TCI-NHIP/HEU 10 th Caribbean Conference on National Health Financing Initiatives Turks and Caicos Islands October 28—30, 2015 TCI-NHIP/HEU 10 th Caribbean Conference on National Health Financing Initiatives Turks and Caicos Islands October 28—30, 2015 TCI-NHIP/HEU 10 th Caribbean Conference on National Health Financing Initiatives Turks and Caicos Islands October 28—30, 2015 NATIONAL HEALTH FINANCING: Optimising the Roles of Ministries of Health and Social Security Organisations Dr. Ramon Figueroa, M.P.H Director Health Services Belize

TCI-NHIP/HEU 1ference on National Health Financing Initiatives Turks and Caicos Islands October 28—30, 2015 TCI-NHIP/HEU 1ference on National Health Financing Initiatives Turks and Caicos Islands October 28—30, 2015 OUTLINE 1.HEALTH SECTOR CHALLENGES 2.SOCIAL SECURITY INSTITUTIONS: 1.K FUNCTION/FRAMEWORK INVESTMENT IN HEALTH POTENTIAL IMPACT FROM HEALTH CONDITIONS 3.STRENGTHS AND WEAKNESSES 4.RECOMMENDATIONS FOR COOPERATION

DEMOGRAPHIC AND EPIDEMIOLOGIC TRANSITION –Chronic Non-Communicable Diseases –Elderly population (6-8% total population…increasing) –Perinatal/Neonatal Mortality (high cost interventions) SYSTEMIC CHALLENGES –QUALITY OF CARE –HEALTH FINANCING –GOVERNANCE CHALLENGES FOR HEALTH SECTOR

Chronic Non-communicable Diseases 1.NCDs are becoming chronic emergency in middle-income and low- income countries 2. NCDs present a particularly daunting challenge for middle- and low- income countries because of the scale of the burden relative to their level of economic development.

The legal bases of the social security scheme are set out in the Social Security Act (1979) and the regulations issued thereunder. The scheme commenced operations on 1 June 1981 and, except for marginal amendments to the benefit regulations, the level of benefits and contributions were not updated until 1 January 2001, when a comprehensive improvement in benefit provisions took place, including a National Health Insurance Scheme which still operates as a project, and the outdated ceiling on contributions were amended, as described below. On 1 January 2003 a voluntary self-employed scheme was introduced; in May 2003 non-contributory pensions to eligible females were introduced, and on 1 July 2003 the rate of contribution was increased from 7% to 8% of insurable earnings, to strengthen the actuarial situation of the long-term branch. Late in 2007 non-contributory pensions for males as from 67 years of age were introduced and the amount of non-contributory pensions were increased to $100 per month, impacting negatively on the actuarial situation of the long-term branch. BELIZE SOCIAL SECURITY FRAMEWORK (BENEFITS)

National Health Insurance Scheme On the basis of recommendations of a National Health Sector Reform Committee, the Government amended the Social Security Act to include a new chapter in order to introduce a National Health Insurance Scheme (NHI). The Act was gazetted on 29 July 2000 but the financing regulations have yet to be implemented. Initially, the project was financed by transfers from the Short-Term Branch, but as from 1 January 2006 a NHI Fund was set up with a $15 million transfer from surplus reserves of the Employment Injury Branch. SSB financing is no longer feasible and as from 2009 the NHI Scheme is funded exclusively by Government transfers, although managed by the SSB. BELIZE SOCIAL SECURITY FRAMEWORK (BENEFITS)

Branch2013 (recommended) (as % of insurable earnings in parenthesis) Short-term27.50 (2.20)19.25(1.54)18.75(1.50) Employment injury12.50 (1.00)23.50(1.96)25.00(2.00) Long-term60.00 (4.80)56.25(4.50) Total100 (8.00) BELIZE SOCIAL SECURITY FRAMEWORK (BENEFITS) Weekly earningsEmployeeEmployerTotal (as % of insurable earnings) Up to $ %6.50%8.00% $140/ % to 2.95%5.63% to 5.02%8.00% The rate of contributions paid by employers and employees is 8% of insurable earnings (7% for the self-insured), up to a contributory earnings ceiling of $320 per week, as follows:

