Foresight study into care research in the Caribbean part of the Kingdom of the Netherlands

Due to a lack of funds, policy and implementing capacity, considerable health inequalities exist between the Caribbean part of the Kingdom of the Netherlands and the Netherlands. Furthermore, obtaining funding for the Caribbean islands has become difficult since the constitutional reform. However, the experience acquired from projects funded in the Caribbean part of the Kingdom of the Netherlands reveals that health gains can be achieved with research and implementing effective outcomes in practice.

Within the Dutch Ministry of Health, Welfare and Sport (VWS) there is policy support to make the ZonMw programmes more accessible for the six Dutch Caribbean islands; Aruba, Curaçao, Sint Maarten, Bonaire, Sint Eustatius and Saba. To this end, a foresight study has been commissioned into the most important issues in the area of health. The results from the foresight study will be used to determine how ZonMw programming can contribute to good health on the islands. Soraya Verstraeten is the project leader of this foresight study and tells us more about it from Curaçao, where she is based. 'The differences in life expectancy between residents of the Netherlands and residents of the islands are growing. That is because far more residents on the islands die from avoidable causes that can easily be prevented or treated with current state of knowledge. For our foresight study, we work with people from everyday practice research and policy to determine what the greatest knowledge questions are and who is involved in health research on the islands. We are prioritising the most important health issues so that we can generate the greatest impact.'

Health inequality

Residents of the Caribbean part of the Kingdom of the Netherlands die more often from causes that could have been avoided with effective healthcare and/or prevention. Previous research has revealed, for instance, that approaches towards dealing with health problems and improving care and well-being are less often applied on the islands than in the Netherlands. 'For example, a lot of progress can still be made in the Caribbean part of the Kingdom of the Netherlands when it comes to the types of cancer that can be diagnosed at an early stage', says Soraya. 'Population screening for breast, uterine and colon cancer started later on Curaçao than in the Netherlands. The other islands are also putting in a lot of effort to set up these three programmes now.'

'The biggest problems are particularly apparent in the relatively high number of people who suffer from chronic diseases such as diabetes and cardiovascular diseases.'

Different circumstances

According to Soraya, the different context is the reason why healthcare on the islands performs less well than in the Netherlands. 'In many respects, there is a lack of resources on the islands. However, the conditions are very different than in the Netherlands. There is sometimes a shortage of certain drugs and materials, professional development is scarcely encouraged and somebody often needs to be brought in from abroad for the maintenance and repair of medical equipment. Sometimes there is a power cut or places are flooded after heavy rain.' The project leader elaborates on this further by stating that no advisory bodies and planning agencies are present to support the governments on the islands in their political and administrative decisions about public health and care. 'An important feature of healthcare here on the islands is that it is highly fragmented. For example, there is no good transfer of information between care providers, as a result of which, medical investigations are sometimes performed twice. Also, in the case of symptoms, a relatively large number of people go to the emergency department in the hospital, whereas they should actually report to their general practitioner. Partly as a result of this, people unnecessarily often avail themselves of hospital care.'

Less budget, higher costs

After the constitutional reforms in 2010, a distinction was made between the BES islands (Bonaire, Sint Eustatius and Saba) and the CAS islands (Curaçao, Aruba and Sint Maarten). Soraya: 'Since this reform, less budget has been available for healthcare on the CAS islands. On Curaçao, drug and hospital care costs have risen considerably in recent years. This has been compensated for by reducing the budgets of government departments and subsidised care institutions as a result of which increasingly less money is available for realising their tasks in the area of mental, youth and preventative care. In addition, applying for grants is often experienced as complex. For standard grant applications, certain requirements that have been tailored for the Dutch context are applied. These are often not feasible for the situation on the islands because there is no sound research infrastructure and there is a lack of strong knowledge institutes. For example, in the Netherlands, the main applicant often already has a contract and a place to work, like at a university, which can give applicants support in applying for a project or realising it. This is often not the case on the islands, where access to scientific literature is already a challenge in some cases. I therefore make a strong plea to match the application procedures for grants with the situation on the islands.'

However, health policy and interventions that have proven successful can fit the context on the islands and contribute to reducing the health inequalities between residents of the Netherlands and those of the Caribbean islands. Here, the focus lies on projects aimed at implementing existing knowledge and strengthening the collaboration between researchers, policymakers and everyday practice. That is why VWS has requested ZonMw to carry out a foresight study.

Foresight study

A foresight study started this year on behalf of ZonMw with researchers from the Caribbean Prevention Centre Fundashon Prevenshon, the Caribbean Project Office, and the Athena Institute of VU Amsterdam, which must collect relevant knowledge questions, map stakeholders and enable them to engage in discussions. With a literature study, interviews with stakeholders, an online questionnaire and seven reflection sessions, the input from researchers, policymakers, practitioners and civil society will be used to give direction to the (further) development of knowledge for improving healthcare on the islands. Soraya: 'An important aspect is initiating a dialogue between researchers, policymakers and people in everyday practice so that people feel connected and can help to shape the necessary strengthening in the care system. Thanks to our bottom-up approach, we have also heard the silent voices, the people who are not often represented in policy circles.'

First results

Meanwhile, the first results from the foresight study have become available. A total of 24 people representing the policy, practice and research perspectives of care took part in in-depth interviews. During these interviews, much attention was paid to the relationship between poverty and health outcomes, the lack of data concerning the spread of diseases and conditions, the gap between knowledge and implementation, and the importance of strengthening the collaboration on the islands and between the islands. During the questionnaire phase, which was disseminated among a broad audience via email and social media, 224 people participated, providing a representative sample of the islands' populace. The most frequently stated priorities are chronic conditions (incl. obesity), mental healthcare and the organisation of care. Subsequently, a reflection session was organised on each island in which stakeholders from that island could participate. During the sessions, views were exchanged about what the findings of the foresight study mean for the future of health research on the islands. 

'The Caribbean islands are, of course, located a long way from the Netherlands and it is therefore easy to lose sight of the deteriorating situation. Although that is not deliberate, I do, however, call for a stronger collaboration between care organisations within the entire Kingdom of the Netherlands so that the health of the island residents can be genuinely improved', says the project leader.

It is expected that the final report of the foresight study will be presented to ZonMw in mid-November. With the results from the foresight study, insights will be obtained into whether and, if so, how ZonMw programming aimed at knowledge about care can be deployed on the islands.