Pan American Health Organization

Suriname

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

The Republic of Suriname is situated along South America’s northeast coast and is bordered by Guyana to the west, French Guiana to the east, and Brazil to the south. It covers an area of 163,820 km2. Most of the population (80%) lives in the narrow coastal plain to the country’s north. Suriname’s interior, mainly consisting of tropical rainforest, occupies some 80% of the country’s territory, and a savanna belt extends along the border with Brazil to the south. Approximately 90% of Suriname’s total land area is classified as forestland; 12% of the land is set aside for natural reserves, national parks, and multiple-use management areas ().

Suriname gained its independence from the Netherlands in 1975. It is a constitutional democracy based on the 1987 Constitution. The Head of State is the President, who is elected by the National Assembly. The President appoints the Council of Ministers. The country is divided into 10 administrative districts: the two urban districts include Paramaribo (the capital city) and Wanica, there are six rural districts in the coastal area, and two districts in the interior. The urban districts occupy 0.5% of the country’s territory and are inhabited by 70% of the population ().

Demographics

According to the most recent census in 2012, the total population was 541,638, with a male-to-female ratio of almost 1:1 (). Relative growth of the population since the census of 2004 was 9.9%, the result of an average annual growth of 1.1%. Population growth was most pronounced in the 60 years and older age group, which grew by almost 30% over the nine-year period, whereas for 0–14 year olds, population increase was 1.6%. Figure 1 illustrates Suriname’s population structure, by age and sex, in 1990 and 2015.

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

The population increased 33.0% between 1990 and 2015. In 1990, the population structure had an expansive structure. By 2015, the pyramidal structure had shifted to ages older than 55 years; at younger age groups, the population structure shows lower expansion, becoming regressive in the age groups younger than 15 years. These changes are a result of a greater decrease in birth rate and mortality, especially in the last two decades.

Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division, World Population Prospects: 2015 Revision, New York, 2015.

The Hindustani ethnic group is the largest in Suriname (27% of the population), followed by the Maroon (22%), Creole (16%), Javanese (14%), mixed ethnicity (13%), and Amerindian (4%). People of Chinese and Caucasian descent together account for 2% of the population. Population growth was the largest in the Maroon group, from 15% in 2004 to 22% in 2012. This could be attributed to higher fertility rates in this group and possibly an increased “self-identification” with their ethnic group (). The census estimated the unemployment rate at between 10.3% and 12.8%. An estimated 6% of the population over 15 years old had not received an education, and the illiteracy rate was about 6%.

The Economy

The economy in Suriname was stable during the 2008–2012 period, with an average annual growth of 4.1%. The main drivers of the economy are the mineral sectors of gold and oil (). Economic growth during this period benefited government spending and subsidies to the social sectors, including the health sector. The drop in international prices of the major export commodities (gold, oil, and alumina) and the closure of the alumina refinery in late 2015 caused substantial fiscal deficits, and resulted in a recession of the economy. Due to declining foreign reserves, by mid-2016 the official exchange rate had devalued by some 90% (). In May 2016, Surinamese authorities reached a loan agreement of US$ 478 million with the International Monetary Fund (IMF) to support an economic reform program. In addition, financial loans were negotiated with other multilateral institutions, such as the Caribbean Development Bank, the Inter-American Development Bank, the Islamic Development Bank, and the World Bank Group, to support economic growth and social security (). The population has been confronted by skyrocketing prices of virtually all goods and services and increasing costs for gasoline, electricity, and other essential commodities. The government presented the Stabilization and Recovery Plan for 2016–2018 (), which delineates an emergency investment program, financed by the various loans. One of the Plan’s aims is to protect the population, especially the very poor and other vulnerable groups, from further economic impact from the adjustment. The IMF program will finance social cash transfer programs to provide financial assistance to lower-income households, the disabled, and the elderly. According to the Stabilization and Recovery Plan, economic growth in 2016 is projected at –2% but is expected to recover to + 2.5% in 2017 as a result of the opening of a new gold mine. The negative effects of the economic recession have already severely affected the population.

