Download Caribbean Health Financing—Progress and Prospects in Dutch

Developments in the Dutch
Antilles & Suriname 2005 –
2015:
Progress and Challenges
Drs. Ru Croes RA
Managing Partner
Legal entity ‘Dutch Antilles’: Curaçao, Bonaire, Saint Martin,
Saint Eustatius (Statia) and Saba.
Major health care reform driver after October 2010: the
dismantling of this legal entity (country) into 3 separate entities:
Country of Curaçao, Country of Saint Martin and the special
Dutch municipalities called ‘Dutch Caribbean’ (Bonaire, Statia
and Saba)
Reform in the Dutch special
municipalities of Bonaire, Statia &
Saba after constitutional change of
October 2010
Universal coverage is reached in
2011
Constitutional reform as change
agent
National Health Insurance financed
by mandatory premium on local
salary & wage and by contributions
from the Dutch fiscal budget.
Broad entitlements comparable to
health coverage in The Netherlands
Single payor of health care, NHI
managed by the Dutch
No co-payments at this moment
Medical referrals (overseas care) if
no local treatment is available
Is this paradise ?
Dutch Dept. of Statistics (2014): life
expectancy at birth of citizens of
the Caribbean Netherlands does
not differ significantly from the
Dutch european citizens
Are there any
challenges for
the NHI in the
Caribbean
Netherlands ?
Life expectancy at 65:
Cutbacks in contributions from Dutch
fiscal budget in order to adhere to
magical 3% deficit rule of the EU
Some benefits have been cut back
and co-payments are not unthinkable
anymore
Cost of overseas care are on the rise
Health care expenditures NHI Caribbean Netherlands in
mln US-dollars: redirecting the budget to specific care &
prevention area’s
162,954
150,519
150,704
2013
2014
168,181
173,514
178,934
118,140
2012
2015
2016
Source: Fiscal budget 2015 The Netherlands
2017
2018
Rapid growth due to immigration 2010-2015
Population Caribbean Netherlands (Municipalities of
Bonaire, Statia & Saba)
24279
18% growth since 2010
24593
23296
22303
21345
20882
2010
2011
2012
2013
2014
Source: Dept. of Statistics The Netherlands
2015
Trend in total expenditures NHI – Caribbean Netherlands
6,751
6,207
6,626
5,297
Health care & administration
expenses NHI per capita (USdollars)
2012
2013
2014
Source: Dept. Of Statistics The Netherlands
2015
Issues with accessibility,
equity, uncontrollable
costs, ineffective health
care delivery systems and
serious question marks
about the quality of the
provided care
Curaçao health
care reform:
Decades of political
struggle
The healthcare system:
- Highly fragmented public &
private subsystems
- Inequitable access to care
- Lack of a fair distribution of the
financial weight of health costs
among citizens (OOP)
- Fragmented funding (several
health insurance systems with
different funding and coverage)
Curaçao: rapid rise in health care costs
Curative health care expenses & related management
costs per capita (USD)
2,862
2,791
2,625
2,544
2008
2009
2010
Source: VIC (Curaçao Institute of Public Health)
2011
Curaçao: rapid rise in health care costs
Curative health care expenses & related management
costs as % of GDP
Rising ratio due to rising health care costs
and waning economic growth
13.8%
13.8%
2010
2011
13.0%
12.6%
2008
2009
Source: VIC (Curaçao Institute of Public Health)
Curaçao: Growth GDP and Healthcare costs are out of sync
Development GDP - Curative Healthcare costs (% growth)
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
2009
2010
GDP
HCC
Source: VIC (Curaçao Institute of Public Health)
2011
Significant debt cancellation
and the conditional obligation
to restructure the fiscal budget
(the capacity for external debt
financing is restricted) was the
main driving force for change
Curaçao health
care reform: ‘Do or
lose control over
public finances’
(the latter actually
happened)
Health care reform principles (e.g.):
• Universal access & coverage
• Mandatory premiums on salary
and wage and maximized
contribution by government thru
fiscal budget
• Complete overhaul of fee systems
• Construction of a new general
hospital to promote integration of
hospital & secondary (specialized)
• Partial universal coverage thru new
insurance system (80% of population
reached)
• Collective funding
• Some reduction in fragmentation of
health care delivery
• Restructured remuneration for GP’s
• Uniform and transparent dispensing
fee for pharmacy’s
Curaçao:
Accomplishments
of health care
reform as per
October 2015
(Work in Progress)
•
•
•
•
Formulary for covered drugs/
medicines
Construction of new general
hospital is underway; ongoing
integration of hospital and
secondary care
Expansion of coverage to nearly
full population is underway
National information system for
GP’s scheduled for 2016
Dismantling of the legal
entity The Dutch Antilles
has profound effects on the
health care reform efforts
(introduction of a NHI)
Saint Martin: one
