Hea l th Care Con fe rence ArubaJ une 1 s t – 3 t h , 2015

Mission

Vision

Strategic plan

C.A. Schwengle, MDMinistry of Health, Elderly Care & SportsC.A. Schwengle, MDMinistry of Health, Elderly Care & Sports

C.A. Schwengle, MDMinistry of Health, Elderly Care & Sports

Provide a Health Care System that delivers ‘qualitative’ care in a manner that is …

… effective

… efficient

… accessible

… acceptable / patient centered

… equitable / does not discriminate

… safe

… AND sustainable (in a broad sense)

C.A. Schwengle, MDMinistry of Health, Elderly Care & Sports

I. Quality / value

II. Sustainability

III.Elderly Care

IV.Sports

WHO, 2006: Quality of Care

Organization for Economic Co-operation and Development

Hea l th Care Con fe rence ArubaJ une 1 s t – 3 t h , 2015

Sustainable Health Care

C.A. Schwengle, MD

Ministry of Health, Elderly Care & Sports

Themes:

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1.AZV: before & since

2.Sustainable?

3.Alternatives?

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AZV: before & since

AZV: before & since 1

Before AZV

Access:Risk selection (private insur.)Limited access for specific groups

Operations:High costs: 9%

Since AZV

Access:No risk selectionEqual access for all (legal) citizens

Operations:Lower costs: 4%

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AZV: before & since2

Before AZV

Governance:Poor structurePoor transparencyPoor check & balances

Fiscal contribution:High fiscal contributionAverage: 65% of total costs

Since AZV

Governance:Better structureBetter transparencyBetter check & balances

Fiscal contribution:Lower fiscal contributionIn 2013: 30% of total costs

Financial structure / system: AZV is financed through private (meanly premium) and public means (fiscal contribution with no clear cut pre-defined correlation). Costs are regulated meanly through budget constraints, pay-per-product arrangements and lump-sum constructions.20

AZV: before & since 3

Before AZV

Data:InconsistentIncomparable

Costs growth rate:High growthAverage: 7,5%

Since AZV

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Data:CentralizedUniform

Costs growth rate:Moderate growth2010 - 2013: 3%

AZV: before & since 4

Before AZVLife expectancy:Decreasing

Since AZV

Source: CBS Aruba 2013

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Life expectancy:Increasing

Total Health Care Expenditure:Care & Cure as % of GDP

Source: AZV March 2014 23

Conclusions1

1. The AZV system is a reflection of our social system.

2. AZV has brought a lot of improvements:

AZV coverage = comparable with the Netherlands

Quality: WHO / Dutch guidelines

Since AZV:

Life expectancy: better

Governance: better

Data: better

Costs: lower

Fiscal contribution: less24

Conclusions2

3. More improvements are needed:

‘Long’ waiting lists Inadequate accessibility Inadequate hospitality Not sustainable !?

Pay-per-product / Budget-restriction / Lump-sum

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Sustainable?

Definition

Sustainable:

Able to be maintained at a certain rate or level.

Able to be upheld or defended.

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Question

Do we have an achievable and sustainable

- payable now and in the future -

health care system?

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Pension prognosis

1960 1972 1981 1991 2000 2010 2030 -

10,000

20,000

30,000

40,000

50,000

60,000

70,000

-

1

2

3

4

5

6

7

8

9

14,0

29

16,2

46

23,5

77

29,2

19

41,9

18

46,2

59

61,8

34

1,646 2,561 4,693 5,991

10,097

15,658

27,282

8

6

5 5

4

3

2

Number of employed persons & pensioners

Employed persons Pensioners Number of employed persons per financial dependents

Source: CBS Aruba 2013

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AZV income: premium & fiscal

What should the magic formula be for the fiscal contribution?

Source: AZV 2013

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AZV Health Care Distribution

50%

18%

8%

7%

5%5%

3% 2% 2%

Hospital & Specialists Prescription drugs Overseas care

Laboratory costs Fam. Physicians IMSAN

Med. Devices Dental care Others

We spend relatively more in specialized and institutionalized

care than we do in prevention, primary and

ambulatory care.32

Cure versus Care

No recent data (National Health Accounts)

Rough estimate (2013): 87% versus 13%

NGO’s: 38,916,817IBISA: 6,187,151Public Health Department: 6,100,933AZV: 354,480,000

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Conclusions 1

Facts:

Health care has become a ‘universal right’

Health care costs seems to grow independently

Health care demand seems to grow independently

Aruba is a small community with limited resources

Aruba has demands equivalent to North America & Western Europe

Aruba has a growing ageing population

Aruba has a shrinking working population34

Conclusions 2

Facts:

AZV is an important improvement, but …

Aruba’s healthcare system = product driven: not quality / value driven

Aruba’s healthcare system = budget limited

Aruba spends more in cure compared to care

Aruba has staggering growing numbers of NCD’S (obesity; CVD; diabetes)

Aruba’s healthcare system is NOT sustainable35

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Alternatives?

What can and should we do?

1. Lower cost

2. Augment income

3. Change in focus and thinking

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Lower costs1

1. Production driven

2. Budget controlled

3. Cure-accent

4. Efficiency & Automation

Quality driven & positive incentives

Quality & volume controlled

Care, Prevention & Health Promotion

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Lower costs2

5. More specific:

- Medication- Laboratory- Overseas care (Cardiovascular / Oncology /

Ophthalmology)- Reducing overconsumption (care givers and

care consumer)- Adapt the AZV package?

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Augment income

1. Better inning of premium (better transparency)

2. Extra private contribution (co-payment / target specific)

3. Health Promotion Fee (bound to a Health Fund)

4. Health Tourism / Medical Tourism

5. Tourist Health Insurance

6. Raising the premium … but conditioned? B-AZV?

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Questions left …

Should we ‘condition’ the Fiscal Contribution?

Should we ‘condition’ the health cost growth rate?

Should we replace the Fiscal Contribution through Indirect Taxation?

Should we define the AZV package into basic & additional package?

Should we seek financial partners for AZV? 42

Balance between our wishes and our

resources is achievable if we are willing and able ...

1. .. to work together

2. .. to deal with the facts

3. .. to reset our expectations

4. .. to be creative

5. .. to invest more in Q, prevention & care

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