Country Profile on the Aging Population

COUNTRY PROFILE

ON THE AGING POPULATION

Paramaribo, 31 May 2004 The Inter-Disciplinary Team INTRA –II Suriname

Abbreviations

ABS Algemeen Bureau voor de Statistiek (General Bureau of Statistics) AOV Algemeen Oudedags Voorziening (General Old-Age Regulation) CAREC Caribbean Epidemiology Centre CBB Centraal Bureau voor Burgerzaken (Central Bureau for Population Affairs) CEDAW Convention on the Elimination of all forms of Discrimination Against Women CIMS Child Indicators Monitoring System CMO Chief Medical Officer CRC Convention on the Rights of the Child DHF/DSS Dengue Hemorrhagic Fever/Dengue Syndrome ER Emergency Room FGD Focus Group Discussions GDP Gross Domestic Product HIV/AIDS Human Immuno-deficiency Virus/Acquired Immuno-deficiency Syndrome ICD International Classification of Diseases IDB Inter-American Development Bank INTRA Integrated Response of Health Care Systems to Rapid Population Ageing MICS Multiple Indicator Cluster Survey MOH Ministry of Health NARB National Advisory Council for the Elderly, Suriname NGO Non-Government Organization PAHO Pan American Health Organization PCS Psychiatric Center Suriname PHC Primary Health Care RGD Regionale Gezondheidsdienst (Regional Health Services) SFL Surinamese Florin (1 US$ = 2,700 SFL) (Currency used before 1 January 2004) SRD Surinamese Dollars (1 US$ = 2.7 SRD) (Currency used as of 1 January 2004) STI Sexually Transmitted Infection SZF Staats Ziekenfonds (State Health Insurance Fund) UN United Nations UNDP United Nations Development Program UNICEF United Nations Children’s Fund UNAIDS Joint United Nations Programme on HIV/AIDS VPSI Vereniging Particuliere Sociale Instellingen (Association of Private Social Institutions) WHO World Health Organization YPLL Years of Potential Life Lost

Table of contents

FOREWORD ...... 1 1. INTRODUCTION ...... 3 1.1. BRIEF PHYSICAL DESCRIPTION ...... 3 GEOGRAPHY ...... 3 PHYSICAL CHARACTERISTICS ...... 3 COMMUNICATIONS...... 3 1.2. SOCIO-ECONOMIC PROFILE ...... 4 ECONOMY ...... 4 GDP PER CAPITA...... 4 SECTOR CONTRIBUTION TO GDP...... 5 POLITICS ...... 6

2. DEMOGRAPHIC TRENDS...... 7 2.1. POPULATION STRUCTURE...... 7 2.2. MORTALITY RATES...... 10 2.2. FERTILITY RATE ...... 11 POPULATION GROWTH RATE ...... 13 TRANSIENT POPULATION ...... 14 LIFE EXPECTANCY BY GENDER...... 14 CRUDE BIRTH RATE...... 15 CRUDE DEATH RATE ...... 15

3. GENERAL ASSESSMENT OF THE LIVING CONDITIONS ...... 16 3.1. SOURCES OF INCOME ...... 16 1. THE PENSION SCHEME FOR CIVIL SERVANTS...... 17 2. PENSIONS IN THE PRIVATE SECTOR ...... 18 3. THE GENERAL OLD-AGE SECURITY ...... 18 SOURCES OF INCOME...... 18 3.2. EMPLOYMENT DATA, DEPENDENCY RATIO AND LABOR FORCE...... 19 LEGAL AND CONSTITUTIONAL FRAMEWORK FOR THE SENIOR CITIZENS ...... 20 NATIONAL AND SECTORAL POLICIES: GENERAL POLICY FRAMEWORK...... 21 POVERTY REDUCTION POLICIES...... 21 POVERTY LEVELS...... 21 3.3. EDUCATION INDICATORS ...... 22 LITERACY ...... 22 3.4. HOUSING / LIVING ARRANGEMENTS ...... 23 LIVING CONDITIONS OF THE SENIOR CITIZENS ...... 24 A. SURVEY OF THE HEALTH CONDITIONS OF THE SENIOR CITIZENS IN THE HINTERLAND.....24

B. FOCUS GROUP DISCUSSIONS IN PARAMARIBO AND WANICA...... 26

4. HEALTH INDICATORS ...... 29 4.1. HEALTH STATUS...... 29 MORTALITY ...... 29 4.2. MAIN CAUSES OF DEATH ...... 30 4.3. SECONDARY AND TERTIARY CARE...... 32 4.4. MORBIDITY ...... 33 THE SENIOR CITIZENS ...... 33 NON-COMMUNICABLE DISEASES ...... 33 HYPERTENSION ...... 33 DIABETES MELLITUS ...... 34 SKIN DISORDERS...... 34 ACCIDENTS AND INJURIES...... 34 ILL-DEFINED CAUSES ...... 35 MENTAL DISORDERS ...... 36 NEOPLASMS ...... 36 COMMUNICABLE DISEASES...... 38 EPIDEMICS ...... 38 STI’S AND HIV/AIDS ...... 38 ENDEMIC DISEASES ...... 39 NOTIFICATION SYSTEM...... 39 4.5. CHRONIC DISABILITY...... 41 CLIENTS AND HANDICAP ...... 41 CLIENTS BY NEEDED CARE ...... 41 4.6. FUNCTIONAL CAPACITY ...... 42 4.7. RISK FACTORS OF NON-COMMUNICABLE DISEASES...... 43 ACADEMIC HOSPITAL DISCHARGES, YEAR: 2000...... 43

5. THE SOCIAL LIFE IN THE 60+ POPULATION...... 45 THE ROLE OF CIVIL SOCIETY, NGO’S, VOLUNTEERS, ETC...... 47

6. BRIEF DESCRIPTION OF THE HEALTH CARE SYSTEM ...... 48 CONSUMPTION PER CAPITA ...... 48 ORGANIZATION OF THE HEALTH SYSTEM ...... 49 HUMAN RESOURCES ...... 50 FACILITIES ...... 51 FINANCES...... 51 EXTERNAL AID AND TECHNICAL COOPERATION...... 52 LEGISLATION ...... 52 INFORMATION SYSTEMS DEVELOPMENT...... 52 RESEARCH ...... 53

FOREWORD

The Inter-Disciplinary Team is pleased to present the country profile Suriname on the aging population with an overview of the living conditions and the health care system in place for the senior citizens.

For this report, the team had to limit its analyses and reports to the group aged 60 years and older. The age of is 60 is in the national legislation the age that officially entitles the group from this age and older to the status of senior citizen and related benefits. The age group of 60 years and over is also the most studied and reported group, when it comes to the status of the senior citizens and related subjects such as health, benefits, etc.

When asked a group of senior citizens in a focus group to define when they feel old, the general opinion was that as long as they are mobile and can help themselves, they consider themselves as “grown-ups” and certainly not as “old”. “You are old when you are not able to take care of yourself”. According to this group, they qualify themselves as senior citizens when they are 70 years old. Growing old is not being linked to age, but to feelings, abilities and infirmities, such as old age complaints and being less mobile, as expressed by them. Becoming dependent is also of importance for feeling old. The more dependent the senior citizens become, the older they feel. “You are old when you are dependent” they say.

This gives a more dynamic interpretation to what being old means to the senior citizens. And it is for the policy makers, together with these senior citizens, to adequately address the feelings of this group and take proper actions to make their living enjoyable. For, according to our observations, there remains a lot still to be done for our senior citizens, in order to provide them with the basic necessities they deserve.

This report is also the result of the visit of Lucy Aarnink (Ageing and Life Course Programme, WHO, Geneva, Coordinator for INTRA II) and Tomlin Paul (INTRA I coordinator Jamaica, University of the West Indies) to Suriname, from 8 – 12 December 2003. The purpose of the visit was to introduce the INTRA Project and assess the possible participation of Suriname as one of the countries (to be paired with Jamaica) in INTRA II and to establish contacts with governmental and non-governmental and academic organizations, to form a national interdisciplinary team to guide the INTRA II project in Suriname

The INTRA I project (Integrated Response of Health Care Systems to Rapid Population Ageing) was launched in 2001, and implemented in six rapidly ageing developing countries – (Botswana, Chile, Jamaica, Korea Lebanon and Thailand) - all characterized by a common demographic feature - increasing life expectancy at birth and decreasing fertility rates.

The overall aim of INTRA I was to examine the health system role and response to ageing with a particular focus on Primary Health Care (PHC). This was achieved through three main objectives:

a) the development of a knowledge base that would assist developing countries in guiding future actions and policies towards integrated health care systems; b) building of inter-disciplinary teams in each of the countries to address and lead debates about health systems transformation; and c) using the evidence to develop a "comprehensive" health care strategy that would further health promotion and prevention interventions at the PHC level. Deleted:

The lessons learned from INTRA I indicated the need to further explore the relationship between the provision, or the lack, of “integrated health services" and the health of the elderly population and well being. The follow-up project, INTRA II, proposes to explore these relationships further by examining relevant factors that influence the organization, management, and delivery of integrated health services within the PHC system. Moreover, this project should lead to a better understanding of the supportive role of community- based care as a means to improve access and utilization of services and to identify factors that may either lead to an accelerated functional decline or the compression of disability as individuals age.

As a result of this visit, the PAHO was requested to coordinate the implementation of the project and the general coordination of the project was delegated to the Ministry of Social Affairs and Housing. The Inter-Disciplinary Team was appointed to guide the introduction of the project. The team consists of the following members:

1. Mr. Albert Mungroo Association of Retired Civil Servants 2. Ms. Marja Themen Director, Association of Private Social Institutions 3. Mrs. R. Codfried-Kranenburg, MD Director, Ministry of Health (represented) 4. Mr. L. Resida, MD,MSc Director, Bureau of Public Health (represented) 5. Mrs. M. Mohammed Ashim, MD Director, Regional Health Services (represented) 6. Mr. E. van Eer, MD Director, Medical Mission (represented) 7. Ms. C. Pawironadi Director, Ministry of Social Affairs and Housing 8. Ms. J. Terborg PhD Director, Pro Health Foundation (Research Inst.) 9. Mr. H. Wezenhagen Director, Bureau Forum NGO’s 10. National Advisory Board on Senior Citizens – Represented 11. Ms. W. Vinkwolk Director, C. Leeflang Foundation (Home Care)

The PAHO coordinator for this project is Mr. P. Ritoe, Technical Specialist, while the coordination in the Ministry of Social Affairs and Housing is in the hands of Ms. Reina Muller, Ministry of Social Affairs and Housing.

The team wishes to thank all persons and institutions that have contributed to the work of the team towards the completion of this report.

Prim Ritoe Coordinator – Suriname

1. INTRODUCTION

1.1. Brief Physical Description

Geography

The Republic of Suriname is located at the north-east coast of South-America between 2o and 6o N latitude and 54o and 58o W longitude. The neighboring countries are French Guiana in the east, Guyana in the west and Brazil in the south. The Atlantic Ocean outlines the northern border.

Physical Characteristics

The total land area of 163,820 km2 is divided into ten major civil “districts”. These ten districts are subdivided into 62 “resorts”, or minor civil divisions. Suriname is divided topographically into the northern coastal lowlands, central savanna area, and southern highlands characterized by tropical rainforest referred to as the “hinterland”. A mere 10% of this land, the coastal area, is well inhabited with 85% of the total population.

Suriname has a tropical climate with a mean annual temperature of 27o C. The relative humidity averages between 80 and 82%. No natural disasters have ever occurred. The capital Paramaribo and the District Wanica, the urban districts, are inhabited by approximately 68% of the total population, while it covers only 0.4% of the land area. The population density of these 2 urban districts together is estimated as 526.5 per km2 for the year 2003. The district Sipaliwini, created in 1984, occupies the largest southern part of the country (130,566 km2), but the population density is estimated at only 0.9 per km2 for the year 2000. The overall year 2003 population density for Suriname is 2.9 per km2 . (See Appendix A for map of country).

The provisional results of the Census 2003 show that the total population of Suriname as per March 31, 2003 was 481,146. The majority of the population lives in the districts of Paramaribo and Wanica.

Communications

Suriname can be reached: • By air from the Netherlands Antilles, Trinidad & Tobago, the Netherlands, French Guiana, Brazil, Guyana and the United States of America. • By land from French Guiana and Guyana. • By sea via regular shipping lines from Europe, USA, the Caribbean and Brazil.

Twenty-five radio stations and thirteen television stations are currently operating in the country. Broadcasts from international television stations can be received through cable subscription. Four daily newspapers are distributed throughout the country.

1.2. Socio-Economic Profile

Economy

Surname’s deteriorating economy was marked by some significant trends on the production and labor market. Many businesses were affected by low profits, increased labor costs and high dependency on imported inputs. The Asia crisis and globalization had severe negative effects on Suriname’s export economy, such as loss of markets and preferential markets. As a result of both domestic and international factors, a considerable proportion of private businesses face a doubtful future.

GDP growth rates deceased from 3% in 1995 to 2% in 1998 (IDB). After the average annual inflation rate had rocketed to an astronomical 369% in 1994 (236% in 1995), it dropped to 21% in 1998. In spite of this positive turn, an estimated 85% of the population continued to live below the poverty line. The cause of this continuing impoverishment was the steady increasing exchange rate of the Surinamese Florin (Sfl) vis-à-vis the American Dollar (during mid year 2000 already Sfl 3,000 : US$ 1).

Simultaneously with new adjustment measures, the Government of Suriname introduced a temporary financial compensation for public servants and for those entitled to social benefits in order to strengthen their purchasing power. The private sector was also asked to give a compensation to its personnel. The economic crisis had unavoidable impacts on the labor market. Structural unemployment, the loss of real income, and an increasing movement towards informal employment were the main trends observed in the late 90s. The negative economic situation increasingly forced women to perform paid labor, thus pushing up unemployment rates for women and consequently forcing them to seek employment in the informal sector. According to the General Bureau of Statistics (ABS) the unemployment rates for women increased from 11% in 1995 to 16% in 1997. For men, the rate was 7% in 1995 and 1997.

Owing to the measures of economic recovery introduced by the newly elected Government in 2000, the exchange rate for the US$ stabilized around Sfl 2,700 on December 2003. As of January 1, 2004, Suriname has changed its currency note from Surinamese Florin to Surinamese Dollar (SRD). The exchange rate is stable at 1 US$ = SRD 2,7.