step at the time
Like Curaçao a highly fragmented
health care subsystems (private/
public/OOP)
- Extension of the mandatory health
care insurance for the private sector
to cover family members
- Civil servants & family members
covered by the Government
- Efforts to unify the subsystems
AZV: universal access to
health and universal health
coverage (2001)
• Right to health
• Equity
• Solidarity
Aruba: stabilization
and searching for
new ways for funding
A rough start with major
challenges to finance the
deficits (unfunded liabilities)
Aruba: Closing of the Valero oil refinery in 2008: dip in GDP
Development GDP v.s. development costs AZV
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
-2.0%
-4.0%
-6.0%
-8.0%
-10.0%
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
GDP 4.6% 4.0% 7.9% 5.0% -9.0% -4.3% 6.7% -0.7% 2.1% 3.0%
AZV 1.90% 5.30% 8.30% 7.70% 5.60% 4.10% 3.60% 3.10% 0.40% 3.80%
GDP
AZV
Source: AZV Financial Statements 2014
Aruba: higher healthcare expenditures after 2009
Health care expenditures AZV as % of GDP
8.1
7.3
6.8
7.5
7.1
6.3
6.2
6.3
6.4
7.9
8.1
8.0
8.1
6.1
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Source: AZV Financial Statements 2014
AZV health care expenses in USD (excluding operating costs)
2005 -2014: 50% increase in absolute terms; but also investments in
quality of care, in health delivery networks and expansion of
entitlements
137
2005
144
2006
156
2007
168
2008
177
2009
185
2010
191
197
198
2011
2012
2013
Source: AZV Financial Statements 2014
206
2014
AZV health care expenses in USD (excluding operating costs)
AZV healthcare expenses per insured
2,000
1,950
1,922
1,906
1,880
1,900
1,850
1,947
1,935
1,815
1,800
1,750
1,746
11,5% increase in the period 2008 –
2014; average less than 2% per year
1,700
1,650
1,600
2008
2009
2010
2011
2012
Source: AZV Financial Statements 2014
2013
2014
Operating costs of AZV Fund per insured (USD)
120
103
105
96
100
89
80
80
85
89
60
40
Operating costs as % of total health care expenses:
2008: 5,9%
2014: 4,6%
20
Policy target: 5%
0
2008
2009
2010
2011
2012
Source: AZV Financial Statements 2014
2013
2014
Allocation of AZV resources 2014 vs 2013
Other
Dental Care
Medical Aids
Outpatient Care Center & Ambulance Transport
Family Physicians
Laboratory Tests
Prescription Drugs
Overseas Care
Hospital & Medical Specialists
0
20
2013
2014
40
60
Source: AZV Financial Statements 2014
80
100
120
Allocation AZV health care expenses 2014
3%
6%
Hospital & Medical
Specialists
Overseas Care
2%
3%
Prescription Drugs
5%
Laboratory Tests
7%
49%
14%
11%
Family Physicians
Outpatient Care Center &
Ambulance Transport
Medical Aids
Dental Care
Other
Source: AZV Financial Statements 2014
Aruba: less government contribution more premiums & health tax
Funding of AZV healthcare expenditures
120%
100%
80%
60%
40%
20%
0%
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Health tax on sales 0%
0%
0%
0%
0%
0%
0%
0%
0%
2%
Premiums
58% 66% 63% 60% 59% 56% 67% 68% 68% 67%
Govt. contribution 42% 34% 37% 40% 41% 44% 33% 32% 32% 31%
Source: AZV Financial Statements 2014
Projected funding total AZV costs: less government
Premium on salary/wage
2%
Government contribution
Health tax
16%
16%
16%
18%
18%
18%
67%
66%
66%
66%
2014
2015
2016
2017
31%
Source: AZV Financial Statements 2014
Suriname: after more than 40 years
of political struggle:
Legal obligation
for all residents
to buy health care
insurance (free to
choose)
The National Basic Health
Insurance for all residents (Law
passed in September 2014)
Many resemblance with the Dutch
Healthcare system
•
•
Mandatory ‘personal’ (private)
insurance for a basic healthcare
coverage defined by Law
Mandatory nominal fee payable
to insurance companies;
distribution of fee between
employee and employer is point
of negotiation
For (exceptional) medical expenses
not covered under the basic
healthcare coverage: The Care
Facility Fund (CFF) funded by
mandatory remittances by the
healthcare insurance companies
participating in the system
The National
Basic Health
Insurance is a
political
compromise
Public & Private stakeholders all
got a share: private insurers,
mandatory basic coverage,
additional coverage, fee for basic
coverage is negotiation point in
collective work agreements,
exceptional medical expenses
financed by insurance companies
thru CFF
Bonaire, Statia & Saba:
Constitutional reform October
2010 - Dutch Municipalities – new
healthcare system
Summary: drivers
of health care
reforms
Saint Martin:
Constitutional reform October
2010 – health care reform on hold
Suriname: National Basic
Healthcare Insurance: political
compromise
Curaçao: Constitutional reform
October 2010 – new health care
system with partial universal
coverage – Work in Progress
Aruba: Stabilization, but
calibrating the funding; less
government more indirect taxation
Health care reform:
Never a dull moment !
Thank You !
Questions ?