Economy: The estimated GDP growth rate in 2003 was 5 %. In 1999, it was estimated that between 50 – 75 % of the population lived below the national poverty line. As of January 1, 2004, Suriname has changed its currency note from Surinamese Florin (Sfl) to Surinamese Dollar (SRD). The exchange rate is stable at 1 US$ = SRD 2.7.

Mortality: In 2001, the estimated death rate was 6.8 deaths per 1,000 population. Approximately 87 % of all deaths registered at the Civilian Registry are certified. Deaths from external causes in 2001 accounted for 11 %, tumors for 11 %, and diseases originating in the perinatal period for 6% of all deaths.

Hypertension and cardio-vascular diseases, including cerebrovascular diseases and external causes were the leading causes of death in 1998 - 2001. The death rate due to malignant neoplasm has remained on the 3rd place. HIV/AIDS death rates are steadily increasing each year from the 8th place in 1999 to the 6th place in 2000 and 2001. The main change in leading causes of death is due to certain conditions originating in the perinatal period, which moved up to the 4th place in 2000 and 2001. The total number of deaths was 3,099 in 2001 and 3,125 in 2002.

SPECIFIC HEALTH PROBLEMS

Analysis by population group

Children: About 80 % of all births take place in a hospital. Around 11.4 % of newborns have birth weights under 2,500 grams. In 2001, infant mortality rate was 15.9/1,000 live births (154 infant deaths). In 2002, the infant mortality rate was 21.1/1,000 live births (215 infant deaths). The perinatal mortality rate in 2002 was 31.7 per 1,000 live births. Most infant deaths are due to conditions originating in the perinatal period (49 %), followed by congenital malformations, and gastrointestinal and respiratory infections.

In 2002, the reported mortality rate for children under five years old was 22.6 deaths per 1,000 live births. The major causes of death in children 1-4 years old were gastrointestinal infections and external causes.

Slightly over 13 % of children under age five in Suriname are underweight and 2.1 % are severely underweight. Approximately 10 % of children are stunted and 6.5 % are wasted. Only 13 % of children aged under four months are exclusively breastfed.

Schoolchildren and adolescents: Accidents and trauma are the main causes of death among the age group 5-14 years old. Among 15-19 year olds, prostitution, crime and drug use are the main problems in socially deprived areas.

Adults: Accidents and trauma are the main causes of death in this age group, followed by HIV/AIDS and cardiovascular diseases. In 2002 – 2003, AIDS was the second and third leading cause of death for males and females in the age group 15-44 years old, respectively. Cancers ranked among the top three causes of death in women, while for men, external causes, cardiovascular and cerebrovascular diseases were of major concern.

About 40 % of women with partners use a contraceptive. The maternal mortality survey for 1995-1999 reported an annual average of 73 maternal deaths per 100,000 live births. The 2001 maternal mortality ratio was 154/100.000 live births (15 maternal deaths). The major causes of maternal mortality were hypertensive disorders complicating pregnancy, complications of delivery and puerperium.

Elderly: People 60 years and older account for 8.5 % of the total population, with slightly more females 53.3 % than males 46.7 % in 2003. The major causes of death were hypertension and heart disease followed by cerebrovascular disease and malignant neoplasm. Most cancer deaths (27 %) were cancer of the gastrointestinal tract, followed by cancer of the reproductive organs (17 %), respiratory organs (11 %), female breast (9 %), blood and lymphoid tissues (9 %) and urinary system (4 %).

Family: About 40 % of households consist of 3-4 members. Of children aged 0-14 years old, 62.2 % live with both parents, 22 % live with their mothers and 7 % live with neither parent.

The disabled: The Ministry of Social Affairs (MSA) coordinates special programs for the disabled. Non-governmental organizations (NGO's) undertake activities on behalf of disabled groups. The Rehabilitation Center of the Academic Hospital provides services to patients referred for fitting of artificial limbs, physical therapy, occupational therapy and speech therapy.

Indigenous groups: The Medical Mission, a government funded, nonprofit organization, provides preventive and curative health care free of charge to the 50,000 people. There are about 20,000 - 40,000 gold miners, an industry predisposing workers to mercury poisoning and malaria transmission; other pertinent conditions are HIV/AIDS and Sexually Transmitted Infections (STI’s).

