Pan American Health Organization

Curaçao

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Outlook
  • References
  • Full Article
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Overall Context

Flag of CuraçaoCuraçao 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.

Curaçao’s population increased relatively little (7.2%) between 1990 and 2015. In 1990, the population structure had a rapidly expansive structure in the age groups older than 25 years, with a slower expansion seen at younger ages. By 2015, the pyramidal structure shifted to ages older than 50 years, with irregular stationary growth under that age. This structure reflects a combination of ageing, decreased fertility, and migration.
Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 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)
Medical specialists 119 7.6
General practitioners 80 5.1
Physical therapists 63 4
Dentists 42 2.7
Psychologists 36 2.3
Oral hygienists 17 1.1
Dietitians 10 0.6
Speech therapists 9 0.6
Occupational therapists 8 0.5
Chiropractors 2 0.1
Podiatrists 3 0.2
Midwives 4 0.25
Pharmacies 29 1.8

Source: Author, based on information from Curaçao, Ministry of Health, the Environment, and Nature.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

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.

Adolescent Pregnancy

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 ().

Noncommunicable Diseases

The high prevalence of noncommunicable diseases remains an important health challenge in Curaçao, particularly cardiovascular disease, malignant neoplasms, and lifestyle-related illness.

Human Resources

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.

Aging

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 ().

Migration

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 ().

Outlook

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

Achievements:
  • 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)
Challenges:
  • 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.

References

1. Central Bureau of Statistics (Curaçao). Statistical information: population tables—mortality 2011–2016. Willemstad: CBS; 2016. Available from: http://www.cbs.cw/website/population_3208/rubriek/population-tables_187.html.

2. Central Bureau of Statistics (Curaçao). Demography of Curaçao. Publication Series Census 2011. Willemstad: CBS; 2014. Available from: http://www.cbs.cw/website/2011-census_3226/item/demography-of-curacao-publication-series-census-2011_757.html.

3. Central Bank of Curaçao and St. Maarten. Economic developments in 2015 and outlook for 2016. Willemstad: Central Bank; 2016. Available from: http://www.centralbank.cw/uploads/files/Economische%20ontwikkelingen%20in%202015%20en%20vooruitzichten%20voor%202016_ENG.pdf.

4. van den Bergh R. De economie van Curaçao—Deel V: Wat deed de overheid na 10-10-10? [The economy of Curaçao—Part V: What did the government do after 10-10-10?]. Available from: http://www.qracao.com/docs/Wat%20heeft%2010-10-10%20economisch%20opgeleverd%20(final).pdf.

5. Department of State, Overseas Security Advisory Council (United States). Curaçao 2014 crime and safety report. Washington, D.C.: U.S. Department of State; 2014. Available from: https://www.osac.gov/pages/ContentReportDetails.aspx?cid=16124.

6. Community Health Services (Netherlands). Meetresultaten luchtkwaliteit Curaçao 2014 [Air quality monitoring results: Curaçao 2014]. Amsterdam: GGD; 2015. Available from: http://www.luchtmetingencuracao.org/static_html/media/15-1133%20Luchtkwaliteit%20Curacao%202014.pdf.

7. Netherlands Organisation for Applied Scientific Research. Bepaling van de elementsamenstelling van een groene aanslag aanwezig op een vijftal locaties op Curaçao met behulp van elektronenmicroscopie en Röntgen microanalyse. The Hague: TNO; 2015. Available from: www.ecovisionnv.com/file/TNO-rapport.pdf.

8. Snoeijs S, Boerma W, Schellevis F. Evaluatie van de structuur en de zorgverlening van de eerstelijnsgezondheidszorg op Curac¸ao. Utrecht: Netherlands Institute for Health Services Research; 2012. Available from: https://www.nivel.nl/sites/default/files/bestanden/Rapport-evaluatie-eerstelijnszorg-Curacao.pdf.

9. Deloitte. Behoeftenonderzoek “Stem van de Oudere”—Grandi ku Orguyo [Needs assessment: “Voice of the Elder”—Grandi ku Orguyo]. February 2013.

10. de Bruijn J, Groot M. Regionale migratie en intergratie op Curaçao [Regional migration and integration in Curaçao]. Willemstad: Ministry of Social Development, Labor and Welfare; 2014. Available from: http://www.gobiernu.cw/web/site.nsf/resources/78B90090AEC497DD04257D42006433E0/$FILE/Onderzoek%20Migranten%20en%20Integratie%20op%20Curaçao_digitaal.pdf.

11. Westerhof RH, Felida LP. Zorgrekeningen curaçao 2008–2011. Willemstad: Public Health Institute; 2012. Available from: http://www.vic.cw/language/nl/eid/1875.

12. Verstraeten SP, Jansen I, Pin R, Brouwer W. De Nationale Gezondheidsenquête 2013: methodologie en belangrijkste resultaten [National Health Survey Curaçao 2013—methodology and key results]. Willemstad: Public Health Institute; 2013. Available from: http://www.vic.cw/language/nl/eid/1875.

13. Verstraeten SP. National report: the 2015 Curaçao Global School-based Student Health Survey (GSHS) study 2015. Willemstad: Public Health Institute; 2015. Available from: http://www.vic.cw/language/nl/eid/1875.

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16. Moesker FM, Muskiet FD, Koeijers JJ, Fraaij PL, Gerstenbluth I, van Gorp EC, et al. Fatal dengue in patients with sickle cell disease or sickle cell anemia in Curaçao: two case reports. PLoS Neglected Tropical Diseases 2013;7(8):e2203. doi: 10.1371/journal.pntd.0002203.

17. Public Health Institute (Curaçao). Factsheet: tienermoeders [Factsheet: teen mothers]. Willemstad: VIC; 2015. Available from: http://www.vic.cw/language/nl/eid/1875.

18. Boersma A, Alberts J, Bruijn J De, Meyboom BJ, Kleiverda G. Termination of pregnancy in Curaçao: need for improvement of sexual and reproductive healthcare. Global Journal of Health Science 2012;4(3):30–38. doi: 10.5539/gjhs.v4n3p30.

19. Public Health Institute (Curaçao). De zorgkaart 2016 [Care map 2016]. Willemstad: VIC; 2016. Available from: http://www.vic.cw/language/nl/eid/1875.

20. Cabinet of the Minister Plenipotentiary of Curaçao. Practical information: health insurance [Internet]. The Hague: KGMC; 2017. Available from: http://www.kgmc.nl/en/health-insurance.

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Reference/Note:

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.

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