The Netherlands Antilles has been an autonomous territory of the Kingdom of the Netherlands since 954. Aruba separated from the territory in 1986, and in October 2010 the Netherland Antilles were dissolved. The Netherlands Antilles comprised five islands: the southern Leeward Islands of Bonaire and Curaçao (near Venezuela), and the northern Windward Islands of Saba, Sint Eustatius, and Sint Maarten. The latter comprises the southern 40% of an island shared with Saint–Martin, a French overseas territory. A distance of 900 km lies between the Leeward Islands and the Windward Islands. Curaçao and Sint Maarten became autonomous territories of the Kingdom of Netherlands, while Bonaire, Sint Eustatius, and Saba became special municipalities of the Netherlands (see Table 1). Their status as European overseas countries and territories will remain in effect until at least 2015.
Up until dissolution, the Netherlands Antilles possessed self–determination on all internal matters and had its own constitution; it deferred to the Kingdom of the Netherlands on issues of defense, foreign policy, and some judicial functions. A governor represented the monarch of the Kingdom of the Netherlands. The central government, based on the parliamentary system, was located in Willemstad, Curaçao. Each island had a local government with an island council and a legislative assembly. The available demographic information is from the territory's 2001 census, with some projections being based on island registry offices. Much of the demographic data are either out of date or unavailable. As of 2010, the total estimated population of the Netherlands Antilles was 197,621 (46% male and 53.1% female), representing a 12.5% increase in relation to 2001. The population under 15 years of age represented 15.1% of the total population, while persons 60 years old and older accounted for 12.7% (see Figure 1 for the territory's population structure in 1990 and 2010).
In 2010, Curaçao had 142,180 inhabitants (71.9% of the total population) and Sint Maarten had 37,429 inhabitants (18.9%), representing 90.8% of the former territory's total population. The corresponding figures for the other islands were as follows: Bonaire, 13,389 inhabitants (6.8%); Sint Eustatius, 2,886 (1.5%); and Saba, 1,737 (0.9%). Most of the population was urban (93.2%). The islands had dynamic annual demographic changes, with net migration outpacing the natural increase (see Table 2). The population included a wide range of ethnic groups and nationalities: most were mixed race Afro–Caribbean (85%) and the remainder of Caucasian, Amerindian, and Asian ancestry. In 2010, there were 2,032 live births and 1,246 deaths. That same year, the total fertility rate was 2.0 live births per woman and the estimated life expectancy at birth was 76.9 years (74.5 years for males and 79.3 for females). The crude total mortality rate was 6.3 deaths per 1,000 population; infant mortality was 8 deaths per 1,000 live births.
The climate of the islands comprising the former Netherlands Antilles is tropical, with average annual temperatures ranging between 27° and 28° C and average annual rainfall of 552 mm (Curaçao).
Papiamentu, Dutch, and English were the official languages of the Netherlands Antilles. Other languages spoken included Spanish, Creole, and Portuguese. In 2008, per capita gross domestic product (GDP) was US$ 19,512, with tourism and services accounting for 84% of GDP. Tourism and related activities were the islands' largest source of employment. Industrial activities accounted for 15% of GDP, primarily oil refining, petroleum transshipment facilities, and light manufacturing. Agriculture only represented 1% of GDP. Between 2006 and 2010, the economy of the Netherlands Antilles continued to prosper, despite the impact of the 2008–2009 global financial crisis. However, Curaçao and Sint Maarten face economic challenges as new autonomous territories, especially Sint Maarten, whose small economy depends on tourism for a whopping 82% of GDP. Following the agreement for separation, Curaçao and Sint Maarten worked out a series of arrangements to prepare and implement their new political administrations. This process included administrative mechanisms to establish new ministries of health and a progressive strengthening of the capacity of the new health authorities to run the health sector.
In 2006–2010, the Netherlands Antilles continued to make progress in the health sphere, despite the international financial crisis of 2008–2009. The territory's relative high level of economic development, significant coverage and benefits of the social security system, a developed health care network, and close relationships with the Netherlands (most inhabitants of the territory were citizens of the Netherlands) helped buffer the impact of the economic downturn.