Analysis by type of health problem

Vector borne diseases: A total of 14,139 cases of malaria were reported in 2003. In endemic areas, 40 % of the cases occur in children under 5 years old and 60 % in children under age 14. Chloroquine resistant malaria due to Plasmodium falciparum is widespread, but quinine resistance has not yet been established. Reported cases of dengue rose markedly from 3 laboratory-confirmed cases in 1997 to 149 in 1998, all sero-type 1. In the interior of Suriname with the highest level of malaria risk, 72.2 % of under five children slept under a bed net the night prior to the survey interview. However, only about 5 % of the bed nets used are impregnated with insecticide.

Vaccine preventable diseases: From 2000 to 2003 there were a total of 8 confirmed tetanus cases (3 cases in 2000, 2 cases in 2001, 2 cases in 2002 and 1 case in 2003) (excluding. neonatal tetanus), 3 confirmed neonatal cases (all 3 cases in 2002), 0 confirmed rubella cases and 0 confirmed cases of congenital rubella syndrome. 72.8 % of children under 1 year old received DTP3, 73.5 % received OPV3, 72.8 % MMR in 2002, and in 2003 the immunization coverage was as follows: DTP3: 76.6 %, OPV3: 76 % and MMR: 69.8 %. In 2000, 87.8 % of children received Polio 1 by age 12 months and this declines to 78.5 % by the third dose. The coverage for measles vaccine was lower than for the other vaccines at 60.2 %. (Source MICS 2000)

Intestinal infectious diseases: Reported salmonella infections rose from 14 cases in 1995 to 87 cases in 1999. In 2000 there were 53 cases. In 2001, there were 48 confirmed cases of salmonella, and in 2002 this number increased to 91 confirmed cases of salmonella.

Shigella infections declined from an average of 20 cases per month in 1995 to 9 in 1999. About 4.5 % of 7,704 stools examined at the Bureau of Public Health (BPH) in 2000 tested positive for helminthes.

Chronic communicable diseases: From 1997 to 2000, a yearly average of 87 suspected cases were reported, of which 53 were confirmed. Of these, 2 were HIV co-infections in 1998 and 9 in 1999. Since 1999, all clinical tuberculosis (TB) patients are tested for HIV. In 2000, 13 out of 90 TB cases, in 2001, 9 out of 80 TB cases and in 2002, 21 out of 100 TB cases were HIV co-infections. A total of 161 new cases of leprosy were reported during 1997-1999, 30 % of all cases occurring in children 0-14 years.

Zoonoses: Sero-prevalence surveys in 1997 and 1998 among blood donors for T. cruzi yielded no positive cases. In 1998, a local outbreak of rabies transmitted by bat bites occurred in the interior. Six children developed clinical symptoms and died; one case was serologically confirmed. During 1999 – 2002, no cases of rabies were reported.

HIV/AIDS: HIV/AIDS was the eighth leading cause of death in 1999 and the 6th leading cause in 2000 and 2001. The death rate steadily increased from 5.6 in 1995, 9.3 in 1997, 16.3 in 1998 and 17.7 in 1999 to 29.2 in 2001 per 100,000 population. The male: female death ratio was 2:1. In 2000-2001, for males and females aged 15-44 years; AIDS was the second and third leading cause of death, respectively, after external causes.

Sexually transmitted infections: Gonococcal infections almost doubled from 327 cases in 1998 to 629 in 1999. Syphilis cases tripled from 67 in 1998 to 233 in 1999. In 1999, 8 cases of congenital syphilis were reported.

Metabolic diseases: Diabetes mellitus was the 5th leading cause of death with 125 deaths, presenting 4.6 % of all deaths in 2000 and with 141 deaths, presenting 5.4 % of all deaths in 2001. In 2002 Diabetes Mellitus is still on the 5th place with 164 deaths, representing 5,5 % of all deaths.

Cardiovascular diseases (incl. cerebrovascular disease): This group has been the leading cause of death for many years, accounting for 28.4 % of deaths in 2000 and 28.0 % in 2001. Of these deaths, 89 % occurred in the age group 45 years and older.

Malignant neoplasms: In 2000 and 2001, malignant neoplasm ranked 3rd as a cause of death; one-third were cancers of reproductive organs. Cervical cancers were the most common, followed by breast cancer in females and prostate cancer in males.

