here - Medwork

Transcription

here - Medwork

A policy framework
For a financially stable health care system in Curaçao
Soenitakumarie Sattoe
Willemstad, Curaçao
July 31, 2013
COLOFON
MASTER THESIS
A policy framework for a financially stable health care system in Curaçao
Willemstad, July 31, 2013
AUTHOR
Soenitakumarie Sattoe
Techno MBA – Student ID: 1045733
University of Curaçao
[email protected]
(5999) 520 6627
SUPERVISORS
Prof.dr.ir. J.I.M. Halman
Mr. A.P. Eliza Msc
University of Curaçao
Drs. Ru Croes RA
Medwork Caribbean N.V.
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ABSTRACT
The state of health of the population of a country is essential in two ways – it reflects the quality
of life of its people and it has impact on economic development. Every country’s aim is to have a
health care system that not only provides affordable- and quality care but also manages its
health care costs in order to sustain its health care system. Major developments have been
made in the control of numerous diseases. However, still countries worldwide are facing major
problems in the health sector. Worldwide it is found that the health care costs increase at a
faster pace compared to the overall economic growth. In recent years, virtually in almost all
countries the expenditure of health care has increased as a percentage of the GDP, Curaçao
therefore is not an exception.
Curaçao is suffering from its constantly increasing health expenditures resulting in large budget
deficits. Curaçao is currently in a financial crisis and an official designation letter (‘Aanwijzing’)
from the Federal Government (‘Rijksregering’) was issued, indicating that drastic cuts have to
be made, especially on the health care costs. Health care costs have drastically risen over the
years and puts major pressure on the expenditures of the Government. The overall level of
funding allocated for health care on a national basis is extremely high (16.6% in 2011). There
are very few effective financing mechanisms and lack of proper control and inefficiencies have
eventually resulted in an uncontrollable increase in the healthcare costs. There is no consistency
in legislation of the health care organization, creating a complicated and less transparent
structure.
Some remarkable figures were gathered when analyzing the causes of increasing health care
expenditures on Curaçao. Three major cost drivers were identified. These are: cultural factors,
drug prescribing and referral practices by General Practitioners and the fact that the drug
industry on Curaçao is lacking proper policies and legislations.
An important cultural factor that generates a lot of care consumption is the tendency of many
locals (‘yu di korsows’) to go to the doctor for every little complaint, even when self-medication
would be sufficient. Most locals go to the doctor just to claim drugs (‘a pill for every ill’) and
often want a referral to a specialist (‘the specialist knows better’). This problem is caused by
both the doctors themselves who in such cases are not showing their professionalism
sufficiently as well as by the patient. A better awareness among the population about what they
can do themselves in case of minor complaints and when a medical examination is required, is
missing.
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An average of ANG 27 MLN is spent yearly on general practitioners. A study of the cost structure
of GP and specialist care (including costs generated by them) in Curacao was done. Some
remarkable figures from this study regarding drug prescribing practices by GP’s in Curaçao
revealed the following:
 A GP (working for BZV-insured) generated in 2006 an amount of nearly ANG 1.5 MLN in
medication costs (over 1.500 patients); the same GP prescribed the majority, i.e. more
than 35.800 prescription items per year;
 The most drug costs at SVB in 2004 were generated by a GP who nearly prescribed
ANG 900.000 (for 1.900 patients). In 2005 this amount had decreased to ANG 739.000;
 A GP with more than 500 PP-patients prescribed in 2006 more than ANG 2.000 for drugs
per patient;
 A GP prescribed in 2006 more than 21.100 prescriptions for about 540 PP-patients,
meaning the highest average of 39.4 prescriptions per average patient.
These are amazingly high numbers and amounts that require in taking firm actions towards the
General Practitioners who prescribe too many medications.
When referrals by the GP’s to secondary care were evaluated, the same study revealed the
following: from the total (estimated) 64.848 SVB insured, 41.232 of these were referred to
specialists and 10.017 referrals to paramedics (psychologist, physiotherapist, etc.). The number
of referrals to specialists is about 63.6% of the total number (SVB) insured (and references to
paramedics were 15.4%).
An average of ANG 62 MLN is spent yearly on specialists. It is not only that the costs that are
associated with the work of the specialists which are relatively high but they also generate
millions in costs for medicines and in the tertiary care level (hospitals and clinics). Specialists
are paid per consultation and there is no (financial) incentive to restrict access to those who are
medically unnecessary. The volume of medical services by specialists, as is the case with the
GP’s, is relatively high and more attention should be paid at inefficient behavior i.e. ineffective
prescriptions for medications and inefficient applications for laboratory tests. Secondary care
providers do not perform based on protocols, which is not in the interest of the quality of care,
nor is effective care provided.
An average amount of ANG 140 MLN is spent yearly on pharmaceuticals. There are two reasons
for high drug costs: the high volume of use of medication (caused by cultural factors i.e. demand
for drugs and prescribing behavior of the doctors) and the costs of medications, from
production to delivery. A large proportion of the selling price (approximately 43%) is composed
only of costs for brokering. It is the profit margin of the manufacturer and the other margins
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that makes drugs so expensive. Reducing these margins would substantially contribute to
reducing the high cost of drugs in Curaçao.
The introduction of a basic health care package has been a long ongoing process. On February
5th 2013 the ‘Basis Verzekering Ziektekosten’ (BVZ) was introduced. BVZ has proofed to be a
tool for the government to reduce the burden on its total expenditures. Despite of the numerous
changes to this law, ‘the total care expenditures of 2013 are developing in accordance with the
calculations done in the ‘Memorie van Toelichting’. The anticipated cost reductions will be
achieved. Management costs will be lower than expected and the operational expenses will be
as calculated in the ‘Memorie van Toelichting’. In other words, the implementation of BVZ is ‘in
control’, according to Westerhof (2013). However, due to major dissatisfaction among the
population and players in the health care field, up till today, changes and corrections are made
to the BVZ law which was introduced on February 5th 2013.
Construction of the new hospital has been a long ongoing process and takes also an important
role in the necessary reforms within the entire health care system of Curaçao.
However, the issue right now is that the health care costs are extremely high due to structural
problems. The major cost drivers are on the primary care level and the secondary care level,
mainly due to absence of health care policies and lack of proper control and management on the
policies that do exists. Meaning, even if Curaçao builds a new hospital (at any cost) but if the
policies remain unchanged or absent, Curaçao will still be dealing with rising health care costs.
Right now, the priority of the government should be at fixing the structural problems within the
entire health care sector.
A study of health systems in the Netherlands, Aruba, Jamaica, Costa Rica and OECD countries
offers a number of strategies for shaping Curaçao’s health care system reform. This study shows
that all countries are dealing with rising health care costs through different policies and plans.
Universalization of the system is a key theme in all countries because the target is to ensure
equal provision of health care for all individuals. The structure of the health care system is
determined by the size of the market and the presence of private sector players. The study also
shows that some countries have managed successful health care sectors with the involvement of
the private sector such as the Netherlands, Jamaica, and Costa Rica. Aruba, on the other hand,
provides effectively health care for the citizens without private sector involvement in insurance
or provision of services. By determining the components of the basic package, the Aruban
system ensures that all individuals can access basic health care and provides room for
additional services covered by private insurers. Preventive health care in Costa Rica proved
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essential in reducing cost and enabling people to improve their health conditions. The different
financing structures used in these countries show that the success of a health care plan depends
on institutional and cultural factors and differs across countries.
Furthermore, it can be concluded that in theory there is no health care system that performs
better in delivering cost-effective health care. Meaning, big-bang health system reforms are not
guaranteed. Rather, it may be more useful and effective for each country to adopt the best policy
practices applied by countries in its own group while using the most suitable elements from
other groups.
A health system is more than a mix of services and medical sessions. It is a structure within
which people, organizations, and institutions work together to organize and allocate resources
for preventing and treating diseases and injuries. This structure has to rest on certain essential
pillars if it is going to work. Without strong guidelines and control management, health
systems do not suddenly provide balanced answers to these challenges, nor do they make the
most effective use of their funds. As most health leaders know, health systems are subject to
powerful forces and encouragements that often overrule rational policy making. Keeping
health systems on course requires a strong sense of direction, and rational investments in the
various layers of the health care system in order for it to provide the kind of services that
produce results.
The implementation of the recommendations in this report requires first a strong and clear
direction from the government, which has been lacking in recent years. A government that
recognizes the need for cost control and reduction should not hesitate in taking the right
measures to gain control. The costs are fairly high, but there are major payoffs in long-term
investments in health care. Such investments not only raise quality of life for the entire
population but also make the health care industry in Curaçao a great force for economic growth.
Health care reform is urgent and strong government commitment is the key to its success.
Curaçao needs decisive leaders with a sense of urgency and proper steering capabilities to
direct; only then the reform of Curaçao’s health system will succeed.
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SAMENVATTING
De toestand van de gezondheidszorg van de bevolking van een land is van belang in de volgende
twee opzichten; het weerspiegelt de kwaliteit van het leven van de bevolking en de effecten van
de economische ontwikkeling van een land. Doel van elk land is om een gezondheidszorg
systeem te hebben, dat niet alleen voorziet in betaalbare en kwalitatief goede zorg, maar ook de
kosten beheert om zodoende te voorzien in een duurzaam zorgstelsel. Wereldwijd blijkt, dat de
gezondheidszorgkosten in een sneller tempo stijgen ten opzichte van de totale economische
groei. In de afgelopen jaren zijn in vrijwel alle landen de uitgaven van de gezondheidszorg
toegenomen als percentage van het BBP. Curaçao is op dit gebied dan ook geen uitzondering.
Curaçao bevindt zich momenteel in een financiële crisis. Een officiële aanwijzing van de
Rijksregering is afgegeven, wat betekent, dat er drastisch bezuinigingen moeten worden
doorgevoerd, in het bijzonder voor wat betreft de gezondheidszorg kosten. De
gezondheidszorgkosten zijn de afgelopen jaren drastisch gestegen en drukken zwaar op de
totale uitgaven van de Overheid. De totale hoeveelheid van de toegewezen middelen voor de
gezondheidszorg op nationale basis is extreem hoog (16.6% van het BBP in 2011). Curaçao
ontbeert een sterke gezondheidszorg infrastructuur en heeft verschillende zwakheden in het
zorgstelsel. Er zijn zeer weinig effectieve financieringsmechanismen, er ontbreekt een goede
controle en inefficiënties hebben uiteindelijk geresulteerd in een oncontroleerbare stijging van
de gezondheidszorg kosten. Er is geen consistentie in de wetgeving van het zorgstelsel, wat
heeft geleid tot een ingewikkelde en minder transparante structuur.
