- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Curaçao is an island state located in the southern Caribbean Sea, approximately 65 km north of the Venezuelan coast. Previously part of the Netherlands Antilles, Curaçao became a constituent country within the Kingdom of the Netherlands in October 2010. The government of Curaçao is established under a framework of a parliamentary representative democracy, with a Prime Minister functioning as the head of government.
In 2015, Curaçao’s population was rapidly aging, fueled in large part by the flight of young adults to continue their education abroad, low fertility rates, and high life expectancy. Moreover, fertility has declined steadily since 2001 and the number of persons 60 years or older rapidly increased between 2001 and 2011. During the 2011 2014 period, life expectancy was 74.8 years for men and 81.0 years for women (). Figure 1 shows Curaçao’s population structure in 1990 and 2015.
As of 1 January 2016, Curaçao had 158,986 inhabitants, with a male to female ratio of 84 to 100, one of the lowest in the world. Since 1960, when the male-to-female ratio was reported at 98:100, the male proportion has steadily declined, mainly as a result of female dominated immigration that is particularly notable in working age groups 30 60 years old ().
With a 2011 GDP per capita of US$ 27,781 (PPP), Curaçao is a considered to be a high-income economy and boasts one of the highest standards of living in the Caribbean region. The main economic sectors are tourism, financial services, oil refining, shipping, and international trade.
Curaçao experienced negative economic growth rate between 2011 and 2014, followed by modest economic growth of 0.3% in 2015 (). This positive economic development was tied to the expansion of public and private spending, resulting in part from the rise in investments in tourism and transportation. Stay-over tourism contributed favorably overall to economic growth, in spite of weak performance in the cruise sector. Refining activities declined during the year, as did wholesale and retail and domestic consumption ().
Since 2010, the government’s economic policies have centered on achieving sustainable public finances. Measures to rationalize public expenditure include increases in the premium and age limit (from 60 to 65 years) for the public retirement plan (AOV), the introduction of a basic health insurance (BVZ), an increase in sales tax, and the improvement of the tax department efficiency ().
The primary security concerns are petty theft and street crime. The number of armed robberies slightly increased from 492 recorded incidents in 2011 to 503 in 2012. Rapes and sexual assaults are infrequent, with 57 incidents reported in 2010 and 27 incidents reported in 2011. Home invasions have also become more common in recent years ().
The islands of the Dutch Caribbean continue to serve as a major transit point for drug trafficking, though intensive international collaboration has significantly disrupted narcotic smuggling in the region ().
Air quality is impaired by operations of the aging Isla oil refinery. Continuous measurement of four air pollutants that are considered most harmful for public health (SO2, total suspended particles, H2S, and PM10) began in January 2010 under the auspices of Curaçao’s Ministry of Health, Environment, and Nature and in collaboration with the Dutch Community Health Services (GGD) in Amsterdam, the Netherlands. Since 2010, the SO2-norm level of 80 µg/m3 (average/year) was exceeded in 2013 (152 µg/m3) and 2014 (170 µg/m3) (). In 2014, inhabitants of neighborhoods downwind of Schottegat harbor complained about the appearance of a green substance in their houses, which was found to have originated from industrial sources and contained levels of harmful vanadium, nickel, and sulphur ().
Following the dissolution of the Netherlands Antilles in 2010, the Ministry of Health, Environment, and Nature was established, and significant health system reforms were undertaken. These measures include the introduction of new payment structures for some health care providers and pharmacies, the integration of a variety of health insurance funds into the basic health insurance (BZV), a reduction in expenditures for medication, and the construction of a new general hospital in Otrobanda.
As a strategy for the implementation and evaluation of future evidence-based policies, plans, and programs, several studies have been conducted concerning the organization of primary health care (), health care needs of the elderly (), migrant health and well-being (), national health expenditures (), health status, risk factors and health care use among the adult population (), and adolescent health (). Results revealed that health expenditures had increased at an average 5% per year in Curaçao between 2008 and 2011, with the greatest increase being seen in hospitals, nursing, and home care (). These increases have made it necessary to examine the health care system to find ways to address these issues.