GDP per capita

Due to the constant fluctuation in the rate of inflation during the years reported, the estimated GDP in US$ is an estimate based on the average exchange rate. Some years this estimate is more representative of the actual GDP than other years, depending on the range of inflation. During the years 1999 and 2000, the inflation rates were extremely dynamic due to difficulties in the economy. The 2000 GDP data is from the National Health Account Study in support of Health Sector Reform.

Table 1. Gross Domestic Product, 1995 – 2000

GDP GDP per capita Year In SRD In SRD In US$ 1995 229.1 million 560,4 1,136.63 1996 325.2 million 786,6 1,889.17 1997 384.3 million 917,3 2,111.90 1998 447,2 million 1,053.2 1,896.38 1999 n/a n/a n/a *2000 n/a n/a 1,914 Source: General Bureau of Statistics, November 2000 * National Health Accounts Study, 2001 n/a = Not available

Sector contribution to GDP

The 2000 data for the different sector contributions to the GDP growth are projected figures from the National Planning Office. The economic hardship endured during the years of 1999 and 2000 are reflected in the National GDP growth, which decreased nearly two-times the value in 1998. The increase in sector contribution from the utilities, Water and Electricity, resulted from an overdue adjustment in the selling price of water and electricity. The large decrease in sector contribution from Mining in 2000 was due to labor strikes in the government owned oil- company.

Table 2. Sector Contribution to Gross Domestic Product Growth, 1995 – 2000

Economic Sectors Growth of GDP per year 1996 1997 1998 1999 20001 National GDP Growth 4.9 4.7 1.6 -1.3 -1.5 Agriculture 1.4 -3.2 -5.5 -13.9 0.3 Mining 7.6 12.1 0.1 1.6 -6.3 Industry 2.2 1.7 18.4 -0.2 0.1 Water and Electricity 9.6 5.5 -2.6 -7.5 7.9 Construction 10.0 n/a n/a n/a n/a Trade, Restaurants, and Hotels 5.9 15.2 0.1 -5.2 -5.2 Transportation, Storage, and Communication 21.4 4.6 2.9 4.5 1.0 Commercial Services (Banks and Insurance) 2.0 1.3 0.7 0.7 0.7 Public Services -1.4 -1.0 0.0 1.0 2.0 Personal, social, and other community 1.4 1.4 n/a n/a n/a services (including bank interest) Source: National Planning Office, 2001 1Projected Figures

The total economical active population (age group 15 – 65) in the two urban districts of Paramaribo and Wanica was approximately 95,000 (32%). According to official statistics women comprised 35% of the labor force, but in reality, this figure is obviously higher because official statistics do not reflect the large proportion of women who are involved in informal and unpaid labor. The total unemployment rate for men and women was approximately 10%. In all years, women experienced a significantly higher unemployment, in most years twice higher than their male counterparts.

Politics

The country report covers two periods of fundamentally different political governance coinciding with the national elections held in May 1996 and May 2000. The fundamental difference is that in 1996 the newly elected Wijdenbosch Government had cancelled the implementation of the Structural Adjustment Program, which the Venetiaan Government had introduced in 1993 to revitalize the country’s economy. However, in 2000 the economic reform program regained immediate effect after a victory of the “New Front” coalition party.

Since the independence of Suriname in 1975, the socio-political climate has been one of continuing turbulence. The country’s independence, de coup d’etat in 1980, and the introduction of a structural adjustment program in 1993 have led to some outside migration. Besides this exodus, the situation in the country was frequently affected by strikes and street demonstrations for the reduction of prices, increases of salaries, availability of housing and eventually the resignation of the ruling Government. The major strikes which began in 1998 and continued in 1999, resulted in accelerated elections in 2000.

The increasing poverty in Suriname created the priority for a poverty reduction plan. With UNDP’s support, the Government initiated a poverty analysis study in 1998, in preparation of a national strategy for poverty reduction. The current Government Declaration emphasizes sustainable development and the initiation of coordinated efforts towards poverty reduction. The government has identified women (heads of households), young people (under 18 years), and people with a disability, senior citizens and low income households as special vulnerable groups. The Ministry of Social Affairs and Housing maintained its responsibility for the monitoring and evaluation of the implementation of the Child Rights Convention, as well as the implementation of child rights promotion (within the framework of CRC and CEDAW, and their specific context to the country).

2. DEMOGRAPHIC TRENDS

Suriname belongs to the countries with a relatively low annual average population growth of 1.3%. The estimated population grew from 409,000 to 425,000 (4.9%), between 1995 and 2000, and to 481,000 in 2003. Disaggregated data were available only until 1995. In this particular year, Suriname’s mid-year population was 408,866. About 33% of the population is youth in the age group 0-14%. More accurate, partial data was recently released in the preliminary report of the Suriname Census 2003, from the General Bureau of Statistics.

The provisional results of the Census 2003 show that the total population of Suriname per 31 March 2003 was 481,146. The majority of the population lives in the districts of Paramaribo and Wanica, while the District of Coronie has the smallest population. The population of Suriname is one of the most ethnically diverse per capita with many different ethno-linguistic groups. The major ethnic groups are Hindostani (East-Indian descent) who account for approximately 37% of the population, and Creole with 31%. The third largest ethnic group consists of Javanese, descendants from Indonesia with 15%. Others include the Negro and indigenous populations who are the predominant population groups in the hinterland of Suriname. The total population consists of 50.2% males and 49.8% females. Comparison with the census of 1980 (355,240 persons), shows that over a period of almost 23 years the population increased with 35,4%. This is an annual growth of circa 1.3%.

Table 3. Total population 2003, by sex and district.

DISTRICT Males Females Total Population Area Density in % (km2) Paramaribo 120,759 122,780 * 243,556 50.6 182 1,338.2 Wanica 43,538 41,988 85,526 17.8 443 193.1 Nickerie 19,801 18,089 37,890 7.9 5,353 7.1 Coronie 1,577 1,380 2,957 0.6 3,902 0.8 Saramacca 8,078 7,291 15,369 3.2 3,636 4.2 Commewijne 12,287 11,268 23,555 4.9 2,353 10.0 Marowijne 7,285 7,131 14,416 3.0 4,627 3.1 Para 8,682 8,169 16,851 3.5 5,393 3.1 Brokopondo 5,836 5,833 11,669 2.4 7,364 1.6 Sipaliwini 13,994 15,363 29,357 6.1 130,567 0.2 Total 241,837 239,292 481,146 100 163,820 2.9 * The difference is caused by 17 diplomats, from whom there was no information provided on gender. Source: Suriname Census 2003 Preliminary Report, 2003

2.1. Population structure

The Census 2003 has not yet released detailed information on the population per age etc. In this paragraph we therefore use the available information published by the Central Bureau for Population Affairs (Centraal Bureau voor Burgerzaken, CBB) over 2002.

Table 4. Number of registered persons at CBB, by age group and gender, 2002

Age Group Male Female Total 0 - 4 21,250 20,576 41,826 5 – 9 21,385 20,266 41,651 10 – 14 19,678 18,985 38,663 15 – 19 22,914 22,077 44,991 20 – 24 25,288 24,919 50,207 25 – 29 24,399 23,818 48,217 30 – 34 19,766 19,104 38,870 35 – 39 18,923 17,467 36,390 40 – 44 15,783 14,611 30,394 45 – 49 11,013 11,064 22,077 50 – 54 7,954 8,449 16,403 55 – 59 6,371 7,018 13,389 60 – 64 5,451 6,254 11,705 65 – 69 4,867 5,418 10,285 70 – 74 3,702 4,087 7,789 75 – 79 2,245 2,622 4,867 80 – 84 1,182 1,493 2,675 85 – 89 492 737 1,229 90 – 94 217 322 539 95 – 99 72 113 185 > 99 24 44 68 Total 232,976 229,444 462,420 Source: Demografische Data 2001 – 2002 (CBB, May 2004)

Table 4 speaks for its self. It shows that the largest age group is that of 20 – 24. The youth under 20 years of age make 36% of the population, while the adult aged 20 – 59 totals 55% of the total population. The group of the senior citizens, > 60 years, make out 8.5% of the population. In 1985 the respective percentages were: 50%, 44% and 6% and in 1995 the respective percentages are: 42.5%, 50% and 7.5%. Following is an overview in table and graph format

Table 5: Summary of the population in 3 age categories, by year

Age group 1985 1995 2002 0 – 19 50 42.5 36 20 – 59 44 50 55 > 60 6 7.5 8.5

Graph 1 shows a steady decline of the total in the group of 0 – 20 year, while there is a steady increase in the group of 20 – 59 years and over 60 years.

Graph 1: Change in age categories in 1985, 1995 and 2002

Age groups in 19985, 1990 and 2002

0 - 20 years 20 - 59 years > 60 years

0 123 1985, 1995 and 2002

Source: General Bureau of Statistics, May 2004

The population pyramid speaks for itself.

Graph 2. Population pyramid 2003

POPULATION PYRAMID 2002

95 - 99

90 - 94

85 - 89

80 - 84

75 - 79

70 - 74

65 - 69

60 - 64 55 - 59 Females 50 - 54 males 45 - 49 Age Group Age 40 - 44

35 - 39

30 - 34

25 - 29

20 -24

15 - 19

10 - 14

5 - 9

0 - 4

30,000- 20,000- 10,000- - 10,000 20,000 30,000

SURINAME

Source: General Bureau of Statistics, May 2004

The following graph gives an overview of the projected population over 60 years of age, in 5 - year intervals, from 1985 to 2025. According to the projection, there is a steady growth of the population in de age group of 60 years and older, from 1985 on. It also shows that the growth of the group of the females is more than the growth of the male group.

Graph 3: Projection of the population over 60 years, from 1985 – 2025

PROJECTION OF POPULATION PYRAMID 1985 - 2025

2025

2020

2015

2010 Interval females 2005 males

2000

1995

1990

1985

40,000- 30,000- 20,000- 10,000- - 10,000 20,000 30,000 SURINAME Source: Compiled from figures from “UNDP Country Profiles 1985 – 2005”

2.2. Mortality Rates

Hypertension and cardio-vascular diseases, cerebro-vascular diseases and external causes were the leading causes of death in 1998 -2000. The death rate due to malignant neoplasms has remained on the 4th place. HIV/AIDS death rates are steadily increasing each year and remains in 8th place since 1999. The main change in leading causes of death is the increased death rate due to certain conditions originating in the peri-natal period, which moved up to the 5th place. The increase in deaths due to certain conditions originating in the peri-natal period are possibly due to two reasons: increase in identification of peri-natal deaths, through efforts of the Bureau of Public Health Epidemiology Department after the 1995 – 1999 peri-natal mortality study; and possibly due to the difficult economic hardships in 1999 and especially in the year 2000.

Graph 4. Crude Death Rates in Suriname for the years 1990-2000.

Crude Death Rates for years 1990-2000

7.4 6.9 6.7 7 6.6 7 6.9 6.6 7 7.1 8 6.4

-2 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Source: CIMS 2000, September 2001.

One distinguishable and interesting trend in the mortality tables and graphs is the large discrepancy between the rank orders of leading causes of death versus the rank order by Years of Potential Life Lost (YPLL). The certified deaths were used to calculate the YPLL, and the value

10 of 65 years served as the standard. Naturally, high death rates in the younger age groups yield higher values for year of potential life lost. Due to the higher death rates from conditions originating in the peri-natal period, it is natural for the YPLL to be high, and thus ranks 1st as the leading cause of death for years of potential life lost. The crude death rate has remained steady over the past decade with an average of 6.9 deaths per 1,000 population.

All death rates remained steady between 1996 and 1998, and then increased in 1999 and 2000. The increases in 1999 and 2000 can be contributed to better reporting and case identification of deaths, and deaths due to causes exacerbated by the economic hardship during these years. The two-fold increase in infant morality based on registered deaths in the year 1996 could not be explained, and was not supported by the data retrieved from death certificates. The increase in 1996 in infant mortality is not perceived to be accurate and could possibly be due to a data collection or entry error.

Graph 5. Vital Statistic Rates in Suriname for the years 1995-2000.

Vital Statistics Rates for years 1995-2000

Rates per 1,000 births 10

0 1995 1996 1997 1998 1999 2000 Still Birth Rate 17.6 21 21.4 22.3 22 25.8 Perinatal Death Rate 27.3 31.5 32.5 32.7 32.6 38.4 Neonatal Death Rate 9 10.7 9.8 9 10.8 14.9 Infant Death Rate 24.7 52.5 22 15.9 22.4 17.8 Maternal Death Rate 0.46 0.43 0.74 0.88 1.08 1.53 Estimated Birth Rate 21.3 22.7 25.8 24.1 23.6 22.5 Estimated Death Rate 6.6 7 6.9 6.6 7 7.1

Source: CIMS 2000, September 2001.

2.2. Fertility Rate

The steady decline in the Total Fertility Rate is most likely due to increased education in family planning and contraceptive use. In the 2000 Suriname Multiple Indicator Cluster Survey, 42.1% of the women married or in union reported current use of contraception.

Graph 6. Total Fertility rates in Suriname for the years 1980-1995.

Total Fertility Rate for 1980 - 1995 and 2002

4 3.6 3.4 3 2.6 2.4 2.2 2 1 0 1980 1985 1990 1995 2002 Year

Source: CIMS 2000, September 2001

A projection of the total fertility rate (children per woman) by decennium is given below. The figure shows a steady decrease in the figures.

Graph 7. Total fertility rates in Suriname for the years 1980-2025.

Total fertility rate

3.5

2.5

1.5

0.5

0 1985- 1990- 1995- 2000- 2005- 2010- 2015- 2020- 1990 1995 2000 2005 2010 2015 2020 2025

Total fertility rate

Source: United Nations Population Division - World Population Prospects: The 2002 Revision

Following is an overview of selected population indicators. There is a steady decline seen in the population change and the births per year. According to the projection, the crude birth will also decline, as well as the net production rate per woman and the infant mortality rate. The life expectancy rate will grow slightly.