Health Determinants and Inequalities
In 2008, 37% of households earned less than US$ 560 per month. The proportion reached 45% among the elderly, with approximately 50% among women but only around 25% of men.1 Most households with higher levels of education received more than US$ 2,793. In 2009, the unemployment rate was 9.7% in Curaçao; 12.2% in Sint Maarten; 6.3% in Bonaire; 6.2% in Saba; and 8.3% in Sint Eustatius. Unemployment was higher among women (11.3%) than men (7.9%) in Curaçao and was 24.7% among the island's youth. Approximately 14% of households had monthly incomes of US$ 280 (adjusted for household size), ranging from 5% in Saba to 16% in Curaçao. Some 32% of households reported that their income was insufficient to cover all necessary expenses. The highest income inequality and lowest median household income were found on Curaçao, where income for the most affluent 20% of households was 14 times higher than that of the poorest 20%. The social security system guarantees each family at least a minimum of resources to meet its basic needs, through a variety of government services. The territory's social security institutions have a number of different premiums and benefit payout amounts, as well as types of beneficiaries, including the elderly, widows, orphans, and persons working in the private sector. A housing subsidy was provided to some low–income groups. In 2009, the adult literacy rate was 96.4% and roughly proportionate by sex. Secondary school enrollment was 78% and the number of years of schooling among adults of both sexes was approximately 14 years.
The Environment and Human Security
Sint Maarten, Curaçao, and Bonaire relied on water supplied by desalination plants, while the supply of drinking water in Sint Eustatius and Saba came mainly from cisterns or groundwater. Curaçao and Sint Maarten have wastewater plants, while the other islands relied heavily on septic tanks. Air pollution and oil–related water pollution surveillance was carried out in connection with an oil refinery in Curaçao as well as for similar environmental risks in other islands of the former territory. Moreover, a preparedness plan was in place for any potential emergency. In 2008, the rate of crime reported to police authorities reached 26.3 per 100 population in Curaçao; 27.5 in Sint Maarten; and 26.9 in Bonaire. A variety of different crimes were reported, ranging from domestic violence and offenses against public morality, to violent crime such as homicide, attempted homicide, and armed robbery. Food safety surveillance was enacted by law and all food processing operations were subject to regular supervision by government inspectors, supported by food safety regulations.
Health Conditions and Trends
Most essential data on deaths and mortality were reported only until the year 2000. Information on chronic diseases and risk factors is based on national community health surveys carried out in four of the islands in 2001, as well as another study carried out in Curaçao (1997). Updated epidemiological information, especially on communicable diseases, was directly reported by the epidemiology and research units of the ministries of health in Curaçao and Sint Maarten.
HEALTH PROBLEMS OF SPECIFIC POPULATION GROUPS
Maternal and Reproductive Health
The total fertility rate decreased from 2.2 live births per woman in 2001 to 2.0 in the period 2007–2009 period. The maternal mortality rate for 2005 was estimated at 13.3 deaths per 1,000 live births. Hospital delivery coverage in the former Netherlands Antilles was approximately 90%.
Infants and Children (under 5 years old)
A total of 2,553 live births were registered in 2006 and 2,661 in 2009. Given the small number of infant deaths each year, the infant mortality rate is quite variable: 13 infant deaths per 1,000 live births in 2007; 6 in 2008; and 8 in 2009. According to the last available estimates (1998–2000 period), the major causes of death for children under 1 year of age were respiratory conditions and congenital deformations. The relative good level of child and maternal health in the former Netherlands Antilles is due to the high level of coverage and quality of maternal and pediatric services.
Between 1998 and 2000, mortality rates were very low among children in the 1–4 years age group, given the small population of the islands and scarce number of deaths annually. During this same period, there was an average of four annual deaths among this group in Curaçao and the leading causes for such mortality were accidents and sepsis. Health departments in the islands reported that underweight among children under 5 years of age was practically nonexistent.
Children and Adolescents (5–19 years old)
Between 1998 and 2000, external causes accounted for the leading cause of death, especially homicide and traffic accidents. Boys aged 5–14 years suffered a higher burden of chronic disease than did girls in the same age group, the most common of which was asthma/bronchitis. In 2001, the fertility rate among the population in the 15–19 years age group was 0.12 per 1,000 women. Curaçao and Sint Maarten had working committees on sex education, safer sex, contraception, and the prevention of HIV/AIDS and other sexually transmitted infections.
Adults (20–64 years old)
Among younger adults, external causes were the leading cause of death, especially homicide and intentional injury, as well as accidents. Mortality rates due to traffic accidents and homicides were higher for males than females. Among females, the leading cause of mortality was breast cancer, while the leading cause of death among men age 45–59 years was ischemic heart disease. Women had a higher frequency of hospital admissions, especially due to pregnancy and child delivery.