Several poverty indicators show positive trends during the 2001-2011 period. The head count index declined from 34% to 25% and the poverty gap index declined from 14.8% to 8.9% over the period. Households with an income below the poverty line are more likely to be headed by women, an unemployed person, a person with a low education, or a person on welfare or state pension (). Income inequality in Curaçao is relatively high compared to Western countries. In 2011, the GINI-coefficient was 0.41, which represented a small decline from the 0.42 figure seen in 2001 ().
Curaçao’s health system largely mirrors that of the Netherlands. A general practitioner is often the first point of contact for questions or concerns about health; as such, the general practitioner functions as the system’s gatekeeper. Emergency services can be contacted directly when seeking care for acute medical emergencies directly.
The health system is structured into primary, secondary, and tertiary care sectors. Primary care includes care provided by general practitioners, paramedics, and pharmacists. Secondary care is provided at St. Elisabeth Hospital, the Adventist Hospital, private clinics of medical specialists, and the psychiatric hospital (the Capriles Clinic). Tertiary care includes care for long-term illnesses and disabilities, and is usually provided in facilities with specialized care and comfort for extended stays. Clinical laboratory services are provided by the national laboratory (ADC) and by several private laboratories.
Preventive care is part of the care provided by the general practitioner, such as flu vaccinations, or is provided by community health organizations such as the Directorate of Public Health. The Department of Community Health Services (G&Gz), which is part of the Ministry of Health, Environment, and Nature, provides preventive care to the community; for example, youth health, traveler vaccinations, and screening for sexually transmitted diseases among sex workers. Youth health services also provided by the White-Yellow Cross Foundation. The FundashonPrevenshon organization provides free breast and cervical cancer screening services. Table 1 shows the breakdown of medical specialists in Curaçao in 2015.
Table 1. Number and coverage of health care providers and pharmacists, by category, Curaçao, 2015
|Specialty||Number||(per 10,000 population)|
Source: Author, based on information from Curaçao, Ministry of Health, the Environment, and Nature.
Leading Health Challenges
Critical Health Problems
Dengue occurs every year in Curaçao, usually during the rainy season, when Aedes mosquito populations are high.
In 2008, an unexpected and dramatic peak in the incidence of dengue fever was observed in Curaçao, associated with significantly lower average, absolute-minimum, and maximum temperatures, suggesting that lower temperatures are also an important factor in the development of higher dengue incidence (). The 2010-2011 outbreak had 1,822 serologically confirmed dengue cases and was associated with four deaths ().
In August 2014, chikungunya virus was reported in Curaçao for the first time, followed by a large outbreak during the 2014-2015 rainy season. The virus infected an estimated 20,000 persons. In January 2016, Zika virus was first reported in Curaçao; by May 2016, 208 laboratory-confirmed cases had been reported.
The adolescent (15 19-year-olds) fertility rate decreased from 52 per 1,000 births in 1998 to 34 in 2013. Of the children who were born in 2013 (n=1,959), 9.2% had a teenage mother, meaning that 3.4% of teenage girls became mothers that year. Three children were born to mothers under 15 years of age at the time of birth in 2013 ().
Many teenage pregnancies are the result of inconsequent use or absence of reliable contraception methods and, moreover, are in many cases unwanted. An estimated 40% to 54% of the total number of teenage pregnancies in Curaçao end in abortion ().
The high prevalence of noncommunicable diseases remains an important health challenge in Curaçao, particularly cardiovascular disease, malignant neoplasms, and lifestyle-related illness.
In 2015, health care services that were fully or partially covered by legislation governing social and health insurances were available through more than 400 health care providers (Table 1) (). That year, there were 119 medical specialists in the country, including 80 general practitioners, 63 physical therapists, 42 dentists, 36 psychologists, and 29 pharmacists.
Although there are several medical universities on the island, Curaçao does not have an accredited medical school whose graduates are allowed to practice on the island. Health professionals in Curaçao are mainly trained in the Netherlands, the United States, and in South America.
As mentioned in the first section of this chapter, Curaçao’s population is rapidly aging in large part as a result of the emigration of young adults who leave the island to pursue their education abroad In addition, fertility has declined steadily since 2001, with the total fertility rate decreasing from 2.4 children per woman in 2001, to 2.1 in 2011, and to 1.9 in 2015. Over this period, the fertility rates of women aged 15 29 years have particularly declined (). The number of persons 60 years or older between 2001 and 2011 leapt by nearly 10,000, reaching 29,846 in 2011. Over the same period, the number of persons aged 0 14 years old decreased from 30,793 in 2001 to 29,395 in 2011. In fact, the number of elderly in Curaçao has surpassed the number of children ().
