1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health better systems, better health Basseterre, St Kitts and Nevis September 24, 2013 St Kitts and Nevis 2011 National Health Accounts and HIV Subaccounts – Policy Implications of Findings

2. OUTLINE OF PRESENTATION NHA—Summary of Study Findings P1—Total Health Expenditure and Universal Coverage P2—Household Out of Pocket Spending P3—Government Health Spending P4—Household and Insurance Spending in Public Facilities P5—Private Health Insurance Coverage P6—Social Security Health Role P7—Spending on Overseas Care P8—Sustainability of HIV Funding 2

3. SUMMARY OF KEY NHA FINDINGS IN 2011 KEY MEASUREMAGNITUDE 1. THE  EC$117.3mn (US$43.4mn) or EC$2313 (US$857) per capita  6% of GDP 2. Financing Sources  H/Hs--$66.2mn (56%); Gov’t--$47.4mn (40%); Employers--$1.7mn (2%); Donors--$2.1mn (2%) 3. Financing Agents  H/Hs--$64.7mn (55%); MOHs--$44.1mn (38%); PHICs--$6.6mn (6%); NGOs-- $1.5mn (1%); Other gov’t and Social Security--$0.3mn 4. Health Providers  MOH Hosps--$60.4(51%); MOH Clinics--$8.1mn (6%); Private Clinics-- $17.4mn(15%); Pharms--$10.0mn(9%); Off-island Centres--$9.2mn(8%); MOH Admin--$3.1mn (3%); Preventive Services--$7.6mn(6%); Other-- 5. Health Functions- Services  IP care--$39.7mn(34%); OP care--$55.4mn(475); Drugs--$10.0mn(8%); Pop- based prevention--$7.6mn(6%); Admin--$3.2mn(3%); Nursing Care-- $0.7mn(15); Capital Formation--$0.8mn(1%) 6. PLHIVs  Spending--$1.7mn (1.4% THE). Most from Gov’t(67%); Donors (28%).  Services:-Prevention--$1.1mn(66%); IP care--$0.4mn (24%); OP care-- $0.2mn(9%). NGOs manage 26% of HIV funds; Gov;t—65% 3

4. TOTAL HEALTH EXPENDITURE AND UNIVERSAL COVERAGE Evidence: THE/GDP = 6% GDP, on par with Caribbean average of 6.1% GDP and PAHO/WHO recommended minimum of 6% GDP. To reach health system goals, may need to increase allocations Due to increasing costs, ageing population, growing prevalence of NCDs In order to provide universal access to high-quality secondary and tertiary care In order to increase financial risk protection Policy Implication: to progress towards Universal Coverage, consider Progressive allocation of more resources to health More efficient spending (reduce waste; maximise resource use) 4

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6. HOUSEHOLD OUT OF POCKET SPENDING Evidence: H/H OOP/THE = 56% High vs Caribbean av. of 32% and WHO benchmark of 20% OOP is regressive, with higher burden for low and middle income groups Policy Implication: To progress towards UHC Consider more prepaid health plans with pooling of income and risk groups i.e. mandatory health insurance or tax-funded options. 6

7. GOVERNMENT HEALTH SPENDING Evidence: At 40% THE and 8.9% GGE (budget), Gov’t Health Spending is less than Caribbean average of 61% and 12% respectively. Policy Implication: To reduce OOP by households and increase pooled prepaid coverage, SKN should consider mechanisms for more tax- based funds (bearing in mind fiscal space challenges) or more social security led health plans 7

8. HOUSEHOLD AND INSURANCE SPENDING IN PUBLIC FACILITIES Evidence: Households and private insurers – mostly the former--spent EC$34.8 mn in public health facilities (hospitals—$34.3 mn; clinics—$0.5 mn). But noticeable disparity given reported user fee collections of approx. $3-4 mn (RE: recurrent revenue data in budget estimates). Policy Implication: Need further analysis to clarify if these are ‘private practice’ payments. Consider strengthening design, targeting, administration of user fees To secure public revenue Limit financial burden on targeted households Set systems in place for likely NHI or other prepaid insurance options. 8

9. PRIVATE HEALTH INSURANCE COVER Evidence: Data showed 32% of H/Hs having some private health insurance. Insurers spent only $6.6 mn (6% THE) on health services i.e. off- island ($3.5 mn); local private ($1.0 mn); public hospitals ($2.1mn). Policy Implication: More attention should be given to:  design of insurance packages in terms of referral arrangements for off-island vs on-island care;  co-payment and co-insurance levels;  the extent to which public facilities may be ‘subsidizing’ care for privately insured persons. 9

10. SOCIAL SECURITY HEALTH ROLES Evidence: Social Security played a minor role in health with spending of $ 0.1 mn compared to other Caribbean neighbours (re: St Lucia; St Vincent; Belize; Bahamas; BVI; Jamaica) where these agencies are directly involved in managing health plans or leading health insurance initiatives. Policy Implication: Consider mechanisms to enhance the role of Social Security in health such as national or group-specific pooled, prepaid plans without jeopardising existing portfolio responsibilities. 10

11. OFF-ISLAND CARE (INPATIENT AND OUTPATIENT) Evidence: Both households ($5.5 mn) and private insurers ($3.5 mn) made significant use of off-island facilities for care (over 3000 visits in 2011). This may be due to the relative absence of advanced care in SKN as well as personal reasons. Policy Implication: Consider more measures on how best to maximize value for money in overseas care in terms of:  professionally-driven vs self-referral arrangements  contracts and choice of off-island care facilities  investments to enhance on-island services thru’ partnerships with external advanced care facilities. 11

12. SUSTAINABILITY OF HIV FUNDING Evidence: Donors provided $0.4 mn for HIV services (or 28% of HIV funds). The majority of this was spent on-  preventive care programs inc. counselling, testing, condoms, information  technical assistance to the MOH on HIV matters. Policy Implication: With ‘graduation’ of SKN (and most Caribbean countries), the inflow of donor funds for HIV may be reduced. Attention should be given to measures for sustaining HIV programs locally especially for social support, research and prevention aspects. 12

13. THANK YOU! 13