Violence and Security

As of 2013, Suriname’s murder rate (5 per 1 million population) and theft, burglary, and robbery rates (below 5%) were among the lowest in the Caribbean. However, domestic violence rates are among the highest in the subregion.

Leading Environmental Problems

Suriname’s Fourth National Report to the Convention on Biological Diversity (2012) () states that the expansion of illegal, small-scale gold mining and the associated use of mercury have detrimental effects on the forest and its ecosystems. To address illegal mining activity, the government established the Commission for Regulation of the Gold Sector. The potential health hazards related to gold mining and mercury use require interventions, monitoring, evaluation, and research (). Diseases resulting from deforestation and disturbances in ecosystems (e.g., vector-borne diseases such as leishmaniasis () are on the rise. The threat of the resurgence of malaria due to the constant influx of migrant workers in the gold and logging sector in the interior needs to be addressed.

Around 70% of the population has access to piped water in or within 200 meters of the house. In some rural districts and in the interior, people rely mainly on rain, creek, or river water (). Threats to the freshwater ecosystems include pollution from urban-domestic and industrial waste, changes in land use, agricultural runoff, droughts and floods due to climate change, and sea level rise (saltwater intrusion) ().

Health Policies, Plans, and Programs

In 2014, the National Basic Health Insurance Law () was passed, providing access to a basic package of primary, secondary, and tertiary care services for all residents of Suriname. To alleviate the shortage of doctors and nurses, admissions to the Faculty of Medicine at Anton de Kom University and to the School of Nursing have increased since 2013. Decentralization of health facilities, especially hospital facilities, was started with the construction of a hospital at the eastern border of the country with financial aid from the French Development Agency (AFD). Another hospital, with a nursing home, was planned for the Wanica district, financed by the Chinese government, but construction has been delayed.

Social Determinants of Health

The Multiannual Development Plan for 2012–2016 of the government of Suriname states that economic development forms the basis for social security and that social security stimulates economic growth (). The plan stresses policies to enable social protection for the population, especially for certain priority groups such as youth. In 2010, the Ministry of Sports and Youth was established and one of its accomplishments has been the construction of sports fields in various neighborhoods. In addition to the law on basic health insurance (), two other major pieces of legislation regarding social security were enacted in 2014: the law expanding pension benefits (), and the law establishing a minimum wage (). To address persisting inequities between urban, rural, and interior regions, and to tackle slum formation in peri-urban areas, the Multiannual Development Plan proposed several large investment projects to increase affordable housing, improve access to piped water, and promote local agricultural production. However, implementation was seriously hampered by the financial downturn in 2015, and a new, five-year plan is being developed ().

Vulnerable Populations

The Multiannual Development Plan for 2012–2016 states that specific government policies will increase social security for the most vulnerable segments of the population. The policies focus on groups with reduced access to basic commodities such as safe water and electricity—particularly inhabitants of the interior, including Maroons and Amerindians— or limited access to health care and social services—which includes the inhabitants of the interior, the poor, elderly, pregnant women, children, and people with a disability. Between 2010 and 2013, the State alleviated some of the needs of the most deprived. In 2013, all children under 16 and senior citizens (60 years and older) were entitled to free health care paid by the government (). Between 2003 and 2013, general child support has increased tenfold and the general pension provision was raised twice (). An after-school program was introduced in 2012 for all elementary schools nationwide, which provided free meals, mentoring, and activities. Due to the financial recession this program was terminated in 2015. To help protect the constitutional rights of the lesbian, gay, bisexual, and transgender (LGBT) community, which suffers from discrimination, there is ongoing dialogue between advocate groups and the government.

The Health System

The first level of care in Suriname’s health system comprises a network of government-subsidized primary health care facilities. The Regional Health Services receives public funds to operate some 43 primary health clinics in the coastal area. In addition, there are some 150 private primary care clinics that are only accessible to the population in the coastal area. Medical Mission, a faith-based organization, receives government funding to manage about 56 primary health clinics in the interior districts.