The foreign-born population has steadily increased over the past decades, accounting from 14.6% of the total in 1981, to 19.5% in 2001, and to 24.0% in 2011. These immigrants arrive mainly from the Netherlands (25.2% of the total foreign-born population), the Dominican Republic (15.2%), and Colombia (12.7%). The share of the population that has never lived abroad decreased from almost 70% in 2001 to 56% in 2011 ().
The undocumented immigrant population was estimated at 15,000 in 2005 by the Foundation for the Welfare of Foreign Immigrant Workers (Stichting BuitenlanderZorg). A lack of public policy in regards to medical care for undocumented immigrants has left the financial burden of providing care to be dealt with by health care providers, such as hospitals, doctors, and midwives. The strict crackdown on illegal immigration by the justice system has created a disincentive for being visible, and kept undocumented immigrants from seeking the necessary preventative care and treatment ().
Monitoring the Organization, Provision of Care, and Performance of Health System
Several governmental organizations are involved with the governance and supervision of the health care system. The policy department of the Ministry of Health, Environment, and Nature is responsible for the governance of the health care system by developing, implementing, and evaluating of policies, laws, and regulations. Supervision is the main task of the Inspectorate for Public Health. The Public Health Institute (Volksgezondheid Instituut Curaçao), part of the Ministry of Health, Environment and Nature, conducts, collects and analyses research to inform policy development.
According to a study published in 2013, 86% of the population 18 years old and older reported that they had visited their general practitioner during the 12 months prior to the study (). Emergency services and preventive services, such as youth health and breast and cervix cancer screening, are available for undocumented migrants ().
Dental services, which are generally not covered by social insurance, are less accessible. In 2013, 12% of the population 18 years old and older said they had experienced an unfulfilled need for dental treatment in the 12 months prior to the survey; insufficient funds was reported to be the main reason for this unmet oral care ().
Before 2013, Curaçao’s health system was two-pronged, whereby social insurance covered most of the population and private insurance generally covered the wealthier segments. For example, in 2011, 86.4% of the population was covered through social insurance, 11.0% through private insurance, and 2.6% had no coverage (). The Basic Health Care Insurance (BZV) scheme was introduced on February 1, 2013, designed to provide uniform coverage to all those insured. The program is executed through the Social Insurance Bank (SVB), and all those registered at the Public Registry are entitled to BVZ coverage through the SVB. The BVZ is financed with income tax collections, with employers and employees contributing. Private insurance is often used for supplementary coverage (). With the introduction of the BVZ in 2013, it is most likely that the share of socially insured persons increased.
Health expenditure amounted to nearly US$ 503 million in 2011 (ANG 900 million), or 16.6% of GDP. Between 2008 and 2011, the total health expenditure increased by 15% in nominal terms. Per capita health care spending was roughly US$ 3,355 (ANG 6,006) per year ().
Health Situation and Trends
Health of Population Groups
Child Health (Under 5 Years Old)
Considering the relatively small number of births and deaths in Curaçao, the child mortality rates tend to fluctuate over the years. During 2010 2015, the neonatal mortality rate varied from 8.9 per 1,000 live births (2010) to 4.4 (2012), infant mortality from 12.8 per 1,000 live births (2010) to 7.6 (2011), and mortality in children under 5 from 13.3 per 1,000 live births (2010) to 8.7 (2013). Between 2003 and 2007 (latest available data), perinatal disorders (ICD-10, code P00 P96) and congenital malformations (ICD-10, code Q00 Q99) accounted for 80% of the mortality among children below age 5 ().
More than 95% of the children who were born in 2007 received the DTaP-vaccine (97.1%, 3 doses), Hib-vaccine (97.0%, 3 doses) and TOPV-vaccine (97.2%, 3 doses) in their first year of life. Among children born in 2007, 93.7% received the first dose of MMR-vaccine in the second year of life ().
Health of Schoolchildren (5 9 years old)
During the 2003-2007 period (latest available data), 9 deaths occurred in the 5 to 9-year-old age group, of which 7 were male. The main causes of death were external causes (5 cases) ().
