program was slowly coming to an end. However, insufficiency of the public sector finances is still a main area of concern. Lowering of the health budget and the massive and sharp rise in inflation those years caused increased poverty and although no official figures exist on the number of poor it was clear that number grew steadily. There still remain clear discrepancies between the level of health care provided to the coastal area as compared to that provided in the rural areas and the hinterland. Government has plans to improve living conditions in the interior and to develop this part of the country as an economically important area, because of the huge natural resources present. There is a broad consensus that the government budget must be re-organized to contain inefficient expenditures. Low remuneration and the resultant shortages of skilled personnel need to be addressed.

2.2 Demographic trends. Total population as 1993 midyear was about 410,000. There are no observed changes in the composition and age distribution of the population even though the general expectations are that the population will become older on the whole. Taking this in mind, serious efforts have been done to establish a national chronic disease program.

2.3 Social trends. Although no special efforts have been announced to increase adult literacy rate the reported literacy rate remains high (up to 95%, both sexes) and virtually all schools that were closed during the civil unrest are now open and functioning.

2.4 Food supply and nutritional status. There are no national data available on the rate of low birth weight and cases of malnutrition, iodine deficiency or anemia. National hospital surveys, although of limited value, still indicate that malnutrition is a problem mainly affecting the poor. A recent survey of policlinic data in some areas disclosed some quite distressing figures of anemia in females. There are no indications that vitamin A and iodine deficiency constitute national health problems. The impression given by the Medical Mission, which is responsible for the delivery of health care in the interior, is that these latter conditions are occurring in very focussed areas. Preliminary analyses indicate that the main constraints faced in improving the nutritional condition are both financial and lack of knowledge of alternatives by large parts of the population. In recent years, many of the foods that were regularly available became scarce, too expensive or totally absent, leaving the people without alternatives they adequately knew about. The nutrition program focusses on education of the masses through school programmes and other means to increase awareness. At the same time steps are undertaken to implement a national nutrition surveillance system.

2.5 Lifestyle. Recent comments of the National Bureau of Alcohol and Drugs indicate that the number of males and females of 15 years old who start tobacco smoking in growing; it is estimated that the average annual consumption of manufactured cigarrettes per adult age 15 and older between 1991 and 1992 was 1,870. There is however no national strategy to combat this phenomenon, although the Ministry of Health (MoH) produces promotional and educational materials from time to time to discourage smoking.

3.1 General protection of the environment. There are no significant changes and trends in the level of general environment quality and safety that have influenced population's health. Some actions, however, have been taken to improve the quality of the environment. As an example, taskforces were established immediately after the installation of the government to take the huge task of combating malaria, to clean-up the capital city of Paramaribo, and to clean-up the central market place. These taskforces used an inter-sectoral approach and defined a structural management to combat the problems encountered. In the light of the renewal of the strategy for health for all much emphasis is placed in the improvement of environmental management and control. The National Institute for Sustainable Natural Resource Development was recently installed, to ensure implementation and monitoring the terms signed by the Surinamese government on the Agenda 21. Solid waste management is carried out by the Ministry of Public Works, but is very incomplete and leads to many households getting rid of their refuse by simply dumping these illegally at some unattended site. There are plans to privatize the collection of solid household waste in the country, but as yet these planshave not materialized.

3.2 Water supply and sanitation. About 95% of the urban population is provided with piped drinking water, of which 90% has house connections, and an additional 5% has easy access. About 70% of the rural population has piped water in the house and another 20% has piped water near the house. There are 47 rural drinking water systems in the coastal area; people in the interior rely on rivers and creeks for their water supply. Morbidity from diarrhoeal disease has increased significantly in recent years; particularly, several shigellosis outbreaks recorded between 1993 and 1996 have been linked to the decline in the quality of drinking water. More recently, major problems were the lack of adequate maintenance, the inability to increase the water supply according to the increasing demand, unrealistic tariffs that do not reflect the real cost and a lack of trained personnel. There are no reliable figures available on the percentage of population served with adequate excreta disposal, although in the coastal area the majority of households have a septic tank system attached. For many years the excreta are being dumped untreated in the river, as other alternatives are not functional as yet. There is a pilot project underway to promote the constructions and use of pit latrines in the interior.

4.1 Human resources for health. A 1996 study of the Planning Bureau of the Ministry of Planning and Technical Cooperation found that there are about 500 vacancies for personnel with university degrees at the central offices of government ministries. In the health care system there are shortages of nurses, medical specialists, pharmacists, dentists, veterinarians, and nutricionists. According to the same source, in the past 5 years, approximately 33% of 567 health care professionals have left the sector or the country -mostly senior nurses and medical specialist; also, many professionals will retire in the next decade. To address the aknowledged negative trend the government declared the nurses a priority group, together with the school teachers; this meant that this group would benefit some special privileges such as salary increase and reduction on bus fare.

