Aruba

Overall Context

Aruba is part of the Lesser Antilles. It is the western-most island of the Leeward Islands, located in the Caribbean, some 25 km off the coast of Venezuela. It has a landmass of 180 km2 (31 km long and 8 km wide) (1). Aruba was part of the Netherlands Antilles until 1986, when it became an independent country within the Kingdom of the Netherlands. The island is autonomous in terms of the administration and management of public policies, but is under the authority of the Kingdom of Netherlands for issues related to defense, foreign affairs, and the administration of the justice (1).

Demographics

According to 2014 data, Aruba had a population of 108,374, with an annual growth rate of 0.99% and a population density of 602 per km2. Many foreigners live in the country, most of them from other Dutch Caribbean islands, the Netherlands, Colombia, Venezuela, and the Dominican Republic (2, 3).

Aruba has a population pyramid in transition, due to the age group older than 45 years. This structure reflects a reduction in fertility rates, migratory movements, and the increase in life expectancy to older ages. Figure 1 shows the changes in Aruba’s population structure between 1995 and 2015.

The male/female ratio is 89.8:100. In 2011, life expectancy at birth was 76.9 years (73.9 for men and 79.8 for women); the total fertility rate was 1.9 children per woman, and the crude birth rate was 10.6 births per 1,000 population (2, 4).

Figure 1. Population structure, by age and sex, Aruba, 1990 and 2015

Between 1990 and 2015, the size of the population grew by 67.2%. In 1990, there was an expansive trend in the over-30 age groups, with stationary growth in people under 25 and a wider structure between those two groups, reflecting a combination of natural growth and migration. In 2015, the pyramid structure shifted toward those over the age of 50, with a combination of constrictive and stationary trends in younger age groups, which reflects an aging population, natural growth with lower fertility, and migration.

Source: Pan American Health Organization, based on data from the UN Department of Economic and Social Affairs. Population Division. 2015 Revision. New York; 2015.

The Economy

According to Central Bank figures, in 2015 the tourism sector drove the country’s economic activity. That year, the country hosted 1,831,954 tourists, 5.3% more than in 2014 (5). Of those visitors, 66.9% were tourists who remained overnight, and 33.1% came from cruise ships.

That same year, the decline in petroleum prices and lower consumption levels had eased inflationary pressures, which led to an inflation rate of 0.5%. Consumption and investment suffered negative growth rates. Declining investments were primarily due to delays in large-scale projects, such as the renovation of the hospital and the construction of the new port for container ships in Barcadera. Aruba’s economy is expected to continue to grow in the next few years, based on investment projects in hotel construction and other infrastructure, the hospital’s renovation, the reopening of the refinery, and alternative energy projects (5).

By the end of 2015, Aruba’s total debt accounted for 82.2% of the Gross Domestic Product (GDP), with most government spending allocated to health, social protection, and education (5). Between 1999 and 2009, government spending allocated to the social sector averaged 61% of the total budget .

The standard of living is high, and all residents, including documented immigrants, are enrolled in social security and covered by health insurance. Primary and secondary education is free, and there is a pension program that guarantees a minimum income for the elderly based on their length of residence.

Social Determinants of Health

According to the last census, in 2010 adult literacy was 99.4% (99.5% for women and 99.3% for men), with a 99% enrollment rate in primary education and a completion rate of 94.8%. Seven out of every ten adolescents attend secondary school. The gender parity index is close to 1.0 for primary and secondary education and 1.4 for tertiary education, with women scoring better (6).

Combating overweight, obesity, and other health-related problems is the main objective of Aruba’s National Plan for 2009 2018 (7). Further, the 2010 2013 National Strategic Plan for Sports and Physical Activity has become the framework for boosting the country’s sports activities. Its purpose was to have the population acquire the habit of engaging in physical activity as a way to bring about its balanced and healthy lifestyle, as well as to enhance competitive sports (8).

Aruba’s National Security Plan for 2008 2012 ranks international drug trade and trafficking and their impact as fourth among six serious threats to national security, and calls on relevant sectors and stakeholders to engage in eradicating them (9). As of the end of 2012, there were 2,226 registered patients who were addicted to alcohol and/or illegal drugs (10).