Table 6: Selected population indicators

Indicator 1985-1990 1990-1995 1995-2000 2000-2005 Population change per year (thousands) 4 2 3 3 Births per year, both sexes combined (thousands) 10 9 10 9 Deaths per year, both sexes combined (thousands) 3 3 3 3 Population growth rate (%) 0.91 0.37 0.76 0.8 Crude birth rate (per 1,000 population) 25.4 22.4 23.9 21.7 Crude death rate (per 1,000 population) 6.4 6.2 6.1 5.9 Total fertility rate (children per woman) 2.92 2.45 2.62 2.45 Net reproduction rate (per woman) 1.35 1.14 1.23 1.16 Infant mortality rate (per 1,000 births) 36.1 33.4 29.1 25.7 Life expectancy at birth, both sexes combined (years) 68.2 69 70.1 71.1 Life expectancy at birth, males (years) 65.8 66.5 67.5 68.5 Life expectancy at birth, females (years) 70.8 71.5 72.7 73.7 Source: United Nations Population Division - World Population Prospects: The 2002 Revision

Population Growth Rate

During the 1980s, the average population growth rate was 1.3%. In the late 1980’s, the military controlled the country. During this time there was a large emigration of Surinamese to other countries (mainly the Netherlands), and resulted in a significant decrease in the population growth rate. Later in the 1990’s the average population growth rate was steady, due to the decrease in the proportion of emigration amongst the population, and increased immigration to Suriname.

Graph 8. Population Growth rates in Suriname for the years 1980-2000.

Population Growth Rates for years 1980-2000

3 2.5 2.5 2.3 1.7 1.8 2 1.5 1.6 1.5 1.5 1.5 1.1 1.1 1.1 1.1 1.1 1.1 0.8 0.6 1 0.4 0.5 0.1 0.1 0 -0.5 -0.2 -1 -1.5 -2 -2.5 -3 -2.5 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Source: CIMS 2000, September 2001.

Transient Population

The total immigrants registered with the Civil Registry increased steadily since the year 1995. Immigrants must be registered with the Civil Registry if their length of stay will be longer than two months. In general, most immigrants arrive during the summer vacation months of July until August, and a small influx around the time of Independence Day festivities in November, of which most of these immigrants are tourists. The majority of immigrants are between the ages of 20-49, and slightly more females than males. The majority of immigrants in Suriname are of either Dutch or “Other Nationality” (excludes Surinamese, American, Guyanese, French, Haitian, Antillean). In 1998 and 1999, the percentage of immigrants of “Other Nationality” greatly increased from 32% to 60%, while the percentage of Guyanese immigrants decreased significantly. Many of the immigrants of the “Other Nationality” include immigrants from other countries in South America, predominantly Brazil, throughout Caribbean region, and China. The gold mining industry attracts many immigrants and affects travel patterns in this region, but particularly within the country. The trend of increased immigration, particularly associated with the mining industry, may affect the determinants and distribution of disease in the near future.

Life Expectancy by Gender

Due to the lack of available and accurate population data, the official national life expectancy has not been calculated in several years, although various estimates have been published. Upon completion of the census in 2003, the life expectancy will be calculated. Some projections for the years 1990-1995 estimated the life expectancy at birth in Suriname around 70 years of age, while there is a gender difference of females living approximately 5 years longer than males. Following overview projects a steady increase of the life expectancy at birth, by sex, from 1985 to 2025. The female group continues to have a higher life expectancy.

Graph 9: Life expectancy at birth, for both sexes, 1985 – 2020

Life expectancy at birth, 1985 - 2020

78 76 74 72 70 Years 68 66 64 62 60 1985- 1990- 19 9 5 - 2000- 2005- 2010- 2015- 2020- 19 9 0 1995 2000 2005 2010 2015 2020 2025 Period

Both sexes combined Male Female

Source: United Nations Population Division - World Population Prospects: The 2002 Revision

Based on the projections of the growth of the 60+ group in graph 3 and the projection of the life expectancy at birth, it may be concluded that Suriname will probably have to deal with a rapid aging population, the majority of which will be women.

Crude Birth Rate

The crude birth rate for Suriname declined steadily since 1992 to a low of 20.8 in 1994, and then rose to 25.8 in 1997. Since 1997, the crude birth rate has again steadily declined each year. The average crude birth rate for the 1990’s was around 23 births per 1000 population.

Graph 10. Crude Birth Rates in Suriname for the years 1990-2000. Crude Birth Rates for years 1990-2000

25.8 30 23.8 24.4 24.1 23.6 22.6 23.3 21.3 22.7 22.5 25 20.8 20 15 10 5 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Source: CIMS 2000, September 2001.

Crude Death Rate

The crude death rate has remained steady over the past decade with an average of 6.9 deaths per 1000 population.

Graph 11. Crude Death Rates in Suriname for the years 1990-2000. Crude Death Rates for years 1990-2000

7.4 6.9 7 7 6.9 7 7.1 8 6.4 6.7 6.6 6.6 6 4 2 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Source: CIMS 2000, September 2001.

3. GENERAL ASSESSMENT OF THE LIVING CONDITIONS

3.1. Sources of income

In 1982, Suriname participated in the World assembly on ageing held in Vienna, Austria. Between 1983 and now, both Government and NGO’s have continued their efforts for the cause of the older person. Up till now, strategies and programs to enhance the welfare of older persons have been incorporated within the Ministry of Social Affairs and Housing – with its own budget – to focus on this target group. The National Advisory Board for policy of the senior citizens(which was established in 1981) advises the Ministry regarding issues of older persons.

To grant the request of the UN as a member country making the society aware of the role of older persons in the community (IYOP 1999), a national commission was installed by the Ministry of Social Affairs and Housing in February 1999. This commission comprised of representatives from the Government and NGO’s. In collaboration with relevant Government agencies and NGO’s several activities were organized and actions were undertaken regarding older persons in Suriname.

The population in Suriname is multi-ethnic with 16 ethno-linguistic groups. The major groups in the urban and rural areas are Hindustani, Creoles and Javanese. The population in the interior consists predominantly of maroons and indigenous people with a variety of ethno-linguistic groups. The total population of Suriname is 481,146 (31 March 2004). Regarding the population aged 60 and above, this was about 8.5% in 2004. About 50 percent of the senior citizens are living in the district of Paramaribo (urban area) due to the fact that 52 % of the Surinamese population lives in this district, which is also the capital of Suriname.

Table 7: Geographic distribution of the senior citizens 60+, by sex, in 2000

District Sex Total % Male Female Paramaribo 9,565 11,235 20,800 50.1 Wanica 2,973 3,121 6,094 14.7 Para 795 719 1,514 3.6 Brokopondo 333 447 780 1.9 Commewijne 1,148 1,166 2,314 5.6 Saramacca 665 675 1,340 3.2 Coronie 180 200 380 0.9 Nickerie 1,465 1,561 3.026 7.3 Marowijne 771 787 1,558 3.8 Sipaliwini 1,478 2,222 3,700 8.9 Total 19,373 22,133 41,506 100 Percent 46.7% 53.3% Source: H. Wirjosentono, Presentation Suriname at 2nd WAA, Madrid,2002

The pension regulation in Suriname consists of: 1. General Old-age Security, which indicates that every person who has reached the age of 60 is entitled to an old age pension. 2. Retirement pension regulations regarding retired civil servants and retired persons from private corporations 3. Invalidity pension 4. Widows/widowers and orphan pension.

In the Surinamese Civil Code there are regulations concerning the support for needy older persons by their children. This guarantees the fact that family support is provided for older persons. Furthermore, there is also a draft bill on home care which regulates that older persons are taken care of in their familiar environment.

The Ministry of Social Affairs and Housing has the responsibility for the public welfare, especially the social care for older persons. Provisions through the Ministry regarding older persons are: • Subsidies to homes for the senior citizens (on the basis of the number of persons) • Financial support. This support consists of a monthly given amount of money to those who cannot provide in their daily living, including the needy senior citizens. • Medical support scheme for the poor. The senior citizens can also apply for this type of support. Those who are considered for this type of support could be partly or entirely exempt from medical costs (such as costs for consultations and costs for hospitalization). • Furthermore, regulations have been made for the vulnerable, including older persons, who suffer from low-frequency diseases and for further medical treatment have to be sent abroad. The government provides the travel and medical costs.

The need for social security is covered in the following 3 regulations: 1. The pension scheme for civil servants 2. Pensions in the private sector 3. The General Old-age Security

1. The pension scheme for civil servants

The pension scheme for civil servants is regulated in the Civil Servants Pension Act of 1972. (Ambtenarenpensioenwet 1972). The target groups are the civil servants, the lawful spouse of the civil servant and the natural recognized children of the civil servant.

The civil servant is entitled to the pension scheme at the termination of its service contract, when the age of 60 years is reached or after 35 years of service, when the age of 55 has been reached. The pension is calculated as 2% of a calculated base salary per qualified year of service, to a maximum of 35 years. The payment ends with the death of the retired civil servant.

The civil servant is entitled to the invalidity pension when the service contract is terminated because of invalidity. The pension is calculated as 2% of a calculated base salary per qualified year of service plus an amount equal to 2% of a calculated base salary for every year from the age of onset of the invalidity, until the age of 60 and depending on the degree of invalidity.

Widows/widowers and orphan pension is paid upon death of the civil servant. The amount to be paid is calculated as 60% of the calculated pension or invalidity pension. The widow(er) is paid until he/she re-marries or starts living with a partner. Orphans receive a calculated amount of 10% of the pension, until they reache the age of 21 or their marriage. The premium for the pension is paid by the employee (10% of the salary) and the employer (5% of the salary).

The Suriname State Pension Fund has currently 39,650 members. Approximately 15,000 pensions are currently paid, totaling approximately 26 million SRD per year. The minimum amount of pension paid is 135 SRD. Retired civil servants also are entitled to the benefits of the State Health Insurance. The Suriname State Pension Fund is, after that of the funds of two private multinationals, the best fund in the country.

2. Pensions in the private sector

There is a variety of pension schemes in the private sector. Most of them depend of the financial viability of the company. These scheme differ form each other in many aspects and there are several limitations to the membership, such as age and health status. In most schemes both the employer and employee contribute.

3. The General Old-age Security

This provision started in1973, but was officially regulated by law in 1981. This scheme is for every Surinamese national living in Suriname, when the age of 60 is reached. Also, non-surinamese nationals are entitled, if they have lived in Suriname for at least 10 years, and have contributed to the Pension fund for at least 10 years, when the age of 60 is reached. The monthly pension is currently 125 SRD per month.

The provision is implemented by the Ministry of Social Affairs. The financing of the fund comes from a deduction of 4% from the salary of every one, in private or government service. The deficit between the contributions and payments are covered by the Government. The total number of recipients was 44,739 in December 2003.This is approximately 9% of the population. There were 20,876 male recipients in December 2003 (4%) and 23,863 females (5%).

Sources of income

The following table gives an overview of the qualified recipients of the General Old-Age Provision by gender and amount paid, July – December 2003. There are no significant changes in the number of qualified claimants and the amounts paid. The amount per recipient is SRD 100. Per October 2003, this amount is increased to SRD 125.

Table: 8. General Old Age Security Claimants by sex, July – December 2002

Month M F Total Amount (SRD) July 2003 17,528 20,397 37,925 3,792,500 August 2003 17,656 20,538 38,194 3,819,400 September 2003 17,759 20,630 38,389 3,838,900 October 2003 17,844 20,735 38,579 4,822,375 November 2003 17,693 20,614 38,307 4,788,375 December 2003 17,764 20,700 38,464 4,808,000 Source: Basic Indicators, Algemeen Bureau voor de Statistiek, June 2003

The following table provides an overview of the poverty lines by size and composition of the households in 2003. This will help forming an idea of the income and spending of the senior citizens.

Table 9. Poverty lines by size and composition of the households, 1st Quarter 2003

Adults\children 0 1 2 3 4 1 248,827 388,169 517,559 641,973 761,409 2 447,888 574,789 696,714 816,151 930,611 3 629,531 751,456 868,405 980,377 1,092,349 4 803,710 918,170 1,032,630 1,142,114 1,251,598 Amounts in SFl. (SFL 1,000 SFL = US$ 0.357) Source: Basic Indicators, Algemeen Bureau voor de Statistiek, June 2003

3.2. Employment data, dependency ratio and labor force

There is no policy so far with regard to the anticipation of the senior citizens in the labor process. This will, for an important part, depend on de population development and whether or not there will be a graying of the population, leading to an increase on the expenses for employment. The security of income is another important condition.

Table 10. Average number of employees by type of activity, 1995 – 2000

Sector 1995 1996 1997 1998 1999* Mining activities 3352 3509 3368 3064 2736 Manufacturing 5617 6513 6361 6473 5894 Public utilities (gas, water, electricity.) 1255 1292 1335 1308 1284 Construction - - - - - Trade, restaurants and hotels 5658 6056 6112 6622 6124 Transport, storage and communication 2133 2365 2290 2308 2059 Financial institutions 1578 1548 1508 1605 1604 Insurance 384 338 324 309 311 Community, social and personal services 1880 1999 2182 2333 2418 Public Administration and Defense 37160 36663 36757 37727 37889 Total 59017 60283 60236 61749 60319

Note: In large enterprises, with 10 or more employees *) provisional Source: General Bureau of Statistics, Nov. 2000

Approximately 60% of the working force is employed by the Surinamese government (Public Administration and Defense), which has remained steady over the years. The 1999 data are provisional figures from the General Bureau of Statistics, but adequately reflect the 3% increase in the unemployment rate from 1998. A steady increase can be observed in the commerce sector (Trade, Restaurants and Hotels) until 1998, and decreases sharply in 1999 most likely due to the economic difficulties that characterized the year.

The male to female ratio of the labor force in 1998 and 1999 were 1.9:1 and 1.7:1 respectively. Nearly 10% of the available labor force was unemployed in 1998 and increased to approximately 14% in 1999. Proportionately, women are over two times more likely to be unemployed than men.

Table 11. Employment data for 1998-2000

Economically 1998 1999* Active Male Female Total Male Female Total Population Labor Force 64,886 34,465 99,351 62,637 36,843 99,480 Employed 60,259 28,557 88,816 56,414 29,299 85,713 Labor force Unemployed 4,627 5,908 10,535 6,223 7,544 13,767 Labor force Source: General Bureau of Statistics, Nov. 2000 *Figures based on data from the 1st half of the year.