The Elderly (60 years old and older)
The population age 60 years and older had the highest proportion of chronic diseases and disability; hospital admissions and mortality increased with age. All the islands had nursing home facilities with a total of approximately 700 beds. In addition, Curaçao had a chronic care hospital and a rehabilitation center.
In 2009, the marriage rate was 5.6 per 1,000 population, and the divorce rate was 2.8 per 1,000 population. The average household size was approximately three persons in 2001. More than 20% of households were headed by a sole breadwinner; of these, 94% were headed by women. Nearly 90% of the single–headed households were headed by a parent. At the time of the 2001 census, 29% of the population aged 30–59 years of age reported not having a partner and another 11% reported not living with their partner.
No data on workers' health were available. The population employed in the public and private sectors had different health insurance arrangements and all employees are covered by accident insurance.
According to the last available information (1998–2000), diseases of the circulatory system were the leading cause of death, with an estimated mortality rate of 195.0 deaths per 100,000 population (including 51.8 from ischemic heart disease and 54.2 from cerebrovascular disease). Malignant neoplasms accounted for 142.6 deaths per 100,000 population. Mortality from external causes accounted for 38.6 deaths per 100,000 population, 10.8 of which were from traffic accidents; 8.0 from all accidents excluding traffic accidents; 8.4 from homicides; and 4.6 from suicides.
Dengue is endemic on the island of Curaçao. A total of 3,457 cases of dengue fever were confirmed between 2008 and 2010. In 2010, there were 1,104 confirmed cases of dengue fever (and one confirmed case of dengue hemorrhagic fever) in Curaçao; 55 in Bonaire; 173 in Sint Maarten; 22 in Sint Eustatius; and 1 in Saba.
In 2009, vaccine coverage with DPT3 (diphtheria/pertussis/tetanus) and polio 3 was 93.6% in Curaçao, while coverage with hepatitis B–3 was 93.4%. In the 2009–2010 period, coverage with the complete vaccination schedule at school was 89.6% at 5 years of age, 82.2% at age 10, and 87.2% at age 11.
Most tuberculosis cases in the former Netherlands Antilles were reported in Curaçao, with 33 new cases and 5 deaths reported in the period 2006–2010. The highest incidence rate of the disease for the period was observed in 2007 (12 cases). Approximately half of tuberculosis cases in Curaçao are imported. In 2010, three cases were confirmed in Sint Maarten.
The last available information on Hansen's disease was from 2004, indicating a low endemic level in the Netherlands Antilles until that time. The annual number of new leprosy cases remained between 2 and 4 during this period.
A total of 446 cases of salmonella infection were confirmed between 2006 and 2010. Shigella infection was also common during this period, with a cumulative number of 120 isolated cases. Half of shigellosis cases occurred in children under 5 years of age.
HIV/AIDS and Other Sexually–transmitted Infections
Between 1985 and 2010, 2,147 persons in the former Netherlands Antilles tested positive for HIV, of whom 57.3% were male and 42.7%, female. Most cases were concentrated in Curaçao (1,426 cases, 66.4%) and Sint Maarten (664 cases, 30.9%).
Approximately 63% of HIV transmission in men was through heterosexual contact.
Chronic, Noncommunicable Diseases
According to the last available census data (2001), 5.1% of the population reported having high blood pressure (ranging from 6.7% in Saba to 3.7% in Sint Eustatius), 3.5% diabetes (ranging from 5.5% in Sint Eustatius to 3.7% in Sint Maarten), 2.8% asthma or chronic bronchitis, and 1.7% heart problems. The prevalence rates of high blood pressure, diabetes, and heart problems increased with age. Among the population over 14 years of age, women were 1.7 and 1.4 times more likely to report having high blood pressure and diabetes, respectively, than men.
According to records from the Cancer Registry, among men between 1999 and 2003, the most frequent sites were the prostate (40%), colon/rectum (10%), lung (8%), stomach (4%), and oral cavity/pharynx (3%). For women, the most frequent sites were the breast (36%), colon/rectum (13%), corpus uteri (8%), cervix uteri (6%), stomach (3%), and ovary (3%) (3). No data were available for the 2004–2010 period.