4.2 Financial resources for health. In the period 1991-1996 the MOH had accoounted for 4% of total yearly government expenditures. In 1996 total government expenditures were SF 85 billion (US$ 210 million). Over 50% of the MOH's expenditures were for personnel costs; other general costs accounted for 25%. The total -government and private- expenditure on health was estimated at SF 16.3 billion (US$ 40 million) in 1996; this was 8% of the gross national product (GNP). Recently the government has mobilized other than the traditional partners to invest in health care in the country: there was an agreement signed which ensured the funds from the Islamic Development Bank for the financing of the construction of 21 policlinics in the interior.

4.3 Physical infrastructure. The population of the interior has suffered most of the destruction of the physical infrastructure of health during anf after the civil unrest in the period prior to 1992. The government is still in the process together with private institutions and local initiatives to improve the situation. Because of the lack of qualified health care professionals many of the health care delivery systems are not functioning adequately, leading to dissatisfaction of the people. The physical infrastructure for health has suffered from the general lack of maintenance that has its trace in all sectors of the society, and there are no clear plans proposed by the government to improve the physical infrastructure for health. The GMTD (combined medical technical service) has recently started its services after some years of preparation to carry out repairs and maintenance on medical equipment for all health facilities in the country; this service is currently being funded out of Dutch and Belgian development aid, but should be able to sustain itself after this initial period.

4.4 Essential drugs and other supplies. The availability of essential drugs has improved over the past years. The MoH released its last version of the essential drugs list in mid 1997. There are some difficulties being encountered with the timely supply of vaccines for the immunization program, which causes unwanted delays in its activities. It seems that reasons such as payment of quota, administrative delays, vaccine spillage and spoiling play an important role in creating the delays. Drug supply is momentarily ensured nationally through a project financed by the Dutch development aid.

4.5 International partnership for health. The major external partners in the development of the health sector are the governments of The Netherlands and Belgium, PAHO, UNICEF, and IDB. Presently a major role for the Islamic Development Bank is being contemplated. It is not clear what percentage of bovernment health expenditure is covered by international aid, but this constitutes a significant part. Suriname has quite successfully integrated itself in the area of the Caribbean and is co-signatary of all important agreements affecting the health status in the Region. There is, however, a lack of follow-up of many of these agreements and the health workers and the population in general are not made owners of these agreements.

5.1 Health policies and strategies. Althought no concrete results are observed yet, recent government policies and strategies that are in the planning phase are envisaged to have a significant impact on health in the future. With the aim of having health care affordable and accesible in the whole country, preparations are being made to implement a general insurance scheme. also within the MOH a separate unit responsible for community participation has recently been established to promote this approach to the improvement of health natiowide. Constraints faced by the country in efforts to improve health policies and strategies include a lack of qualified health planners, leaving the available ones heavily over-burdened.

5.2 Intersectoral cooperation. Efforts to institutionalize intersectoral cooperation have met success over the years. It is however realized that such cooperation is essential in the development of health. The concept of intersectoral cooperation was put into action with the establishment of the intersectoral taskforces at the beginning of this administration.

5.3 Organization of the health system. There have been some changes in the organizational structure of part of the health system. The National AIDS Program has been transfered to the department of dermatology and sexually transmitted diseases. Some other plans for reform of (parts of) the health system are in the planning base, but as yet remain unclear. Changes in the organizational structure of the health system involves (re-)training of existing personnel, the necessity of which is often not fully appreciated; nevertheless, adequate training and re-training possibilities are very scanty in the country.

5.4 Managerial process. No significant changes in the managerial process for health have been observed that has influenced health. The shortage of adequately trained health managers and the low remuneration of such professionals has a string negative bearing in the development of the total health sector. Presently there is a consensus to hire expatriates to fill the gaps in the system.

5.5 Health information system. The establishment of a reliable national health information system has been one of the priorities for years. Currently actions are being undertaken with external help to improve the quality of data compilation and management at the primary source, v.g., hospitals, which seems to be a very important link in the process. Much emphasis is given to data collection and management of chronic diseases, infectious diseases, cancer, perinatology and others.

5.6 Community action. Participation of the community in the improvement of their health is strongly emphasized by the present government. Communities and their leaders are being involved in this process. The envolvement of local communities in the fight against malaria stands as a clear example of community participation for health. Also the local communities in some remote areas were able to build their own policlinics. There is a good cooperation with the Ministry of Regional Affairs in the country in efforts to increase the community participation.

5.7 Emergency preparedness. There exists no emergency preparedness plan for the country although at different ocassions thought has been given to the subject and a carefull start has been attempted. Presently it is not clear what priority will be given to this matter by the present government.