The Ministry of Social affairs implemented a study in 1993 to assess the living conditions of the 55+ population in Paramaribo. In general, the impression is that a significant majority of this group is in situation of arrears and disadvantage. This is for a great part due to the appreciation that these senior citizens receive in the society and the social economic crisis experienced by the greater part of the population. It can be concluded that many senior citizens live in relative and absolute poverty. The policy of the government with regard to the senior citizens aims at the social integration of the senior citizens. The important starting-point to this end is the quality of life. Growing old in a healthy and happy status, together with as long as possible independent functioning and being appreciated in society, are the most important conditions fore the quality of live of the senior citizens. It should be promoted that the senior citizens can participate in society as equally qualified, through the creation of conditions for independent living conditions.

Legal and constitutional framework for the senior citizens

Currently there are no laws and/or a network of regulations with regard to the senior citizens in Suriname. 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 draft legislation on home care services deals with the general provision of services to the general group of the senior citizens, specifically the senior citizens with a handicap, those who are chronically ill, terminal patients, ex-hospital patients needing after care and children in need, with their parents. The advisory report on the introduction of a general health insurance plan for Suriname stresses the implementation of a Social Insurance System.

National and sectoral policies: general policy framework

The Government Policy Document 2000 – 2005 states that the Government will work towards the further implementation of a modern social security system with incorporation of the existing forms of social security systems. Many efforts have been taken since 1986 to introduce a comprehensive legislation on social security, but without success, due to its content and complexity. But there is a draft decree ready with several topics included in it, with regard to the social security system.

Poverty reduction policies

Poverty eradication policies are not yet in implementation, but policies toward 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.

Even though there is no clear insight with regard to the income of the senior citizens, there are indications that a majority of the senior citizens live under difficult financial circumstances. An important part of the senior citizens has as their only source of income de General Old Age Security (see 3.1).

Poverty levels

Unfortunately no consistent data is available to provide detailed information on the different poverty levels or the resulting social and health ramifications. 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 of Social Affairs 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 poverty line. The National Planning Office estimated for the year 1999-2000 that on average 52.4% of the households are considered

21 living in poverty, which equates to 59.2% of the population. The 1999/2000 estimates are 30% greater than estimates thirty years earlier. These estimates reflect pre- and post- independence times.

3.3. Education indicators

Literacy

Overall literacy of the population aged 15 years and older is 86.2% . The overall literacy percentage declines steadily across age groups until age 65+ where it is 62.8% (Suriname MICS Report 2001)

The deficiencies in available and accurate education data have also made it difficult to estimate the literacy rates amongst the populations, a very important education indicator. In the CIMS Report 2000, the General Bureau of Statistics estimated the literacy rate for the population aged 15 years and older, for the two most populated districts (Paramaribo + Wanica = 68% of the population of Suriname), for the first half of the year 2000, as 93.5 for males, 90.9 for females, and 92.2 overall.

The 2000 Suriname Multiple Indicator Cluster Survey estimated the overall literacy rate of the population sampled aged 15 years and older to be 86%, with a significant difference in the literacy rate of the hinterland population estimated at 51%. In general, the female literacy rate was lower than male across all geographic areas and the literacy rate declined steadily across age groups sampled. Deficiencies in the Research and Planning Department of the Ministry of Education have resulted in little educational data collection over the past years, but there are plans for improvement. The available data in following table was collected by the General Bureau for Statistics through direct contact with the inspectorates and schools.

Table 12. Students by gender and education level, for the 1998/1999 and 1999/2000 school years.

Education Level 1998 – 1999 school year 2000-2001 school year Pupils Schools Pupils Schools Male Female Total Male Female Total Pre-Primary 7,576 6,939 14,515 265 6,150 6,136 12,286 263 Primary 32,741 31,112 63,853 272 31,526 29,892 61,418 269 Lower Secondary 13,540 15,182 29,022 127 12,675 15,255 27,930 120 Upper Secondary 2,673 5,060 7,733 13 2,967 5,645 8,612 14 Tertiary NA NA NA NA NA NA 4,037 NA Source: CIMS 2000, Sept. 2001

Although the enrollment of male pupils is slightly higher than that of females for pre-primary and primary education levels, the trend is quite different for secondary level of education. The male to female ratio for the 1998/1999 school year was 0.9:1 and decreased to 0.8:1 for the 1999/2000 school year for secondary education. Without current and accurate population data it is difficult to develop any inferences for the trends presented in the available education data. The Suriname Multiple Indicator Cluster Survey was a national survey conducted in the year

2000, in which 4,585 households were selected in the sample and 4,293 household questionnaires were successfully completed. Of the households interviewed, the overall primary school attendance was 86% for the children sampled. The geographic distribution of the households revealed different patterns in primary school attendance, although overall there was no significant difference in male and female attendance.

Of the households interviewed in the urban, rural, and hinterland areas, the percent of children attending primary school was 95%, 91.5%, and 56% respectively. The percentage of children who enter grade 1 of primary school that eventually reach grade 5 for the urban, rural, and hinterland areas respectively were 85%, 67.5%, and 28.5%. The difference amongst education attainment by geographic distribution is further complicated, as the rural and hinterland areas have little access to education beyond primary school. There are no schools beyond primary level in the hinterland, and there are very few secondary schools in the rural areas. Most of the secondary and all of the tertiary levels of education can be accessed only by attending school in the capital.

3.4. Housing / living arrangements

A survey regarding the quality and care demand in the homes for the senior citizens has already been conducted. Some of the relevant results are mentioned in chapter 4. The government will work on strategies for the implementation of proposals from the multi annual policy for older persons, such as health care, living conditions and the wellbeing of the senior citizens. There are a number of homes for the senior citizens. But the majority of the senior citizens choose to live in their own environment, which is a socio-cultural given situation in Suriname. A contributing factor is the role-function of the senior citizens in family settings.

It is important to study the circumstances under which the senior citizens are living in Suriname. Indications are that it is necessary to turn to restructuring of the senior citizens care. In this regard a study is being done on the quality of the care services provided, and the availability of these services for the senior citizens. It is a fact that within the cultural and family ties, the elderly remain living in their family setting, as long as possible. Lack of family support in a home setting or need for professional care are reasons for the elderly to move to external housing arrangements.

The placement of senior citizens in a home is determined by the following factors: • The decreasing socio–economic situation of the country, so that all members of the family are forced to work in order to contribute to the family household. The financial situation of the senior citizens is also a contributing factor for the senior citizens to be placed in a home. • The physical living circumstances of the senior citizens who have a house and who cannot adequately maintain this. This target group is a priority group in the social housing scheme of the government. In the policy paper of the government it is stated that special provisions will be made available to the senior citizens, c.q. families where senior citizens live in.

• Even though this has not been studied, one can assume that in this modern time, with more recreation possibilities, the younger family members cannot or do not pay attention to their grandparents.

Living conditions of the senior citizens

The PAHO implemented in 2001 the project “Living Conditions of the Senior citizens in the Hinterland of Suriname, funded by the Canada Fund. A survey on the living conditions of the senior citizens was done in 8 randomly selected villages (of the 52 villages with a health facility) in the hinterland and a number of focus group discussions were held in Paramaribo and Wanica District. The findings of the surveys in the hinterland and the focus group discussions are summarized here.

A. Survey of the health conditions of the senior citizens in the hinterland

1. Existence of safe water • Villagers rely on water from the river and creeks. • Only two of the 100 respondents mention boiling the water before use. Boiling depends on availability of firewood or gas. • Many villages report stomach pain and diarrhea as most frequent reasons for visiting a doctor. There might be a possible link with the water supply and absence of latrines.

2. Water distribution • There is no safe water distribution system in the villages. • Much time and efforts are spend to get water for daily needs. Especially the senior citizensface hardship to collect water. • In some villages, the water is carried in buckets from the source to the house. The water is stored in buckets, oil drums and barrels in or outside the house.

3. Sanitary facilities • Only some villagers report having a latrine. Those villagers who do not have a latrine report going to the jungle or use the river for their needs.

4. Electricity • Some of the villages have electricity for a few hours during the night; some of the villages do not have electricity at all. • Fuel supply and maintenance/repair of the generators is a problem for continuity. Villagers depend too much on the Government in Paramaribo. • Food cannot be kept fresh if there is no electricity and refrigerator. • Villagers need recreational activities during the day and in the evenings.

5. Housing • Most houses are made of wood and have a zinc roof. Some have grass or leaf roofs also. These roofs need urgent repairs.

6. Medical costs • According to the survey, villagers have to pay for their medical needs, while these villagers, covered by the Medical Mission, have free medical services. • In some villages some villagers had difficulties obtaining a “gezondheidskaart” (card for free medical services) from the Ministry of Social Affairs. • There is complete ignorance as to how to apply for cards for medical assistance.

7. Education • More than half of the senior citizens surveyed have no education or have not completed primary education. • None of the surveyed senior citizens in Krabu Olo, Kajapati, Gosutu ever went to school.

8. Income • The payment of pensions, social support, General Old-Age Pension (AOV) etc. in the hinterland are not done on a regular monthly basis, because of problems with transportation and other infrastructural problems. • The villagers mention different amounts are as their AOV income and for their income from the Ministry of Social Affairs.

9. Health needs • The most important needs experienced by the senior citizens are medicine, better food and eye-glasses. Other needs are improved health care access, a doctor in the village and clean water.

10. Healthy living • High blood pressure, eyesight and mobility problems are most frequent reasons to visit the doctor. • Some villages did not report meat or bread in their menu. Fruit and eggs were mentioned only in one village. • The majority of the villagers mention burning, next to throwing in the jungle, followed by dumping in the river as the most common practice for trash disposal.

11. Health Facilities • Some of the senior citizens could not visit the doctor because there was no doctor in the village when they needed one or • They did not have money to pay the doctor. • Other reasons were: no medicine in the clinic, or no transportation available.

12. Community support • The majority of the surveyed senior citizens reported that there is a support network available to them, like the family network. • Neighborhood and community work are also an important support.

B. Focus group discussions in Paramaribo and Wanica.

It appears from the FGD’s that the situation of the Senior Citizens in Suriname needs improvement, especially in the following areas:

1. Finances • The Senior Citizens need money to be able to finance their primary needs. Most of the Senior Citizens must live from the General Old Age Provision (AOV) of the Ministry of Social Affairs, which is not sufficient. • The AOV is just sufficient to cover the recurrent expenses (gas, telephone, electricity and water). After having paid for these expenses, there is hardly enough money left for food and other services such as medical and home care, and household services. Not all the medical prescriptions can be obtained when needed, with the medical card. In many instances, cash payment is required for needed medications. Without money, the elderly are also deprived of social activities.

2. No attention from and no voice in the society. • The Senior Citizen receives no or hardly any attention of the society; they feel lost and neglected. • They can neither contribute in political sense. • The young generation does not give the Senior Citizens the due respect; respect for the senior citizens is considered a lost legacy.

3. No facilities for Senior Citizens • There are hardly any provisions for Senior Citizens. They have to travel to the city every month to pay their bills for water, electricity and telephone. • Because there is no special transportation available for the senior citizens, it is difficult for them to reach the city. • There is no transportation available that is adapted to the conditions of the senior citizens. Recently some offices introduced special lines for the senior citizens, so that they do not need to wait for long in the lines before they can be attended.

In general, when talking about “Senior Citizens” we think of old people. According to the senior citizens who participated in the FGD’s, this is not correct. Many senior citizens do not feel old; they are quite mobile and still can help themselves. As long as they can do this, they see them selves as “grown-ups” and certainly not as “old”. “You are “old” when you are not able to take care of yourself”.

According to the FGD’s the senior citizens qualify themselves as senior citizens when they are 70 years old. Growing old is not being linked to age, but to feelings and infirmities, such as old age complaints and being less mobile. Old people are those who use walking sticks. Frequently mentioned old age complaints are high blood pressure, diabetes, forgetfulness, arthritis/joint pains, and problems with the eye sight. “Old age complaints are experienced as very annoying, but one has to learn to live with it, for there is no remedy for old age”.

Becoming dependent also is of importance for feeling old. The more dependent the senior citizens become, the older they feel. “You are old when you are dependent”.

Long waiting times are also a torment for the senior citizen, because who comes first, is served first. It often happens that they must wait for hours in uncomfortable wooden chairs until they are received. Getting a prescription from the pharmacy is also difficult. If they are lucky, they can have the prescription after some waiting time. Sometimes they have to come back the next day. Many of the prescriptions are not covered by SZF, so that the clients, including the senior citizens, have to purchase these out of pocket or purchase their medication over the counter.

Travel by public transportation is problematic most of the times. Some drivers do not stop for the senior citizens, or the step to enter the bus is too high for the senior citizens. Taking a taxi is financially not affordable. To pay their bills, the senior citizens must come to Paramaribo, since there are not many branch offices in their neighborhood. Waiting times at these offices are also a common problem. Some offices now have started with special lines for the senior citizens.

Other factors: a. The future. The FGD’s made clear that the senior citizens depend on their own fate. They have no influence on what is going to happen. The only thing they can do is waiting. This results in the situation where the senior citizens not really are concerned with the future, but are more concerned about the present day, about survival and then looking at tomorrow. In some FGD’s they mentioned that they are looking forward to a better future. b. Training. The training as senior citizens nurse is not adequate to work in geriatric care. The training lacks subjects such as social communication with the senior citizens. People are not motivated to work as in nursing care for the senior citizens. Most of them do it because they need the job.

The study recommends that an in-depth study is needed to map out the situation of Senior Citizens. The following aspects need to be addressed in the studies: - The needs of the Senior Citizens on national, district and community level. - Provisions for the Senior Citizens. - The financial situation of the Senior Citizens - The quality of the training of workers for the senior citizens.

With regard to the needs of the Senior Citizens, actions need to be taken for the improvement of existing provisions and to set up new provisions. - There is need for special busses for the senior citizens. - The access to medical care must be improved. - Special rates for water, electricity and telephone should be introduced. - Community approach is needed in the work. - Community centers should be set up with facilities such as offices where the bills for water, electricity and telephone can be paid.

- The senior citizens homes must expand their role and a mutual collaboration must be set up. - The training of senior citizens care providers must be improved in quality. - An association for the promotion of the interests of the senior citizens should be set up.