Tijdens dit onderzoek zijn er opmerkelijke cijfers verzameld met betrekking tot de oorzaken
van de toenemende uitgaven in de gezondheidszorg. De drie belangrijke oorzaken van hoge
zorgkosten die zijn geconstateerd, zijn: Culturele factoren, voorschrijf- en verwijsgedrag van de
artsen en het feit, dat er geen beleidsregels en wetgeving bestaan binnen de farmaceutische
industrie op Curaçao.
Een belangrijke culturele factor, welke bijdraagt aan de hoge kosten is, dat de ‘yu di korsow’
heel snel geneigd is om naar de dokter te stappen voor ieder klein kwaaltje, ook al zou zelf
medicatie of uitzieken voldoende zijn. De meeste lokalen gaan naar de dokter om medicijnen
voorgeschreven te krijgen (bij iedere kwaal hoort er een pil) en ook liefst een verwijzing naar de
specialist (‘de specialist weet het beter’). Dit probleem wordt veroorzaakt door de arts zelf, die
hun professionalisme in dergelijke gevallen niet voldoende tonen, en ook door de patiënt,
aangezien een beter bewustzijn ontbreekt over, wat men kan doen in geval van kleine kwaaltjes
en klachten en wanneer wel of geen medisch onderzoek vereist is.
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Jaarlijks wordt gemiddeld ANG 27 MLN uitgegeven aan huisartsen (1e lijn zorg). In 2007 werd
een onderzoek met betrekking tot de kostenstructuur van de huisartsen en specialisten op
Curacao uitgevoerd. Enkele opmerkelijke en verbazingwekkende cijfers uit dit onderzoek zijn
als volgt:
 Een huisarts (voor BZV verzekerden) genereerde in 2006 een bedrag van bijna ANG 1.5
MLN aan medicatie kosten (meer dan 1500 patiënten). Dezelfde huisarts schreef de
meerderheid voor m.a.w. meer dan 35.800 receptregels per jaar;
 De meeste geneesmiddelen kosten bij SVB in 2004 werd gegenereerd door een huisarts
die bijna ANG 900.000 voorschreef (voor 1900 patiënten).
 Een huisarts met meer dan 500 PP-patiënten schreef in 2006 meer dan ANG 2.000 per
patiënt voor aan medicijnen.
 In hetzelfde jaar (2006) schreef een huisarts 21.100 recept regels voor aan ongeveer
540 PP-patiënten. Met andere woorden, het hoogste gemiddelde van 39.4 voorschriften
per patiënt.
Deze zijn verbazingwekkend hoge aantallen en bedragen, die aangeven, dat er krachtige
maatregelen genomen moeten worden in het kader van het voorschrijfgedrag van de artsen.
Ook werd het verwijsgedrag van de huisartsen naar de 2e lijn zorg geëvalueerd. Uit hetzelfde
onderzoek bleek het volgende: van de totale (geschatte) 64.848 SVB verzekerden, werden
41.232 doorverwezen naar specialisten en 10.017 werden doorverwezen naar paramedici
(psycholoog, fysiotherapeut etc.). Het aantal verwijzingen naar specialisten is ongeveer 63.6%
van het totale aantal (SVB) verzekerde. Verwijzingen naar paramedici waren 15.4%.
Jaarlijks wordt gemiddeld ANG 62 MLN uitgegeven aan specialisten zorg (2e lijn zorg). Het is
niet alleen, dat de specialistische zorg relatief veel hogere tarieven kent, maar de specialisten
genereren ook miljoenen aan kosten voor medicijnen en in de 3e lijn zorg (ziekenhuizen).
Specialisten worden per consult betaald en er is geen (financiële) prikkel om de toegang tot de
2e lijn zorg, die medisch onnodig zijn te beperken. De medische diensten door de specialisten is
relatief hoog, zoals het geval is bij de huisartsen. Meer aandacht moet worden besteed aan
inefficiënt gedrag (voorschrijven van medicijnen en onnodige lab onderzoeken). Specialisten
presteren ook niet op basis van medische protocollen, hetgeen ook niet in belang is van de
kwaliteit van de zorg en dus is er ook geen sprake van effectieve zorg verlening.
Jaarlijks wordt gemiddeld ANG 140 MLN uitgegeven aan geneesmiddelen. De twee redenen,
waarom de geneesmiddelen kosten zo hoog zijn: het hoge volume van het gebruik van
medicijnen (veroorzaakt door culturele factoren en het voorschrijf gedrag van artsen) en de
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kosten samenstelling van medicijnen van productie tot levering. Een groot deel van de
verkoopprijs (ongeveer 43%) bestaat uit winstmarges voor de tussenhandel. De winstmarges
van de producten en tussenhandel maakt de medicijnen zo duur. Door wetgeving en regeling in
het leven te roepen om deze marges te verlagen zou wezenlijk bijdragen aan de vermindering
van de hoge kosten van geneesmiddelen op Curacao.
De invoering van een basispakket is een langlopend proces geweest. Op 5 februari 2013 werd
de Basis Verzekering Ziektekosten (BVZ) geïntroduceerd. BVZ blijkt wel een instrument te zijn
voor de overheid om de lasten van haar totale uitgaven te verminderen. Ondanks het feit, dat er
meerdere reparatie wetten toegepast zijn aan de wet BVZ, ‘Ontwikkelen de zorguitgaven van
2013 zich conform het gestelde in de Memorie van Toelichting (MvT). Het bedrag aan
kostenreducties, zoals opgenomen in de MvT, wordt gerealiseerd. De beheerskosten van 2013
zullen lager uitkomen dan in de MvT voorzien. De premie opbrengsten ontwikkelen zich
conform het gestelde in de MvT. De uitvoering is "in control". Het exploitatieresultaat zal
conform MvT zijn. Het bovenstaande is inclusief Ambtenaren en gelijkgestelden, kortom
dezelfde populatie als in de MvT’ volgens Westerhof (2013). Echter, introductie van BVZ heeft
geleid tot grote ontevredenheid onder de bevolking en de spelers binnen de gezondheidszorg.
Tot op heden vinden wijzigingen en correcties plaats binnen het basispakket.
De bouw van een nieuw ziekenhuis is ook een langlopend project en speelt een belangrijke rol
in de nodige hervormingen binnen de gehele gezondheidszorg op Curaçao. Echter, op dit
moment is het probleem, dat de zorgkosten zeer hoog zijn als gevolg van structurele problemen.
De belangrijkste kosten-veroorzakende factoren zijn op de eerste lijn en tweede lijn zorg niveau,
vooral door het ontbreken van goede beleidsmaatregelen, gebrek aan controle en beheer over
de beleidsmaatregelen die wel bestaan, maar niet toegepast worden. Hetgeen betekent: al krijgt
Curaçao een nieuw ziekenhuis (koste van wat het kosten moet), maar blijft het beleid
ongewijzigd of afwezig, dan zal Curaçao nog steeds te maken hebben met stijgende zorg kosten.
Op dit moment moet de prioriteit van de regering liggen bij het verbeteren en implementeren
van hervormingsstrategieën, welke de structurele problemen binnen de gezondheidszorg
oplossen.
Dit vergelijkend onderzoek van gezondheidszorgsystemen in Nederland, Aruba, Jamaica, Costa
Rica en de OECD-landen geeft een aantal inzichten voor het vormgeven van het Curaçaose
zorgstelsel. De informatie in dit rapport beschrijft de strategieën, die Curaçao zal moeten
implementeren om haar gezondheidszorgkosten op korte (en lange) termijn te kunnen
beheersen. Uit dit onderzoek is gebleken, dat vrijwel alle landen te kampen hebben met
stijgende zorgkosten en dat deze kosten beheerd worden met behulp van beleidsmaatregelen
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en plannen. Een basispakket is een belangrijk thema in vrijwel alle landen, omdat het doel van
een zorgsysteem is: ‘het verstrekken van gelijke gezondheidszorg, welke betaalbaar en
toegankelijk is voor een ieder’. De structuur van de gezondheidszorg wordt bepaald door de
omvang van de markt en de aanwezigheid van de hoeveelheid spelers in de private sector. Uit
dit onderzoek is gebleken dat er landen zijn, die erin geslaagd zijn om succes te boeken met de
betrokkenheid van de private sector, zoals Nederland, Jamaica en Costa Rica. Aruba, aan de
ander kant, biedt effectieve gezondheidzorg zonder betrokkenheid van de particuliere sector.
Door het bepalen van de componenten van het basispakket, zorgt het Arubaanse systeem
ervoor, dat iedereen toegang heeft tot de gezondheidszorg en biedt ruimte voor aanvullende
verzekeringen door particuliere verzekeraars, indien gewenst. Preventieve gezondheidszorg in
Costa Rica is essentieel gebleken in het verminderen van kosten en het stelt de mensen in staat
om hun gezondheid te verbeteren. Door gebruik van verschillende financieringsmechanismen
blijkt, dat het succes van een gezondheidszorgsysteem afhankelijk is van institutionele en
culturele factoren, welke van land tot land verschillen. Uit dit onderzoek kan ook worden
geconcludeerd, dat er in theorie geen gezondheidszorgsysteem is, wat beter presteert, als er
gekeken wordt naar kosteneffectiviteit. ‘Big-bang’ hervormingen worden niet gegarandeerd. In
plaats daarvan, wordt er geadviseerd om de beste praktijken op beleidsgebied van andere
landen over te nemen en de meest geschikte elementen daaruit toe te passen in eigen land.
Een gezondheidszorgsysteem is meer dan een verhouding tussen vraag en aanbod van de zorg.
Het is een structuur, waarbinnen mensen, organisaties en instellingen samenwerken om zich te
organiseren, middelen (financieel) beschikbaar te stellen voor preventie en behandeling van
ziekten. Een gezondheidszorgstructuur dient te rusten op bepaalde essentiële pilaren om goed
te kunnen functioneren.
Zonder sterke richtlijnen, beheer en controle op het gezondheidszorgsysteem, biedt het systeem
niet plotseling uit zich zelf oplossingen op uitdagingen, noch zullen de fondsen op een meest
effectieve manier gebruikt worden. Zoals de meeste gezondheidzorgleiders weten, zijn
gezondheidszorgsystemen onderhevig aan sterke krachten en aanmoedigingen, die vaak
rationele beleidsvorming ‘overrulen’. Om gezondheidssystemen op koers te houden, is een
sterk gevoel van richting, en rationele investeringen in de verschillende lagen van de
gezondheidszorg vereist. Zo zal het zorgsysteem op haar beurt ook de verwachte diensten en
resultaten opleveren.