There are five hospitals, four of which are located in Paramaribo and one in the district of Nickerie at the western border. The only psychiatric hospital is located in Paramaribo. The Bureau of Public Health (known as the BOG, for its Dutch acronym) is responsible for the public health programs, including environmental health and sanitation, and also operates a public health laboratory. Access to specialized and emergency care for those living in the interior remains a challenge because of the organization of services, coverage of care, and high transportation costs either by air, road, or boat to a hospital in the capital. Access to secondary care occurs through referrals by primary care physicians.

During the 2010–2014 period of economic growth, the health care infrastructure improved nationwide. Medical Mission and Regional Health Services expanded and renovated their facilities. This period also saw an expansion and decentralization of private laboratory diagnostic services, and private primary care, dental care, and other paramedic practices. The two private and three public hospitals, especially the Academic Hospital Paramaribo, renovated and expanded their facilities and invested in equipment and staff for specialty care (gastroenterology, oncology, intensive care, renal dialysis, etc.). The national radiotherapy center, a department of the Academic Hospital, became operational in 2013, resulting in a substantial decrease in the number of patients sent abroad (mainly to Colombia and Cuba) for cancer treatment. Investments in facilities and training of health workers in chronic care were supported by external and government funding and resulted in the opening of two polyclinics (so-called “One-Stop Shops”) in 2013, which focus on patient-centered, multidisciplinary diabetes care.

The main threat affecting the entire health care system is the financial downturn. The Medical Association and Parliament have urged the government to intervene to prevent the health care system from collapsing, putting the health and lives of residents at risk.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

The endemicity of all four serotypes of the dengue virus and the outbreaks of chikungunya and Zika fever in all regions of Suriname (rural, coastal, and interior) illustrate the failing vector-control measures against the Aedes aegypti mosquito. An entomological survey by the BOG in 2015 revealed high Ae. aegypti indices in homes and water containers. The survey found that informal waste disposal and inadequately covered water containers, used primarily where there is limited piped water supply, particularly in rural areas and the interior, are important breeding sites. Another concern is the presence of Ae. aegypti mosquitoes in hospitals due to construction problems related to open water drainage and flooding of cellars ().

Malaria

Malaria has been virtually eliminated in the residential villages of the interior since 2007; the main risk groups are migrant, small-scale gold miners, mainly from Brazil. The government of Suriname, supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria, targets these populations for anti-malaria activities, using locally trained “malaria service deliverers.” Their work is increasingly concentrated in the mining areas along the southeastern border with French Guiana. Government and donor funds will be used to reach malaria elimination by 2020, ensuring that the areas with low or no transmission remain malaria-free and scaling up the control activities in the migrant populations ().

Neglected Diseases and Other Infections Related to Poverty

Cutaneous leishmaniasis is an increasing public health problem. The number of cases diagnosed and treated at the Dermatology Services Clinic of the Ministry of Health in the capital increased over the 2004–2012 period, and is related to gold and timber extraction in the interior of Suriname (). Similarly to malaria, people working in these areas (mainly Brazilian gold miners) are at greatest risk, and men are affected nine times more than women. Others who visit the interior (armed forces, teachers, tourists) are also at risk, but at a lower level than miners (). Preventive messages targeted at the various risk groups need to be scaled up, as does the dissemination of diagnostic and treatment protocols among health workers in order to prevent a continued rise in the spread of leishmaniasis.

According to the recently developed Leprosy Control Guidelines, as a result of the Ministry of Health’s efforts to combat leprosy (which are supported by legislation and regulations from the 1970s), the incidence of leprosy at the national level had decreased to elimination levels in 2014 (). Some rural and interior districts continue to experience incidence levels above the elimination level, however. The guidelines stress the importance of screening and active contact tracing, specifically in rural areas and in the interior.