Accidents and violence: External causes, mostly accidents and violence, account for 8.5 % of registered deaths. They are the leading cause of death in both males and females aged 15-44 years.

Emerging and re-emerging diseases: In 1998, 2 cases of meningococcal meningitis and 5 cases of Haemophilus influenzae type B, were reported. In 1999, there were 3 cases of Cryptococcus neoformans and 6 cases of Haemophilus influenzae type B. There were 3 reported deaths due to meningitis during 2000.

RESPONSE OF THE HEALTH SYSTEM

National health policies and plans: In May 2004 the Sector Plan Health Care 2004-2008 was approved by the cabinet. This plan consists of seven strategies:
1. Strengthening primary health care and prevention.
2. Improving the efficiency as well as the quality of hospital care.
3. Promoting financial access to health care.
4. Control of the cost for health care.
5. Strengthening of support systems.
6. Human Resources development.
7. Improving and safeguarding quality.

Actual improvement of the health sector in Suriname i.e. improved services for patients requires implementation of the many recommendations coming from the health sector reform studies. Studies conducted in preparation of the Sector Plan Health Care 2004-2008 identified three basic pillars for the reform of the health sector:
1. Improve efficiency: cost control measures;
2. Improve equity: protection of the underprivileged;
3. Improve quality: quality assurance instruments.

Also in 2004, the government approved the National Strategic Plan on HIV/AIDS, which clearly indicated the need for a multi-sectoral approach. Its priority areas include:
1. Coordination, policy formulation, legislation and advocacy
2. Prevention
3. Reduction of stigma and discrimination
4. Treatment Care and Support
5. Monitoring and Evaluation

Institutional organization of health systems: The core-institutions are the Ministry of Health's (MOH) Central Office and the Bureau of Public Health (BPH), and Inspectorate. The central office and inspectorate are responsible for standard-setting, inspection and monitoring and the BPH is responsible for program development. The government provides primary health care to the poor through the Regional Health Service (RHS) and through the Medical Mission (MM). Primary Care clinics, managed by large firms, provide services to their employees and their families. The Foundation for Family Planning, a NGO, provides reproductive health care services. All hospitals are located in the coastal area. There are 3 public hospitals and 2 private hospitals and 1 psychiatric hospital. The private Diakonessen Hospital, through an agreement with the MM, provides hospital care to patients from the interior. Hospital care for these patients is paid by the Ministry of Social Affairs (MSA). The RHS operates a total of 41 clinics in all 8 coastal districts.

With a total of 1,318 (excluding psychiatry beds) Suriname has 2.7 beds per 1,000 population. The average bed occupancy rate showed a steady decrease to around 60 % in the mid 90s, after which a slow raise followed, with 63 % in 2002. The average length of stay of 7.2 days in 2002 is clearly one of the indicators that stands paramount to other countries.

With regard to senior citizens there are currently no laws and/or a network of regulations in place. The Civil Code of Suriname includes provisions on the duty to support the senior citizens and needy persons by their children. These provisions are however not fully practiced.

Following up on the Universal Declaration of the Human Rights of the United Nations of 10 December 1984, there is a draft legislation (on home care services and the general health insurance) and a number of study reports on this matter.

The advisory report on the introduction of a general health insurance plan for Suriname stresses the implementation of a Social Insurance System.

Poverty eradication policies are not yet in implementation, but policies towards poverty reduction are well underway for priority groups mentioned before. The Ministry of Social Affairs is in charge of the general wellbeing and specifically the social care for the senior citizens in Suriname. To this end, a number of provisions are implemented for the senior citizens with regard to poverty reduction.

• Subsidy to the homes for the senior citizens. The subsidy is given on the basis of the number of occupants of the homes.
• Financial support to the needy to cover the cost of living, etc.
• Free medical services to the poor and near poor
• Monthly payments to those with a free medical service card.

The Ministry of Social Affairs is the responsible institution for certifying the people living in poverty and near poverty, and ensuring that the economically disadvantaged population has access to state subsidized healthcare. The Ministry provides access to state subsidized health care to approximately 42 % of the population (1996 estimate), of which most access care at the government hospitals and clinics. From the data collected in the 1999/2000 Household Budget Survey, it was estimated that between 50-75 % of the population lives below the national poverty line.