SOCIAL SECURITY BOARD ACTUAL BENEFITS EXPENDITURES FOR THE YEARS ENDED DECEMBER 31, PARTICULARS INCOME TOTAL CONTIBUTIONS INCOME 60,329,075 61,223,009 64,524,849 66,866,173 72,069,579 NET INVESTMENT INCOME 24,784,437 16,582,122 11,742,837 19,069,448 26,186,332 INCOME APPORTIONED TO E.I. BRANCH 14,780,623 14,999,637 15,808,588 16,382,213 17,657,047 EMPLOYMENT INJURY EXPENDITURES INJURY BENEFIT 1,213,412 1,111,070 1,170,552 1,268,766 1,474,079 DISABLEMENT GRANT 395, , , , ,854 FUNERAL GRANT 1,000 4,500 9,624 6,700 2,833 MEDICAL EXPENSES - EI 1,443,560 1,048, ,876 1,050,550 1,624,233 APV DISABLEMENT BENEFITS 580, , ,524 1,220, ,479 APV DEATH BENEFITS 389, , , , ,394 TOTAL EMPLOYMENT INJURY EXPENDITURES 4,024,310 4,026,244 3,286,424 4,232,464 4,647,872 % E.I. BENEFITS TO TOTAL CONTRIBUTIONS REVENUE6.7%6.6%5.1%6.3%6.4%

STATEMENTS OF INCOME AND EXPENDITURES – NATIONAL HEALTH INSURANCE FUND YEARS ENDED DECEMBER 31, 2010 TO DECEMBER 31, 2014 Belize Dollars 2= INCOME Contributions: Government of Belize 15,834,472 14,000,004 14,245,864 Total contributions 15,834,472 14,000,004 14,245,864 EXPENDITURES Benefits: National health insurance benefits 14,299,110 12,808,924 12,804,932 13,426,568 13,355,728 Total benefits 14,299,110 12,808,924 12,804,932 13,426,568 13,355,728 Operating expenses: Administration, Establishment and Financial 728, , , , ,005 Total operating expenses 728, , , , ,005 TOTAL EXPENDITURES 15,027,850 13,540,531 13,543,803 14,306,419 14,147,733 EXCESS OF INCOME OVER EXPENDITURES 806, , ,201 (306,415) 98,131

POTENTIAL IMPACT FROM HEALTH CONDITIONS 1.Increase in Sickness benefits payouts due to Chronic Non- communicable diseases 2.Loss of income due to sickness and incapacity. 3.Economic loss for country due to decreased productivity and increased cost of care for catastrophic diseases: Renal failure, amputations, blindness, cancers (prostatic, breast, cervical, colorectal)

MINISTRY OF HEALTH SOCIAL SECURITY AGING POPULATION CNCD Competing priorities Financing gap Population demands Human Resource Gap REFORM

Strengths and Weaknesses Strengths/weaknesses Social Security Organizations Ministry of Health Comments Knowledge and experience HR expertise brain drain/recruitment agencies Financing (3.2% PHE; total H.E 5.4%)….6% PHE Reform of contributory scheme; Financing gap Purchasing++++ Pooling; single purchaser; contracting Collection Information System Statutory Authority/ Governance Regulatory Capacity (Public Service challenge) Policy ObjectivesPension Scheme Health of population (Universal Coverage) Legislative Changes Social Protection for workers Governance/ regulation of health sector. FinancialTechnical

1.Reform of SS Contribution scheme 2.Policy Adjustment/Legal framework: Include Health as part of the SS scheme; Social Protection 3.Development of Expertise within SSB: Purchasing Function; Collection; Pooling 4.Health Financing Reform as a key element for Universal Health Coverage 5.Increasing Health expenditure to 6% of Public Expenditure in Health with SSB contributing to pool. RECOMMENDATIONS

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