In 2002, over 70% of the adult population of the Netherlands Antilles (except Curaçao) was overweight or obese, especially women. Only one in four adults reported exercising regularly. No data were available for the 2004–2010 period.
Saba, Sint Eustatius, and Sint Maarten islands lie within the hurricane belt. Hurricanes Omar (2006) and Earl (2010) hit Sint Maarten and neighboring islands, resulting in some structural damage but no casualties.
Other Health Problems
Available information on the proportion of population by type of disability is based on 2001 census data. Accordingly, 8.5% of the population reported having one or more disabilities, ranging from 10.5% in Saba to 5.0% in Sint Maarten. The most commonly reported disability was impaired vision (2.5% of the general population). The visually impaired accounted for a higher percentage of the population in Saba (4.0%), while only 0.1% of the population was blind. With regard to other reported disabilities, 0.7% of the population was hearing impaired; 0.1% was deaf; and 0.4% had mental health–related disabilities (0.5% in Curaçao and less than 0.2% in the other islands). There are no more recent data available.
Risk and Protection Factors
According to the results of a series of population health studies performed in the islands carried out in 2001 by Grievink et al., 69.1% of the study population regularly consumed alcohol and most people had bad eating habits, with low levels of both vegetable (57.2%) and fruit (46.0%) consumption. The study found that 26.0% performed insufficient routine physical exercise and 16.9% smoked at the time.
Health Policies, The Health System, and Social Protection
HEALTH POLICIES AND THE HEALTH SYSTEM'S STEWARDSHIP ROLE
Until October 2010, the Ministry of Public Health and Social Development of the Netherlands Antilles was located at Willemstad in Curaçao. It included a Directorate of Public Health, a Directorate of Social Development, a Support Bureau, and an Inspectorate of Public Health, in addition to health care, health protection, and pharmaceutical affairs divisions. The arrangements to implement the new national ministries of health in Curaçao and Sint Maarten included allocating new functions to civil servants at the central level as well as in the island territories. These changes in Curaçao were facilitated by the previous existence of the Ministry of Health for the Netherlands Antilles, in Willemstad.
Following the governmental changes prepared prior to the dissolution of the former Netherlands Antilles and subsequently adopted in 2010, Curaçao and Sint Maarten worked on establishing the necessary legal framework to support the restructuring of the Ministry of Health, the national health insurance system, and the financial system, as well as embarked on the necessary structural and functional changes in health care, public health services, and other public related services.
HEALTH EXPENDITURES AND FINANCING
In 2009, spending on health and social services accounted for 6.7% of GDP. With GDP growing at an annual rate of 1.2%, spending on health care (as a percentage of GDP) continued to rise at a higher rate than growth of GDP. In general, most inhabitants were covered by health insurance, through a variety of institutional arrangements. The main health care financing institution was the Social Security Bank (SVB), which provided compulsory health insurance coverage for employees of the private sector. The SVB had offices on all five islands of the former Netherlands Antilles and was headquartered on Curaçao. In 2001 (last available information), it covered 36.4% of the population. Pro–Pauper Insurance, which covered 16.3% of the population in 2001, provided health care insurance through the individual local island governments for the unemployed, the very–low–income population, and private–sector retirees who lacked insurance coverage. The government of Curaçao was responsible for providing health insurance coverage to the island's active government employees and pensioners of the oil sector. The central government covered 15.4% of the population, including health insurance coverage of its employees and pensioners. Private health insurance (10.6% of coverage) was purchased by individuals whose annual salaries exceeded the maximum for eligibility under the SVB insurance system. Often the private sector purchased supplemental private insurance that enabled eligibility for SVB insurance. Health care centers provided services, received out–of–pocket payments when due, and billed the insurance institutions of the SVB and the Bureau of Health Cost Administration (BZV) according to preestablished rates (which were either mandated by law or the product of negotiations). Health care centers also billed private insurance companies for services rendered to their policy holders.