Health insurance: The main types of health care financing are:
1) the State Health Insurance Fund with a comprehensive package of health benefits for 35 % of the population (civil servants and their dependents)
2) The MSA with free of charge primary and secondary health care services of the poor and near-poor covering about 42 % of the population; and
3) Private firm insurance plans and private health insurance plans covering about 20 % of the population.

Health promotion: There are several health promotion activities in the areas of environmental health, reproductive health, community health, disease prevention and control and public health education, initiated and implemented by NGO’s, as well as GO’s and supported by the international development partners. Initiatives of NGO's have taken an active role in attaining certain health outcomes, for example the Community Health Development program, implemented by ProHealth or the activities of the Foundation for Clean Suriname in the area of environmental health. The national health promoting schools committee is a government led initiative, taking the lead in the healthy schools initiative. In the area of disease prevention, the fight against HIV/AIDS is a multi-sectoral activity. The Bureau of Public Health (BPH) not only provides public information on the prevention of malaria, dengue, leptospirosis, yellow fever, other communicable diseases and breast-feeding practices, but has also taken the lead in the prevention of non-communicable diseases through Disease Prevention and Health Promotion.

Surveillance systems: Systems for all reportable diseases include hospital surveillance and telephone sentinel systems. A surveillance system for maternal deaths began in 2000.

Potable water and sewerage services: Approximately 73 % of the population has access to drinking water: 92.6 % in urban and 66.6 % in the coastal zone, while only 20 % in the interior. Many distribution systems are compromised because of poor maintenance, water theft and leakages. Mercury pollution in the interior and excessive pesticide use on agriculture lands in coastal areas and the widespread use of septic tanks pose a major threat to drinking water quality. Considering the fact that disinfection is not practiced, the statement that piped drinking water in Suriname is safe can not be substantiated. 88 % of the population of Suriname is living in households with sanitary means of excreta disposal, mainly septic tanks. There are vast differences between the urban and the coastal zone with over 98 % and the interior where only 30.5 % having sanitary means of excreta disposal. The sludge from septic tanks is disposed of in the Suriname river.

Municipal solid waste services: The solid waste services and related activities are the responsibility of several government agencies from different ministries. A proper waste collection and disposal organization is only available in Greater Paramaribo. Nationally solid waste management is strongly centralized and collection in the districts is arranged from Paramaribo. Legislation is weak and requires updating. A master plan for solid waste is currently being developed. The Department of Solid Waste of the Ministry of Public Works is responsible for collecting and disposing of garbage and other wastes in the Greater Paramaribo Area. Indiscriminate dumping sites are very common in Paramaribo and throughout coastal and rural areas. Many people also burn their waste together with yard wastes. No waste separation occurs and some hazardous waste can be expected to be mixed with domestic waste. There is some recycling of PET (e.g. at schools) and a deposit system on glass bottles with locally produced beer and soft drinks. Commercial waste is burned or hauled by private contractors.

In the past SURALCO (Suriname Aluminum Company) accepted used hypodermic needles from hospitals for incineration in their medical waste incinerator. From April 2002 a medical waste incinerator serves several hospitals in Paramaribo. The WASPAR Foundation operates this incinerator, which was donated by the ALCOA Foundation. PAHO provided low cost drum incinerators (and operator training) to clinics in the coastal zone and the interior for the destruction and disposal of their medical waste.

Environmental health: Suriname’s environmental institutional framework is based on different government levels among the National Environmental Council, the National Institute for Environment and Development, and Ministries that deal with sector-specific environmental issues through the Inter-Ministerial Advising Commission.

A technical collaborative project proposal has been developed between Brazil and Suriname to reduce the negative impact of the small scale gold mining on health and the environment to be funded by the government of Brazil. The Children’s Environmental Health Profile has provided a framework for inter-sectoral collaboration to address issue of environmental pollution and children’s health.

Other aspects of concern include the removal of asbestos roofing material from government buildings, including schools, the absence of recycling opportunities for hazardous substances, the indiscriminate use of agro-pesticides on agricultural products for the domestic market, and the general lack of registration of importation of hazardous substances.