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De implementatie van de aanbevelingen in dit rapport vereist ten eerste een sterke en
duidelijke richting van de overheid. Daar heeft het de afgelopen jaren aan ontbroken. Een
overheid, die de behoefte aan kostenbeheersing en reductie onderkent, zou niet moeten
twijfelen in het nemen van de juiste maatregelen om snel orde op zaken te stellen. De
investeringskosten zijn tamelijk hoog, maar de terugbetalingen hiervan op lange-termijn zijn
ook enorm. Dergelijke investeringen verhogen niet alleen de levenskwaliteit van alle burgers,
maar zorgen ook voor een forse economische groei in de zorgsector op Curaçao. Hervorming
van de gezondheidszorg is dringend. De overheid moet nu laten zien dat het ernst is. Curaçao
heeft daadkrachtige en beslissingen-nemende leiders nodig met een gevoel van urgentie,
die de juiste sturing kunnen geven; alleen dan zal de hervorming van het Curaçaose
zorgstelsel slagen.
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PREFACE
This report is my master thesis for the conclusion of my Master program at the University of
Curacao. This research project has been one of the most valuable learning processes in my life. It
was very interesting to study the concepts of- and relations within the entire health care sector.
To discover how countries deal with the health care of their population despite of all the
challenges has been quite interesting. I sincerely hope the results of this study may, as
intended, somehow contribute to the current challenge of the transition towards a financially
stable health care system in Curaçao.
This research would not have been possible without the support of many people. First of all, I
would like to thank Prof.dr.ir. J.I.M. Halman for his guidance, support and patience, who helped
me define my topic and read my numerous revisions. I would like to thank particularly Drs. R.
Croes for agreeing to serve as my supervisor and for providing advice as well as necessary
material and insight to perform my research. I am greatly thankful to the panel of experts, Drs.
D. Pinedo, Drs. G. Spijker and Mr. R. Westerhof who have provided tremendous support and
invaluable suggestions during the evaluation of my thesis. I would also like to thank the
following people who have contributed to this thesis: Mr. A.P. Eliza Msc, Mr. R. Anandbahadoer
and Drs. I. Gerstenbluth.
And finally, a special thank you goes to my dearest husband, Kees van Dongen, who has always
inspired me to pursue my dreams, who has endured this long process with me, always offering
his support and love.
This thesis is dedicated to my two beautiful children, Rohan & Keesha van Dongen, who have
brought me endless joy since the day they were born and became part of my life.
Soenita van Dongen-Sattoe
Willemstad, August 2013
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TABLE OF CONTENTS
COLOFON ............................................................................................................................................................................. 2
ABSTRACT ........................................................................................................................................................................... 3
SAMENVATTING ............................................................................................................................................................... 7
PREFACE ........................................................................................................................................................................... 12
LIST OF FIGURES AND TABLES ............................................................................................................................... 16
LIST OF ABBREVIATIONS .......................................................................................................................................... 17
1. INTRODUCTION ........................................................................................................................................................ 18
1.1 Project context.................................................................................................................................................... 19
1.2 Problem mess...................................................................................................................................................... 19
1.2.1 Problem statement ................................................................................................................................... 20
1.3 Objectives and scope........................................................................................................................................ 21
1.4 Research questions........................................................................................................................................... 21
1.4.1 Research strategies and material ....................................................................................................... 22
1.4.2 Research process framework .............................................................................................................. 23
LITERATURE REVIEW
2. HEALTH CARE SECTOR IN CURACAO .............................................................................................................. 25
2.1 Background Health care sector in Curaçao ............................................................................................ 25
2.2 Structure of the health care system in Curaçao .................................................................................... 26
2.3 Health care costs in Curaçao ......................................................................................................................... 27
2.4 Causes of rising health care expenditures in Curacao ....................................................................... 33
2.4.1 Cultural factors .......................................................................................................................................... 33
2.4.2 Primary care level..................................................................................................................................... 33
2.4.3 Secondary care level ................................................................................................................................ 35
2.4.4 Cost of pharmaceuticals ......................................................................................................................... 35
2.4.5 Various other factors leading to high health care costs ............................................................ 36
2.5 Current developments in the health care sector .................................................................................. 38
2.6 Construction of the new hospital (‘Nos Hospital Nobo, NHN)........................................................ 39
2.7 Introduction of the Basic Health Care Package ..................................................................................... 44
2.7.1 Insurance and Coverage overview before BVZ............................................................................. 44
2.7.2 ‘Basis Verzekering Ziektekosten’ and its effects .......................................................................... 45
2.8 Conclusion of chapter ...................................................................................................................................... 48
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3. PILLARS OF A WELL-FUNCTIONING HEALTH CARE SYSTEM .............................................................. 49
3.1 Health care systems in general .................................................................................................................... 49
3.2 Leadership and governance .......................................................................................................................... 50
3.3 Health Information Systems ......................................................................................................................... 51
3.4 Health financing ................................................................................................................................................. 52
3.5 Human Resources for health ........................................................................................................................ 53
3.6 Crucial medical products and technologies............................................................................................ 53
3.7 Service delivery .................................................................................................................................................. 54
3.8 Health care system efficiencies in OECD countries and lessons learned ................................... 54
DATA ANALYSIS
4. HEALTH CARE REFORMS IN THE DUTCH KINGDOM AND THE CARIBBEAN ................................. 59
4.1 Health systems evaluation: Curaçao, The Netherlands, Aruba, Jamaica and Costa Rica ..... 50
4.2 Comparing health care costs on Curaçao and the rest of the world............................................. 53
4.2.1 Cross case analysis: Curaçao, Netherlands, Aruba, Jamaica and Costa Rica ..................... 54
4.3 Aruba and Its Health care System .............................................................................................................. 56
4.3.1 Health care System and its Structure ............................................................................................... 56
4.3.2 The General Health Insurance Plan ................................................................................................... 56
4.3.3 Why Aruba is successful in managing its health care costs..................................................... 57
4.3.4 Challenges and Recent Developments ............................................................................................. 59
4.3.5 Conclusion.................................................................................................................................................... 59
4.4 The Netherlands and Its Health care System ......................................................................................... 60
4.4.1 Health care system and its structure ................................................................................................ 60
4.4.2 Health care Financing ............................................................................................................................. 61
4.4.3 Challenges and recent developments ............................................................................................... 61
4.4.4 Conclusion.................................................................................................................................................... 63
4.5 Jamaica and Its Health care System ........................................................................................................... 63
4.5.1 Health care System and its Structure ............................................................................................... 64
4.5.2 Health care financing............................................................................................................................... 67
4.5.4 Conclusion.................................................................................................................................................... 68
4.6 Costa Rica and Its Health care System ...................................................................................................... 69
4.7 Conclusion of Chapter ..................................................................................................................................... 71
14
DESIGN
5. POLICY FRAMEWORK DESIGN ........................................................................................................................... 72
5.1 A policy framework for health cost management on Curaçao ....................................................... 73
5.1.1 Strategies for cost control and management within the health care sector ..................... 74
5.1.2 Restructuring the health care sector of Curaçao ......................................................................... 79
6. PANEL OF EXPERTS: POLICY FRAMEWORK VALIDATION..................................................................... 84
6.1 Evaluation Questions for each chapter .................................................................................................... 84
6.2 Important remarks by panel of experts ................................................................................................... 84
6.2.1 Evaluation Chapter 2 ............................................................................................................................... 84
7. FINAL CONCLUSIONS & RECOMMENDATIONS ........................................................................................... 88
7.1 Conclusions .......................................................................................................................................................... 88
7.2 Recommendations ............................................................................................................................................ 89
REFERENCES ................................................................................................................................................................... 91
ANNEXES........................................................................................................................................................................... 97
1. Panel of Experts:................................................................................................................................................... 97
2. List of Interviewees ............................................................................................................................................. 98
3. List of websites consulted ................................................................................................................................ 99
15
LIST OF FIGURES AND TABLES
Figure 1 – World health expenditure as share of GDP (%), 2008-2010 …………………………………………………18
Figure 2 – Research framework: a policy framework for a financially stable health care system ……………24
Figure 3 – Top 4 health care expenditures in Curaçao ………………………………………………………………………….30
Figure 4 – Resources of financing of health care expenditures in Curaçao, 2011 …………………………………...31
Figure 5 – Cost drivers in health care ………………………………………………………………………………………………….33
Figure 6 – Overview of the pharmaceutical sector on Curaçao ……………………………………………………………..35
Figure 7 – Status of the NHN project …………………………………………………………….…………………………………….40
Figure 8 – Financing options for the NHN project ……………………………………………………………………………….41
Figure 9 – Cross case analysis: health care costs as % of GDP ………………………………………………………………54
Figure 10 – Cross case analysis: Top 2 health expenditures within the Kingdom ………………………………….55
Figure 11 – Cross case analysis: resources of financing health care costs ……………………………………………..55
Figure 12 – Distribution of medical expenditures by service in Aruba, 2011 ………………………………………...58
Figure 13 – Organization structure of NHF, Jamaica …………………………………………………………………………….65
Figure 14 – Financing flows in the Jamaican health sector, 2009 ………………………………………………………….67
Figure 15 – General overview of the current health care sector on Curaçao ………………………………………….80
Figure 16 – The future health care structure of Curaçao ………………………………………………………………………82
Table 1 – Total care expenditures of Curaçao from 2008-2011 …………………………………………………………….29
Table 2 – Overview of government funding before and after BVZ implementation ………………………………..46
Table 3 – Health systems evaluation: Curaçao, The Netherlands, Aruba, Jamaica and Costa Rica …………...50
Table 4 – Overview of health care expenditure of Aruba 2010-2012 …………………………………………………....58
16
LIST OF ABBREVIATIONS
AZV
– Algemene Ziektekosten Verzekering
AWBZ – Algemene Wet Bijzondere Ziektekosten
BVZ
– Basis Verzekering Ziektekosten
BZV
– Bureau Ziektekosten Voorzieningen
CZA
– Curaçaose Zorg Authoriteit
COFOG – Classification of Functions of Government
CCSS
– Costa Rican Social Security Fund
EBAIS – Basic Comprehensive Healthcare Teams
FHN
– Fundashon Hospital Nobo
GDP
– Gross Domestic Product
GP
– General Practitioner
GTZ
– Garantie Toegankelijkheid Zorg
HRH
– Human Resource for Health
IVG
– Inspectie voor de Volksgezondheid
ICHA
– International Classification for Health Accounts
JADEP – Jamaica Drug for Elderly Program
MSGB – Medisch Specialisten Geïntegreerd Bedrijf
MOH
– Ministry Of Health
MOF
– Ministry Of Finance
NGO
– Non Governmental Organization
NHF
– National Health Fund
NCD
– Non-communicable disease
NII
– National Insurance Institute
OECD – Economic Co-operation and Development
OV
– Ongevallen Verzekering
PPP
– Purchasing Power Parity
PAHO – Pan American Health Organization
RHA
– Regional Health Authorities
SHA
– Systems of Health Accounts
SVB
– Sociale Verzekerings Bank
UNICO – Universal Health Coverage
WHO – World Health Organization
ZFW
– Ziekte Fonds Wet
17
1. INTRODUCTION
Worldwide it is found that the health care costs increase at a faster pace compared to the overall
economic growth. Causes are worldwide trends such as an aging population, higher life
expectancy and also the appearance of new diseases that require both more research and other
expensive medications (Department of Economic Affair, 2010) and thus lead to increased costs.