The Health System

The country’s health insurance system provides universal coverage through a network of service providers organized into primary, secondary, and tertiary levels of care; services tend to be more curative than preventive. Family doctors are the cornerstone of the primary care level, which is based on a model geared to the diagnosis, monitoring, and management of patients. Patients are referred to the Dr. Horacio Oduber General Hospital, which has 288 beds and a 79% occupancy rate. The average hospital stay is 6.9 days, with 12 admissions per 1,000 population (2). The hospital is currently undergoing expansion and remodeling in order to meet higher demand for quality health services, primarily due to the aging population and to the rise in noncommunicable diseases. The hospital includes the San Nicolas Medical Institute, which functions as a self-contained, comprehensive national center for outpatient care focusing on noncommunicable diseases.

Elderly persons who cannot continue to live at home may be institutionalized in three geriatric homes with some 250 beds, all told. Most patients receive physical and psychiatric care coordinated by specialists assisted by a team of nurses.

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Leading Health Challenges

Critical Health Problems

Dengue, one of the country’s health priorities, was detected in 1970, with the worst epidemic occurring in 1986. The highest incidence occurred in 2011, with 2,850 reported cases (2, 11).

Most of the cases of hepatitis B reported between 2003 and 2011 were men between the ages of 25 and 44. The majority of the cases were imported.

According to data from the Central Statistics Bureau Health Monitor, the most frequent form of transmission for the human immunodeficiency virus (HIV) was heterosexual contact (59%), followed by men having sex with men (29%); those 25 44 years old were the most affected. In 2010 3,162 HIV screening tests were administered at the national laboratory, 23 of which (0.55%) were positive. In 2011, there was one case of mother-to-child transmission (1, 11).

With regard to teenage pregnancy, between 2006 and 2011 the percentage of live births among mothers under the age of 20 ranged from 12.1% to 13.5%. In 2012, 12% of children had teenage mothers, compared to 11.3% in 2013. In 2011, the birth rate among 15 19-year-olds was 39 live births per 1,000 population, compared to 36 in 2012 and 33.7 in 2013 (4, 11).

Chronic Conditions

Between 2005 and 2012, chronic, noncommunicable diseases were the leading cause of morbidity and mortality. According to the 2006 STEPS survey for Aruba, an increase in the prevalence of noncommunicable diseases such as heart disease, stroke, and cancer, and risk factors such as hypertension, elevated blood glucose, and high cholesterol was confirmed in the 55 to 64 year age group (1).

Between 2000 and 2010, the leading cause of death was linked to diseases of the circulatory system, which were responsible for 33% of total deaths in that period, followed by malignant neoplasms, which accounted for 25% of total deaths.

According to the 2006 STEPS survey, 16.2% of people 25 64 years old used tobacco (twice as many men as women) (12, 13). According to a health survey of young adults conducted in 2012, 27.9% of youth in high schools had used tobacco at least once (14).

In 2010, the greatest number of potential years of life lost (PYLL) was due to external causes, mainly traffic accidents, with 1,077 PYLL for men, surpassing the number of cases due to ischemic heart disease (559.3 PYLL) for that population group.

Human Resources

In 2013, Aruba had 43 general practitioners and 78 specialists (1.82 per 1,000 population); there were 0.35 dentists per 1,000 population. In 2010, the ratio of general surgeons to population was 1 per 21,520 and 1 per 35,867 for psychiatrists. In general, health service providers are contracted by the general health insurance fund (Algemene Ziektekosten Verzekering, or AZV), including all primary care physicians, specialists, and most dentists, physical therapists, and midwives (1, 2).

Aruba has no national medical school, so most health professionals are trained in the Netherlands, the United States, Colombia, and Costa Rica. There are three foreign medical schools in Aruba, but their graduates cannot practice on the island. The country risks “brain drain” through the emigration of its health professionals, as professionals who study and graduate abroad tend to remain there to take advantage of better employment opportunities and higher salaries.

The Environment and Human Security

Aruba has no natural source of fresh drinking water and there is very little rain. Drinking water is produced through desalination (reverse osmosis) of ocean water at the country’s desalination plant, which is the second largest in the world. The water distributed by the network is safe and high quality, and is supplied to all residents and businesses, thus providing 100% water and sanitation coverage. The sewer system is adequate and all households have their own septic tank (1).

Aging

The percentage of people aged 60 and older increased from 7% in 2000 to 17.9% in 2014. During that period, the age group under 14 declined from 23.1% to 19.2% (1, 2). In 2013, the dependency ratio was 57.6%.