5.8 Health research and technology. With the help of international and regional institutions improvements in the public health laboratory facilities are carried out to better equip them for their screening and research tasks in health. It is envisaged that health research will be promoted with this development. Cooperations with other relevant institutions are encouraged to carry out joint operational research. Suriname is also participating in regional studies such as Chagas research with CAREC, and laboratory survey on intestinal bacterial sensitivity, also with CAREC.

6.1 Health education and promotion. In recent years the health education component of the local health system has grown significantly. The concept of promotion of health lifestyles is generally adopted and other players are contributing considerably in the whole of health education and promotion. There are plans to increase the "package" of the health education department with other less traditional subjects, such as prevention of traffic accidents.

6.2 Maternal and child health-family planning. In 1994 it was estimated that 80% of births were attended by trained personnel. The average number of antenatal visits per pregnancy was 6. A survey of the family planning agency "stichting lobi" in 1992 showed that 48.4% of women of childbearing age used a contraceptive.

6.3 Immunization. In Suriname the immunization coverage rates for DPT3/OPV3 vaccination for infants reaching their first birthday have fluctuated between 71% and 79% yearly. In 1995 this was 85%, but then dropped again to 79% in 1996. The coverage for measles vaccination was 79% in 1995 and 71% in 1996. Immunization coverage has suffered from the unstable situation in the interior during the civil unrest and the frequent disruptions in vaccine delivery and availability in the country.

6.4 Prevention and control of locally endemic diseases. Of the different endemic diseases in the country most emphasis is given to the control of malaria. As a result of the commitment of the government towards the control of this disease a taskforce was recently established to coordinate emergency control activities and develop a plan for the further structural malaria control. The erradication of leprosy by the year 2000 is well under way. The health services continue to fight against diseases like HIV/AIDS, STDs, and various parasitic diseases with variable success. Much emphasis is presently given to early detection and self protection in the control of these diseases. Community participation remains one of the major elements in the control of malaria.

6.5 Treatment of common diseases and injuries. There have been no significant changes in the concepts approaches or strategies for the treatment of common diseases and injuries over the recent years. Efforts are directed towards improving the availability of the main drugs for treatment, through the recent edition of the list of essential drugs by the MOH. As a partly NGO's iniciative, plans were worked out to improve the emergency medical service to the population by training also others than the traditional health care providers -the fire department, police, etc- in emergency procedures. This training was conducted in cooperation with a USA-based NGO.

7.1 Life expectancy. The latest figures for life expectancy at birth for males and females combined is estimated at 68.8 years. This figure continues to be low if related to the rest of the Caribbean. Although no official reason for this relatively low figure is given, it most probably reflects the general status of the health care in the country and also the difficulty of estimating reliable demographic indicators, because of the incompleteness of reports.

7.2 Mortality and Morbidity. Infant mortality per 1,000 live births increased between 1990 and 1994 from 21.1 to 25.1, while rates of maternal mortality per 100,000 live births declined from 12.2 in 1991 to 8.7 in 1994. Perinatal mortality estimated rates fluctuated between 18.6 in 1990, and 32.9 in 1992, with the latest rate estimated in 1994 being 29.8. In the period 1990-94 the leading causes of death in Suriname were hypertensive heart disease (16.8%), cardiovascular accidents (10.9%), malignant neoplasms (8.7%) and accidents and traumas (7.5%). There have been observed 4 important trends in the country's mortality profile: a dramatic decline in the number of suicides between 1983 and 1994, when suicides disappeared from the list of ten leading causes of death; an increase in the number of deaths due to gastro-enteritis; a decrease in the number of deaths due to accidents and trauma; and a significant decline in the number of traffic accidents between 1991 and 1994, to rise again after that year; the number of traffic-related deaths in 1996 was 50. The number of malaria cases diagnosed in the country in 1996 was 15,833. In general, the analysis of morbidity and mortality data is hampered by the under-reporting and the lack of standardization in reporting systems. Also the fact that physicians still report many death causes as "unknown" adds to the difficulties in analysis. Emphasis will be given on development of the systems that are already in place and to coordinate their reporting among each other to create national data. There are no routine reporting systems in place that report on the prevalence of blindness.

8.1 Overall assessment and strategic issues, futures vision and proposed strategies. The general health status of the population leaves much room for improvements. Although in the field of management of infectious diseases much emphasis is being given traditionally, the area of chronic diseases deserves some serious attention. The main constraints in development of the health system in the country fall in the category of insufficient funds and qualified personnel in the top and middle category of health management. The impression is that not all available external funds for health development are being used because of the small absortive capacity. Nevertheless the government is actively searching for other external donors. The broad objective of the present government is to have adequate primary health care available and affordable for the population. The basic strategies to achieve this objective are improvement of health facilities in the whole country, building of new facilities in the interior and preparing a national health insurance scheme. No time frame for the implementation of these broad strategies have been given publicly, but it is envisaged that these are an integral part of the strategies to be implemented in the government period from 1997 to 2001.