Maternal Mortality

Providing universal access to health care for mothers and their newborns remains a challenge, and disparities in access are often related to geographic location, health care, literacy, and insurance coverage (). Although all insurance schemes cover some access to preconception, antenatal, and delivery care for women older than 16 years, there is often no full coverage of the required care package. The latest Multiple Indicator Cluster Survey (MICS), conducted in 2010 (), showed that some 30% of interviewed women mentioned that, although they are insured, they had to make additional payments for antenatal services, for example for sonograms. Health insurance companies have restrictions with regard to hospitalized newborns, leaving parents with catastrophic out-of-pocket costs (). The Safe Motherhood and Newborn Health Action Plan was developed to address the lack of uniformity in protocols (ante-, intra-, and postpartum and emergency obstetric care), which has limited monitoring of the quality of services, especially in primary health care ().

According to the MICS 2010 results (), the use of modern contraceptives has hardly increased over the past five years, with some types of contraceptives being not covered or only partly covered (e.g., female sterilization). Abortion is illegal in Suriname, and the Safe Motherhood Action Plan addresses the fact that because abortions are not registered, it is not possible to track actual numbers.

HIV and AIDS

HIV and AIDS present the largest burden from a single disease in Suriname, representing the main cause of premature death and years lived with disability (). Prevalence is more than five times the national average for subgroups including men who have sex with men and sex workers, although incidence in these populations is declining. Challenges remain to reaching sex workers in remote areas and “hidden” men who have sex with men ().

The National Strategic Plan for HIV stresses the need for stronger intersectoral cooperation involving nongovernmental, LGBT, faith-based, and community organizations. The plan addresses the problem of teenage pregnancies (one in every six live births is to a teenage mother), which is an indication that condom use among youth is still insufficient. Adolescents (10–19 years old) in the rural interior, from mostly Amerindian and Maroon villages bordering areas with gold mining activities, are more at risk than others.

Men have higher readmission hospitalization rates due to AIDS () and lower viral suppression than women, which is indicative of less adherence to treatment and care(). The National Strategic Plan for HIV highlights the importance of strengthening the continuum of care for people living with HIV and AIDS between the different levels of the health system by using a patient-centered, multidisciplinary team approach that also addresses the stigmatization of those with the disease (). Another priority area in the plan is the elimination of mother-to-child transmission of HIV. The problem of repeat pregnancies in HIV-positive pregnant women indicates a need for the integration of effective sexual reproductive health and family planning services.

Tuberculosis

Among new tuberculosis (TB) cases, more men than women are being diagnosed (2.4:1 ratio), which is higher than would be expected given average global male-to-female ratios (). About one-third of TB patients are HIV-positive, and the country’s Tuberculosis Plan for 2015 to 2020 () calls for integrated actions to address the high coinfection rate of HIV and TB.

Another priority area in the Tuberculosis Plan is outreach to migrant populations. Brazilian miners working in Suriname have been found to have sputum smear–positive TB, and positive contacts; some prefer to seek treatment in French Guiana.

Chronic Conditions

Noncommunicable diseases (NCDs), particularly cardiovascular disease (CVD), are the main causes of mortality and morbidity in Suriname. The main risk factors of the NCD epidemic in Suriname are unhealthy diet, overweight and obesity rates, sedentary lifestyle, and high smoking rates in men (). The STEPS survey conducted in 2013 shows that CVD risk in rural areas does not significantly differ from urban areas as might be expected (); this could be an indication that urbanized lifestyle (e.g., easy access to processed foods and drinks) has penetrated rural areas. The interior region still has significantly lower CVD risk factor rates.

The Parliament passed comprehensive tobacco control legislation in 2013, which was an important step by the government to curtail the detrimental effects of at least one NCD risk factor (). Other legislation and regulations regarding healthy foods and the promotion of sport and recreation are still pending. The recently established Health in All Policies (HiAP) initiative, an intersectoral platform involving government, private sector, and civil society, is designed to address the social determinants of health through the adoption of targeted policies (). The NCD Action Plan for 2012–2016 includes actions for several priorities and emphasizes the importance of an intersectoral approach ().