Monitoring the Health System’s Organization, Provision of Care, and Performance

Aruba’s Public Health Law, in effect since 1989, states that the Ministry of Health is charged with monitoring the quality of public health and medical services. The law also mandates that the Department of Public Health carry out the surveillance, monitoring, and inspection of various aspects of health care. Since 2008, this department has worked on revising and updating the country’s health policies and regulations (1). Health spending has been steadily increasing, from 6.76% of GDP in 2000 to 11.3% in 2010 . Health care is primarily funded by tax contributions and premiums paid by employers and employees to the AZV. Since 2011, health insurance quotas have accounted for an ever-greater proportion of the national budget, allowing the proportion of tax contributions to diminish without decreasing the overall health sector’s budget; available funds were allocated to health-related social projects such as infrastructure to promote physical activity among the population. In December 2014, legislation mandated a 1% tax on goods and services as a way to reduce the state contribution to general health insurance.

The primary health care program known as the “Health Bus,” launched in September 2012, expanded coverage for individuals and families, as well as their access to schools, businesses, and communities engaged in promotion, prevention, timely diagnosis, control, and outpatient treatment activities. From September 2012 to August 2013, 6,682 people (6.5% of the population) were seen by Aruba’s “Health Bus,” which made it possible to identify the overweight and obese population and investigate diseases such as hypertension and diabetes mellitus, as well as educate the population about risk factors, control of noncommunicable diseases, adherence to treatment, and promotion of a healthy lifestyle (15).

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Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

The total fertility rate decreased from 2.8% in 1991 to 1.8% in 2013. Between 2009 and 2014, the contraceptive methods most frequently distributed by the Family Planning Foundation were oral contraceptives (51.1%), followed by condoms (28.1%), injectable contraceptives (17.4%), and intrauterine devices (2.5%) (1).

Child Health

Aruba’s high coverage rates for prenatal care (99%) and deliveries in health care facilities (96%) are noteworthy. In terms of vaccination, 98% of children receive the DPT3, Polio-3, and MMR vaccines during their first year of life (1).

Mortality

Overall mortality in 2012 was 5.7 deaths per 1,000 population. This figure was higher in men than in women, due to noncommunicable diseases, particularly diseases of the circulatory system (32% in men and 29% in women) and neoplasms (27% in women and 22% in men). External causes represented 13% of deaths in men and 4% in women; while infectious causes accounted for 8% of deaths in men and 7% in women. “All other diseases” accounted for 27% of deaths in women and 19% in men, and the category “not specified” accounted for 6% of deaths in both sexes (3).

The Central Bureau of Statistics (Health Monitor)¹ reported no maternal deaths in 2006 2010; in 2011 2013, only one maternal death was registered each year. In 2013, there were nine deaths in the under-1 age group, five of which occurred in the perinatal period (1).

Between 2007 and 2010, there were 4 deaths among 10 14-year-olds and 14 deaths in the 15 19-year group; 71.4% of deaths among 10 19-year-olds were male. The most common cause of death was external causes (57.1%), mainly traffic accidents. In 2013, there was one death in the 1 4-year age group, none in the 5 14-year group, and five in the 15 24-year age group (1).

Morbidity

Communicable Diseases

Between 2006 and 2013, four types of dengue virus were in circulation, and the following outbreaks were reported: in 2006, 3,502 cases; in 2009, 3,210; in 2011, 2,850; and in 2014, 833 cases. Those aged 25 64 years were the most affected (2, 11). In 2015, 206 cases of laboratory-confirmed dengue were reported and 335 cases were confirmed by epidemiological link, compared to 103 and 1,319 cases, respectively, in 2016. That year, up to epidemiological week 47, there were eight cases of laboratory-confirmed chikungunya virus, 929 cases confirmed by epidemiological link, and 859 clinical cases. With regard to Zika virus, up to epidemiological week 47 of that same year, 28 laboratory-confirmed cases were reported, with 652 confirmed by epidemiological link, and 624 clinical cases.

Only six cases of malaria were reported in 2008 2014, all imported, and there were no cases of cholera. Between 2008 and 2012, there were no reported cases of acute flaccid paralysis, tetanus, diphtheria, rubella, or congenital rubella. From 2010 to 2012, three cases of whooping cough were reported. In 2011, there was one case of mumps, and one case of measles (in a child under age 1). From 2008 to 2012, 16 cases of nonspecific viral hepatitis were reported. That year, there were 2 cases of hepatitis A, compared to 13 cases in 2012, 2 in 2013, and 9 in 2014 (2, 3).

In 2005 2010, there were 247 reported cases of salmonellosis, averaging 41 cases per year, which primarily affected the 25 64-year age group. Cases began to decline until reaching 27 reported cases in 2014. Shigellosis occurs less frequently than salmonellosis, with 83 cases reported between 2005 and 2010, averaging 14 cases per year. This average dropped to five cases per year in 2011 2014 (2, 3).