Health of Adolescents (10 19 years old)
During the 2003-2007 period (latest available data), 44 male and 17 female deaths occurred in the 10 19-year-old age group. The main causes of death for males were homicide and/or assault (41%), transport accidents (25%), and neoplasms (7%). The main causes of death for females were transport accidents (24%), congenital malformations (18%), pregnancy and/or childbirth, and neoplasms (both 12%) ().
In 2015, the Global School-based Student Health Survey () found that substance use of tobacco and alcohol was similar between the genders, while marijuana use was more common among male than among female students.
Health of Adults
Results from a 2013 National Health Survey conducted in Curaçao provide an overview of the current status of health, risk factors, prevalence, and health care use among the population 18 years old and older (). Most of the adult population (73.4%) describes their health as “very good.” Males, young adults, and better educated respondents were more likely to report that they were in “very good” health.
Health of the Elderly (65 years old and older)
Between 2011 and 2014, life expectancy was 74.8 years for men and 81.0 years for women (). The self-reported number of years spent in good health is similar for men and women; given that women generally outlive men, they may spend more years of their lives in ill health. The main chronic conditions among the elderly are hypertension (46%), diabetes mellitus (26%), and high cholesterol (23%). Fewer men (68%) than women (78%) reported living with at least one disease. During the 2012/2013 flu season, one in ten of the elderly was vaccinated against influenza.
Severe physical limitations in mobility, daily activities, sight and/or hearing are common among the noninstitutionalized elderly population: 33% of the 65 74-year-olds, 54% of 75 84-year-olds, and 68% of those 85 years old and older reported to be severely limited in one or more aspect. One in five (20%) elderly reported that they require help during self-care or to perform household activities ().
During the 2003-2007 period (latest available data), 9.8% of deaths resulted from coronary heart disease, 6.7% from malignant neoplasm of the prostate, 6.5% from stroke, 5.4% from cardiac arrest, and 5.0% from malignant neoplasm of the lung and trachea.
No cases of malaria were reported between 2008 and 2012.
In 2014, 94 new HIV-positive individuals were registered, totaling 1,830 registered HIV-positive individuals. The 15 24-year-old age group is the only one in which more young women (n=103) than young men (n=83) were HIV-positive (). The number of babies with HIV/AIDS is low, because of testing and treatment of almost all pregnant women.
In 2013, a quarter (27%) of the population between the ages of 15 and 24 years who were tested by the national laboratory (ADC) was infected with Chlamydia trachomatis, compared to 15% of the overall population tested ().
Between 2002 and 2010, 14 confirmed cases of leprosy were reported in Curaçao (). Other parasitic infections related to poverty are rare to absent.
Between 2010 and 2012, eight cases of laboratory-confirmed Mycobacterium tuberculosis were reported, accounting for an average annual incidence rate of 1.8 cases per 100,000 population.
The national immunization program provides protection against 10 diseases: diphtheria, tetanus, whooping cough (pertussis), Haemophilus influenza type b, polio, measles, mumps, Rubella, Streptococcus pneumonia and Hepatitis B. No cases of diphtheria, mumps, whooping cough, measles or polio were reported during the 2008-2012 period. There was one case suspected of tetanus based on clinical symptoms ().
No cases of human rabies virus were reported during the 2008-2012 period ().
Chronic, Noncommunicable Diseases
Cardiovascular disease (ICD-10, code I00-I99) was the main major cause of death for both men and women in Curaçao, between 2003 and 2007 period (latest available information), accounting for 37% of the total number of deaths (). In 2013, 0.9% of the population 18 years and older reported to have had a heart attack during the 12 months prior to the National Health Survey. Other heart diseases, such as angina pectoris, were reported by 3.2% of that population ().
Malignant neoplasm (ICD-10 code C00-D48) was the second major cause of death among both men and women, reported as the cause in 26% of the total number of deaths for the 2003 2007 period (latest available data) ().
Malignant neoplasms of the prostate (26%), the lung and bronchi (19%), and colon (9%) were the leading sites of cancer deaths among the male population. Among the female population, the leading sites of cancer deaths were the breast (26%), the colon (13%), and the ovaries (7%) ().
