Pan American Health Organization

Bonaire, Sint Eustatius, and Saba

Netherlands Municipalities in the Americas

  • Introduction
  • Bonaire
  • St. Eustatius
  • Saba
  • References
  • Full Article
Page 1 of 5


The islands of Bonaire, St. Eustatius, and Saba became special municipalities of The Netherlands on October 10, 2010, transferring the public administration responsibilities from the Government of the Netherlands Antilles to The Netherlands. As a result of this change, residents gained access to a universal health care insurance system, improved health care and education, social housing for low-income residents, and improved access to clean drinking water. Many of these benefits have already been realized ().

Health care policy for Bonaire, St. Eustatius, and Saba is set by the Ministry of Health, Welfare, and Sport. All legal residents have access to mandatory general health insurance, which took effect on January 1, 2011, replacing all existing regulations and private insurance. This insurance scheme, known as ZVK, replaced the AVBZ insurance scheme and provides medical coverage and long-term care, including care by general practitioners and specialists; hospital, paramedical, maternal and obstetrics, pharmaceutical, and dental care; and patient transportation. Long-term care, including home care, is available for the elderly and for persons with disabilities. If specialized care is unavailable in the municipalities, transportation is provided to take patients to Colombia.

Total health care costs in Bonaire, St. Eustatius, and Saba amounted to an estimated US $102 million in 2012. Per capita health care expenses were US $4,834 in 2012. The ZVK is funded through personal income tax (roughly US$ 65 million) and premiums paid by employers (roughly US$ 37 million) (). The Dutch government finances all deficits, as outlined in the Insurance Decree BES, 2010.

Other health policy measures also have been put in place since the change in status. For example, in an attempt to detect rare conditions, heel-prick screening was implemented for newborns in Bonaire January 1, 2015, and in St. Eustatius and Saba on October 26, 2015. The blood samples are sent to The Netherlands for screening for 17 disorders. In addition, the Dutch Parliament granted an increase in the length of maternity leave in all three islands from 12 to 16 weeks.


Overall Context

Located 70 km off the coast of Venezuela, the island of Bonaire has an area of 288 km2, a population of 19,400 residents, and a population density of 67 people per km2.

Figure 1. Population structure, by age and sex, Bonaire, 2015

Source: Statistics Netherlands, 2015.

Bonaire has experienced rapid population growth of 23% between 2011 and 2016, for an increase of 3,600 population over the five-year period. Between 2011 and 2014, the number of households grew 17%, to 6,800. The number of households under 40 years old increased 22%, the number of households for the age group 40 60 years old increased 11%, and those for the group 60 years old and older increased 21% between 2011 and 2014. In 2016, 52% of the population was male and 48%, female; 31% was married, 58% had never married, 8% was divorced, and 3% was widowed. Figure 1 shows Bonaire’s population structure in 2015.

As of January 1, 2016, 37% of residents were born in Bonaire, 18% were born in Curaçao, and 2% were born in Aruba; 14% came from the Dutch mainland, and 18% from Latin America. Two-thirds of the population speaks Papiamento, and only 15% speak Dutch as a native tongue.

Both the average and median disposable income for private households have gradually increased since 2011. Both increased 4% between 2012 and 2014. In 2014, the average disposable income of private households reached US$ 30,700, and the median income reached US$ 23,400. Statistics Netherlands (the Dutch Central Bureau of Statistics) reported that as of January 1, 2013, life expectancy in Bonaire, St. Eustatius, and Saba was 80.2 years.

The working-age population 15 74 years old is 14,500, and the employment rate is 68.9% 70% among men and 65% among women. The unemployment rate was 6.4% in 2014. The leading employment sectors are government, construction, health care, tourism, and retail. Bonaire’s economy has roughly 7,800 jobs, 20% of which deal with tourism. Average annual wages in 2014 were US$ 22,840, increasing 1% on an annual basis.

Economic growth in 2014 was 1.6%, with the country’s GDP estimated at US$ 403 million. Government and real estate activity were the main drivers of growth, and respectively contributed 17.5% and 17.9% to GDP. The financial services sector added 10.4% of value to the island’s economy, and tourism has traditionally contributed around 16%. Direct tourism spending brings US$ 160 million into the island’s economy, with an estimated value-added of US$ 60 million for the sector (). Inflation in Bonaire remained low in 2016, at 0.5%, after registering deflation of -0.9% the prior year. A drop in electricity prices late in the year helped to offset the rise in oil prices ().

Leading Health Challenges

Crime decreased in 2015 compared to 2013, with the number of violent crimes falling from 116 to 87. The number of sexual offenses dropped from 19 to 6. Drug-related crimes decreased from 54 to 44 and property crime dropped from 111 to 63. The number of weapons-related crimes increased from 11 to 18 ().