There were 56 cases of pulmonary tuberculosis in 2008 2014, with the highest number of cases occurring in 2012, with 21 cases (2, 3, 11).

In 2003 2011 an average of 35 new cases of hepatitis B were reported each year. This figure has declined considerably, from more than 40 annual cases in 2011 2013 to just 12 cases in 2014. In both 2013 and 2014, two cases of hepatitis C were reported (2, 11).

Between 1984 and 2010 there was an average of 26 new cases of HIV each year, ranging from a low of 12 to a high of 28. In 2011 2014, the number of reported cases ranged between 14 and 25. In 2010, Aruba had a prevalence of HIV infection of 0.4%, with 435 people infected. According to figures provided by the Department of Public Health, between 2000 and 2014, a total of 298 HIV-positive cases were registered (224 men and 74 women) (1, 2, 11).

Chronic Noncommunicable Diseases

According to the 2006 STEPS survey, the prevalence of hypertension was 19.8% in men and 12.2% in women in the 25 64-year age group (1).

In 2010, mortality from ischemic heart disease also took a high toll, with a rate of 35.9 deaths per 100,000 population (66.9 in men and 15.7 in women), as did diabetes, with a rate of 24.2 deaths per 100,000 population (36 in men and 16.1 in women). That same year, malignant neoplasms were the leading cause of death in the overall population, with a mortality rate of 104.3 deaths per 100,000 population (129.4 in men and 90 in women). From 2000 to 2009, the most common malignant neoplasm sites in men were the trachea, bronchus, and lung (70.2%), which caused 13.9% of deaths, while 97.8% of all deaths from neoplasms in women were due to breast cancer (1, 11).

Cancer of the digestive system was the second leading cause of death in the general population, with 481.7 PYLL in men and 630 PYLL in women, followed by cerebrovascular diseases (440.9 PYLL), chronic lower respiratory disease (361.2 PYLL), and in women, breast cancer (363 PYLL) and cervical cancer (229 PYLL) (11).

There is a high prevalence of diabetes in Aruba. According to the 2006 STEPS survey, 8.3% of the population between 25 and 64 years old reported having type 2 diabetes (9.2% in women and 7% in men). Between 2000 and 2009, diabetes was the leading cause of death in the category “deaths from all other diseases” (31.5% of all deaths; 60.9% in women and 39.1% in men) (1).

Nutritional Disorders

Between January and August 2013, 1,600 people over 18 years of age were overweight (38.9%). Of this group, the prevalence of obesity was 38.2%.

Among preschoolers, overweight was 11% in 2008 2009, remaining the same for this group in 2011 2012. Obesity in that population fluctuated between 10% and 11% throughout the study period. Among fifth-grade students, overweight ranged from 22% in 2008 2009 to 25% in 2011 2012; the figure was higher in middle-school students (26% in 2009 2010 and 27% in 2010 2011). Obesity remained constant at 17% (16).

Available information on physical activity among boys and girls in 2011 2012 only refers to preschool children. Of the 1,235 boys and girls studied, only 541 were involved in sports, mainly swimming, baseball, and soccer. Participation was greater in boys than in girls (52% and 36%, respectively) (16).

Risk and Protective Factors

The Ministry of Public Health and Sports coordinates policies aimed at halting illegal-drug dependence. The Anti-Drug Foundation of Aruba is the nongovernmental organization that is most active in the prevention of drug use; the organization conducts awareness campaigns and organizes conferences and programs for young people, parents, and workers. The Addiction Management Foundation also works in this regard, by treating addiction. The foundation is engaged in the voluntary rehabilitation of addicted patients, based on Dutch laws and procedures. As of 2016, it reported that its 36 beds were filled, with an average stay of one year, and a high rate of relapse and readmissions. The patients are addicts living on the street who are picked up and taken to the institution to complete a one-year treatment program.

According to a study covering 2011 2012 (10), the most-frequently consumed drugs by students were marijuana (44.4%), cocaine (5%), and ecstasy (3.9%).

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Prospects

Despite its health system’s advances, Aruba faces significant health problems. Among these are the country’s aging population, the predominance of chronic, noncommunicable diseases and their risk factors, and drug and alcohol use by its young people. As these problems continue to evolve over time, various challenges will undoubtedly emerge in the implementation of public policies aimed at their prevention, control, and treatment.