The study recommends that the qualities of the training of senior citizens care givers needs improvement. More attention must be paid to subjects with regard to social intercourse with the senior citizens. The trainings must be organized on a central level and there must be an authority that controls the trainings, so that all trainings comply with minimal standards and norms. In order to stop the uncontrolled growth of private trainings in senior citizens care, these trainings must be removed from the private sector. There is need for an association to take care of the interests of the senior citizens, from where a platform for senior citizens affairs can be set up that advises the government in related matters. This way the senior citizens have more influence on the national issues regarding Senior Citizens so that they have a voice in society.

4. HEALTH INDICATORS

4.1. Health status

Mortality and morbidity data indicate that people are getting sick and dying from preventable and manageable illnesses. Preventable infectious diseases such as malaria, diarrhea, and acute respiratory infections are still prevalent, as are malnutrition and complications of pregnancy. In addition, a growing number of deaths are attributable to chronic and acute conditions. Chronic conditions such as diabetes mellitus and hypertension are among leading causes of death in the country. Vascular accidents, violence, cancer and diseases of the digestive system are also leading killers. The data on morbidity and mortality due to preventable and manageable conditions indicate that the primary health care system is not functioning as well as it should be. Preventive care needs to be strengthened, and chronic conditions need to be more effectively managed by the providers of primary care.

Mortality

Hypertension and diabetes remain the leading causes of death, and in the year 2000, cerebrovascular diseases moved back to second place, as in 1998. The death rate due to malignant neoplasms has slightly increased each year and is not far from third place. HIV/AIDS death rates are steadily increasing each year and remains in 8th place since 1999. The main change in the leading causes of death is the increased death rate due to certain conditions originating in the perinatal period, which moved up to 5th place. The increase in deaths due to certain conditions originating in the perinatal period are possibly due to two reasons: increase in identification of perinatal deaths through efforts of the Bureau of Public Health, Epidemiology Department, after the 1995-1999 perinatal mortality study; and possibly due to the difficult economic hardships in 1999 and especially in the year 2000.

The number of years of potential life lost due to external causes and HIV/AIDS are also alarming, as most of these deaths are preventable. The higher death rates due to external causes and HIV/AIDS amongst the age groups that compose the largest percentage of the economically active population could have long-term repercussions, further complicating the socioeconomic situation in Suriname.

The increase in percentage of death certificates received and improved data collection and analysis of the mortality data are vital in understanding the health and wellness of the population.

The recent improvements have greatly contributed to the analysis in this document and will remain vital in ascertaining and monitoring the health and wellness of the population of Suriname.

4.2. Main causes of death

The 10 leading causes of death have been stable in the past years. Chronic conditions take an important place in this overview. This, including HIV in the 10 leading causes of death, resembles the picture in the developed world. The occurrence of respiratory infections and gastrointestinal disorders is however characteristic for the third world.

Table 13: Ten leading causes of death with rates per 1000, of the total population, 1998 - 200016.

1998 1999 2000 CAUSES OF DEATH Rank No. Rate Rank No. Rate Rank No. Rate Hypertension and 1 438 1.03 1 468 1.09 1 446 1.02 Cardiovascular Diseases

Cerebrovascular Diseases 2 266 0.63 3 229 0.53 2 326 0.75

External Causes 3 228 0.54 2 239 0.56 3 263 0.60

Malignant Neoplasms 4 202 0.48 4 223 0.52 4 252 0.58

Gastrointestinal Disorders 5 139 0.33 5 182 0.42 6 184 0.42

Certain conditions originating 6 96 0.23 6 128 0.30 5 192 0.44 in the perinatal period

Diabetes Mellitus 7 70 0.17 7 96 0.22 7 125 0.29

HIV/AIDS 9 69 0.16 8 85 0.20 8 110 0.25

Acute respiratory infections 8 70 0.17 9 83 0.19 9 73 0.17

Diseases of the urinary system 10 65 0.15 10 81 0.19 10 65 0.15

Other causes 601 1.42 671 1.56 641 1.47

Total Certified Deaths 2244 5.29 2485 5.78 2677 6.14 80% 87% % Certified Deaths 85%

Total Registered Deaths 2814 6.63 2922 6.79 3090 7.09 Source: The Chief Medical Officer Report 2000

Following is an overview of the leading causes of death in Suriname by age and sex (classified according to the ICD 10 (1997 – 1999). It shows that the cardio-vascular diseases take a pertinent first place in the overview, for both males and females. Cerebro-vascular diseases, malign neoplasms, and gastro intestinal disorders are the same for males as well as females in the age group of 65 and over.

Table 14: Causes of death in selected age groups 45 – 64 year Males 45 – 64 year Females Cardio vascular diseases 246 Cardio vascular diseases 157 Cerebro vascular diseases 125 Malign neoplasms 107 External causes 111 Cerebro vascular diseases 104 Gastro intestinal disorders 101 Gastro intestinal disorders 49 Malign neoplasms 94 Dabetes mellitus 43 > 65 year Males > 65 year Females Cardio vascular diseases 351 Cardio vascular diseases 351 Cerebro vascular diseases 209 Cerebro vascular diseases 202 Malign neoplasms 136 Malign neoplasms 115 Gastro intestinal disorders 97 Gastro intestinal disorders 59 Diseases of the Urinary System 53 Acute respiratory infections 59 Adapted from: Doodsoorzaken in Suriname 1997 – 1999 BOG, December 2000

The following table gives an overview of the number of deaths and the proportional mortality, due to selected causes of death.

Table: 15 Number of deaths & proportional mortality due to selected causes by age & sex, 2000

AGE GROUPS IN YEARS DISEASE TOTAL 0 – 4 5 – 14 15 - 24 25 - 44 45 - 64 65+ # % # % # % # % # % # % # % Hypertension M 47 54 0 0 0 0 0 0 3 75 16 62 27 52 (I10-I15) F 40 46 0 0 0 0 1 100 1 25 10 38 25 48 Diabetes M 71 57 0 0 0 0 0 0 6 60 35 64 29 49 (E10-E14) F 54 43 0 0 0 0 0 0 4 40 20 36 30 51 Ischaemic Heart M 117 60 0 0 0 0 0 0 13 76 48 62 56 55 Disease (I20-I25) F 78 40 0 0 0 0 0 0 4 24 29 38 45 45 Cerebrovascular M 182 56 0 0 0 0 1 50 16 76 54 65 108 50 Disease (I60-I69) F 144 44 0 0 0 0 1 50 5 24 29 35 107 50 Suicides (X60-X84) M 39 72 0 0 1 100 9 69 21 72 5 71 2 66 F 14 26 0 0 0 0 3 23 8 28 2 29 1 34 Homicides (X85- M 13 68 0 0 0 0 2 50 8 89 0 0 3 75 Y09) F 6 32 1 100 0 0 2 50 1 11 1 100 1 25 Mental and M 5 60 0 0 0 0 1 100 0 0 1 50 3 75 behavioral F 4 40 0 0 0 0 0 0 1 100 1 50 1 25 disorders (F00-F99) Source: The Chief Medical Officer Report 2000

4.3. Secondary and tertiary care

The Ministry of Social Affairs implemented in 2002 a study to assess the quality and accessibility of the supply of care services of the senior citizens homes and care institutions in Suriname. Interviews were taken in 3 groups of respondents: clients, personnel and management of 13 senior citizens homes.

The results show that 11.4% of the 88 responding senior citizens still have a partner. About 40% did never have a lasting relationship. The majority of the residents in the senior citizens centers studied are Creole (53%), or of mixed origin (27%). The majority of the residents have passed primary education (42%), while 24% have completed junior high school. Only 1% has completed higher education or University. About 14% never went go to school. The study also shows that 76% of the senior citizens have the Old Age Pension as single source of income, while 14% has the Old Age Pension plus a retirement pension as civil servant.

In 2004 the Ministry of Social Affairs conducted a study on the need for nursing homes in Suriname. Seventy-two clients of nursing homes were interviewed. The study showed that 61% of the clients are in the age group of 60 and older. The study also shows that: - In the senior citizens homes 24% of the clients are younger than 60. - In the hospitals, 35% of the clients are older than 60 years - In the psychiatric hospital 60% is older than 60 years.

Asked about close relatives, 56% responded having close relatives. Thirty five percent of these clients receive visits from their children, 15% from second line relatives, and 10 % by the parents. It is seen that 23% of the clients receive visits only once per month, while 15% receive visitors once a week or twice per month. Thirteen percent receives daily visitors. Following table gives an overview of the length of stay of the clients.

Table 16. Length of stay in the nursing homes

Duration Absolute Percent < 6 months 5 7 6 – 11 months 5 7 1 – 2 years 14 19 3 – 4 years 8 11 5 – 6 years 8 11 7 – 8 years 5 7 9 – 10 years 9 12 11 – 12 years 3 4 13 – 14 years 1 1 15 – 16 years 3 4 17 – 18 years 2 3 19 years and longer 9 12 Total 72 100 Source: Onderzoek naar de behoefte aan een verpleeghuis, Min SOZAVO, Januari 2004

4.4. Morbidity

The Senior citizens

Very little data is collected and analyzed about the senior citizens. In the year 2001, more attention was focused on the aging population. The leading causes of death in the senior citizens are heart disease, cerebro-vascular disease, and malignant neoplasms. Male patients aged 65 years and older were the leading age group to be discharged from Academic Hospital for ill- defined causes in the 1999 and 2000. Discharges for prostate cancer were highest amongst male patients aged 65 years and older. Hospitalizations for hypertensive disorders were also highest in the age group of 65 years and older. Nearly 30% of all Academic Hospital discharges for injuries due to falls were amongst elderly women, of whom two times were as likely as the elderly males to be hospitalized for injuries due to a fall.

Non-Communicable Diseases

Data on non-communicable diseases were available from the Medical Mission for 1999, Regional Health Services for 1999 and 2000, and some hospital data from 2000. There is currently no national system of monitoring non-communicable diseases. The Regional Health Service and Medical Mission clinics register consultations by total consults per the specified diseases, and thus only totals of consultations per specific disease can be analyzed. The Regional Health Services conducts many individual and community activities for their chronic patients. Some activities include special consultation days for the chronic disease patients, introduction of special diabetes care and healthcare informational activities with the community. Medical Mission has registered the occurrence of chronic disease in approximately 50% of villages with Medical Mission health centers in the hinterland, a population of approximately 28,000 people.

Hypertension

The Regional Health Services had 28,850 and 23,352 consultations for hypertension for the years 1999 and 2000 respectively. The decrease in total consultations for hypertension in 2000 was most likely due to strikes amongst the physicians during this year. In 1999, hypertension composed 15% of all consultations at the Regional Health Services, and similarly 14% for the year 2000. It is the leading disease-specific cause for consultation at the Regional Health Services. According to the data reported by the Regional Health Services, for all hypertension and diabetes consults, females are two times more likely to visit the clinics for diabetes consults than men, and three times as likely to visit the clinics for either hypertension or the combination of diabetes and hypertension. In 1999, the Medical Mission reported 600 hypertension patients in their chronic disease registry, with a prevalence rate of 21.4 per 1,000 population in the hinterland. This Medical Mission data represents approximately 50% of villages with Medical Mission health centers.

The available data on discharge diagnoses for the year 2000 from Academic Hospital reveal very different trends in hospitalizations for hypertension and diabetes amongst the different sexes. The discharge diagnoses reflect a more balanced distribution of hospitalizations for hypertension and diabetes amongst the sexes, while actually slightly more males than females hospitalized for these diseases.

Diabetes Mellitus

The Regional Health Services had 19,721 and 15,750 consultations for diabetes for the years 1999 and 2000 respectively. The decrease in total consultations for diabetes in 2000 was most likely due to strikes amongst the physicians during this year. In 1999, diabetes mellitus composed 10% of all consultations at the Regional Health Services, and approximately 9% for the year 2000. According to the diabetes data reported by the Regional Health Services, for all the diabetes consults, females compose 66% of the consults for diabetes, and nearly 75% of the visits for a combination of diabetes and hypertension. In 1999, the Medical Mission registered 70 diabetes patients, with a prevalence rate of 2.5 per 1000 population in the hinterland. The Academic Hospital discharge diagnoses data depict the age group of 45-59 years with the largest number of discharges for diabetes.

Skin Disorders

The Regional Health Services reported 11,767 and 10,599 consultations for skin-related disorders, approximately 6% of the total consultations. No current data on skin disorders was available from the Dermatological Services, the national institution for dermatological disorders, or the Medical Mission.

Accidents and Injuries

The emergency department of the Academic Hospital monitors the total visits for external causes to the Emergency department. Some of the results from the year 2000 are in Table 8. Although the Emergency department visits for accidents and injuries remains fairly constant over the years, there was a significant increase in the number of patients presenting to the Emergency Department for symptomatic/disease medical help from 1998 through the year 2000. There is currently no monitoring system for accidents and injuries at the national level. The Medical Mission reported 1,726 health center consults for accidents in the year 2000.

Table 17. Academic Hospital Emergency Department 2000-2002 Reports.

Cause of visit to the ER Department (Total patients) 2000 2001 2002 A. Transportation Accidents Land Transportation Accidents 2,829 3,060 3,284 Other Transportion Accidents 234 56 81 Total Transportion accidents (A) 3,063 3,116 3,365 B. Other Accidents and Injuries Accidental falls 2,390 2,353 2,294 Accident caused by fire and flames 50 70 37 Accident by drowning, asphyxiation 973 728 669 Suicide and self-inflicted injury 325 290 354 Homicide and injury purposely inflicted by other persons 3,070 3,249 3,321 Child abuse 75 104 49 Other external causes 5,979 4,791 5,018 B. Total Other Accidents and Injuries 12,862 11,585 11,742 C. Total Accidents and Injuries (A+B) 15,925 14,701 15,107 D. Total Visits for medical help other than accidents and injuries 23,531 19,243 18,830 Total Emergency Department visits (C+D) 39,456 34,694 34,694 Other ER data: Total ER patients admitted to hospital 6,276 Total ER patient deaths 199 Total patients deceased upon arrival to ER 163 Source: Academic Hospital Emergency Department, January 2003

Ill-defined causes

The Regional Health Services reported 34,043 and 29,172 consultations with ill-defined causes in the years 1999 and 2000 respectively. Ill-defined causes is the leading cause for consultation. Some reasons for the large number of consults classified as ill-defined can be: inadequate communication between the physician who makes the diagnosis and the personnel who report the consult, and the large number of patients that present with general symptoms and lack of lab confirmation of a specific disease at data reporting time (due to either patient not tested, timeliness of lab results, or lab results do not confirm a specific disease/illness).

