Sint Marteen

Overall Context

Sint Maarten became a constituent country on October 10, 2010, after having been part of the Netherlands Antilles within the Kingdom of the Netherlands for over 50 years. Sint Maarten is situated in the northeastern Caribbean Sea, located at the northern end of the Leeward group of the Lesser Antilles. The northern land border is shared with Saint Martin, one of the French overseas collectivities in the Americas.

In 2014, the population was 37,224, of which 18,201 (48.9%) were male and 19,023 (51.1%) were female, for a male-to-female ratio of 105:100.

There were 511 births registered in 2013, slightly more than in 2010 (496), and considerably more than the 414 registered in 2012 (1). According to a UNICEF report, this increase may be related to births among the many undocumented immigrants. The total fertility rate was 2.0 children per woman, and there were 60 births per 1,000 women aged 15-44 years old (1).

The average life expectancy at birth for total population in 2011–2012 was 77.1 years for females and 69.2 years for males (1).

The proportion of the elderly population in Sint Maarten has been steadily increasing. In 2002, 5% of the population was 60 years or older, compared to 5.9% in 2007 and 11% in 2012. The age groups between 50 and 60 years old represented 22% of the population, with the older segment of that group projected to grow most. This demographic shift will be a major contributor in the rise of health care costs and will put added pressure on the limited financial and human resources in the health sector. Figure 1 shows Sint Maarten’s population structure, by age and sex, for 1992 and 2015.

Figure 1. Population structure, by age and sex, Sint Maarten, 1992 and 2015

Sint Maarten’s population increased 26.9% between 1992 and 2015. In 1992, the population structure had an expansive pyramidal shape in the age groups over 30 years of age. The population younger than that showed a regressive shape between the ages 15 and 30 years and an expansive shape in the population younger than 20 years old. By 2015, the regressive shape had shifted to the groups older than 30 years, showing stationary growth below that age, as a result of decreases in birth and mortality rates in the last decades.

Source: Central Bureau of Statistics of the Netherlands Antilles (2005), Department of Statistics Sint Maarten.

Roughly 19% of the population belongs to a household consisting of a married couple with children, and 15% live in single-parent households. Within this latter category, single mothers with one or more children represent 13.18% of the population.

Sint Maarten is a small and open island economy, with tourism being the major driver of economic activity, which makes the country vulnerable to global economic developments. Sint Maarten’s economic growth decelerated between 2014 and 2015, when it experienced a weak GDP expansion paced at +0.4% in 2015. Growth in tourism, construction (from private investment), and yacht repair were responsible for the expansion. A reduction in government spending dampened the expansion (2). Agricultural activity remains a minimal contributor to the economy, with only 10% of land suitable for domestic agricultural production. Over 90% of food products are imported. The economy is projected to grow less than 1.0% in 2016 and 2017, according to the International Monetary Fund (3).

In 2013, 7.8% (US$ 19 million) of the national budget was allocated to the health care system, a figure that decreased to 6.3% (US$ 15 million) in 2014. The national budget allocation for education was 18.4% and 19.4% during 2013 and 2014, respectively (see Table 1).

Table 1. Government budgetary distribution (in million US$), by sector and total, Sint Maarten, 2013–2014

There were 216 ambulance calls associated with violence such as wounds, cuts, stabbings, and gunshots in 2009, dropping by approximately 50%, to a total of 110, in 2010. Crime statistics reported by the St. Maarten Police Force for 2014 (4) pointed to a decrease in overall crime incidents, though cases of physical violence had risen. Between 2010 and 2014, there was a 46% reduction in the number of capital offenses, to 1,140. Homicides and attempted homicides rose from 7 homicides and 12 attempted homicides to 10 and 23, respectively, over the same period. Crimes against physical integrity increased from 402 in 2010 to 547 in 2014; sex offenses rose from 17 to 26; the number of other offenses declined 28% to 148 (see Table 2).

Table 2. Criminal offenses, by type and percentage change overtime, Sint Maarten, 2010 and 2014

The main environmental issues are water and sanitation, water pollution, garbage collection, hospital waste management, and landfill management. Drinking water is obtained from seawater through reverse osmosis (desalination) and rainwater collection at home. Sewage coverage is scarce, with only a small portion of households in the country connected. Part of the problem is that the government fails to collect fees for sewerage connections, which would help cover the costs of sewerage management expenses and the costs of new connections.