In 2013, 9.3% of the adult (18 years and older) population reported that their doctor diagnosed them with diabetes mellitus (), a substantial increase from the 5.6% reported in 1993/1994 Health Survey (). Among the population 65 years old and older, diabetes was reported by 23.0% (). The 2013 National Health Survey showed that the blood glucose values of 26.1% of the respondents who reported they were diagnosed with diabetes were higher than 200 mg/dl, which implies a poor adherence to their prescribed medications ().
In 2013, 1.8% of the population 18 years old and older reported having had chronic obstructive pulmonary disease during the 12 months prior to the survey ().
In 2013, 19.9% of the population 18 years old and older reported that their doctor diagnosed them with hypertension, and this condition was more commonly reported among women (23.5%) than among men (15.4%) (). This is a substantial increase from the prevalence reported during the 1993/1994 Health Survey of 14.5% (). Among the population of 65 years old and older, hypertension was reported by 41.0% ().
The 2013 National Health Survey showed that only 32.5% of the respondents who reported they were diagnosed with hypertension had their hypertension controlled to a blood pressure of <140 mm Hg systolic and <90 mm Hg diastolic, which implies poor adherence to their prescribed medications ().
The 2015 Global Student-based Health Survey (GSHS) shows that 3.7% of students reported going hungry in the 30 days prior to the survey because there was not enough food in the home; 9.3% reported this happened sometimes ().
In 2013, 39.3% of the males 18 years old and older was overweight and 23.3% was obese. Among females in this population group, the figures were 34.7% and 32.6%, respectively ().
Accidents and Violence
Transport accidents (ICD-10, code V00 V99) were the second leading cause of death for adolescent males 10 19 years old and the leading cause for females in that age group during the 2003 2007 period (latest available data). Overall, 3% of the male deaths and 1% of the female deaths were caused by transport accidents ().
Of the total number of deaths between 2003 and 2007, 5% of male deaths and 1% of female deaths were caused by homicide and/or assault ().
During the 2013 National Health Survey, moderate to severe psychological complaints were reported by 8.1% of the population 18 years old and older (Mental Health Inventory 5). One in ten (10.7%) adults reported a low vitality, defined as low energy levels, exhaustion and fatigue. Both indicators were 2.5 times more commonly reported among women than among men ().
Risk and Protective Factors
Legislation that prohibits smoking in enclosed public spaces such as restaurants and bars was introduced in 2015. In 2013, 15.5% of persons 18 years old and older reported that they smoked (), a figure somewhat lower than the prevalence in 1993/1994 of 17.1% (). The prevalence of daily cigarette smokers was 10.1%. Of female smokers (current and previous) that were ever pregnant, 18% reported they had smoked during their pregnancy ().
In 2013, 62% of those 18 years old and older said that they had consumed alcohol during the 12 months prior to the survey. Daily alcohol consumption was reported by 4.7% of the adult population. Men were more likely than women to report excessive alcohol consumption (4.4% vs. 1.2%). Heavy alcohol consumption was also more common among males (12.0%) than among females (2.0%) ().
In 2013, 3% of the population 18 years old and older reported that they used soft drugs, and 0.5% said they used hard drugs during the 12 months before the survey ().
In 2013, 47% of the population 18 years old and older reported that they did not spend at least 10 minutes on a physical activity during the 7 days prior to the survey. Of the 53% that reported they were physically active for at least 10 minutes, 28.2% only performed activities of light intensity, such as walking, stretching, or light swimming. Physical activity was more common among men (60%) than among women (40%) ().
Health care affordability is a challenge that will loom large in the coming years in Curaçao. Driven by a growing and aging population and a high prevalence of noncommunicable diseases. Heightened expectations surrounding the quality of care and innovative and costly health technologies and treatments exacerbate the problem.
Box 1. Health achievements and challenges, Curaçao
- Life expectancy in Curaçao has improved over time
- Infant mortality has decreased in the last few years.
- Vaccination coverage above 97% has been achieved for those children born after 2007 (assessed on the basis of coverage with Dtap, Hib, and tOPV vaccines)
- Increase in the elderly population.
- The leading causes of death are due to noncommunicable diseases, which are increasing among the elderly population.
- Health care costs will rise due to an increase demand on the system.
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1 Percentage of the population that lives under the poverty line.
2 BMI 25-29.9 kg/m2.
3 BMI 30 or more kg/m2.