1. NHI in Turks and Caicos Islands—Performance Assessment and Lessons for the Future Presented by Zaneta Burton (contributions by Mr. Hernado Montas( Actuary))

2. Establishment of the NHIP The Turks & Caicos Islands (TCI) was able, after complex technical and policy assessments, to establish a successful National Health Insurance Plan in 2009. The establishment of the NHIP involved a structural reform of the health delivery model; namely Improvement of health services and delivery in the TCI, The introduction of a governance structure to ensure the Government’s commitment to the efficient operation of the scheme, Fiscal and economic affordability, The reform also ran parallel with the construction and equipment of modern hospitals in the two main islands via a Public Private Partnership between the Government of the Turks and Caicos and InterHealth Canada. The PPP main goal was improving the quality of domestic primary and secondary health services, and reducing the cost of offshore services.

3. Establishment of the NHIP Design of the NHIP had four basic components The definition of an affordable benefit package; Assessment of the actuarial cost; The finance structure; and The design of the legal bases of the scheme

4. Establishment of the NHIP The financing model is based on Government Contribution TCIG fund Treatment Aboard Programme TCIG pays “actuarial transfers” to cover Wards of the State Private Sector Contributions Employer/Employee share 6.0% (Qualifying Compensations Up To $7,800 per month) Self-employed pay $250/month (no income disclosure), or $150 or $50 with income disclosure Pensioners pay 2.5% of pension benefits exceeding $2,000/month

5. Successes Significantly reduce overseas cost, NHIP has successfully reduced the cost for Treatment Abroad Programme from $40 million for 10,000 Turks & Caicos Islanders in 2008 to just over $9 million for over 30,000 beneficiaries. This has occurred in part through a managed move from U.S. facilities to regional facilities and in part because ICL has been able to offer a wider range of services on-island. The plan has allowed the population of the TCI a higher quality of medical care, with an allocation of public funds targeted to health care lower than under the older model. Improved medical facilities and achieved on-island specialty services. Total population now has access to a more diverse medical care versus a small percentage of the population before. Effective management procedures have also allowed a significant reduction in offshore clinical services, allowing the Government substantial savings when compared to the offshore expenses before the inception of the scheme.

6. Graph of overseas expenditure trends

8. Successes The cost of administration of the scheme, which comprises multiple tasks such as monitoring on-islands and offshore services, clinical services by non-preferred local providers, liaising with the hospitals managed by InterHealth Canada concerning clinical services and refunds, plus the usual in-house administrative tasks such as statistics, IT and operational issues. Effective management by the Board has allowed the plan to operate at an optimal level concerning the on-island services and offshore referrals.

9. Global Economic Challenges After the inception of the scheme the economy of the TCI was impacted by the worldwide economic recession, limiting the ability of the Government to budget the transfers assessed in the actuarial estimates, thus impeding the constitution of the contingency reserve set forth in the regulations, to enhance the ability of the plan to sustain catastrophic losses, a situation abetted by the absence of NIB timely transfers for clinical services arising from employment injury and occupational diseases as set forth in the regulations, a key issue also under evaluation by the Board.

10. Operational Challenges and Resolutions Registration The rapid initial registration process resulted in some issues in recording Legal residents appropriately A re-registration drive improved the correct capture of Legal residents and their dependents through the collection of source identification documents Contributions The method of allowing the payment of contributions overt the counter at the banks resulted in challenges in recording the payment amounts to the correct contributors Employers are now required to make payments at the NHIB offices or online via a credit card only after submission of the Contribution Calculator

11. The Way Forward Amendments to the NHIB Ordinance Continued cost reduction strategies Ensure continued access to universal health care within the TCI of all residents with particular emphasis on those most vulnerable such as children, the elderly and the unemployed or indigent Reduce the risk to the NHI Fund and that of TCIG thereby ensuring viability and sustainability of the NHIP. Find ways to increase the revenue base of the NHI Fund Improve management and procurement of pharmaceutical drugs Focus from curative care to preventative care

12. Thank you NHIB Building a Healthy Nation on person at a Time