Health Situation and Trends

According to survey results reported by Statistics Netherlands, in 2013, 70% of Bonaire’s population 15 years old and older rated their health as “good” or “very good.” Nearly 80% of the population in this age group reported that they had consulted a general practitioner in the year prior to the study. Just over half of residents had visited their dentist at least once over the year prior to the study (). Data from other studies on nutritional disorders showed that 60% of the population of Bonaire was overweight in 2013, and a quarter was seriously overweight. Other health data showed that 8% of the population suffered from diabetes (6.8% of men and 9.3% of women); 18.5% of the population was affected by high blood pressure over the previous 12 months (14.9% of men and 22.7% of women); 4.4% of the population indicated they had been impacted by heart disease (4.6% of men and 4.2% of women); 3.2% of the population had cancer (2.4% of men and 4.1% of women); and 48.1% of the population reported having no disorders (57.2% of men and 37.8% of women) ().


Its tropical climate exposes Bonaire to risks of mosquito-borne diseases. A report from the National Institute for Public Health and the Environment of the Netherlands for epidemiological week 44 in 2016 (October 31 November 6) confirmed 60 Zika virus infections since monitoring began the week of November 23, 2015; no cases were reported among pregnant women. Between November 23, 2015, and November 6, 2016, 45 probable and confirmed cases of dengue were reported in Bonaire, 22 in women and 23 in men. For the same period, 37 probable and confirmed cases of chikungunya were reported, 23 in women and 14 in men ().

St. Eustatius

Overall Context

The municipality of St. Eustatius is located in the Leeward Islands in the Caribbean Sea, between St. Kitts and Anguilla. It extends for 21 km2 and has a population of 3,200 inhabitants, with a population density of 152 persons per km2 (). In terms of provenance, 34% of residents were born on the island, 11% were born in Sint Maarten, 6% in the Dutch mainland, and 9% in Curaçao or Aruba; 79% of the population holds Dutch nationality. Most of the population (68%) is multilingual: 85% speaks English as a first language, 6% speaks Dutch, and 7% speaks Spanish. Figure 2 shows St. Eustatius’ population structure in 2016.

Figure 2. Population structure, by age and sex, St. Eustatius, 2015

Source: Statistics Netherlands, 2015.

Income inequality is greatest in St. Eustatius among the three island municipalities, with median disposable income among the highest income quartile being US$ 64,000, compared to US$ 8,000 for the lowest quartile. Average household income increased for the two lowest income quartiles between 2011 and 2014, at a pace of 11% and 10%, respectively. The two top income quartiles experienced an expansion of 9% and 7%, respectively, in the same period.

The economy employs 1,100 workers, and 12% of jobs in St. Eustatius are tourism-related. The average annual wage in 2014 was US$ 33,340, which represented a growth of 1.8% compared to the prior year. On 1 January 2016, the minimum wage increased 4% in St. Eustatius, and is slated to increase again on 1 January 2017.

Statistics Netherlands reports that GDP contracted in 2014, falling 4.4% to US$ 100 million; this followed a virtually flat GDP the prior year (0.8% growth). GDP per capita in 2014 was US$ 25,100, a reduction of 6.6% compared to 2013 for the indicator. The population of St. Eustatius declined 21% between 2014 and January 1, 2016. The reduction in the male population was more rapid than in the female population, resulting in a shift of 3 percentage points in the population distribution, to 52% male and 48% female, from 55% and 45%, respectively.

A deflationary price environment persisted in St. Eustatius in 2016, with prices declining 0.1% for the year. The drop was mainly the result of a 20% increase in electricity prices in 2015, which manifested itself as a drop in 2016. Food products and gasoline prices increased late in the year, contributing to inflation ().

Leading Health Challenges

The number of violent crimes recorded in 2015 was 26, the same as in 2013. Sexual offenses increased from 8 to 10 for the same period. Property crimes were reduced from 19 in 2013 to 8 in 2015 ().

Health Situation and Trends

According to results from a several 2014 Statistics Netherlands surveys, 80% of the population in St. Eustatius reported that they were in “good” or “very good” health. However, 30% of the population was moderately overweight and 30% was obese. Those studies also showed that 10.6% of the population suffered from diabetes (8.7% of men and 13% of women); 20.6% of the population reported they had suffered from high blood pressure in the prior 12 months (15.3% of men and 27.5% of women); and 52.2% of the population reported having no disorders (58.1% of men and 44.7% of women) ().

Most (71.7%) of the population had visited a general practitioner in the year prior to the survey, and just under half (47.6%) had contacted a specialist. Half of residents had visited a dentist at least once in the past year ().


Its tropical climate exposes St. Eustatius to risks of mosquito-borne diseases. A report from the National Institute for Public Health and the Environment (31 October 6 November 2016) confirmed 16 Zika virus infections since it began measuring on November 23, 2015. No cases were reported among pregnant women ().