Garbage collection, too, is insufficient, and does not meet the population’s needs. Landfill management is handled through a public–private partnership. In its 2015-2018 plan, the Ministry of Public Housing, Spatial Planning, Environment and Infrastructure acknowledges that there are structural challenges for improving service, as well as misconduct by businesses regarding the payment of the nominal fee for business waste collection (5).

The Health System

Sint Maarten’s health care system is privately managed, although the responsibility for securing quality health care and for developing legislation, guidelines, and policy falls under the auspice of the Ministry of Public Health, Social Development and Labor. The Ministry also plays a key role in protecting and promoting public health and in optimizing health care distribution, quality, and accessibility.

The Social & Health Insurances (SZV) administers and manages the national health and social insurance schemes, including general old-age insurance, widowers and orphans insurance, accident insurance, sickness benefits insurance, severance pay insurance, and general insurance for exceptional medical expenses (long-term). An estimated 30% of the population is uninsured, and 10% of the population has private health insurance.

Sint Maarten has primary and secondary health services, delivered by a mix of private and nonprofit providers. Primary care is delivered by general practitioners or family physicians, the District Nursing department of the White and Yellow Cross Care Foundation (“White and Yellow Cross”), dental care providers, and paramedics. The Turning Point Foundation; governmental organizations such as the Baby Wellness Clinic (“Baby Clinic”), youth health care services, and ambulance services; voluntary health care delivery services; and health NGOs such as the Sint Maarten AIDS Foundation, the Diabetes Foundation of St. Maarten (DFS), and the Positive Foundation (for cancer prevention) also are part of primary care services.

Secondary, or specialized, health care consists of clinical and outpatient services provided by nurses and medical specialists within a health care facility. Care by medical specialists is mainly accessible through referral by a general practitioner or another medical specialist (within the framework of intercollegiate consultations). Specialized health care is provided at three health care institutions: the St. Maarten Medical Center (SMMC); the White and Yellow Cross; and the Mental Health Foundation.

Complex care services are accessed outside of Sint Maarten, guaranteed through arrangements between the insurer, mainly Social & Health Insurances (SZV), and facilities in Aruba, Colombia, Cuba, Curaçao, the Dominican Republic, the United States of America, and Venezuela.

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Leading Health Challenges

Chronic Conditions

Given Sint Maarten’s current epidemiological-transition stage, communicable diseases remain a challenge among the population, while noncommunicable diseases (NCDs) continue to rise. According to the most recent census (2011), the leading NCDs were high blood pressure (10.7%), followed by diabetes mellitus (5.3%) and asthma (2.6%). In the 2011 census, diseases such as sickle cell anemia, cancer, and Alzheimer’s disease were included for the first time.

Human Resources

The Sint Maarten Medical Center’s hospital staff consisted of 260 faculty including 157 direct patient care staff, clinical attendants, administrative staff, and technicians. In 2012, of the total nursing staff working on the island, 115 were registered nurses, 16 practicing nurses, 2 geriatric nurses, and 12 nursing assistants (see Table 3). Statistics from 2013 confirm that 78 medical specialists were available across 17 specialties.

Table 3. Density of human resources and beds in health, by category, Sint Maarten, 2013

In 2014, 33 students started the Licensed Practical Nursing Course offered at the Sint Maarten Medical Center. The Center is certified to provide training and internships at various levels; it also offers certification for nursing assistants and professional nursing programs.

Health Knowledge, Technology, and Information

The integrity and completeness of Sint Maarten’s Health Information System (HIS) depends on the input of government agencies, health care providers, and health insurers. To date, health information continues to be generated and collected on paper, which hinders data consolidation and consequently hampers effective and timely decision-making. While there are some digital reports and surveillance bulletins, these are not tied to administrative and technical health data. The government is currently appraising various software and hardware programs in an effort to integrate health information among the many health-related institutions involved. As of this writing, data are collected independently and in isolation by each organization, insurer, health care provider, or government agency. For example, the Sint Maarten Medical Center began launching a new hospital information system in 2015, connecting wards within the hospital and allowing for staff to digitally make notes and view patient exam results and medical history (6). The system does not cover external health information or surveillance by other institutions.