Mental Health

The high rate of suicide and suicide attempts is considered one of the main public health problems by the government. Each year more people die from suicide than from traffic accidents and homicide combined, and Suriname ranks sixth in the world for the number of suicides committed (). Many factors contribute to the country’s inordinately high number of suicides, including easy access to highly effective means to commit suicide (pesticides); sensational media coverage of suicides; stigma around mental health issues; intolerance toward the LGBT population; and domestic violence (). The National Plan for Suicide Prevention for 2016–­2020 advocates a strong, intersectoral approach to address the drivers of this public health problem ().

Human Resources

It has been the policy of successive governments to scale up the number of health workers to address shortages. Concrete measures in training and education are under way. Between 2013 and 2015, enrollment doubled in the Medical Faculty of the Anton de Kom University of Suriname (). In 2013, the Ministry of Health approved the development of a residency training program in family medicine and a revolving fund was established to support residents to continue their training abroad (mainly in the Netherlands). The Central Institute for Training in Nursing and Allied Professions (COVAB) () has increased specialized training for geriatric, diabetes, and dialysis nursing. Accredited courses for doctors, nurses, and other health professionals have been provided by the Foundation for Continuing Education of Medical Professionals (SPAOGS) for the past 10 years (). In 2013, the Scientific Research Center of the Academic Hospital Paramaribo was established to improve research capacity among health workers ().

Health Knowledge, Technology, and Information

Limited progress has been made in developing an integrated health information system, including electronic medical records. The implementation of telemedicine and telehealth, especially for remote areas, remains a priority. The government has developed an eGovernment Strategy for 2012–2016 that is in its implementation phase (). One result is that many government documents and audio and video productions, including from the Ministry of Health, are now available online.

The Environment and Human Security

Suriname’s Report on Sustainable Development projects that continued population growth and the expected decrease in precipitation will negatively affect the availability of water in the country by 2050 ().

A climate change policy document is still lacking and Suriname has chosen to use the REDD+ structures (i.e., reducing emissions from deforestation and forest degradation) set out by the United Nations Framework Convention on Climate Change for the planning process. Climate change and sea level rise will result in increased storm surges, wave attacks on the shoreline, land loss, salinization, and loss of biodiversity on the coast (). The National Biodiversity Action Plan provides a framework for incorporating biodiversity, cultural, and nature conservation measures and values into national development plans and sector plans ().

Suriname lacks an integrated waste management policy for the operations of the country’s open dumps, illegal dumping, and littering along roadsides and in open waters which continue to pose hazards to health and the environment (). Moreover, the country does not have a dedicated facility to store or dispose of hazardous waste and no regulations for the safe use and storage of pesticides.

The government recognizes that a sustainable agricultural sector is a priority to ensure food security for the population, and several agricultural development plans are in progress (). The Ministry of Agriculture’s Food Safety Strategy report identifies many gaps in food safety management in Suriname. These relate to policy and regulation, as well as standardization and licensing; inspection and surveillance are fragmented and laboratory capacity needs strengthening. Moreover, food technology and public information and education are poorly developed. To tackle these problems the report recommends the establishment of an inter-ministerial National Food Safety Platform to provide the framework for overall coordination and integration of food safety management ().

Aging

Investments have been made in providing economic and health security for the elderly in Suriname. The government increased the general pension allowance and has enrolled every citizen over 60 years of age in the national basic health insurance scheme. In its effort to improve specialized health care for the elderly, the Ministry of Health supported training for the first clinical geriatrician in the country, and the nursing school has developed a geriatric nurse training program (). Legislation regulating the qualifications of staff and facilities for institutional care, including care of the elderly, came into effect in 2014.

Migration

Suriname’s migration has reversed from a negative to a positive balance since 2005 (). Most registered labor immigrants are Chinese, employed in large and small businesses, particularly restaurants. The need for highly skilled workers, e.g., medical doctors and nurses, has been partly resolved by recruitment from Cuba and the Philippines.