Rising health care costs - A world problem
In the United States, the proportion of Gross Domestic Product (GDP) spent on health care
increased from 13 % in 2000 to nearly 17 % of GDP in 2009. This proportion is by far the
highest in the Organization for Economic Co-operation and Development (OECD) and more than
7% higher than the average of 9.6 % in the OECD countries (Department of Economic Affair,
2011). In 2009, the Netherlands spent 11.9% of its GDP on health care. Furthermore, health care
costs in the Netherlands increased in 2011 with 3.2% (‘Centraal Bureau voor Statistiek’, 2012).
The cause of the increase of health care costs in the Netherlands is not only determined by
aging, but also by new treatment options and price developments (‘RIVM’, 2010).
Figure 1 illustrates that in the course of time the growth rate of health care costs in virtually all
countries has increased. It shows that the Western OECD countries, such as the U.S.,
Switzerland, France, Germany and The Netherlands are spending for many years a fair amount
of their income on health care. The U.S. is hereby clearly the outlier (‘Centraal Bureau voor
Statistiek’, 2012).
Figure 1. Health expenditure as share of GDP (%) 2008-2010
Source: The World Bank, 2012; World Development Indicators
18
1.1 Project context
Not only abroad countries are facing problems in the health care sector in terms of funding. This
is also the case for Curaçao. In 2011 the total health care costs in Curaçao was estimated at
16.6 % of the GDP (‘Zorgrekeningen Curaçao 2008-2011’, 2012). The specific problem on
Curaçao in the health care sector is that the costs are constantly rising and are likely to become
unmanageable. In the organization of health care on Curaçao there is no integration and
insufficient cooperation between the various components within the health care sector (i.e. no
integration between systems of the medical providers and health care insurance provider,
insufficient cooperation between the health care insurance provider, medical provider and
various health care institutions). Also ad hoc health care decisions are taken by the government.
Moreover, there is no consistency in the legislation of the health care organization, creating a
complicated and less transparent structure. Furthermore, health care related data is not linked
to a central system, making it very difficult to be able to monitor the health care sector. At the
same time, there is a lack of adequate and up-to-date health data. The Ministry of Health has
taken actions to reduce health care costs by introducing a basic health care insurance package
(‘Landsverordening Basis Verzekering Ziektekosten’, 2013).
1.2 Problem mess
The following section provides an overview of the problem mess from which the problem
statement, main research question and the sub questions are formed, which need to be
answered after finalizing this research.
Rising Health care costs in Curaçao
Curaçao is currently in a financial crisis. An official designation from the Federal Government
(‘Rijksregering’) was issued, indicating that drastic cuts have to be made, especially on the
health care costs (Rijksoverheid, 2012).
The total care costs consist of health care costs and welfare1 (social care1) costs. Care is
distinguished in health care (cure) and welfare. Health care includes the 1st and 2nd line care.
Health care also includes the supply of pharmaceuticals and medical- and support services.
Welfare includes guidance, such as for the disabled and all forms of childcare, youth care and
boarding facilities. Based on recent data published (Curaçaose Zorgrekening 2008-2011, 2012),
the breakdown of total care expenditure of 2011 shows that 83% (ANG 750 MLN) was
accounted for health care and 17% (ANG 150 MLN) for social care. As a percentage of GDP this is
13.8% and 2.8% respectively. The expenditure on health care in 2011 was ANG 4.996,- per capita
and for welfare it was ANG 1.010,- per capita. The health care costs increased in the period of
1
19
‘Welzijn zorg’
2008-2011 by an average of 6% per year. Within the health care sector in Curaçao in 2011 the
top four expenditures were formed by hospitals (24%), suppliers of drugs (19%), providers of
(district) nursing and home care (10%) and specialist practices (9%). In 2008 this was 24%,
22%, 11% and 9% respectively (Curaçaose Zorgrekening 2008-2011, 2012).
Health care costs have drastically risen over the years and put major pressure on the
expenditures of the Government. Information obtained from interviews and observations (see
Annex 1) show that the major problem areas are affordability and financial sustainability of the
health care system in Curaçao. It was already clear that health care was actually bankrupt
already: care providers and resources, hospitals and pharmaceuticals could not be paid.
Expenditures in turn are greater than income. Revenues and expenses are so out of balance that
a debt is incurred by a structural deficit that increases annually (Post, 2002).
To finance the deficits, other funds (pension) are drawn from. It was also found that the health
care system of Curaçao is dealing with structural problems. Attention is only paid to managing
the expenditure side (demand). When restructuring within the health care field, attention
should be paid to all areas of the health care sector. With an incoherent and totally unregulated
structure on the health care providers’ side (supply) it will be impossible to gain structural
efficiency within the health care system. This inconsistency also exists within the insurance
system, both in terms of types of insured and implementing entities (Post, 2002). Various
factors within the health care structure of Curacao have led to increased healthcare costs. These
factors are discussed in section 2.4.
1.2.1 Problem statement
Every country’s aim is to have a health care system that not only provides affordable- and
quality care but also manages its health care costs in order to sustain its health care system.
Currently, Curaçao is dealing with health care costs that are constantly rising and have now
reached an unmanageable risk. While the introduction of the basic health care package makes
important progresses in reducing costs, much more is needed to restrain in the rising health
care costs. In 2011, the total health care expenditure of Curaçao was over ANG 900 MLN. This
amount corresponds with 16.6% of GDP and this percentage continues to rise every year.
Unfortunately, our system is not delivering value corresponding to the estimated average of
ANG 775 MLN spent annually on health care only (Curaçaose Zorgrekening 2008-2011, 2012).
Experts agree that an estimated 20 to 30 % of that spending – up to ANG 230 MLN a year – goes
to care that is inefficient, redundant, or wasteful (Manager Cure, SVB, March 2013 &
Epidemiology Unit, GGD, personal communications, October 2012).
20
1.3 Objectives and scope
Objective of the research
The information gathered and analyzed during this research can be used as a guide by the
government in structuring and defining strategies for a successful and sustainable health care
system. Furthermore, the information gathered will allow the government to make sound
decisions in a responsible manner when it comes to health care.
Objective within the research
The objective within this research is to provide insight in what is causing the rising health care
costs on Curaçao. Based on best practices, a policy framework for managing health care costs on
short term and sustaining the health care system of Curaçao on long term will be developed.
Scope of the research
The focus of this research is on health care costs. Thus an analysis of welfare (social care) costs
is beyond the scope of this master thesis. A breakdown of the total care costs (health care and
social care) is provided in section 2.3., Table 1. Furthermore, recommendations in this research
are done by taking quality of care into account when it comes to managing overall health care
costs.
1.4 Research questions
Main research question
What strategies are necessary to increase the control mechanisms within the health care system
to improve the management of health care costs on short term and what strategies will lead to a
financially stable health care system in Curaçao in a longer term?
Sub research questions
1) What is causing the rising health care costs in Curaçao?
2) What strategies are currently implemented to control health care costs in Curaçao?
3) What are effective strategies for controlling health care costs based on international
standards?
4) What strategies have been implemented by other countries to control their health care
costs?
5) What strategies will lead to a financially stable health care system in Curacao based on
the conducted research above?
21
1.4.1 Research strategies and material
To answer the main research questions, the sub questions have to be answered first.
The first sub question, ‘What is causing the rising health care costs in Curaçao?’
Since the health care data is not linked to a central (uniform registration) system, this makes it
very difficult to gather data. The lack of reliable and recent data (economic health care data,
practical or more care-related data) and accessible registration makes it difficult to conduct a
thorough analysis of the health care system and its costs in Curaçao. To analyze and answer this
sub question available literature on the health care sector, health care providers and various
papers regarding the health care structure and costs in Curacao is reviewed. Furthermore,
interviews are held with experts in the field. This sub question is answered in chapter 2 of this
master thesis.
The second sub question, ‘What strategies are currently implemented to control health care
costs in Curaçao?’ The Ministry of Finance and Ministry of Economic Affairs is contacted to
gather data on recent plans of the government. To assess the basic health care package which
was introduced on February 5th 2013, the law ‘Basisverzekering Ziektekosten’ is thoroughly
analyzed since this was one of the measures taken to manage health care costs. Local insurance
schemes are reviewed as well. This sub question is answered in chapter 2 of this master thesis.
The third sub question, ‘What are effective strategies for controlling health care costs based
on international standards?’ To answer this question literature review on developing and the
criteria’s for a well-functioning health care system are reviewed and studied. Furthermore
lessons learned from international countries (OECD) are reviewed and studied. This sub
question is answered in chapter 3 of this master thesis.
The fourth sub question, ‘What strategies have been implemented by similar countries to
control their health care costs?’ To answer this sub question, the health care systems of two
countries in the Dutch Kingdom and the health care systems of two countries in the Caribbean
are evaluated. A cross-case analysis between the different health care systems is performed.
Implemented strategies to maintain and control health care costs are reviewed as well. This sub
question is answered in chapter 4 of this master thesis.
The fifth sub question, ‘What are effective strategies that will lead to a financially stable
health care system in Curaçao?’ To answer this question literature on developing and the
criteria’s for a well-functioning health care system are reviewed and studied. Best practices
within the Dutch Kingdom and the Caribbean are analyzed and suitable strategies for Curaçao
are then identified. This sub question is answered in chapter 5 of this master thesis.
22
As a result, the main research question is answered by summarizing the strategies most suitable
for Curaçao to control and improve its costs management when it comes to health care costs
and restructuring the current health care system to a financially stable health care system on
the long term. The main research question is answered in chapter 6 based on the research
conducted above.
1.4.2 Research process framework
A study of the problems within the health care sector related to rising health care costs on
Curaçao is performed based on interviews with experts in the field and available literature.
Based on the assessment criteria of a well-functioning health care system, Curaçao’s health care
system is evaluated. Current developments and the impact of measures taken to manage the
health care costs in Curaçao are analyzed as well.