THE HEALTH SERVICES
Health services in the islands-provided mainly by private foundations and companies-were organized around local health care networks. There was a main hospital on each island. According to the last available information (2001), Curaçao had eight hospitals and clinics with beds (including psychiatric and geriatric hospitals). Sint Elisabeth Hospital in Curaçao, with 539 beds, was the main and largest of the islands' hospitals. The Antillean Adventist Hospital had 40 beds. There was also a surgical clinic with 45 beds, a psychiatric hospital with 200 beds, a child care rehabilitation center with 12 beds, a maternity clinic with 17 beds, a chronic care hospital with 1,690 beds, and the Brasami Center for drug rehabilitation with 63 beds. The Sint Maarten Medical Center is a general hospital with 79 beds, providing basic specialties and general surgery. Hospitals in small islands-Bonaire, Sint Eustatius, and Saba-were primarily general hospitals, with referral of patients when needed to Sint Maarten or Curaçao. These local hospitals included San Francisco Hospital (Bonaire, 35 beds), Queen Beatrix Medical Center (Sint Eustatius, 20 beds), and the Saba Clinic (Saba, 14 beds). There were 7 nursing home facilities in Curaçao as well as another in each of the other islands, providing a total of 700 geriatric beds. At the end of 2009, there were 48 pharmacies (33 in Curaçao) and 6 health institutions operated their own pharmacies.
Pharmaceuticals and medical supplies were imported by private companies and distributed through hospitals, clinics, and pharmacies. New drugs required official registration with the Department of Public Health and Environmental Protection; however, it granted waivers to pharmacies of the main hospitals for the use of unregistered drugs. The Inspectorate of Health had a vigilance and warning system in place for adverse effects or pharmaceutical emergencies that should arise at the local or international level.
Knowledge, Technology, Information, and Human Resource Management
Most of the technologies used in the Antillean health care system were digitally based, according to international standards. This was facilitated by health care personnel information technology training. At the time of this writing, the new Ministry of Health in Sint Maarten was in the process of detailing and implementing its health information system. Curaçao inherited the information system used by the former central government of the Netherlands Antilles. Health information technology was subject to inspection by the Inspectorate of Health.
The last available information on health care personnel in the Netherlands Antilles dates back to October 2001. Accordingly, at that time there were 333 practicing physicians, of whom 138 were general practitioners and 143 specialists. The distribution of human resources in the islands was proportionate to the population size and existing health care centers on each island. Almost 90% of health care personnel were located in Curaçao. There were a total of 101 general practitioners and 126 specialists in Curaçao, and 23 general practitioners and 14 specialists in Sint Maarten. The availability of physicians in the other islands was low: 17 in Bonaire; 3 in Sint Eustatius; and 1 in Saba. Most of these physicians were general practitioners. Other health personnel included 60 practicing dentists, 676 registered nurses, 467 practical nurses, 47 pharmacists, 9 midwives, 216 paramedics, 41 operating assistants, and 14 anesthesiologist assistants. In 2010, there were 23 general practitioners registered with the Public Health Department on Sint Maarten. Most medical practitioners and specialists, including public health medical specialists, had been trained in the Netherlands, although a small percentage had trained in the United States, Latin America, and Europe. Most of the physicians trained in the Netherlands were also registered with the Dutch Medical Specialist Registry, requiring mandatory re–registration every 5 years in order to keep their specialist licenses current. In the former Netherlands Antilles, preparations had been made to introduce mandatory re–registration (but had not been implemented). The Inspectorate of Health of the Netherlands Antilles had a central registry of all health personnel of the Netherlands Antilles.
Health and International Cooperation
Leading international collaboration partners included various entities of the Pan American Health Organization and World Health Organization, such as the Caribbean Epidemiology Center (Trinidad and Tobago) and the International Agency for Cancer Research (France). Also, there was collaboration with Dutch health institutes, hospitals, and universities.
Synthesis and Prospects
Following the dissolution of the Netherlands Antilles and the implementation of new national health systems in Curaçao and Sint Maarten, the islands face public health and organizational challenges with respect to consolidating the new public health structures. Challenges for health expenditure and health systems stem from the epidemiologic transition, with a focus on issues such as obesity and chronic diseases, as well as communicable diseases including dengue, HIV, tuberculosis, influenza A(H1N1), and emerging communicable diseases. This reinforces the importance of implementing the International Health Regulations, as well as health information and monitoring systems, health promotion, and responsive health care interventions. The ongoing restructuring of health care systems will allow each country and new municipality to better face upcoming challenges. Health insurance systems are assumed to emphasize disease prevention and health care coverage. Technical guidance will be needed to ensure national capacity for implementing health projects and plans, as well as information and reporting systems. Curaçao accords priority to the building of a new hospital, to incorporating medical specialists into the human resources of hospital and hospital outpatient clinics, and to strengthening primary health care.
1US$ 1 = Netherlands Antilles Guilders 1.79 in 2008.
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