The National Basic Health Insurance Law requires that all residents, including registered immigrants, have health insurance (). Legally employed migrants in Suriname have a right to public pensions but do not have access to other social welfare payments. All children, irrespective of their legal status, have a right to education (). Estimates are that the numbers of undocumented immigrants, especially from Brazil and Guyana, are far higher than documented immigrants. Undocumented immigrants are not entitled to any social benefits, including free health care, which poses barriers for their access to health care.

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

The estimated total health expenditure was 6% of GDP in 2014 (). A decline in spending for public social programs is ongoing as a result of the financial downturn, but a recovery to previous levels is projected after 2017 ().

In 2014, the Basic Health Insurance Law came into effect, ensuring that every resident has access to basic health insurance. The government subsidizes children under 16, those over age 60, and pregnant women (). Employees pay up to 50% of the premium and employers cover the other half; the government pays the coverage of those unable to pay. The basic health care package as defined in the law includes access to primary health care services, secondary care, and a defined package of tertiary services (e.g., oncology, renal dialysis, cardiology, and surgery). The law sets payment caps for specialized services such as renal dialysis, MRI, cancer medication, etc. This limits accessibility to the full treatment course for some diseases, forcing patients and their families to spend considerable amounts of money to initiate or continue lifesaving treatments.

Legislation regarding blood supply was also enacted in 2014, with the aim to safeguard and secure the safety of blood supply in the country. The law passed in 2014 to regulate the qualifications of staff and facilities for institutional care for the elderly also applies to human resources in organizations caring for children and people with disabilities.

A report on Health in All Policies was the result of a first-time assessment conducted in 2015 () to compile evidence regarding inequity, risk factors, and social determinants for disease in Suriname. The first National Consensus Workshop on HiAP followed the assessment, and the 15 largest contributors to disease were grouped into six policy domains that addressed common social determinants.

Prospects

In the past decade great progress has been made in the control of malaria; the corresponding MDG has been reached and efforts are focused on the elimination of this disease. Universal access to good-quality care, in particular maternal and neonatal care, will remain a priority in the coming years, as maternal and infant mortality rates still are above the MDG targets. EPI vaccination coverage of infants needs to be scaled up to reach the MDG target. The efforts to stop mother-to-child transmission of HIV have been successful, and the elimination target is within reach, but mother and child health services need to be strengthened to ensure sustainability of this program. Other priority areas of HIV control need to be addressed, such as attending to at-risk populations (youth, men who have sex with men, and sex workers), adopting novel treatment adherence strategies, and integrating TB and HIV screening and care services.

Significant legislation was enacted to provide universal health insurance coverage, establish a minimum wage, and expand pension benefits. Tobacco control legislation came into force, but more needs to be done legislatively to facilitate healthy lifestyle choices and curtail the high incidence of NCDs. This requires programs in schools and workplaces, increased availability of healthy food in urban and rural areas, and construction of recreational and sports facilities. Environmental health hazards, such as the use of mercury in mining and handling of pesticides, also require regulatory action. These interventions demand strong collaboration in a setting where policy-making is fragmented across different sectors.

In 2015, the first steps were taken to promote a Health in All Policies vision across sectors These important initiatives needs to be fostered, expanded, and put into concrete action in the coming years. Strong intra-sectoral and intersectoral action will be required to tackle some of the country’s most pressing health challenges, such as preventable perinatal and maternal mortality, NCDs, accidents, environmental hazards, and mental health, and to meet the targets of the United Nations Sustainable Development Goals for health (SDG 3) by 2030, which include a continuation of the MDG agenda.

In Suriname the economic crisis threatens the gains achieved, as well as the possibility of efficiently addressing ongoing and new health challenges. Safeguarding the health agenda in these times of crisis must remain a priority and continued advocacy and support by the international community is crucial in this regard.

References

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Reference/Note:

1. Under one case per 10,000 population.

2. Bureau of Public Health (BOG). Causes of death 2011–2013.

3. Bureau of Public Health (BOG). Causes of death 2011–2013.

4. Below one case per 1,000 inhabitants.

5. Bureau of Public Health (BOG). Zika update, June 2016.

6. Bureau of Public Health (BOG). Causes of death 2011–2013.

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