Benchmarking is performed by means of a best practice analysis where health care cost
management and reforms have taken place. Health care systems within the Dutch Kingdom and
the Caribbean are analyzed. Health care structures and reform strategies of these countries are
reviewed and a cross case analysis is performed. Based on this best practice analysis and the
international standards of health systems, the gaps within Curaçao’s health care system are
identified. Strategies for developing a financially stable health care system for Curaçao are
identified and recommended.
23
Literature on health
care structure and
policies in Curaçao.
(Chapter 2)
Literature on a wellfunctioning health care
system. (Chapter 3)
Benchmark: analysis
of implemented
strategies to manage
health care cost
internationally.
(Chapter 4)
Criteria for developing strategies for
health care cost management.
(Chapter 3 & 4)
Develop a policy
framework for
managing health care
costs in Curaçao.
(Chapter 5)
Conclusions
&
Recommendations
(Chapter 6)
Current health care system status and
basic health care package assessment.
(Chapter 2)
Figure 2 Research framework:
A policy framework for a financially stable health care system in Curaçao.
24
2. HEALTH CARE SECTOR IN CURACAO
This chapter provides an overview of the health care system in Curaçao. The emergence of the
health care sector is analyzed followed by the health care structure. The health care costs
together with the causes and effects are reviewed and analyzed. The most remarkable in the
analysis of the costs were the management and policy costs which have increased dramatically
over the years. The inefficiencies of the organizational structure of the health care sector in
Curaçao are discussed also. The recently introduced basic health insurance (BVZ) is also
thoroughly analyzed. This chapter concludes with the current measures taken to reduce the
health care costs and how this will influence the total government budget of Curaçao.
2.1 Background Health care sector in Curaçao
The emergence of health care in Curaçao
Health care in Curaçao has primarily arisen from religious and private-charitable initiatives. In
addition, the arrival of the Shell refinery (1916) and also the business sector had a significant
impact on the structure of health care. Still, the refinery and also a number of other companies
have their own medical services for employees and family members. Historically, the health
care has never been a task of the government. However, over time the understanding grew that
by taking actions, diseases could be prevented. Examples include measures in the field of
hygiene. This was seen as a task of the government. Additionally, social consciousness grew,
with the result that the government at one point started to feel more responsible for the health
of the population as a whole. This led to Public Health care services on all islands and based on
this came the public insurance scheme for the ‘poor’, the so-called PP-system (Mercera, 1993).
Mercera (1993) further explains that in most countries, the health care system of a country is
based on a certain structure and is developed based on economic, financial and cultural factors,
which was not the case in Curaçao. The result of not having a health care structure in place from
the beginning created an unequal growth in different areas of care. Because of the absence of
legal rules within the health care sector, several facilities were developed in the course of the
years that were hardly aligned with each other.
This had two major consequences (Mercera, 1993), namely:
 Fragmentation, overlap, duplication and incompleteness of facilities i.e. inefficiency.
 The lack of proper control and proper legislation that has eventually resulted in an
uncontrolled increase in the health care costs.
25
There has never been good insight into the costs due to the lack of a uniform registration
system. Information about the development of health care is very limited. It is important to
consider and explore how the current structure of health care in Curaçao works and based on
this it needs to be determined how much each of the participating health care sectors costs.
Insight into the structure of a health care system is of high importance for developing sound
health care policies (Epidemiology Unit, GGD, personal communications, October 2012).
2.2 Structure of the health care system in Curaçao
The health care structure is based on two approaches (Knappen & Boas, 2005), namely:
 Place of care: Inpatient- (intramural), outpatient- (extramural) and semi mural care.
 Echeloning
The first approach is based on the place where the care is provided (Knappen & Boas, 2005).
 Inpatient (intramural) care is provided at or from an institution where the main
objective is to take into care and nursing the patient, i.e. A hospital.
 Outpatient- (extramural) care, i.e. Non-hospital care, in this case the patient is not
hospitalized. Such patients can live independently but may have reasons to get some
form of care i.e. GP treatment at home or district nursing.
 Semi mural care is characterized more as an intermediate facility. In this form of care
patients are admitted into a facility under the supervision of the institution. These
patients are not treated at the institution. Examples in Curaçao are: Ricardo's House and
Fundashon Sonrisa.
The second approach is based on the echeloning method. The term "echelon" is often used in
connection with health care. According to Van Hemel (2007) echeloning refers to the health
services in a number of care types, ‘lines’ or echelons. The purpose of this cascading format is to
create a system that is more efficient for patients when using the complex health care system.
This echeloning model consists of four care types, namely:
 Zero line care: this care includes everything a patient does himself (or uses caregiving),
i.e. self-care by own family, neighbors or by private organizations, such as the elderly
care.
 Primary care: health care that is provided by a medical professional in the first contact of
a patient with the health care system.
26
This care is usually easily accessible and affordable for everyone. Examples are the GP
care, paramedical care, obstetric care, district nursing, ambulance, etc.
 Second line care: general health services available in hospitals and is concerned with
specialized medical care. This includes both clinical and outpatient care. Also treating
patients in a nursing home and mentally disabled patients in a special institution are
covered by the secondary care. An example is ‘the Mgr. Verriet Institute’.
 Tertiary care: includes high specialist centers such as academic hospitals or clinics
where special care is being provided, such as transplantation or burn treatments, etc.
After analyzing the above two methods it can be concluded that these roughly correspond to
each other. It can also be concluded that outpatient care corresponds to the zero and first line
care.
2.3 Health care costs in Curaçao
Globally, the annual health care expenditures rise by approximately 5% to 6%. In 1970 the
average health expenditures in OECD countries were 5% of the GDP. In 2010, the same health
care expenditures increased to an average of 10% of GDP (OECD, 2012). This increase was
mainly caused by advances in the medical technology field, by an aging population and the
increase in chronic diseases and multiple chronic diseases. It is expected that global health care
spending will continue to rise in the coming years. This means that politicians and policy
makers (governments) continuously need to understand and manage the anticipated changes in
the financial flows in health care (OECD, 2012).
Due to the ever rising health care costs, there is a need, also in Curaçao, to gain insight into
health care expenditures and its financing. Throughout the years several reports were produced
to provide insight. One of the first was the ‘Quick scan health care expenditures’ of Boas (2003).
Based on the recommendations of this report the Financial Healthcare Statements (‘Financieel
Overzichten Gezondheidszorg, FOG’) were produced until 2007. As a result of unfinished
discussions between the participating actors, the production of the Financial Healthcare
Statements was ceased in 2007. At the end of 2008 it was decided to opt for a classification
system with well-defined categories that are relevant for Curaçao and which may serve as a
basis for providing insight into the health care expenditures. This eventually led to starting the
project ‘Health Accounts Curaçao’, with the aim of producing an overview of the health care
expenditures (according to the classification) over the years 2000 – 2004 and based on 2004 to
make projections for 2008 and 2012. After the dismantling of the Netherlands Antilles on
October 10, 2010, based on an updated Terms of Reference decisions were made by the Council
of Ministers on how to continue with the execution and settlement of the project Health
27
Accounts Curaçao. In November 2011 this project made a new start. Health Accounts Curaçao
2008 – 2011 (‘Zorgrekeningen Curacao 2008 – 2011) was published in December 2012.
(Westerhof, R., personal communications, March 2013)
Health Accounts Curaçao 2008 – 2011 was produced based on the System of National Accounts
(SNA) model of care accounts of the Central Bureau of Statistics of the Netherlands. This system
is an internationally agreed upon set of recommendations on how data is collected from
economic activities and how these should be classified. SNA 2008 is the latest set of guidelines
on collection and classification of economic activities (European Commission, 2009). SNA 2008
distinguishes among other government functions in COFOG (Classification of the Functions of
Government) terms. ‘Zorgrekeningen Curaçao’ (see Table 1) is based on the three core
questions within the Systems of Health Accounts (SHA) which are further developed in the
International Classification for Health Accounts (ICHA). ‘Zorgrekeningen Curaçao’ is developed
based on the international classifications of ICHA and contains the following information:
 Who delivers the products and services according to the Classification of the Functions
of Government (COFOG), SHA and ICHA-Health care providers;
 What these products and services cost according to and confirmed between insurers,
government and health care agreements;
 How these are financed according to ICHA-Health Care Financing.
To prevent any misunderstanding, note that ‘Zorgrekeningen Curaçao 2008 – 2011’ gives
insight only into the costs and financing of health care and therefore says nothing about the
quality and accessibility of care in Curaçao (Westerhof, R., personal communications, March
2013).
28
Tabel 1: Total care expenditure of Curaçao from 2008 – 2011
Source: ‘Zorgrekeningen Curaçao 2008 – 2011’
The figures of ‘Zorgrekeningen Curaçao 2008-2011’ show e.g. that the health care costs
increased in the period of 2008-2011 by an average of 6% per year. The welfare costs increased
by an average of 1%.
29
Specialists practices
2008
District nursing and home
care
2011
Suppliers of drugs/medicines
Hospitals
ANG 0
ANG 50,000,000
ANG 100,000,000
ANG 150,000,000
ANG 200,000,000
Figure 3. Top 4 expenditures
Source: ‘Zorgrekeningen Curaçao 2008-2011’
Within the health care sector in Curaçao in 2011 the top four expenditures were formed by
hospitals (24%), suppliers of drugs (19%), providers (district) nursing and home care (10%)
and specialist practices (9%).
Policy and management costs
These policy and management costs are all expenses related to the direct care expenditures i.e.
overhead costs which include all personnel and material expenses related to care activities by
Government institutions, Social insurance (SVB, BZV) and the excess carriers
(‘eigenrisicodragers), private insurers (such as Ennia and Fatum), non-governmental
organizations. In principle, these costs can be seen as structural costs. However, incidental costs
are also made. In 2011, policy and management costs as a percentage of health expenditure are
the highest, government (35.3%) and private insurers (28.3%). Policy and management costs
increased by 22% from 2010 to 2011. The increase of 22% is incidental costs as these were
costs that were made by USONA and the Government in preparation of the project ‘Nos Hospital
Nobo’ (Westerhof, R., personal communications, February 2013). The NHN project started in
the first quarter of 2011. Millions were spent in preparations of the NHN project. Most of these
expenditures were on consultancy costs (research, preparation of the ‘Programma van Eisen’
and call for tenders by USONA). An estimated amount of ANG 13.5 MLN has been spent up to
now in the NHN project (Ministry of Finance, 2013). The NHN project is discussed further in
section 2.6. Furthermore, consultants were also hired for research purposes and writing plans
for several other projects related to health care, which is discussed further in section 2.5.
(Westerhof, R., personal communications, February 2013).
30
Pharmaceuticals (Medicines):
Drug spending hardly increased from 2008 to 2009, because of the introduction of a 10%
personal contribution to one of the public funds. In 2009, this measure was reversed which
increased the number of beneficiaries in 2010 which caused an increase of 5% from 2009 to
2010. Drug spending in Curaçao is indeed very high when compared to other countries (further
explained in section 4.5).