The Labor Inspectorate of the Ministry of Labor, Technology and the Environment does perform occupational health inspections, but these inspections are limited to registered entities, while much of the economic activities are in the informal sector. Recent investigation indicates that low radioactive waste handling and storage does not pose a significant problem in Suriname.

Ambulatory, emergency and in-patient services: All existing five hospitals offer an array of specialist outpatient services. Ambulatory and in-patient services are provided by all hospitals. There are two emergency medical care units, located in the Academic Hospital in Paramaribo, and the Nickerie hospital in Nickerie District in the west. The Military Hospital functions as an ambulatory facility for army personnel and their families.

Diagnostic services and blood banks: All blood donors are screened for HIV, HTLV, hepatitis B and C, malaria, and syphilis through the National Reference Laboratory for HIV and other international reference laboratories.

Health supplies: The Drug Supply Company of Suriname provides drugs on the National Drug List. 90 % of all drugs are imported and 10 % are manufactured. The availability of drugs in Suriname is problematic; many patients complain about availability of prescribed drugs. In certain years almost 50% of the drugs of the national Essential Drug List were not available. To compensate this scarcity many drugs are imported illegally, bypassing customs and quality inspection. All vaccines are obtained through PAHO's revolving fund for Vaccine Procurement.

Human resources: In May 2000, 295 medical doctors and 105 medical specialists were working in the private and public health sector. The Regional Health Service operates 41 clinics staffed by 50 physicians, 58 registered nurses, 64 nurse aids and 12 midwives. There were 24 pharmacist-assistants, 34 physiotherapists, 25 dentists, 838 registered nurses, 474 nursing aids and 57 midwives in professional practice. Traditional midwives attend to the maternity needs of 25 % of women in the interior. Many nursing graduates have left the country to work in countries where wages are better. By May 2000, 295 medical doctors have been working in the private and public health sector. The male: female ratio is 2:1.

The medical assistants of the Medical Mission follow a 3-year course which is accredited by the Ministry of Health. These medical assistants (total of 60) serve at the health centers of the Medical Mission in the hinterland. The Youth Dental Services also offers a 3-year course for dental assistants. Only one dentist works with the Youth Dental Services, although there are many dental auxiliaries.

The Psychiatric Center Suriname (PCS) is a governmental hospital located in Paramaribo, and provides services for mental and behavioral disorders. None of the other hospitals have either in- or outpatient facilities for treatment of psychiatric patients. The PCS currently has 6 practicing psychiatrists, one psychologist and other supportive staff, but no medical specialists. Patients in need of further medical attention receive care from the area specialists, and patients in medical care receive needed psychiatric care through the psychiatrists from PCS.

Financing: In the year 2000 Suriname spend a total of Sf 105 billion, or US$ 79 million on health care, which is equivalent to US$ 180 per capita. Given a per capita Gross Domestic Product (GDP) of US$ 1,915 this means that 9.4 % of the GDP was spent on health care. Health expenditures in the region traditionally vary from 4 to 8 % of the GDP. The public and the private sector spend the same on health care: Government about 44 %, the private sector (company cost coverage and households out-of-pocket health expenditures) together about 42 %. The remaining 14 % comes from external sources (donors). The contribution of the private sector to health care is significant. Especially the out-of-pocket expenditures of households are an area of concern.

Of the total health expenditures 55 % goes to secondary care (public and private hospitals, medical specialists, hospital lab and x-ray services, hospital drugs), 34 % goes to preventive and primary care (BPH, RHS, Medical Mission, private GP’s, others), while the remaining 11 % goes to other aspects (administration, training, etc.).

External technical cooperation and financing: In 1998, the Government and Inter-American Development Bank cooperated in a program to support health sector reform (IDB grant US$ 2,750,000). The European Community provided resources for strengthening STI/HIV services in the interior of Suriname. Specialized service arrangements are in place with the Netherlands. An adolescent reproductive and sexual health project was financed by the UNFPA. Support is received from the International Planned Parenthood Federation for the Foundation for Family Planning (Stichting Lobi). International organizations (Rotary International) and the governments of other countries (France, USA) provide funding to the "Roll Back Malaria" activities. PAHO, UNDP and UNICEF have ongoing programs and financing available to support technical cooperation in various health sector areas.