Overall Context

Saba, located in the Leeward Islands, has a population of nearly 2,000 inhabitants. The island stretches for 13 km2 and has a population density of 150 persons per km2 (). The population grew 5% between 2014 and 2016, increasing by 136 people. The population is evenly distributed between males and females. Most (53%) of households are single-person and 20% are couples without children. Figure 3 shows Saba’s population structure in 2016.

Figure 3. Population structure, by age and sex, Saba, 2015

Source: Statistics Netherlands, 2015.

In terms of provenance, 28% of residents were born in Saba, 14% were born in Sint Maarten, 5% were born in Aruba and Curaçao, and 5% were born in the Dutch mainland; 60% of the population has Dutch nationality.

English is the main language, spoken by 93% of the population; 32% speak Dutch, 3% speak Spanish, 4% speak another language, and 57% of the population is multilingual.

The working-age population (15-74 years old) in 2014 was 1,520, with 900 people employed. The unemployment rate was 2.5%. Labor force participation is notably low at 59.3%, and 35% of inhabitants are not looking for a job or are not available for work. This is largely related to the number of medical students living on the island, few of which have a part-time job and many of which, being foreigners, lack work permits. Over 24% of the population is not seeking employment or cannot work because of their level of education.

Only 28% of residents were born in Saba, and 26% were born elsewhere in The Netherlands or the former Netherlands Antilles; the remaining 46% were mostly born in Canada, the Dominican Republic, or the United States. People of Dutch nationality employed on the island largely work in the hotel and catering industry, in education, or for the government, and tend to have attained secondary or higher levels of education.

There is one primary and one secondary government-funded school on the island; 248 students attended these schools in the academic year 2015-2016, only 6 of whom were enrolled in vocational education. Government-funded schools located on Saba reach the secondary education level. The university on the island is the Saba University School of Medicine, which offers a basic sciences curriculum of 10 semesters.

On average, households had US$ 25,300 in disposable income in 2014, an increase of US$ 1,500 over the previous year. Households in which the primary income-earner was between 40 and 60 years old had the highest income, benefitting from more work experience and access to better jobs. This category had a median disposable income of US$ 29,100, an annual gain of US$ 2,000. The median income at retirement age 60 years and older was US$ 21,200.

A slight economic contraction (-0.2%) was recorded in 2014. GDP was US$ 46 million in 2014, which translated into a GDP per capita of US$ 25,100. The population declined at a faster pace than GDP, leading to a per capita GDP increase of 4.7%. Economic growth in 2013 was 5.5%.

Saba’s economic drivers are tourism, the Saba Medical University School, and fisheries. The economy posted growth in 2015, on the back of solid performance from all three of these sectors. Infrastructure investments executed in 2015 included work at the airport, the harbor, and the electricity plant. Inflation rose in the third quarter of 2016, to 0.2%, mainly resulting from the price of toiletries and natural gas. Food prices declined 1.6% annually, driven by the cost of fresh produce, milk, and sugar (). The minimum wage was increased 6.5% on January 1, 2016, and is due to be increased again on January 1, 2017.

Leading Health Challenges

Crime was down in Saba between 2013 and 2015, falling from 40 cases to 27 (). Just over half of all crimes were violent crimes in 2015, including 8 incidences of battery, 13 threats of battery, 14 instances of domestic violence, 1 murder (unsolved), and 1 attempted murder ().

There are several projects aimed at improving Saba’s water supply. New cisterns under construction will help the municipality better cope with drought; in 2013 water had to be brought in by the Dutch Navy to contend with a drinking water shortage due to drought and malfunctions at the water plant (). A new pipe system connecting Fort Bay to The Bottom will improve water delivery, and a bottling facility for drinking water is in under study.

Health Situation and Trends

Statistics Netherlands reports life expectancy at birth at 80.2 years. Statistics Netherlands also reported that 80% of residents in 2014 rated their health as “good” or “very good.” In terms of nutritional conditions, 30% of the residents were moderately overweight and 33% were obese. Half of the inhabitants had visited their dentist in the last year. The same studies reported that 7.7% of the population suffers from diabetes, with a higher rate among women (10.1%); 15.4% of the population reported that in the prior 12 months they had suffered from high blood pressure (15.2% of men and 15.5% of women); and 62.2% of the population reported having no disorders (68.9% of men and 55.4% of women). Most (72%) of the population had consulted a general practitioner in the prior year; 32.9% had consulted a specialist ().


Its tropical climate exposes Saba to risks of mosquito-borne diseases. Reports (31 October to 6 November 2016) from the National Institute for Public Health and the Environment confirmed 10 Zika virus infections since measurements began on November 23, 2015; no cases were reported among pregnant women ().

Sint Maarten Laboratory Services (SLS) and the Saba Health Care Foundation (SHCF) recently signed a service-level agreement designed to improve the quality of services at SHCF’s laboratory. The agreement offers SHCF technical support, knowledge transfer, training, and refresher courses, with a focus on hematology, immunology, medical microbiology, pre-analysis, and quality assurance.


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