Financing of Health Care Expenditure in Curaçao:
In 2011, 60% of health expenditures were financed by the government, 26% were financed
from premium incomes, and 11% were financed by private health insurance, co-payments and
out of pocket payments. The remaining 3% were financed from other resources. In 2008 these
were 54%, 26%, 13% and 7% respectively.
7%
6%
4% 3%
60%
Government
Public Health Insurance
20%
AVBZ
Private Health Insurance
Out of Pocket payments
Other
Figure 4. The resources of financing of health expenditure in Curaçao in 2011
Source: ‘Zorgrekeningen Curaçao 2008-2011’
Government
The government funding in 2011 was ANG 533 MLN. This is 60% of the total funding in 2011.
Compared to 2008, the public funding increased by ANG 94 MLN. This is an increase of 22%, an
average of 7% per year. In addition to the budgeted amounts for the financing of health care, the
government also covers any shortfalls in the public funds. In 2011 this was an amount of ANG
77 MLN. If these deficits are not settled by the government with its funds, claims will rise
against the government. According to the balances of the funds, there are substantial amounts
due to be paid by the government. These claims also explain the payment arrears of the care
providers.
31
The Public Health Insurance
Besides the government as financier, the public sector lender has two other financiers, the so
called social insurance i.e. the Public Health Insurance and AVBZ (‘Algemene Voorzieningen
Bijzondere Ziektekosten’).
In 2011, the funding from the public health insurance was ANG 180 MLN (20% of the total
funding in 2011). Compared to 2008, the premium income from the public health insurance
increased by 23%, nearly 8% per year. The deficits in the public funds are partly financed by the
government and partly by the ‘schommelfonds OV’. In the period of 2008 to 2011, the deficit
totaled ANG 77 MLN.
AVBZ (‘Algemene Voorzieningen Bijzondere Ziektekosten’)
In 2011, the financing from AVBZ was ANG 56 MLN (6% of total funding in 2011). Within the
AVBZ fund, in the period of 2008 to 2011 there was unnecessary funding of ANG 40.1 MLN by
the government.
Private Health Insurance
In 2011, the financial contribution from the private insurers was ANG 59 MLN (7% of the total
funding in 2011).
Out of pocket payments
In 2011, funding from the private payments (co-payments and out of pocket) was an amount of
ANG 39 MLN (4% of total funding in 2011). Revenues from private payments in 2011 increased
with 15% compared to 2008. The increase is due to higher out-of-pocket payments.
Other resources
More than 80% of the other resources of financing consists of funds from the ‘schommelfonds
Ongevallen Verzekering (OV)’ and resources of non-governmental organizations. In 2011, the
funding from other sources was ANG 38 MLN (3% of the total funding in 2011). It is expected
that this funding will decline significantly in 2013 due to the depletion of the ‘schommelfonds
OV)’ and the diminishing resources of the non-governmental organizations.
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2.4 Causes of rising health care expenditures in Curacao
Cost drivers in health care:
Cost
drivers
Patient
Cost
drivers
GP’s
Cultural
factors
Specialists
Hospital
Medication &
Lab tests
Figure 5. Cost drivers in health care
Source: ‘Zorg voor de kosten’, 2007
2.4.1 Cultural factors
An important cultural factor that generates a lot of care consumption is the tendency of many
locals (‘yu di korsows’) to go to the doctor for every little complaint, even when self-medication
would be sufficient. Most locals go to the doctor just to claim drugs (‘a pill for every ill’) and
often want a referral to a specialist (‘the specialist knows better’). Only when the GP complies
with these expectations (getting medication and a referral) is he or she a ‘good doctor’. Many
GP’s fulfill the patients requests (especially when the waiting room is crowded and they want to
get rid of nagging patients and also out of fear that if patients do not get their requests fulfilled
they will go to another GP, which means a loss of revenue). Hence the phrase often used is ‘On
Curaçao, the quality of the doctor is inversely related to its popularity’. This problem is caused
by both the doctors themselves who in such cases are not showing their professionalism
sufficiently as well as by the patient. A better awareness among the population about what they
can do themselves in case of minor complaints and when a medical examination is required, is
missing (Vugt van, 2007).
2.4.2 Primary care level
An average of ANG 27 MLN is spent yearly on general practitioners only (‘Zorgrekeningen
Curaçao 2008-2011’). A study of the cost structure of GP and specialist care (including costs
generated by them) in Curacao was done. Drug prescribing behavior and referral to secondary
care was evaluated (Vugt van, 2007).
33
Some remarkable figures from this study regarding drug prescribing practices by GP’s in
Curaçao revealed the following:
 A GP (working for BZV-insured) generated in 2006 an amount of nearly ANG 1.5 MLN in
medication costs (over 1,500 patients); the same GP prescribed the majority, i.e. more
than 35,800 prescription items per year;
 The most drug costs at SVB in 2004 were generated by a GP who nearly prescribed ANG
900,000 (for 1,900 patients). In 2005 this amount had decreased to ANG 739,000;
 A GP with more than 500 PP-patients prescribed in 2006 more than ANG 2,000 for drugs
per patient (Average amount set for PP is ANG 835 compared to SVB where the average
amount per patient is set to ANG 214);
 A GP prescribed in 2006 more than 21,100 prescriptions for about 540 PP-patients,
meaning the highest average of 39.4 prescriptions per average patient, including the
ones that do not go to the doctor!
These are amazingly high numbers and amounts that require in taking firm actions towards the
GP’s who prescribe too many medications.
Referrals by GP’s to specialists:
When referrals by the GP’s to secondary care were evaluated, the same study (Vugt van, 2007),
revealed the following: from the total (estimated) 64.848 SVB insured, 41.232 of these were
referred to specialists and 10.017 referrals to paramedics (psychologist, physiotherapist, etc.).
The number of referrals to specialists is about 63.6% of the total number (SVB) insured (and
references to paramedics were 15.4%).
Inquiries were made during the study and one explanation for the many referrals was that
about 90% of GP’s established in Curaçao do not have a specialized GP degree, but only a basic
medical degree (there is no specialization for GP). These non-specialized doctors are considered
to have insufficient skills and knowledge to function as the gatekeeper at a primary care level.
However, no hard figures were gathered. Another explanation was that it could be the result of
the 'automatic' behavior of GP’s who refer patients easily to secondary care level, especially if
there is no financial incentive for the GP to 'hold on' to the patient and treat these patients
themselves (Vugt van, 2007).
When the coherence between prescribing behavior and referral behavior of the GP’s was
analyzed during the same study (Vugt van, 2007) the following was revealed: GPs who prescribe
(often more expensive) medications also refer relatively more. Of the top 10 highest
prescribers, seven were above the average of 63.3%; on average these 10 GP’s scored 74% of
the referrals. Of the 10 lowest prescribers nine were under 63.3%; these GPs scored an average
34
51% of the referrals. The conclusion is that the 'expensive' prescribers were also relatively 'fast'
referrers. In other words there are GP’s who are twice as expensive for the insurers.
2.4.3 Secondary care level
Based on the numbers of (‘Zorgrekeningen Curaçao 2008-2011’) an average of ANG 62 MLN is
spent yearly on specialists only. It is not only that the costs that are associated with the work of
the specialists which are relatively high but they also generate millions in costs for medicines
and in the tertiary care level (hospitals and clinics). It should be noted that the specialists are
paid per consultation. There is no (financial) incentive to restrict access to those who are
medically unnecessary. The volume of medical services by specialists, as is the case with the
GP’s, is relatively high and more attention should be paid at inefficient behavior i.e. ineffective
prescriptions for medications and inefficient applications for laboratory tests. Secondary care
providers do not perform based on protocols, which is not in the interest of the quality of care,
nor is effective care provided (Vugt van, 2007).
2.4.4 Cost of pharmaceuticals
The costs are obviously determined not only by the number of prescriptions, but also by their
price. It matters a lot whether the expensive brand drugs are prescribed, or the (much) cheaper
generics. An average amount of ANG 140 MLN is spent yearly on pharmaceuticals
(‘Zorgrekeningen Curaçao 2008-2011’).
There are two reasons for high drug costs:
 the high volume of use of medication (as discussed in 2.4.2 and 2.4.3)
 the costs of medications, from production to delivery
The pharmaceutical sector on Curaçao looks as follows:
37%
Manufacturer
Importer
50%
Pharmacy
Patient
Figure 6. Overview of the pharmaceutical sector on Curaçao
Source: ‘Zorg voor de kosten’, 2007
35
Currently, the importer is the only supplier of a certain brand drug (‘spécialités’): the importer
is obliged to buy from the manufacturer because legally an original factory invoice is required.
As a result, it is almost impossible, to make parallel imports as in Europe. Because of the
monopoly, the manufacturer supplies expensive drugs to the importer, who then also delivers
expensive drugs to the pharmacy (the pharmacy also does not have a choice in purchasing). The
comments from the Inspectorate of Public Health are nuanced: ‘the manufacturer is able to sell
expensive because he delivers to a country where regulation of the pharmaceutical market
barely exists’ (Fontilus, P. and Vos, G., 2002).
Prices are regulated in Curacao and maximum margins are allowed. For the importer margins
are set to a maximum of 37% of its total cost (of packaged pharmaceuticals), while the
pharmacy may use a maximum margin of up to 50%. In practice importers and pharmacy
margins use the average margin between 34% and 39% respectively (Fontilus, P., 2005).
Based on the total costs of drugs in Curacao, the allocation of these costs according to Fontilus
(2005) is as follows:
 Manufacturers/exporters: 45%
 Pharmacy: 26%
 Importer: 17%
 Sales tax: 8%
 Duties: 3%
 Other: 2%
Thus, in addition to the profit that the manufacturer makes on the product (percentage
unknown) a large proportion of the selling price (approximately 43%) is composed only of costs
for brokering. It is the profit margin of the manufacturer and the other margins that makes
drugs so expensive. Reducing these margins would substantially contribute to reducing the high
cost of drugs in Curaçao.
2.4.5 Various other factors leading to high health care costs
Overcapacity on the supply side
On several occasions calculations were made on the number of required medical professionals.
The last calculation dates from 2005 according to the report ‘Santu Remedi’ (WeWIG, 2006).
Eleven specializations show overcapacity in comparison to the necessary capacity. There are far
too many GP’s (about one third too many, equaling 37 GP’s) and too many dentists (a quarter).
Among the paramedics, two-thirds of the numbers of physiotherapists are unnecessary (90
36
present, about 27 required). Such overcapacity in the medical sector leads to higher medical
costs. Indeed, several professionals want to make a living with a relatively limited number of
patients and the only way to do that is to provide more care than necessary. As discussed earlier
in section 2.4.3 there are too many medical specialists; there also too many paramedics.
