IMPLICATIONS OF NATIONAL HEALTH ACCOUNTS (NHA) FINDINGS FOR UNIVERSAL HEALTH COVERAGE (UHC) IN BELIZE By Dr Stanley Lalta—HEU/UWI Presented at PAHO-MOH Belize Forum on Health in Development October 10, 2013

OUTLINE OF PRESENTATION NHA as Measuring-Policy Tool for Flow of Funds Summary—Scope of Study and Main Findings Inferences from Findings:-  Effectiveness of Spending  Efficiency of Spending  Adequacy of Spending  Equity in Funding  Sustainability of Funding  National Health Insurance Option(s)

Donors Business H.H’s Gov’t NGO’s Insurers SSB H.H’s Overseas NGO’s Private for Profit Public Facilities Admin Prevention Pharmacy-Lab Outpatient - Public/Private Outpatient - Public/Private MoH Inpatient Care- Public/Private Inpatient Care- Public/Private Financing Sources: -who pays/ contributes Financing Agents: -who pools, manages funds, purchases services Health Providers: -who provides services, owns facilities Health Functions: -what services are bought NHA AS A MEASUREMENT-POLICY TOOL FOR FLOW OF FUNDS

Summary-Scope of Study & Main Findings ScopeAnalyse existing health accounts of the MOH along with related reports on health spending in Belize (IDB, WHO, WB, PAHO) Total Health Expend (THE) About 5.3% of GDP or US$235 per capita in In real terms, THE grew faster than GDP in all except 2 years between Public Share of THE Public share (i.e largely MOH spending) was 65%. MOH received about 12% of overall gov’t budget. In real terms, MOH budget grew faster than overall budget in all except 3 years between Private Share of THE Private share was 30% with Out of Pocket Payments (OOP) constituting the bulk of this. Social SecurityRelatively limited role in funding (vs managing NHI) health care. External Support Donors provide about 5% of funds expended in health sector

Inferences(1)-Effectiveness (using WHO, 2010 data) Country THE per cap (US$) THE%GDP Life Expec- tancy (years) Probability of Dying 0- 5 years (per ‘000) Probability of Dying 15—60 years (per ‘000) Belize Bahamas Barbados Guyana Dominica Jamaica Surinam T& T Costa Rica Guatemala Mexico

Inferences (2)—Efficiency in Spending  Reasonable ‘allocative’ efficiency in MOH spend:- 30% of funds to health promotion, illness prevention and primary care. About 5% to administration  More data needed on ‘technical’ efficiency in public and private sector i.e avoidance of waste in procurement of supplies, inventory management, length of inpatient stay, maintenance, use of treatment protocols, duplication of tests, referrals for overseas care.

Inferences (3)—Adequacy of Spending  With THE amounting to 5.3% GDP, Belize is spending less on health than comparable Caribbean (about 6%) and Central American neighbours (about 6.5%).  Given its burden of disease (triple burden of infectious and maternal-child health conditions; CNCDs and trauma) and middle income status (GDP per cap of US$4180 in 2011), Belize should be progressively spending 6%--7% of GDP on health.

Inferences (4)-Equity in Funding Equity in funding issues relate to:-  High poverty rate (41% in 2009 Poverty Study)  High OOP payments (30% THE)  Limited private insurance coverage  Limited coverage under NHI. In keeping with UHC principles, need for more universal prepaid risk-income pooling plans so regressive ‘catastrophic’ burden of OOP and health inequalities are minimised

Equity in Health and UHC

Inferences (5)-Sustainability of Funding Sustainability of funding issues relate to:-  Increasing resource gap (see graph)between a)Increasing demand for and costs of services (due to epidemiology, technology, demography, expectations etc) b)Slow growing supply/availability of resources (due to fiscal/budgetary constraints, shifting of donor funds

Aging Population Chronic Diseases Technology Inefficiencies Workers’ Demands Expectations Demand for & Cost of Health Services Slow Growing Economy Demand from Other Sectors Less External Support/Grants Availability of Resources Health Financing Dilemma $ Time Period

Inferences (6)—NHI Option(s)  Given challenges with Adequacy of spending Equity and sustainability of funding Securing goals of UHC  Renew consideration of NHI option(s) bearing in mind SSB’s experience/expertise in benefits management SSB’s contribution rate (8%) is less than the 10% ++ in most Caribbean countries Experience with NHI in other Caribbean countries International experience with SHI avoiding US pitfalls

Current and Proposed NHI Plans in Caribbean (S—Single Carrier; M—Multiple Carriers) A. Universal Coverage; Broad Package Current— Aruba (S) Bermuda (M) Cayman Is (M) Turks & Caicos (S) Proposed— Anguilla (S) BVI (S) Bahamas (S) Jamaica (M) St Vincent (S) St Lucia (S) T’dad & T’bgo (S) B. Partial Coverage; Broad Package Current— Antigua (S) Curacao (M) Surinam (M) St Maarten (M) C. Universal Coverage, Limited Package Current- Belize (S) D. Partial Coverage, Limited Package Current— Bahamas (S) Jamaica (S) T’dad & T’bgo (S) Barbados (S)

Obamacare—Mandated Universal Coverage or Individual Choice

Policy Choices in Universal Health Coverage