Mental disorders

There is currently no national monitoring of the magnitude of mental disorders in Suriname, although some facilities such as the Psychiatric Centrum Suriname collect limited data. The PCS reported 570 admissions in the year 2000 for mental and behavioral disorders. The males were twice as likely as females to be admitted.

The Academic Hospital reported 103 discharges in the year 2000, up from 90 in 1999, for mental and behavioral disorders. For both years, males were two times as likely as females to be discharged for mental and behavioral disorders. The age distribution for both sexes revealed those between the ages of 25-44 and 65 years of age or older were most likely to be discharged for mental and behavioral disorders.

The impacts of mental disorders and public health are more recent areas of discussion which need to be further investigated in the near future.

Neoplasms

There is one pathology laboratory in Suriname and very few other sources of data on malignant neoplasms, yet there is no official national cancer registry in place despite previous attempts. Efforts to develop a national cancer registry beginning with the histological data available are currently under way, with the possible introduction of the Canreg in Suriname.

In 1996 there were 55 cases of malignant neoplasms of the cervix identified at the pathology laboratory, which increased to 65 in the year 2000. The predominant ethnic groups affected by cervical cancer are women of Negro and East Indian descent, between the ages of 35 and 64. The Stichting Lobi, a national family planning foundation, started a National Pap Smear Project in 1998 in an attempt to identify cervical cancer cases in an earlier stage of the malignancy. The number of cases of malignant neoplasms of the female breast followed a similar trend with 45 cases in 1996, and 75 in the year 2000. Again the predominant ethnic groups were females of Negro and East Indian descent, but between the ages of 40 and 64.

Malignancies of the lung have remained steady over the years 1996-2000. The age groups most affected are those between 55 and 74 years of age. The male to female ratio is 3.5, with the predominant ethnic groups affected are people of Negro-descent, Javanese, followed by people of East Indian descent.

In general, the malignancies reported by the Pathology Laboratory reveal several distinct patterns. For males, the incidence of all cancers increases slightly beginning at age 30, but then increases sharply between the ages of 50-90 years. For females, the incidence of all cancers clearly increases between the ages of 30-80 years The highest incidence of cancers is amongst the population of Negro- descent with approximately 41%, followed by people of East Indian descent with nearly 28%, and the Javanese population composes 16%.

Graph 12. Malignancies reported by the Pathology Lab (AZ) by age and sex ,2000.

60 Malignancies 2000

30 Total

0 0-10 10-20 20-30 30-40 40-50 50-60 60-70 >=90 70-80 80-90

Age group Male Female Unknown

Source: Pathology Laboratory-Academic Hospital, CMO 2000.

Graph 13. Male malignancies by type, 2000. Graph 14. Female malignancies by type, 2000.

Endome Urethra 6% 6% Other Other 31% Breast 33% Prostate 28% 32%

Unknown Colon & Skin Location Skin Rectum Cervix 6% 15% 11% 8% 24%

Source: Pathology Laboratory-Academic Hospital, CMO 2000

The National Pap Smear Project conducted by Stichting Lobi in cooperation with the Leiden University began in 1998 and completed in 2001. Of the 59,000 women interviewed, this was the first pap smear for approximately 27% of the women. From the pap smears collected, cytology was not established for 1226 patients, and 643 were pre-malignant. Of the 643 pre- malignant cases, this was the first pap smear for 17% of the women. The results of the study revealed the largest number of pre-malignant cases were in women between the ages of 30-40 years. The highest prevalence rates were observed in the Bush Negro and Creole/Mixed women.

Communicable Diseases

The Epidemiology/Biostatistics department of the Bureau of Public Health compiles and analyzes communicable disease reports weekly, and submits reports monthly to the Caribbean Epidemiology Centre (CAREC), the PAHO, and the Ministry of Health. Communicable diseases are identified regularly through weekly hospital surveillance, sentinel surveillance (30 stations), and occasionally through physician and outbreak reports.

Epidemics

In 1998 there was a Dengue Type I epidemic from February until June in the coastal areas of Suriname. During the 1998 epidemic there were 495 hospitalized cases, 149 laboratory confirmed, and 60 cases of DHF/DSS in which 1 patient died. During the years 1999 and 2000, Suriname endured an epidemic of Dengue Types I and II from October of 1999 until June 2000, when it finally returned to endemic levels. The 1999-2000 epidemic was complicated by the re- emergence of Dengue Type II, with 1582 cases hospitalized, 392 laboratory confirmed cases, and 144 cases of DHF/DSS. A Dengue Crash Program was established and a Dengue Control Manual developed to aid in managing the current epidemic and preventing future Dengue outbreaks.

STI’s and HIV/AIDS

In accordance with the syndromic approach of sexually transmitted infections, data is collected by the Dermatological Services, Stichting Lobi (Family Planning), the Regional Health Services, and the Medical Mission. The Medical Mission reported an incidence of sexually transmitted infections in the hinterland of 0.5-6 cases per 1000 population older than 15 years of age in 1999.

Table 18. STI’s, HIV/AIDS, in Suriname, 1998-2000. Infection/Disease 1998 1999 2000 AIDS 110 NA NA HIV 186 267 286 Chlamydia NA 4 NA Genital Discharge (Telefonade) 1460 1235 1511 Genital Discharge (Dermatology Services) NA 947 NA Genital Discharge (MZ) NA NA 763 Genital Ulcers (Telefonade) 83 43 55 Genital Ulcers (Dermatology Services) NA 334 NA Genital Ulcers (MZ) NA NA 93 Gonococcal Conjunctivitis NA 11 NA Gonococcal Infections 327 629 NA Syphilis 67 233 NA Congenital Syphilis NA 8 NA

Source: Epidemiology Data 1995-1999, September 2000; CAREC Reports 2000

HIV/AIDS data is collected by the National AIDS Program. Due to inadequate classification of AIDS amongst HIV positive patients, AIDS cases have not been calculated consistently. Although the number of HIV positive cases is still relatively low compared to other countries in the Caribbean region, the doubling time of the number of reported HIV cases in Suriname is 2.5 years, in contrast to the average of 4 years amongst the other Caribbean countries. The Academic Hospital averaged about 65 discharges for HIV/AIDS from 1999-2000. The predominant ethnic group infected by HIV and dying due to AIDS is the population of Negro descent with high risk behaviors, mostly living areas of lower socioeconomic levels and between ages of 15 and 44. The male to female ratio for HIV infection was 1.7 in 1996 and dropped to nearly 1.0 in 2000.

Endemic Diseases

The main endemic disease affecting Suriname is Malaria. The number of malaria positives has increased sharply since 1997 from 5,077 to 9,014 in 1999, and decreased slightly to 8,913 in 2000. Although there are three types of malaria in Suriname, Pl. falciparum, malariae, and vivax, Pl. falciparum composes approximately 89% of the malaria positives confirmed. With the majority of malaria cases of the type Pl. falciparum, the resultant death rate due to malaria is not surprising. The number of deaths each year has increased also from 15 to 19 to 24 in the years 1998, 1999, and 2000 respectively. The deteriorating malaria situation is also affecting expectant mothers. The number of indirect obstetric deaths due to malaria increased in the years 1998-2000. Approximately 59% of the malaria positives confirmed by the Medical Mission are from the Marowijne region of the hinterland of Suriname. The Medical Mission estimated the Annual Parasite Index as 152.6 and the Annual Falciparum Index as 136.0 for the year 1999, and both are medium-high risk levels in the hinterland region. Although there have been several initiatives such as bed net projects and spraying, much more needs to be done to begin to decrease the incidence of malaria, a major public health issue in Suriname for many decades.

Notification System

The years of economic hardship, 1999 and 2000, were plagued with strikes of health personnel. The strikes affected the quality and consistency in disease reporting, and affect the analysis of the health trends of these years. Lack of reporting, inconsistent reporting, lack of uniformity in reported data, and late reporting all were issues affecting the notification system during the years 1999 and 2000.

Table 19: Selected causes of death by age and sex CAUSE GROUPS PER ICD-10 TOTAL 45 - 59 60-64 65 + YPLL TOTAL DEATHS CERTIFIED M 1539 243 128 623 27,243 (0.00-6.00) F 1132 158 102 527 18,259.50 U 6 1 1 2 124.5 1.00 Communicable diseases M 202 31 12 52 4,756 (A00-B99, G00-G03, J00-J22) F 128 18 6 31 3,547.50 U 1 0 0 0 63 2.00 Neoplasms M 1024 19 12 67 2575.5 (C00-D48) F 129 32 21 45 1408.5 3.00 Diseases of the circulatory system (I00-I99) M 438 94 48 240 3014 F 333 53 40 215 1433.5 U 1 0 0 1 0 3. 02 Hypertensive disease M 47 11 5 27 249.5 (I10-I15) F 40 4 6 25 146 3. 03 Ischemic heart disease M 117 35 13 56 890.5 (I20-I25) F 78 20 9 45 409 U 0 8 4 0 0 3. 06 Heart failure M 31 3 4 22 81.5 (I50) F 22 4 6 11 115.5 3. 07 Cerebrovascular diseases M 182 32 22 108 1015.5 (I60-I69) F 144 16 13 107 445 5.00 External causes M 198 31 3 18 6035.5 (V01-Y89) F 64 6 5 11 1981.5 U 1 0 0 0 45.5 6. 00 All other diseases (D50-D89, E00-E90, M 315 53 43 133 4810 F00-F99, G04-G98, H00-H59, H60-H95, J30- F 232 42 20 106 337.5 J98, K00-K93, L00-L99, M00-M99, N00-N99, U 1 1 0 0 13 O00-O99, Q00-99 6. 01 Diabetes mellitus M 71 18 17 29 468 (E10-E14) F 54 17 3 30 52 6. 05 Chronic lower respiratory diseases (J40- M 23 2 2 17 125.5 J47) F 14 0 2 7 288.5 6. 09 All other diseases of the digestive system M 59 14 6 22 908.5 (remainder of K00-K93: K00-K31, K50-K55, K57- F 32 5 1 18 422 K66, K71, K72, K75, K80-K93) U 0 0 0 0 0 6. 10 Diseases of urinary system M 38 8 6 18 337.5 (N00-N39) F 27 4 8 11 228 6.14 Remainder of all other diseases M 39 5 2 19 640 (remiander of A00-Q99: D55-D89, E00-E07, E15- F 32 5 0 19 341.5 E34, E65-E90, H00-H59, H60-H95, L00-L99, M00-M99, N41-N99) U 0 0 0 0 0

Source: The Chief Medical Officer Report 2000

4.5. Chronic disability

According to the 2004 Ministry of Social Affairs study, most of the clients (19%) have stayed 1 – 2 years in the institution, while 12% is there for 9 – 10 years in the institution and longer than 19% in the institution. The study also shows that most of the clients in the psychiatric institution stay there 5 – 6 years. The clients in the hospitals and the senior citizenshomes stay there between 1and 2 years. The study also shows that of the clients staying in the institution on a social indication, more than 55.5% has a handicap, of which the majority (33.3%) have a physical handicap.

Clients and handicap

Table 20: Clients in nursing homes by handicap

Handicap Absolute Percent Physical 24 33.3 Mental 6 8.3 Double handicapped 10 13.9 None 32 44.5 Total 72 100 Source: Onderzoek naar de behoefte aan een Verpleeghuis, SOZAVO, Januari 2004

Looking at the reasons for their stay, it shows that 37.5% of the clients need reactivation/ revalidation therapy and continuation of observation, while 18% need care for chronic diseases.

Clients by needed care

Table 21: Clients in the nursing homes, by needed care

Needed Absolute Percent Reactivation/revalidation 11 15 Reactivation/revalidation and continuation of observation 27 38 Reactivation/revalidation and chronic diseases 2 3 Reactivation/revalidation and other services (ADL) 1 1 Continuation of observation 9 13 Chronic diseases 13 18 Other (terminal care ) 2 9 No response 7 10 Total 72 100 Source: Onderzoek naar de behoefte aan een Verpleeghuis, SOZAVO, Januari 2004

Looking at the indication for admission in the institution, it shows that 22% of the clients were admitted with only a physical condition, while 18% has only a mental condition. The study also shows that 18 % of the clients need specialist medical care, while 58 % does not need this.

Following overview provides a clear picture of the needy elderly.

Table 22: Number of people requiring daily care

Numbers of people requiring daily care, total population, proportion of total population requiring care, and dependency ratio by region, country and year, based on two severest Global Burden of Disease study disability categories (levels 6, 7). Prevalence (thousands) by age in years Total Preval. Prop.total Depend population Incr. % pop % ratio % * Year 0-4 5-14 15-44 45-59 60+ total (000) 2000 0.3 0.6 10.9 2.3 4.3 18.4 417.2 0 4.4 7.2 2010 0.3 0.5 11.2 3.9 4.6 20.5 433.1 11 4.7 7.1 2020 0.2 0.5 10.5 5.7 5.8 22.7 440.4 23 5.1 7.5 2030 0.2 0.4 9.2 6 9.8 25.6 442.1 39 5.8 9.1 2040 0.2 0.4 8 6.1 12.7 27.4 435.3 49 6.3 10.6 2050 0.2 0.3 7.2 5.1 15.5 28.4 417.9 54 6.8 12.5 *(total number of dependent people)/(population aged 15-59)

Sensitivity analysis. Numbers of people requiring daily care, total population, proportion of total population requiring care, and dependency ratio by region, country and year, based on three severest Global Burden of Disease study disability categories (levels 5, 6, 7). Prevalence (thousands) by age in years Total Preval. Prop.total Depend population Incr. % pop % ratio % * Year 0-4 5-14 15-44 45-59 60+ total (000) 2000 0.8 1.4 15.6 3.4 6.2 27.3 417.2 0 6.6 10.7 2010 0.7 1.2 16.1 5.7 6.6 30.3 433.1 11 7 10.5 2020 0.6 1 15 8.3 8.4 33.3 440.4 22 7.6 11.1 2030 0.5 0.9 13.2 8.8 14.1 37.6 442.1 37 8.5 13.4 2040 0.5 0.8 11.5 8.9 18.4 40.1 435.3 47 9.2 15.5 2050 0.4 0.8 10.3 7.5 22.4 41.4 417.9 51 9.9 18.3 *(total number of dependent people)/(population aged 15-59) Source: UN Population Division: World Population Prospects: The 2002 Revision

4.6. Functional capacity

The 88 persons interviewed in 2002 by the Ministry of Social Affairs in the study to assess the quality and accessibility of the supply of care services of the senior citizens homes and care institutions in Suriname (see 4.4.) responded as follows, with regard to their activities of daily life:

Table 23: Functional capacity of the respondents in the elderly homes

Activity Self help capacity Yes % No % With difficulty % Standing/Sitting 80 91 4 5 4 5 Dressing 80 91 7 8 1 1 Use of WC 80 91 2 2 6 7 Bathing 78 89 9 10 1 1 Eating 86 98 1 1 1 1 Cooking 28 32 58 66 2 2 Laundry 34 39 53 60 1 1 Dishes 41 46 47 53 0 0 Cleaning 25 28 61 69 2 1 Reading 47 53 26 29 15 17 Walking 65 74 13 15 10 11 Small chores 38 43 46 52 4 5 Source: Dienst WOP, SOZAVO, September 2002

4.7. Risk factors of non-communicable diseases

The following table gives an idea of the non communicable diseases in age groups, showing also the most common diseases in the elderly group.