Aging

In 2014, the productive age group (20-64 years old) accounted for 66% of the population, followed by the 0-19-year-olds (27.9%), and 65-year-olds and older (6.1%). The percentage of the elderly population is increasing steadily, shifting the socioeconomic landscape and adding stress to the demand for health care services.

Migration

In 2012, Sint Maarten’s population included persons of 91 recognized nationalities, with 118 different countries of birth. Most immigrants come to Sint Maarten for employment opportunities. For example, many private businesses, such as hotels, restaurants, and resorts, are owned by immigrants. Certain specialist positions can only be filled by foreign workers with qualifying training and experience (7). Immigrants also meet labor needs in areas such as construction, catering services, and cleaning (8).

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

As of this writing, Sint Maarten’s health system operates through several insurance schemes, a fragmentation that hinders the country’s ability to provide health services with equity and efficiency.

Prior to becoming a constituent country in 2010, Sint Maarten enacted legislation that established the Social & Health Insurances (SZV), which administers and manages the national health and social insurance schemes, including general old-age insurance, widowers and orphans insurance, accident insurance, sickness benefits insurance, severance pay insurance, and general insurance for exceptional medical expenses (long-term). For civil servants, the SZV also executes the General Specialized Illness Insurance Act and the Governmental Health Insurance Fund; the former covers the health insurance plan for all civil servants and their family members.

Several ordinances regulate aspects of the insurance system, such as the compensation of medical expenses for low-income workers and the unemployed,¹ the responsibilities of the Social Insurance Bank (SVB) in providing coverage for low-income employees,² the medical coverage for civil servants,³ and the medical coverage for retired civil servants.⁴ The General Ordinance on Special Medical Expenses (AVBZ) deals with non-insurable risks, handicaps, and open-ended care. Sint Maarten also operates under several rules and regulations that were designed in the Netherland Antilles and reflect Dutch principles of social welfare; as of April 2010, the rules and regulations pertaining to social security were incorporated into Sint Maarten’s Ministry of Public Health, Social Development, and Labor. The Ministry of Public Health faces major challenges in guaranteeing universal access to health services, ensuring good governance, and fulfilling an effective steering role. It should be noted that the public health budget is 2% of GDP.

The Sint Maarten Medical Center, a private, nonsubsidized medical center, provides primary and secondary health care to Sint Maarten’s citizens; it also provides health care support to nearby islands, including Saba, St. Eustatius, and Anguilla, thus serving an estimated population of 54,000. The Center has an outpatient care department and an inpatient care department. It also has an emergency and radiology department equipped with a computed tomography scan and three radiography machines; a dialysis department with seven chairs and dialysis machines; and specialized clinics for the consultation of various medical specialists. The inpatient care department includes medical, pediatric, and surgical wards; an intensive care unit and delivery room; an operating theater and recovery room with an on-call system in case of emergency operations; an admissions department; and a patient care department. In 2014, SMMC had 66 beds.

In 2014, the Sint Maarten Medical Center attended 523 deliveries, 1,826 surgical interventions, 13,477 ER visits, 28,239 outpatient consultations, and 3,916 admissions, with a 4.7-day average length of stay. Outpatient care in 2014 was broken down as follows: internal medicine 3,634, pediatric 5,810, ophthalmology 1,673, dermatology 2,125, cardiology 1,384, OB/GYN 7,510, and surgical 6,103.

The country has a reference laboratory, Sint Maarten Laboratory Services (SLS), which provides laboratory services for ambulatory and hospitalized patients 24/7. The laboratory guidelines, protocols, and external quality controls follow those set by the Netherlands’ health system. SLS also functions as an environmental laboratory, providing the government with important testing and monitoring of water surface quality and the sewage treatment plant.

Finally, it is important to highlight the role that two agencies play: the government-funded White and Yellow Cross and the Baby Clinic. The first provides care for the elderly through nursing home care, geriatric care, rehabilitation, and a residence for the disabled. The Baby Clinic provides maternal and child health services. The Baby Clinic provides maternal and child health services, covering pregnant women and 90% of children 0-4 years old; private pediatricians cover the remaining 10%. The facility’s staff includes three nurses, one receptionist, a general practitioner, a dentist, and a receptionist.