Normally, the price of the product would decline with overcapacity but because there is no real
market mechanism present in the health sector (particularly the secondary care), and because
the prices are fixed, overcapacity does not lead to lower prices of medical procedures but to a
volume increase at constant prices, thus leading to increased costs (Vugt van, 2007). The best
way to achieve cost control is to limit the number of all medical practitioners (GP’s, specialists
and paramedics).
This has been done once in the past in Curaçao, by means of the ‘Moratoriumwet’ (1997).
However, it is unclear, but certainly incomprehensible why limiting the number of physicians in
sectors where there is a surplus (almost everywhere) was not continued. Given the need to
reduce and gain cost control in health care, such a measure is unavoidable.
Inefficiencies in the health care system leading to increasing health care costs
The following information was gathered during interviews (see annex 1) with experts in the
field, observations and available papers in which the health care system of Curaçao was
evaluated:
The organization of health care, i.e. the structure in Curaçao is not very well integrated,
meaning, among other things, that there is not enough cooperation between the different
players in the health care field. There is a variety of legislation in place to organize the health
sector, making the structure complicated and less transparent. The information is not linked to
any central system, which makes it very difficult to have any control or to make sound decisions.
At the same time, the lack of adequate and up-to-date data (for example: economic health data,
usage data or more care-related data) and accessible registration procedures hamper a
thorough analysis of the health system. Another organizational-structure problem is the
fragmentation of the health care institutions and the fact that most specialists have no close
links to the hospital, because they also have their own practice, the so-called ’ofisinas’
(Epidemiology Unit, GGD, & Manager Cure, SVB, personal communications, January 2013).
There is a structural deficit in financing health care costs, partly because the premium income is
not enough to cover all costs. One of the problems involved is the insurance package for the
unemployed (PP patients), which covers a wide range of care without any limit, while the
37
insured do not have to pay a premium which is fully subsidized (Economic Outlook Curaçao,
2011).
Generally, health care consumers (patients) all over the world are not aware of the costs
involved and do not have many incentives to lower their consumption, because most patients
have medical insurance. As mentioned previously, there is also a lack of adequate and up-todate economic health data, which makes it difficult to analyze and monitor the factors (diseases)
leading to high costs (Economic Outlook Curaçao, 2011).
2.5 Current developments in the health care sector
Coverage measures and current projects:
Partly at the request of the Board of Financial Supervision (‘College Toezicht’), a number of
coverage measures were determined in 2009 which should have led to a balanced public health
care budget in the future. In the last couple of years, the government has been paying more
attention to the health sector and many plans and policy papers have been written (which
explain the high policy and management costs in section 2.3, table 1). The most important
measures to be taken were on the cost of medications, the restructuring of cure and the
Integrated Medical Specialists Company (Economic Outlook Curaçao, 2011).
Merger of SVB and BZV:
Restructuring of cure took place when SVB (Social Insurance Bank) and BZV (Health Cost
Bureau) got merged. The merger of BZV and SVB was supposed to result in economies of scale
and cost reductions through better efficiency and coherency in tariffs, however, in practice the
merger did not result in any savings (Manager Cure, SVB, March 2013). An evaluation process of
the cost effectiveness of the recent merger of BZV and SVB is necessary to evaluate whether the
cost saving goals have been reached and at the same time pursue any additional savings in this
matter.
Cost/tariff model for medical practitioners:
At the government‘s request, the consultancy company ‘Tragpi’ developed new, transparent and
fair cost/tariff models for medical practitioners. The plan was completed in May 2010 and
presented to the Island Council of Curaçao to be decided on. The intention was to introduce the
new tariffs by January of 2011. A good cost model allocates costs to the right patient and clearly
shows the links between costs, resources, procedures and patient groups, making it easy to
analyze relevant costs. Cost models are also a tool that support investment decisions and allow
the forecast of the effects of certain changes (Economic Outlook Curaçao, 2011). The cost/tariff
model was implemented for the general practitioners only. The decision on the implementation
38
of this cost model for the remaining group of medical practitioners (specialists and paramedics)
has been put on hold. There was no information available on when this cost model might be
implemented for the remaining medical practitioners (Manager Cure, SVB, March 2013).
Reducing pharmaceutical costs
As for reducing the cost of medications, the government has taken three steps to reduce
pharmaceutical costs: 1) Setting a maximum price for drugs. This measure was implemented on
September 1st 2012. 2) Limiting the volume increase of drugs by introducing a dispensing fee
(‘receptregelvergoeding’). This measure was implemented on February 1st 2013. 3) Stimulate
the import and use of generic drugs. The import of generic drugs has increased and there are
two companies specifically for importing only generic drugs. The targeted savings on costs of
drugs by these three measures is set to ANG 50 MLN by 2015 (Westerhof, R., personal
communications, March 2013). Measures on reducing pharmaceutical costs were implemented
together with the coverage measures, which entails the introduction of a basic health care
package (further explained in section 2.6). The financial effects of these measurements are
shown in table 2, section 2.6.2.
Introduction of the Integrated Medical Specialists Company (GMSB)
The GMSB model forms the basic principle behind the new hospital. GMSB ensures that
secondary – and tertiary care provided by medical specialists are integrated and that the
current structure of various private clinics, the so-called “ofisinas”, will disappear. Apart from a
reduction in costs, GMSB will encourage teamwork between the medical providers, which is
expected to result in better quality of care. The GMSB concept started by renovating the current
clinic at the St. Elisabeth Hospital (SEHOS) and also building a new clinic (Economic outlook
Curaçao, 2011). The renovation of the current policlinic, with facilities to accommodate 20
specialists, is ready (Manager Cure, SVB, March 2013).
2.6 Construction of the new hospital (‘Nos Hospital Nobo, NHN)
Status of the NHN project
The NHN assignment to USONA was ‘realization of a new operational and sustainable hospital
for Curaçao’. A Quality and Performance Board (QPB) consisting of four management groups
(Ministry of General Affairs, Ministry of Finance, Ministry of Health, Environment and Nature,
Ministry of Transport, Traffic, and regional planning) is the client (‘Land Curaçao’). The NHN
project is delegated and directed by this group. USONA executes the NHN project with a team of
20 experts and in close cooperation with the QPB (USONA, 2013).
39
The NHN project is not only about the physical building. The NHN project consists of dozens of
sub-projects that are related to care, finance and technology, which play a major role in the
improvement of the entire health system of Curaçao. The NHN project focuses on improving and
providing quality and affordable care in the most efficient manner. The hospital is part of this
project. The new hospital is intended to become a modern hospital based on international best
practices. A hospital where patient centered care is provided, where nurses, specialists and
other employees work together and where quality care and safety is guaranteed by means of
protocols and use of quality assurance systems (USONA, 2013).
USONA executes the NHN project commissioned by the Government according to an agreement
concluded between Curaçao and SONA. This agreement was signed on August 10, 2011. In early
2012 the Government designated the ‘Amstel terrein’ as the construction site and location for
the new hospital. As per August 2012 USONA was ready to start with the construction of NHN.
However, due to the note (‘aanwijzing’) of the Board of Financial Supervision (‘College
Toezicht’) there were no funds to build the new hospital. In consultation with the Government,
USONA came with a temporary solution and a contract was signed with the company ‘Ballast’ on
January 4, 2013. However, later in January 2013, the Government (Prime Minister D. Hodge)
requested SONA a re-evaluation of the project NHN by the Government. SONA was requested
not to proceed and as a result, SONA had to suspend the construction of the new hospital. To
this date, the status of the project NHN is unchanged (USONA, 2013).
Figure 7. Status NHN project
Source: USONA, 2013
Financing of the NHN project
On January 4, 2013, with consent of the Government, SONA and Ballast Nedam Infra BV signed
the contract for the construction of NHN. This contract states that the hospital will be built for
USD 108 MLN (maximum price) and that the field work will be a total of USD 3.2 MLN. Thus, the
total amount for the hospital construction is ANG 200.160.000,-. The same contract also
includes the maintenance for the first 15 years. The total amount of ANG 200.160.000,- includes
the field work (‘bouwrijp maken en terreinwerkzaamheden’), the construction of the building,
connection to utilities, sales taxes (‘OB’), import duties and the permanent establishment (‘vaste
inrichting’). This contract does not include the following: cost of land, medical equipment, ICT
40
and inventory. Medical equipment, ICT and inventory will be procured at a later stage (USONA,
2013). It should be noted that only the construction of the building will cost ANG 200.160.000,-.
All other costs related to the new hospital (i.e. financing for land, medical equipment, ICT and
inventory) and reforms (research & policy development, training of SEHOS staff etc.) are all
additional costs. This means that the financing (loan) would be allot more than ANG
200.160.000,-. The additional financing have to be taken into account when drafting the total
budget for all costs involved with the construction of the new hospital and having the new
hospital operational. An assessment of the business case by USONA is necessary to review what
exactly the costs are for having a new hospital build and operational. Review of the business
case upon request was not available by USONA.
Figure 8 provides an overview of the financing options which have been proposed by USONA to
the Government.
Figure 8. Financing options for the NHN project
Source: USONA, 2013
According to USONA, a bond loan is preferred because this is the cheapest option. In case the
official designation letter (‘Aanwijzing’) is not removed in a timely manner, preparations have
been made for private financing. According to USONA, private financing on short- or medium
term is possible because:
41
 The NHN project is financially viable; the business case is sound and has been tested by
SOAB (Government Accountant Bureau office Curacao). Also the current prevailing
interest rates are within the business case;
 There are financiers interested in the local market;
 The Government has indicated in a letter to meet the additional conditions that
financiers ask, which are:
- Closure SEHOS when NHN is operational. All staff will be trained and taken over
in NHN.
- Remediation SEHOS debts.
- Indexation of hospital rates.
- No new licenses for secondary care institutions.
- Financiers have influence on the board of NHN.
Consequences if the Government stops with the construction of NHN
There are consequences in cost, time and quality (USONA, 2013).
 Impact on cost: tens of millions dollars of loss of the costs that have been incurred the
past two years in the preparation (research, design, procurement) of the project NHN
(see policy & management costs in section 2.3). SONA is entitled to receive all costs
incurred according to the contract. However, it is still not clear what the consequences
will be in case of breach of contract with the contractor. Postponement of the
investment in the construction of NHN also means the absence of a significant economic
boost for the country, with a substantial impact on the growth rates for 2013 and 2014.
The Ministry of Finance estimates the consequences will to amount several tens of
millions of dollars (USONA, 2013).