Table 24: Distribution of selected Non-Communicable Disease by Age And Sex – Academic Hospital Discharges, Year: 2000

DISEASE TOTAL AGE GROUPS IN YEARS < 1 1 – 4 5-14 15 - 24 25 - 44 45 - 59 60 - 64 65 + Ill-defined causes M 376 26 21 12 31 73 78 20 114 (R00-R99) (1) F 300 13 34 8 16 77 60 22 70 Hypertension M 315 0 0 3 1 26 111 38 136 (I10-I15) F 333 1 0 0 2 26 80 49 175 Cerebrovascular M 291 1 0 0 1 40 78 42 129 Diseases (I60-I69) F 226 1 1 0 3 44 26 133 Neoplasms M 170 2 1 3 8 25 27 26 78 (C00-D48) F 343 1 1 3 10 148 95 29 56 Diabetes (E10-14) M 0 0 0 2 12 32 10 19 F 62 0 0 2 7 7 17 4 25 Nutritional Deficien M 78 15 29 3 5 10 7 0 9 cies (E40- F 94 7 14 1 12 29 12 8 11 E64,D50-D53) Mental disorders M 69 1 0 0 2 18 24 5 19 (F00-F99) F 34 0 1 1 1 11 3 4 13 Source: Report of the Chief Medical officer, 2000

The following table provides an idea of the diagnoses in patients in de older age groups, admitted in the Academic Hospital Paramaribo, the main public hospital.

Table 25: Discharge diagnoses from Academic Hospital by age & sex, 2000

Code Description 45-59 60-64 65+ M F M F M F 0.00 Ill-defined causes 78 60 20 22 114 70 1.01 Intestinal infectious diseases 20 22 17 4 36 31 1.02 Tuberculosis 6 1 1 1 8 2 1.03 Certain vector-borne diseases 21 11 2 2 4 5 1.07 HIV Disease (AIDS) 4 2 0 0 0 0 1.08 Acute respiratory infection 18 9 18 8 27 19 1.09 Other infectious and parasitic diseases 30 11 7 7 14 16 2.01 Malignant neoplasm of stomach 0 0 0 0 0 0 2.02 Malignant neoplasm of colon and rectosigmoid junction 1 1 0 0 2 1 2.03 Malignant neoplasm of digestive organs & peritoneum, except stomach & colon 1 1 0 0 1 1 2.04 Malignant neoplasm of trachea, bronchus and lung 0 0 0 0 0 0 2.05 Malignant neoplasm of respiratory & intrathoracic organs, except trachea, 0 0 0 0 0 1 bronchus & lung 2.06 Malignant neoplasm of female breast 0 0 0 0 0 0 2.07 Malignant neoplasm of cervix uteri 0 0 0 0 0 0 2.08 Malignant neoplasm of corpus uteri 0 0 0 0 0 0 2.09 Malignant neoplasm of uterus, parts unspecified 0 0 0 0 0 0 2.10 Malignant neoplasm of prostate 2 0 3 0 21 1 2.11 Malignant neoplasm of other genitourinary organs 0 3 0 1 0 2 2.12 Leukemia 0 0 2 0 0 3 2.13 Malignant neoplasm of lymphoid, other hematopoietic and related tissue 2 1 0 0 0 0 2.14 Malignant neosplasm of other and unspecified sites 7 9 10 12 23 15 2.15 Carcinoma in situ, benign neoplasms and neoplasms of unknown behavior 10 61 7 6 22 11 3.01 Acute rheumatic fever & chronic rheumatic heart disease 0 4 0 0 0 3 3.02 Hypertensive disease 111 80 38 49 136 175 3.03 Ischemic heart disease 131 63 42 26 50 47 3.04 Pulmonary heart disease, diseases of pulmonary circulation & other forms of 2 7 2 4 10 11 heart disease 3.05 Cardiac arrest 0 0 0 0 1 1 3.06 Heart failure 38 27 15 16 75 73 3.07 Cerebrovascular diseases 78 44 42 26 129 133 3.08 Atherosclerosis 0 0 0 0 0 1 5.01 Land transport accidents 14 7 4 1 12 3 5.02 Other and unspecified transport accidents 0 0 0 0 0 0 5.03 Falls 10 7 2 5 22 42 5.05 Accidental drowning and submersion 1 0 0 0 0 0 5.08 Exposure to smoke, fire, and flames 1 1 0 0 0 0 5.10 All other accidents 30 16 5 6 24 33 5.11 Intentional self-harm (suicide) 7 2 0 1 3 2 5.12 Assault (homicide) 15 2 1 1 2 0 5.13 Event of undetermined intent 0 1 1 1 0 0 5.14 All other external causes 1 1 1 1 2 2 6.01 Diabetes mellitus 32 17 10 4 19 25 6.02 Nutritional deficiencies & nutritional anemia 7 12 0 8 9 11 6.03 Mental and behavioral disorders 24 3 5 4 19 13 6.04 Diseases of nervous system, except meningitis 38 35 18 12 60 55

6.05 Chronic lower respiratory diseases 12 5 7 15 27 11 6.06 Remainder of diseases of the respiratory system 60 34 35 43 99 64 6.07 Appendicitis, hernia of abdominal cavity, & intestinal obstruction 19 5 4 0 19 5 6.08 Cirrhosis and certain other chronic diseases of the liver 0 0 0 0 0 0 6.09 All other diseases of the digestive system 150 83 49 37 120 85 6.10 Diseases of the urinary system 69 57 42 16 80 37 6.11 Hyperplasia of the prostate 3 0 9 0 24 0 6.12 Pregnancy, childbirth, and the puerperium 3 6 0 0 0 0 6.13 Congenital malformations, deformations and chromosomal abnormalities 3 6 1 2 2 0 6.14 Remainder of all other diseases 361 420 181 197 615 691 Source: Report of the Chief Medical officer, 2000

5. THE SOCIAL LIFE IN THE 60+ POPULATION

The preliminary results of the Civil Servants Registration in 2001 (Ministry of Home Affairs 2001) give an indication that older persons are integrated at the policy level of the Government.

The place of the senior citizens in the Surinamese society is not a homogeneous one. Because of the multi-ethnic society the place of the older persons depends on the cultural group to which they belong. Especially in the groups of Asian descent they are often part of the family, they play an important role in the upbringing of the grandchildren and their opinion is of great importance in family decisions. Research has shown that older persons take the view that their children have to take care of them if they become old and infirm. They prefer to function independently as long as possible in their familiar surroundings, because they assume that they will lose their independence in a home for the senior citizens.

There are several umbrella organizations which continue their efforts for the cause of the senior citizens. Furthermore there is a union that look after the interest of retired civil servants. In Suriname there are committees, associations, volunteers, religious groups that make house visits or support the senior citizens.

In 2002 the Ministry of Social Affairs implemented a survey on the quality and accessibility of the care by senior citizens homes and institutions of care in Suriname. The social motivation of the people involved in these activities has also been evaluated. Senior citizens join these institutions in search of company and recreation, to avoid loneliness. Within the institutions there are sufficient activities, but only 59,1% participates. The reason of non-participation is mostly their health condition and the fact that they are not interested in these activities. The type of activities implemented for the senior citizensare short trips, handicraft, film evenings, contact sessions, etc.

There has been no specific study done on the social live of the senior citizens at home. It is important to note however, that those who live at home, participate in community activities through their community organizations and religious organizations, in going to church, participation in singing groups, bible studies and group prayers, home visits to each other, etc.

As regards life long learning, no activities could be detected in the policy of the Ministry of Education. The day centers organize group training and education activities and educative day trips.

In order to fulfill the commitment as a member state towards the call of the United Nations to sensitize the society about the role the senior citizens play in society, the Ministry of Social Affairs installed in 1999 the nation a commission “International Year of the Senior citizens1999”. This commission had as its task: • stimulate local, national and international actions o order to sensitize the society of the role of the senior citizens • develop a policy that is aimed at the solving of problems faced by the senior citizens. • Many activities have been initiated since, such as the observance of the national day for the senior citizens, on October 1st. Furthermore a letter of request was sent to several authorities to treat the senior citizens with priority when waiting for services.

One of the tasks of the Ministry of Social affairs is the care for the senior citizens in Suriname. For the implementation of this policy, the Ministry deems it necessary to collaborate with the private initiative providing services to the senior citizens. To this end it appointed in 1981 the National Advisory Council for the Senior citizens. (NARB)

The NARB is an advisory body to the Minister of Social Affairs with regard to senior citizens policy. Its special tasks are: • advise on the policy with regard to legislation and subsidy • advise with the implementation of a general system of licensing for building institutions for admission, nursing and caring of senior citizens • advise on the so called open – senior citizens care activities • study and inform about reports and advises wit regard to senior citizens care • maintain contacts with relevant persons and institutions • report periodically on important activities.

In the past the NARB has proven its existence and reported on many activities implemented and issues experienced, such as: • The absence of a vision/policy for the work of the senior citizens on short term, mid term and long term. There is a terms of reference, but the strategic goals and quantified objectives have to be worked out yet. • Communication between the government and the NARB and between the NARB members themselves need improvement. There are draft bylaws ready, where the accent is paid on the strengthening of the advisory boards, the role and function with regard to policy development and monitoring.

The role of civil society, NGO’s, volunteers, etc.

There are several institutions that are active in the work of the senior citizenssuch as: the Association of Private and Social Institutions (VPSI), the Bonf of retired civil servants, etc. The VPSI is working on the organization of activities for the senior citizensin Suriname. They organized computer trainings for the senior citizens, social activities on the International Day of the Senior citizens, etc. There are plans for a “meals on wheels” system, and a library for the senior citizens. There are other comities, associations, volunteers etc. who conduct house visits to the needy senior citizens. A number of private organizations have day care centers for the senior citizens. Also, the religious organizations and the service clubs have activities that contribute to the support of the senior citizens.

There are no research activities or centers that conduct these studies on aging. Within the Ministry of Social Affairs there is a Scientific Research Department and the Bureau of Public Health has a Geriatrics Department. There is consensus about centralization and coordination between these institutions.

There are no plans or programs for emergency situations. The Government pays for the costs for the senior citizens who have to travel to the Netherlands for medical treatment in low frequent diseases. There are also provisions for assistance with a wheelchair. The support depends on the circumstances, in the form of gifts or loans or a combination of these.

The Ministry of Social Affairs has formulated a plan of activities to improve the service to the senior citizens. Some of these are: - formulate a long term policy o the senior citizens - Continue improvement and accessibility of services and care - Structuring ad further operationalization of home care, in collaboration with the private organizations - Minimum requirements for homes for the senior citizens - Institution strengthening of the Department for elderly care - Improve accessibility of medical services - Expand supply of services and support with recreational activities - Network with private organizations - Development of quality standards for elderly care

6. BRIEF DESCRIPTION OF THE HEALTH CARE SYSTEM

Consumption per capita

The cost of healthcare per capita increased from US$ 43.58 in 1995 to US$ 101.71 in 1997, but the year thereafter, the cost seemed to decrease again. The 2000 data was from the National Health Account Study in support of Health Sector Reform, which studied health account data more extensively, and thus projected a very different figure for healthcare cost than in previous years. The percentage of GDP per capita spent on healthcare averaged around 4% for the years prior to the 2000 data from the National Health Account Study. The estimates determined in the National Health Account Study gave a value over two-times the average healthcare cost as a % of GDP for the previous 5 years.

Table 26. Healthcare cost as percentage of GDP, 1995 – 2000

Healthcare cost per capita, 1995 – 2000 Year Cost in US$ % of GDP 1995 43.58 3.83 1996 75.24 3.98 1997 101.71 4.82 1998 66.43 3.50 1999 NA NA *2000 180.33 9.42 Source: Collected financial healthcare information, MOH, Unpublished *National Health Account Study, 2001

The following table gives a more comprehensive view of the health expenditure in US$.

Table 27: Selected national health account indicators: measured levels of expenditure on health, 1997 – 2001 1997 1998 1999 2000 2001 Total expenditure on health 9.5 9.9 9.8 9.9 9.4 General Government Expenditure 52.4 61.7 59.6 63.3 60.2 Private expenditure on health 47.6 38.3 40.4 36.7 39.8 General Government Expenditure 17.1 18.2 17.6 18.9 17 External resources for health 9 9.5 17.6 9.8 12.4 Social security expenditure on health 32.2 34.9 33.3 28.1 22.8 Out of pocket expenditure 30.5 33.7 32.7 39.9 57 Private prepaid plans 1.7 1.4 1.3 1 0.7 Per capita total expenditure on health At average exchange rate (US$) 207 194 104 186 153 At international dollar rate 371 404 402 407 398 Per capita Government expenditure on health At average exchange rate (US$) 108 120 62 118 92 At international dollar rate 194 249 239 258 240 Source: World Health Report 2003, Annex 5

Hypertension and diabetes remain the leading causes of death, and in the year 2000 Cerebrovascular diseases moved back to second place similar to 1998. The death rate due to malignant neoplasms has slightly increased each year and is not far from third place. HIV/AIDS death rates are steadily increasing each year and although it remains in 8th place since 1999. The main change in the leading causes of death is the increased death rate due to certain conditions originating in the perinatal period, which moved up to 5th place. The increase in deaths due to certain conditions originating in the perinatal period are possibly due to two reasons: increase in identification of perinatal deaths through efforts of the Bureau of Public Health Epidemiology Department after the 1995-1999 perinatal mortality study; and possibly due to the difficult economic hardships in 1999 and especially in the year 2000.