The Baby Clinic also caters to school-aged youth. To that end, it employs a youth health care physician, two registered nurses, and an administrative staff member. The Clinic also offers dental care coordinated by a dental and oral health promoter.

The SZV strives to contain costs through measures such as cost indexation, new agreements with international institutions for referrals abroad, and fraud reduction, in parallel with improved collections compliance efforts, to ensure the long-term sustainability of the health system. However, challenges remain in terms of access to treatment and the adequate use of diagnostic/medical equipment and information technology.

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Health Situation and Trends

Health of Population Groups

Child Health

The infant mortality rate between 2010 and 2013 rose from 4 births per 1,000 live births to 12, an increase attributable to improved registration.

For the age group 0-14 years old, the 2011 population census reported that 89% had a positive opinion of their health, two-thirds of which reported having “very good” health and one-third reporting “good” health. The most common disease reported in this age group in the 2011 census was asthma or chronic bronchitis, affecting 4% of this group. This was followed by multiple disabilities (0.59%), sickle cell disease (0.28%), and diabetes (0.12%). According to the 2011 census, more than 94.6% of this age group reported having no disability (9).

A study carried out in 2009 by students from Hanze University of Applied Sciences (Hanzehogeschool) in Groningen (the Netherlands) showed that among children 0–4 years old, at least one-third of the population studied was overweight, and among those, almost 45% were obese or severely overweight (10).

Health of Adolescents

According to the 2011 census, 92.8% of the 15-19-year age group referred to their health as “very good” or “good.” The 2011 census reported that for the 15-19-year age group, asthma / chronic bronchitis / CARA (chronic aspecific respiratory affections) was the most prominent disease, reported by 4.6% of the population in the age category. This was followed by 0.6% with multiple disabilities and 0.34% with sickle cell. Notably, the proportion of those reporting high blood pressure among 15-19-year-olds (0.21%) was more than twice that among 0-4-year- olds (0.09%). No disability was reported by 93.1% of those in the 15-19-year age category (9).

In 2010, Hanze University of Applied Sciences conducted a study among 12-18-year-olds. Results showed that almost 40% of the children studied were overweight and some 54% were obese. The conclusion of the study was that secondary school students are at risk of becoming obese as a result of their nutritional behavior and lack of physical activity (11).

Health of Adults

In the 2011 census, 87.0% of adults aged 20-64 years appraised their health as “very good” or “good,” evenly split between “good” and “very good.” For adults in this age group, the 2011 census reported that high blood pressure was the leading disease (9.14%), followed by diabetes (2.9%), and asthma/chronic bronchitis (1.4%). Among this age group 80.4% reported having no disability (9).

Health of the Elderly

According to the 2011 census, 60.6% of those 65 years old and older reported their health as “very good” or “good.” Of them, 36.6% reported “very good” health and 33.4% reported “good” health. The census also reported that 18.2% of this age group stated that they had high blood pressure, 7.0% diabetes, 1.5% glaucoma or eye pressure, 1.0% heart problems, and 24.6% other diseases; 38.8% of the group reported having no disability (9).

Mortality

Between 2010 and 2013, there were 685 deaths, averaging 171 deaths per year.

Ischemic heart disease was the leading cause of death in 2010 and 2012: one in four inhabitants of Sint Maarten died from ischemic heart disease. Diabetes mellitus ranks second as a cause of death, with 13% (or 23 deaths) in both 2010 and 2012. Mortality due to malignant neoplasms increased by more than 71% between 2010 and 2012 (12).

Morbidity

Communicable Diseases

In regards to vaccine-preventable diseases, no cases of rubella or congenital rubella were notified in 2010-2013. In 2010, a single measles case was reported, notified by a cruise ship. In 2012, there was one confirmed case of tetanus reported in a 63-year-old male; he was flown to the Dominican Republic for treatment (13–16).

The Ministry of Public Health uses a bus to deliver its outreach vaccination program. In May 2013, the Youth Health Care Section of the Collective Prevention Services introduced the pneumococcal vaccine; in September 2013, the human papilloma virus (HPV) vaccine was established for preadolescent girls 9-10 years old (16).

