The Caribbean Netherlands: Health System Review.

This analysis of the health system of the Caribbean Netherlands reviews developments in governance, organization, financing and delivery of care, health reforms and health system performance on the islands of Bonaire, St Eustatius and Saba (the BES islands). Since the dissolution of the Netherlands Antilles in 2010, residents of the BES islands live in special municipalities of the Netherlands, each with its own government (public entity). The Ministry of Health, Welfare, and Sport (VWS) in The Hague, through the Department of Care and Youth Caribbean Netherlands (ZJCN), oversees the health system and the mandatory, centrally financed health insurance scheme. The publicly funded system had per capita spending on health (US$ 6 471) below that of the European Netherlands (US$ 6 729) in 2022; without logistical costs of referrals (accommodation and ground transportation, flight tickets, per diem allowances), per capita health spending on the BES islands was US$ 5 895, though these levels have not been adjusted for purchasing power parity. Cost-sharing within the public system is low, but voluntary insurance for uncovered services is unavailable, and data on out-of-pocket payments are unknown. Limited on-island care capacity necessitates many off-island referrals to cross-border contracted providers, which are fully covered by insurance. Challenges include recruiting and retaining qualified staff, although an agreement with Amsterdam University Medical Center helps to provide specialist care in the hospital on Bonaire. Besides primary and secondary care, there are long-term, dental and mental care facilities. Each island has at least one pharmacy, and protocols are in place for off-island care needs. The next development stage aims for an "equivalent" level of services as in the European Netherlands, improving from the "acceptable" standard set post-2010. Poverty is higher on the BES islands than in the European Netherlands. Health risks include limited access to fresh foods, physical inactivity and behaviours like alcohol and tobacco use, highlighting the need for better disease prevention and health promotion. Although life expectancy at birth was higher on the BES islands in 2019 than in the European Netherlands, data on health outcomes and system performance indicators are lacking. Enhancing evidence-based interventions and comparisons with the European Netherlands, other Dutch Caribbean islands and the wider Caribbean region can support future planning and health system assessments.