One distinguishable and interesting trend in the mortality tables and graphs is the large discrepancy between the rank order of leading causes of death versus the rank order by “Years of Potential Life Lost”. The certified deaths were used to calculate the years of potential life lost, and the value of 65 years served as the standard. Naturally, high death rates in the younger age groups yield higher values for years of potential life lost. Due to the higher death rates from conditions originating in the perinatal period, it is natural for the years of potential life lost to be high, and thus it ranks 1st as the leading cause of death for years of potential life lost. The number of years of potential life lost due to external causes and HIV/AIDS are also alarming, as most of these deaths are preventable. The higher death rates due to external causes and HIV/AIDS amongst the age groups that compose the largest percentage of the economically active population could have long-term repercussions further complicating the socioeconomic situation in Suriname.

The increase is percentage of death certificates received and improved data collection and analysis of the mortality data are vital in understanding the health and wellness of the population. The recent improvements have greatly contributed to the analysis in this document and will remain vital in ascertaining and monitoring the health and wellness of the population of Suriname.

Organization of the Health System

The Ministry of Health (MOH) is responsible for health system management, more specifically: the availability, accessibility and affordability of health care. The main responsibilities of the MOH are: planning, policy development, evaluation, coordination, and the setting of standards in the health system. The core institutions of the health care system are: Central Office of the Ministry of Health, the Bureau of Public Health and the Inspectorate. The Central Office and the inspectorate function at the level of national health planning and standard-setting, inspection, and monitoring while the Bureau of Public Health is responsible for the monitoring of programs and public health issues, as well as policy development.

At the operational level, the health care providers include the government subsidized primary health care organizations, the Regional Health Service (RGD), which covers the coastal area and the Medical Mission who covers the population living in the hinterland.

Also, the majority of general practitioners are in private practice and serve people that are covered by the State Health Insurance (SZF), private companies, private insurance, or patients who pay out of pocket. Specialists provide inpatient and outpatient care in the local hospitals and health centers. Government target programs, such as special health programs and services for the entire population (Ex. STI’s, leprosy, youth dental care, malaria, tuberculosis, and immunization). Many non-governmental organizations are recognized by the government to provide specific health care services, e.g. the Foundation for Family Planning (Stichting Lobi), specialized in the field of reproductive health.

Many non-governmental organizations are recognized by the government to provide specific services, including primary health care services, for target programs. Some examples include: the Foundation for Family Planning, specialized in the field of reproductive health, and other foundations working in the field of health information and education.

Human Resources

In the past 5 years of student enrollment (1994 – 1999), 64 physicians have graduated from the Anton de Kom University of Suriname, Faculty for Medical Sciences. An inventory of physicians revealed that by May 2000, 194 medical doctors are working in the private and public health sector. The male : female ratio is 2 : 1.

At the same time, 101 medical specialists are present in the country. At least 11 are retired. The sex ratio in this group is 6 : 1 in favor of the male gender. Twenty physicians are currently enrolled in foreign medical specialty course. Physicians must obtain further education outside of Suriname for specialization. Due to lack of further specialized education in medicine as well as public health has resulted in a national shortage of qualified medical specialists, and senior level public health practitioners.

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. Not all graduates practice as dental assistants although some are employed in other types of work within the foundation. Only one dentist works with the Youth Dental Services, although there are many dental auxiliaries.

The Psychiatric Center of Suriname (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. The Psychiatric Centrum Suriname 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.

Facilities

There are 4 hospitals in Paramaribo of which two are private. Another hospital in the district of Nickerie has been strengthened through a project of the International Development Bank. Smaller ‘hospitals’ and health centers in the districts and the hinterland are operated by the Regional Health Services and Medical Mission. The available beds in these health centers are mostly used for deliveries and observational purposes. The average length of hospital stay is approximately 7 days for all hospitals, except Academic Hospital which is 9 days. For specialized and advanced care, patients are referred to one of the five hospitals.

The Military Hospital delivers outpatient services for army personnel and their family. The psychiatric hospital in Paramaribo has a capacity of 280 beds. The duration of stay can vary from 2 days up to more than 2 months. The Medical Mission has 47 health centers in the hinterland. The different regions are supervised by 8 medical doctors, while 70 health assistants work at the health centers. The 48 Health centers of the RGD are located in all 8 districts in the coastal area. These physicians deliver primary health care.

Fifty-two physicians are employed by the Regional Health Services (RGD). Emergency medical care is delivered by the Academic Hospital, the only unit with 24-hour service. The data in Appendix B indicates that approximately 40.000 visits occurred with miscellaneous causes. Approximately forty percent are accidents and injuries, while the other half consists of physical signs and symptoms requiring some type of medical help. See Appendix B for more detailed health system resources.

Finances

In 1997, 4.8% of the GDP was spent on healthcare; this was a 25% increase since 1995. The costs per capita exceeded US$ 100.00 in 1997.

Table 28. Health expenditure as a percentage of the total government expenditure, as percentage of GDP, per capita

Healthcare GDP Healthcare Population Costs per Exchng. Costs per costs (x Sf 1000) costs in % of capita (Sf) rate per capita (x Sf 1000) GDP US$ (US$) 1995 8,783,970 229,112,000 3.83 408,866 21,483.74 493.00 43.58 1996 12,952,257 325,207,000 3.98 413,428 31,328.93 416.38 75.24 1997 18,508,720 384,305,000 4.82 418,921 44,181.89 434.38 101.71 1998* 15,665,590 447,184,000 3.50 424,590 36,895.81 555.38 66.43 2000# 105,464,700 NA 9.42 435,797 241,456.20 NA 180.33 * The figures of 1998 are not final # National Health Account Study, 2001

Financing of health services can be divided into: • Governmental • State Health Insurance Fund/MOH • Ministry of Social Affairs • Other Ministries • Private (individual) and company (collective) Insurance Funds • Out of pocket • Foreign donations

External aid and technical cooperation.

Patients with certain diseases who need more extensive treatment not available in Suriname, are sent to other countries (usually the Netherlands) for therapy. This is regulated through a project financed by the Dutch Development Fund. The main non-governmental organizations that provide support for the health system through technical cooperation are the PAHO/WHO and UNICEF, as well as other United Nation programs such as UNAIDS.

Legislation

During the years 1998-2000, the only legislative document enacted was the Narcotics Act, which was developed to be in accordance with international guidelines. The Narcotics Act was approved by the National Assembly in 1998. Some other legislative documents prepared during 1998-2000 were aimed at updating and restructuring the legislation regarding Public Health in the following areas: quality assurance, mental health, sexually transmitted diseases, food legislation, plant and animal health.

Information Systems Development

The Bureau for Public Health maintains 3 types of surveillance systems: • The hospital surveillance system All 4 hospitals in Paramaribo are visited each week for the reporting of most communicable disease, perinatal and maternal mortality, and malnutrition cases. The Nickerie hospital is will be included in this surveillance system by 2003.

• the sentinel surveillance by phone, the so-called Telefonade Thirty sentinel stations (RGD and private clinics in the coastal area) are weekly contacted by phone to report a list of diseases such as gastro-enteritis, rash and fever, upper respiratory tract infections, STI syndromes etcetera. The main purpose is to identify trends in disease over time. Many epidemics can be anticipated through an increased reporting of cases by the sentinel stations.

• the Epidemiology surveillance system All reportable diseases must be reported to the Epidemiology department at the Bureau of Public Health. Nurses at the unit investigate each case and their controls if necessary.

Reporting of diseases of the Expanded Programme on Immunization are also coordinated by the Epidemiology department. The Epidemiology department also requests data on most communicable diseases from institutions such as the Dermatology Services, the TB clinic, the National Blood Bank etc., in order to report these to CAREC in their quarterly Communicable Disease Reports.

Note that there is no system for non-communicable disease surveillance in the country. The many other institutions and services within the health system have their own information systems, but there is no consistent flow or type of information. Most of the health information reaches the MOH central planning unit through the reports of the Bureau of Public Health. Furthermore, the MOH relies on the year reports of each institution separately. As a consequence, year reports are submitted years too late or sometimes not at all. In the last 2 years the need for health information has increased tremendously. Policy makers recognize the shortcomings in the absence of an operational health information system. With assistance from the PAHO, efforts towards development of a National Health Information System for Suriname began in 2000. A national working group was established to clearly identify steps in a plan of action towards development of a National Health Information System.

Research

The year 2000 was a productive year for research in Suriname as the health system aimed to improve collection of available data to begin to monitor many different indicators and assess the health system activities. The following are a few major research projects that began in the year 2000:

Health Sector Reform Studies

In support of the Health Sector Reform, 9 studies were identified to assist the Government of Suriname to develop and initiate policy reforms to improve the efficiency, equity, quality and financial sustainability of the Health Care in Suriname. The studies will consist of five interrelated components: • strengthening the policy making capacity of the Ministry of Health; • improving the financial sustainability of the SZF; • modifying reimbursement methods; • improving the targeting of public subsidies by the MSA , and • develop quality assurance mechanisms.

The Household Study of Health Care Utilization and Expenditures started in may 1999 and was finished in February 2002. The study of the National Health Account and the study of Actuarial Model for the SZF (State Health Insurance Fund) started in January 2001 and completed in February 2002. The final reports of Primary Health Care Evaluation study and the Analysis of Payment Systems for Primary, Specialty Outpatients and Inpatients Care were presented in February 2002. The study of MSA (Ministry of Social Affairs) Health Cards Awarding and the study of Quality Assurance Program already started in August 2001 en will be finished in May 2002.

Two other studies about Purchasing and Auditing at SZF and Integration of SZF and MSA started in March 2002 and will be finished in August 2002.

Suriname Multiple Indicator Cluster Survey 2000 (MICS)

MICS 2000 survey was conducted to provide end of the decade information on a core set of indicators of specific aspects of the situation of children in coordination with other international organizations as established at the World Summit for Children in NY in 1990. The survey covered sample populations stratified into urban, rural, and hinterland geographic areas of Suriname and was to serve as a basis for action. The summary indicators covered areas such as Infant and Under-five Mortality, Education, Water and Sanitation, Child Malnutrition, Breastfeeding, Low Birth Weight, Immunization Coverage, Diarrhea, Acute Respiratory Infection, IMCI Initiative, Malaria, HIV/AIDS, Contraception, Prenatal Care, Assistance at Delivery, Birth Registration, Orphanhood and Living Arrangements of Children.

Child Indicators Monitoring System (CIMS 2000)

The CIMS 2000 research was conducted to begin to address issues as established in the 1993 Convention on the Rights of the Child and the World Declaration on the Survival, Protection and Development of Children. CIMS is a compilation of data related to the welfare of families, specifically children, to serve as a monitoring system of these important indicators. The publication was a compilation of national data already collected properly and regularly regarding the child-specific indicators, which will serve as a system of continuous flow of national data.

Cervical Cancer in Suriname

In 1998, the Stichting Lobi Foundation began a National Pap smear Project in cooperation with the Leiden University of the Netherlands, and was completed in the year 2001. Although the goal was to collect pap smears from 75% of the women in Suriname aged 25-55 years, approximately 60,000 women, 66% was achieved. The objectives were to establish the prevalence of pre-malignant differences with respect to ethnicity, age, geographic location, and socio-cultural practices. Risk factors such as sexual behavior and smoking were also ascertained.

Cardiovascular Risk Factor Investigation (CVRFO)

In the year 2000, the CVRFO set out to evaluate the prevalence of cardiovascular risk factors in the different ethnic groups in Suriname. It is known that cardiovascular diseases are an important cause of morbidity and mortality in Suriname, but the CVRFO studied the prevalence and distribution of risk factors such as smoking, hypertension, and diabetes in the different ethnic groups. The objectives of the CVRFO were to evaluate the cardiovascular risk factors to aid in identification and development of activities to prevent and reduce the incidence and prevalence of cardiovascular disease, and ultimately death.

Literature

1. Annual Report of the Chief Medical Officer, 2000 Ministry of Health, Suriname, 2003 2. Basic Indicators, Suriname. Algemeen Bureau voor de Statistiek, Juni 2003 3. Demografische Data Suriname 2000 Centraal Bureau voor Burgerzaken ivm Second Word Assembly on Ageing, 2002 4. De Pensioenregeling in Suriname. B. Joella 5. Doodsoorzaken in Suriname, 2001 Bureau voor Openbare Gezondheidszorg, November 2003 6. First Periodic CRC Report of the Republic of Suriname, period 1995 – 2000 7. Onderzoek naar de behoefte aan een verpleeghuis Ministerie van Sociale Zaken en Volkshuisvesting, Januari 2004 8. Onderzoek naar de kwaliteit en bereikbaarheid van het zorgaanbod van bejaardentehuizen en zorginstellingen in Suriname Ministerie van Sociale Zaken en Volkshuisvesting, September 2002 9. Part 2: Policies and Programs for Older Persons Ministerie van Sociale Zaken en Volkshuisvesting 10. Presentation Suriname Second World Assembly on Ageing Heidi Wirjosentono, April 2002 11. Sociale Gids 2000. Ministerie van Sociale Zaken en Volkshuisvesting, 2000 12. Statistical Index – The World Health Report. WHO, 2003 13. Suriname Census 2003- Preliminary Report General Bureau of Statistics, Census Office, September 2003 14. The living conditions of the Elderly in Suriname PAHO/VPSI/Peace Corps, April 2002 15. The social life in the 60+ population Reina Muler, Ministerie van Sociale Zaken en Volkshuisvesting 16. They do not acknowledge us anymore. Focus group study on the situation of Senior Citizens in Paramaribo and Surroundings PAHO/VPSI, December 2001 17. White Paper: Health Sector Reform in Suriname Ministry of Health/IDB/Manodj Hindori, 2003 18. World Population Prospects: the 2002 Revision United Nations Populations Division, February 2003