In terms of vector-borne diseases, in 2010, three dengue fever cases were reported in 2010; no severe dengue cases were reported. In 2011 and 2012, 22 and 38 dengue cases were reported, respectively. By 2013, there were 310 dengue fever cases and 6 severe cases reported, for a total of 316 confirmed cases. Of these, 44% were among females and 52% were among males; 4% were registered as “unknown.” Those 25-44 years old were the most affected by the disease, accounting for 35% of all cases (13).

Sint Maarten reported its first confirmed case of chikungunya on December 6, 2013; 8 cases were confirmed in the country that year.

There were no autochthonous malaria cases reported during in 2010–2013. However, there were two imported cases of malaria¾one from Nigeria in 2011, and one from India in 2012.

For the 2010 to 2013 period, no cholera cases were reported. Salmonellosis was the leading enteric disease reported, with 11 cases between 2010 and 2013. Two cases of shigellosis were reported (16).

In 2011, there were 18 new cases of HIV reported, 57.1% among males and 49.9% among females. Of these, four were diagnosed as AIDS, equally divided among males and females. The age groups most affected by HIV were 20-24-year-olds and 40-44-year-olds.

In 2013, 83.3% of adults diagnosed with HIV were being treated with antiretroviral drugs 12 months after diagnosis. There were no vertical transmissions from two HIV-infected mothers receiving antiretroviral therapy treatment.

General practitioners request HIV tests, which are then analyzed at Sint Maarten Laboratory Services. There is some duplication of laboratory testing, which is a matter of concern within the HIV surveillance system.

Chronic, Noncommunicable Diseases

To address diabetes in the country, the Diabetes Foundation of Sint Maarten conducts glucose testing and blood pressure measurements; in 2011 315 persons were tested. According to glucose tests administered among females, 30.6% were negative for diabetes, 6.6% were undiagnosed, and 62.8% were diagnosed as type 2 diabetes; only five persons among the last group presented satisfactory control at the time of testing. Among males, results were 46.6% not-diabetic, 30.1% undiagnosed, and 23.3% type 2 diabetes (17). A similar study was conducted in 2012 among 250 women and 74 men. Results from this study among females were 44.8% negative for diabetes, 9.2% undiagnosed, and 46% type 2 diabetes. Among males, results of this later study were 49% negative for diabetes, 11% undiagnosed, and 40% type 2 diabetes (18).

Mental Health

In 2014, the government launched the National Mental Health Plan 2014–2018. The Ministry of Public Health, Social Development, and Labor subsidizes the Mental Health Foundation (MHF), which is the sole provider for community-based mental health services on the island. Social insurance covers 80% of the population, providing total coverage for psychotropic medications. The other 20% is either not insured or has private insurance (16).(19). In 2012, diagnostic admissions were primarily for schizophrenia (45%) and mental and behavioral disorders due to psychoactive substance abuse (29%).

Disability

There were 3,843 persons (11.4% of the population) with disabilities in 2014. Visual impairments were the most common disability (2,370, accounting for 61.7% of disabilities), followed by multiple disabilities (1,112, 28.9%), physical disability (170, 4.4%), and intellectual/mental disability (61, 1.6%). Blindness was present in only 0.8%.

The 2011 census measured the age distribution of disabilities: 81.8% of the population reported having no difficulties, ranging from 88.4% the 0–14-year age group to 53.8% among the age group 65 years old and older (see Table 4).

Table 4. Prevalence of disabilities by type of disability, Sint Maarten, 2012

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Prospects

The outlook will depend on Sint Maarten’s capacity to address five core issues: 1. reducing the burden of communicable diseases, such as by improving early detection and control of communicable diseases; 2. reducing the burden of noncommunicable diseases, by improving early detection and promoting healthy lifestyles; 3. promoting health at crucial stages of life, and tackling social determinants of health; 4. strengthening governance and health system development; and 5. improving emergency and disaster preparedness, surveillance, and response. Also, Sint Maarten authorities must work to promote and coordinate health development through strategic alliances and networks.

Sint Maarten faces significant challenges in financing services within the current health care system, which is currently based primarily on institutions receiving financing from the State. The State must analyze the current health care system and its sustainability, based on lessons learned, to structure a quality health care system with universal access and coverage that is financially sustainable.