The efforts made to reduce childhood overweight and obesity by promoting sports are impressive, but if results are to endure, these efforts must be sustained and must be able to reach the entire population, including the elderly. Lifestyle choices, development challenges, and other social determinants affect drug-use among adolescents and young adults, and require comprehensive and intersectoral actions. To support health promotion and health care within the framework of universal health, more and better public health infrastructure is imperative, as well as cooperation with institutions that provide health training (academic and practical) for human resources.

In Aruba the number of pregnancies among adolescents has progressively declined in recent years; this calls for an in-depth analysis of this data must be analyzed in greater detail and for its wide dissemination. Furthermore, the facts that women now complete schooling and are increasingly attending higher education institutions is a positive determining factor in terms of women’s health and development.

Aruba must continue to strengthen its strategies aimed at health promotion, disease prevention, and treatment and must engage all stakeholders in the system in order to fully address chronic, noncommunicable diseases and their risk factors.

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References

1. Pan American Health Organization. Health in the Americas 2012. Washington, D.C.: PAHO; 2013. Available from: https://www.paho.org/salud-en-las-americas-2012/index.php?option=com_content&view=article&id=19:aruba&Itemid=130&lang=en.

2. Central Bureau of Statistics (Aruba). Statistical yearbook 2014. Oranjestad: CBS; 2015. Available from: http://cbs.aw/wp/wp-content/uploads/2016/10/05-02-H-Statistical-Yearbook-2014.pdf.

3. Central Bureau of Statistics (Aruba). Statistical yearbook 2012. Oranjestad: CBS; 2013. Available from: http://cbs.aw/wp/wp-content/uploads/2015/09/Statistical-YB-2012-final.pdf.

4. Central Bureau of Statistics (Aruba). Statistical yearbook 2013. Oranjestad: CBS; 2014. Available from: http://cbs.aw/wp/wp-content/uploads/2014/10/SY-2013-final.pdf.

5. Central Bank of Aruba. State of the economy 2015. Oranjestad: CBA; 2016. Available from: http://www.cbaruba.org/cba/readBlob.do?id=3810.

6. United Nations. UNSTATS: Millennium Development Goals indicators-Aruba, 2010 [Internet]. New York: UN; 2012. Available from: https://unstats.un.org/unsd/mdg/Data.aspx.

7. Government of Aruba, Special Committee on Obesity. National Plan Aruba 2009-2018: for the fight against overweight, obesity and related health issues. Oranjestad: GOA; 2008. Available from: http://www.hls.aw/main/images/Plan%20National%20Aruba%202009-2018%20.pdf.

8. Ministry of Public Health and Sports (Aruba). Aruba den movecion: National Strategic Plan for Sports and Physical Activity 2010-2013. Oranjestad: MPHS; 2010.

9. Department of Economic Affairs, Commerce, and Industry (Aruba). National Security Plan Aruba: 2008-2012. Oranjestad: DEACI; 2008. Available from: http://www.arubaeconomicaffairs.aw/National_Security_Plan_-_English_version.pdf.

10. Diaz H. Baseline assessment of the drug problem in Aruba. Oranjestad: University of Aruba, Center for Research and Development; 2012.

11. Central Bureau of Statistics (Aruba). Health monitor 2013. Oranjestad: CBS; 2014. Available from: http://cbs.aw/wp/wp-content/uploads/2015/09/Health-Monitor-2013.pdf.

12. Central Bureau of Statistics (Aruba). STEPS Aruba 2006: risky living-an analysis of the risk factors underlying the main chronic diseases in Aruba. Oranjestad: CBS; 2013. Available from: http://cbs.aw/wp/index.php/2013/02/27/steps-aruba-2006/.

13. Central Bureau of Statistics (Aruba). STEPS Aruba 2006: chronic disease risk factor surveillance-data book. Oranjestad: CBS; 2013. http://cbs.aw/wp/index.php/2013/02/27/steps-aruba-2006/.

14. Department of Public Health (Aruba). Youth health survey: Aruba 2012. Oranjestad: DPH; 2013. Available from: http://despa.gov.aw/images/pdf/YouthHealthSurveyAruba2012.pdf.

15. Instituto Biba Saludabel y Activo (Aruba). “Health Bus”: one year of service to Aruba’s population. Oranjestad: IBiSA; 2013. Available from: https://www.ibisaaruba.com.

16. Department of Public Health, Youth Health Care Unit (Aruba). Annual anthropometric research. Oranjestad: DPH; 2013.

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