2. ​ Health Care Conference Aruba ​ June 1 st – 3 th, 2015

3. Mission Vision Strategic plan C.A. Schwengle, MD Ministry of Health, Elderly Care & Sports C.A. Schwengle, MD Ministry of Health, Elderly Care & Sports

4. C.A. Schwengle, MD Ministry 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)

5. C.A. Schwengle, MD Ministry of Health, Elderly Care & Sports I.Quality / value II.Sustainability III.Elderly Care IV.Sports

6. WHO, 2006: Quality of Care

10. ​Organization for Economic Co-operation and Development

11. ​ Health Care Conference Aruba ​ June 1 st – 3 th, 2015

16. Sustainable Health Care C.A. Schwengle, MD Ministry of Health, Elderly Care & Sports

17. Themes: 1.AZV: before & since 2.Sustainable? 3.Alternatives? 17

18. AZV: before & since

19. 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 selection  Equal access for all (legal) citizens Operations:  Lower costs: 4% 19

20. AZV: before & since 2 Before AZV Governance:  Poor structure  Poor transparency  Poor check & balances Fiscal contribution:  High fiscal contribution  Average: 65% of total costs Since AZV Governance:  Better structure  Better transparency  Better check & balances Fiscal contribution:  Lower fiscal contribution  In 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

21. AZV: before & since 3 Before AZV Data:  Inconsistent  Incomparable Costs growth rate:  High growth  Average: 7,5% Since AZV 21 Data:  Centralized  Uniform Costs growth rate:  Moderate growth  2010 - 2013: 3%

22. AZV: before & since 4 Before AZV Life expectancy: Decreasing Since AZV Source: CBS Aruba 2013 22 Life expectancy: Increasing

23. Total Health Care Expenditure: Care & Cure as % of GDP Source: AZV March 2014 23

24. Conclusions 1 1. The AZV system is a reflection of our social system. 2. AZV has brought a lot of improvements: AAZV coverage = comparable with the Netherlands QQuality: WHO / Dutch guidelines SSince AZV: Life expectancy:better Governance:better Data:better Costs:lower Fiscal contribution:less 24

25. Conclusions 2 3. More improvements are needed: ‘‘Long’ waiting lists IInadequate accessibility IInadequate hospitality NNot sustainable !? Pay-per-product / Budget-restriction / Lump-sum 25

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27. Sustainable?

28. Definition Sustainable:  Able to be maintained at a certain rate or level.  Able to be upheld or defended. 28

29. Question Do we have an achievable and sustainable - payable now and in the future - health care system? 29

30. Pension prognosis Source: CBS Aruba 2013 30

31. AZV income: premium & fiscal What should the magic formula be for the fiscal contribution? Source: AZV 2013 31

32. AZV Health Care Distribution We spend relatively more in specialized and institutionalized care than we do in prevention, primary and ambulatory care. 32

33. Cure versus Care ​ No recent data (National Health Accounts) ​ Rough estimate (2013): 87% versus 13% ​ NGO’s: 38,916,817 ​ IBISA: 6,187,151 ​ Public Health Department:6,100,933 ​ AZV:354,480,000 33

34. Conclusions 1 Facts: HHealth care has become a ‘universal right’ HHealth care costs seems to grow independently HHealth care demand seems to grow independently AAruba is a small community with limited resources AAruba has demands equivalent to North America & Western Europe AAruba has a growing ageing population AAruba has a shrinking working population 34

35. Conclusions 2 Facts: AAZV is an important improvement, but … AAruba’s healthcare system = product driven: not quality / value driven AAruba’s healthcare system = budget limited AAruba spends more in cure compared to care AAruba has staggering growing numbers of NCD’S (obesity; CVD; diabetes) Aruba’s healthcare system is NOT sustainable 35

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37. Alternatives?

38. What can and should we do? 1.Lower cost 2.Augment income 3.Change in focus and thinking 38

39. Lower costs 1 1.Production driven 2.Budget controlled 3.Cure-accent 4.Efficiency & Automation Quality driven & positive incentives Quality & volume controlled Care, Prevention & Health Promotion 39

40. Lower costs 2 5.More specific: - Medication - Laboratory - Overseas care (Cardiovascular / Oncology / Ophthalmology) - Reducing overconsumption (care givers and care consumer) - Adapt the AZV package? 40

41. 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? 41

42. 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

43. 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 43

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