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References

1. Department of Statistics (Sint Maarten). Statistical yearbook 2014. Philipsburg: STAT; 2015. Available from: http://bearingpointcaribbean.esimg.net/wp-content/uploads/2015/06/cbs_2014_Statistical_Yearbook_2014_Sint-Maarten.pdf.

2. Central Bank of Curaçao and Sint Maarten. Annual report 2015. Philipsburg: CBCSM; 2016. Available from: http://www.centralbank.cw/uploads/files/Annual%20Report%202015.pdf.

3. International Monetary Fund. Kingdom of the Netherlands—Curaçao and Sint Maarten: 2016 Article IV Consultation Discussions – press release; staff report; and informational annex [country report]. Washington, D.C.: IMF; 2016. Available from: https://www.imf.org/en/Publications/CR/Issues/2016/12/31/Kingdom-of-the-Netherlands-Curaçao-and-Sint-Maarten-2016-Article-IV-Consultation-Discussions-44194.

4. Police Force of Sint Maarten. Crime figures 2014 in comparison with 2010, 2011, 2012 and 2013. Philipsburg: KPSM; 2015. Available from: http://smn-news.com/images/stories/pdffiles/crim%20cijfers%202014.pdf.

5. Ministry of Public Housing, Spatial Planning, Environment and Infrastructure (Sint Maarten). Ministry plan 2015–2018. Philipsburg: VROMI; 2015. Available from: http://www.sintmaartengov.org/Policy%20and%20Reports/151027%20-%20VROMI%20Ministry%20Plan%202015%20-%202018%20v2.9.pdf.

6. Sint Maarten Medical Center. New hospital information system improves patient management [news release]. 19 Jan. Cayhill: SMMC; 2015. Available from: http://smmc.sx/News/ArticleID/103/New-Hospital-Information-System-improves-patient-management.

7. United Nations Development Programme. First Millennium Development Goals report: Curacao and Sint Maarten 2011. New York: UNDP; 2011. Available from: http://www.undp.org/content/undp/en/home/librarypage/mdg/mdg-reports/lac-collection.html.

8. United Nations Children’s Fund. The situation of children and adolescents in Sint Maarten. New York: UNICEF; 2013. Available from: https://www.unicef.nl/media/1359112/sint_maarten_sitan_public_version__28english_29.pdf.

9. Department of Statistics (Sint Maarten). Census 2011. Philipsburg: STAT; 2012. Available from: http://www.stat.gov.sx.

10. Hanze University of Applied Sciences. Youth obesity research, students. Groningen: HUAS; 2009.

11. Hanze University of Applied Sciences. Youth obesity research, students. Groningen: HUAS; 2010.

12. Ministry of Public Health, Social Development and Labor, Collective Prevention Services (Sint Maarten). Leading causes of death on Sint Maarten, year 2010 and 2012. Philipsburg: VSA; 2014.

13. Ministry of Public Health, Social Development and Labor, Collective Prevention Services (Sint Maarten). Annual communicable disease report 2010. Philipsburg: VSA; 2011.

14. Ministry of Public Health, Social Development and Labor, Collective Prevention Services (Sint Maarten). Annual communicable disease report 2011. Philipsburg: VSA; 2012.

15. Ministry of Public Health, Social Development and Labor, Collective Prevention Services (Sint Maarten). Annual communicable disease report 2012. Philipsburg: VSA; 2013.

16. Ministry of Public Health, Social Development and Labor, Collective Prevention Services (Sint Maarten). Annual communicable disease report 2013. Philipsburg: VSA; 2014.

17. Diabetes Foundation of Sint Maarten. Report: 13th Annual Diabetes Fair, July 22nd–23rd, 2011. Philipsburg: DFS; 2011.

18. Diabetes Foundation of Sint Maarten. Report: 14th Annual Diabetes Fair, June 15th–16th, 2012. Philipsburg: DFS; 2012.

19. World Health Organization. WHO-AIMS report on mental health system in St. Maarten. Geneva: WHO/Ministry of Public Health, Social Development and Labour (Sint Maarten); 2013. Available from: http://www.who.int/mental_health/who_aims_country_reports/st_maarten_who_aims_report.pdf.

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