 Consequences in Time: at least two years of delay if the government stops now. However,
the need for a new hospital would still remain. Furthermore, another Program of
Requirements (research, design, procurement etc.) would need to be established and
then be re-tendered. All of this would also mean additional costs and time (USONA,
2013).
 Consequences in quality: improvement in quality of care will be delayed by at least two
years and care would have to be provided by the outdated SEHOS with all the risks
involved. The quality of care and the incentive boost for other necessary reforms in the
healthcare system also remain off the table if the construction of NHN is delayed
(USONA, 2013).
42
To conclude
The NHN project initiated by USONA does not only concern the construction of a new hospital
but also concerns sub projects related to the entire health care sector: medical aspects,
financial- and economic aspects, legal and administrative aspects are taken into account when
designing and building the new hospital. The construction expenses of the hospital is set to
ANG 200.160.000,-. However, all other costs related to the construction of the hospital (i.e.
financing for land, medical equipment, ICT and inventory) and reforms (research & policy
development, training of SEHOS staff etc.) are not included, all of these are additional costs. This
means that the financing (loan) would have to be greater than ANG 200.160.000,-. These
additional costs have to be taken into account when drafting the total budget for all costs
involved with the construction of the new hospital and having the new hospital operational. An
assessment of the business case by USONA is necessary to review what exactly the costs are for
having the hospital build and operational. Review of the business case upon request was not
available by USONA.
The issue right now is that the health care costs are extremely high resulting in large budget
deficits for the government. As described in section 2.4 the major cost drivers are on the
primary care level and the secondary care level, mainly due to absence of health care policies
and lack of proper control and management on the policies that do exists. Meaning, even if
Curaçao gets a new hospital (at any cost) and the policies remain unchanged or absent, Curaçao
will still be dealing with rising health care costs. Right now, the priority of the government
should be at fixing the structural problems within the entire health care sector. Parallel with
this, the government should assess the NHN project (current business case) and proceed with
the process of building a new hospital since this is a necessity to improve quality of care. Since
millions have been spent already in the NHN project, to prevent claims and additional research
costs related to a new hospital, it is recommended to review the business case which was
carried out by USONA and adjust this business case where necessary with the proper priority
setting within the NHN project.
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2.7 Introduction of the Basic Health Care Package
A calculation by the ‘SVB’ reveals that, if policies remain unchanged, in the coming years large
deficits will develop within the collective National Health Services. Intervention is therefore
inevitable. The introduction of a basic health insurance, including increased contributions, is
one of the most crucial measures to manage the risk of un-payable health care in the future
(Economic Outlook Curaçao, 2011). In 2011, the government budgeted an amount of ANG 312.4
MLN for health care, compared to ANG 297.6 MLN in 2010.
The difference in the total amounts budgeted for 2010 and 2011 is mainly the increase of ANG
11.8 MLN in the contribution to the fund for health care costs of retired civil servants (FZOG).
Almost half of the total health care budget (ANG 146.3 MLN) is allotted to the Health Cost
Bureau (BZV) for the contribution for Pro- Pauper (PP) patients. According to the Ministry of
Finance, health care is one of the largest budgetary risks because of its share in the total public
budget and external overpowering factors such as an ageing population, the increase of the
frequency of chronic disorders, the high costs of technology, a rising price index and the rise in
the costs of the different health care institutions (Economic Outlook Curaçao, 2011).
The introduction of a basic health care package has been a long ongoing process. The current
government had to take immediate measures on cutting costs in order to manage the total
government budget. On February 5th 2013 the ‘Basis Verzekering Ziektekosten’ was introduced.
2.7.1 Insurance and Coverage overview before BVZ
Several health-insurance systems exist in Curaçao. The Social Insurance Bank (SVB) sponsored
by the Government of the Netherlands Antilles which has a branch on each of the five islands
and its main office on Curaçao. SVB provides health-insurance coverage for employees of
nongovernmental organizations and the private sector. The costs of health-insurance benefits
are covered through the premium system. The premium system implies that the employer, the
government and the employee each contribute to covering the health costs. The government
covers the premium for the PP-patients (further explained below) (Economic Outlook Curaçao,
2011).
The health insurance premium is 12.5 %, of which the employer contributes 8.3 %, the
employee 2.1 % and the government 2.1 %. Pro-Pauperi (PP) Insurance is health-insurance
coverage provided by the Government of Curaçao for the unemployed and the population up to
a stipulated maximum income. Civil Servant Health Insurance is provided by the island
territorial governments. Both PP-insurance and civil-servant health insurance are provided by
the Health Cost Bureau (BZV). On the other hand, private health insurance is mandatory for
44
people earning an annual income which exceeds a stipulated maximum income (ANG. 57.174
per year). SVB and BZV together comprise approximately 84 % of the health care sector of
Curaçao, the remaining 16% is covered by out of pocket payments (Economic Outlook Curaçao,
2011).
2.7.2 ‘Basis Verzekering Ziektekosten’ and its effects
The law, ‘Basis Verzekering Ziektekosten’ of February 5th, 2013 implies the following:
BVZ (‘Basis Verzekering Ziektekosten’)
The basic health care insurance package consists of necessary care. The BVZ covers medical
care, paramedical care, obstetric care, medicines, hospital (3rd class) and dental care up to 18
years. BVZ does not cover dental care for 18 years or older, glasses or contact lenses, physical
therapy and cosmetic treatments.
The premium has been set at 12% of which 9% is paid by the employer and 3% is paid by the
employee. The income limit for employees has been set at ANG 100.001 per year. The premium
for pensioners has been set to 10% and the income limit at ANG 100.001 per year.
The nominal premium has been set at ANG 82. Children under 18 years and people earning less
than ANG 12.000 per year are exempt.
Most important remarks regarding BVZ:
 Insured must enroll at one pharmacy;
 Insured may change his/her doctor once per year;
 Insured may change from his/her pharmacy once per year (except emergencies);
 Insured must pay ANG 1,- per prescription item.
For whom does BVZ apply
BVZ applies to residents (employees belonging to the premium income limit and people with an
income lower than ANG 12.000,-) and non-residents with a contract and working permit.
Excluded are: government officials (temporary), the privately insured and out of pocket payers.
Financing BVZ
Out of the funds of BVZ the following expenses will be paid:
-
The health care costs
-
Policy and management costs
BVZ will be managed by SVB. Monitoring and supervision on the funds of BVZ will be executed
by ‘Curaçaose Zorgauthoriteit (CZA)’ and ‘Inspectie voor de Volksgezondheid (IVG)’.
45
The income of the BVZ fund consists of:
 The nominal premium
 The income-based premium
 Government contribution
 Other income
Financial effects of the BVZ
Table 2. Overview of government funding before and after BVZ implementation
Source: ‘Memorie van Toelichting Landsverordening Basis Verzekering Ziektekosten, January
16th, 2013’, & Westerhof, R., personal communications, March 2013)
46
According to the ‘MvT’ (Memorie van Toelichting Landsverordening Basis Verzekering
Ziektekosten, 2013), the law is based on the assumption that the economic growth will be zero
and inflation will be 2%. Health care costs will increase annually with 5%. Based on this
assumption the government will pay ANG 235 MLN in 2013, ANG 244 MLN in 2014 and
ANG 251 MLN in 2015. Table 2 illustrates the forecast scenario of BVZ according to the ‘MvT’ of
January 16th, based on the law BVZ introduced on February 5th, 2013.
Total care costs will increase by 5% on an annual basis. Policy and management costs will be
gradually reduced by ANG 20 MLN by 2015. Merging BZV and SVB is one of the actions that
were taken to reduce policy and management costs (Westerhof, R., personal communications,
March 2013). However, this has not shown in practice (Manager Cure, SVB, personal
communications, March 2013).
Costs on medicines will be gradually reduced by ANG 40 MLN. This will be achieved by reducing
the import tax on medicines, reducing profit margins of importers, importing only generic drugs
and introducing a dispensing fee for medicine (Westerhof, R., personal communications, March
2013).
Costs reduction will also be a result when government entities and their systems are connected.
Fraud prevention, compliance and misuse of drug prescriptions will result in efficiency which
will result in costs savings. Fraud and compliance costs will be gradually reduced by ANG 10
MLN (Westerhof, R., personal communications, March 2013).
The introduction of BVZ will move the burden from the government to the citizens and
organizations. BVZ has less coverage (in comparison to different types of coverage’s for
different groups of the population) and thus has reduced costs. BVZ covers the necessary care as
per ‘trechter van dunning’. Strategies used to design BVZ do not conflict with the duty of care of
the government. The following was taken into account when designing BVZ: access to care, the
nature of care, the funding of care, the guarantee of continuity of care (‘Landsverordening Basis
Verzekering Ziektekosten’, 2013). By taking these measures, Curaçao is on its way to reducing
its health care costs. Despite of the numerous changes to this law, ‘the total care expenditures of
2013 are developing in accordance with the calculations done in the ‘Memorie van Toelichting’
(table 2). Cost reductions will be achieved and the implementation of BVZ is ‘in control’,
according to Westerhof (2013). However, due to major dissatisfaction among the population
and players in the health care field, up till today, changes and corrections are made to the BVZ
law which was introduced on February 5th 2013.
47
2.8 Conclusion of chapter
By means of interviews (see annex 1), observations and available papers the following sub
questions have been answered in this chapter:
 What is causing the rising health care costs in Curaçao?
 What strategies are currently implemented to control health care costs in Curaçao?
To conclude: Curaçao is suffering from its constantly increasing health expenditures resulting in
large budget deficits. Curaçao is currently in a financial crisis and an official designation letter
(‘Aanwijzing’) from the Federal Government (‘Rijksregering’) has been issued, indicating that
drastic cuts have to be made, especially on health care costs. Health care costs have drastically
risen over the years and put major pressure on the expenditures of the Government (as
discussed in section 2.3).
As discussed in section 2.4 the major cost drivers which cause the rising health care costs are on
the primary care level and the secondary care level. Furthermore, the cost of pharmaceuticals in
Curaçao is also much higher than in other countries (further discussed in chapter 3).
We have also discussed that the government has taken various measures to reduce its health
care costs (discussed in section 2.6 and 2.7). BVZ has proved to be a tool for the government to
reduce the burden on its total expenditures. Despite of the numerous changes to this law, ‘the
total care expenditures of 2013 are developing in accordance with the calculations done in the
‘Memorie van Toelichting’ (table 2). Cost reductions will be achieved and the implementation of
BVZ is ‘in control’, according to Westerhof (2013). However, due to major dissatisfaction among
the population and players in the health care field, up till today, changes and corrections are
made to the BVZ law which was introduced on February 5th 2013.
Construction of the new hospital has been a long ongoing process and takes an important role in
the necessary reforms within the entire health system of Curaçao. However, the issue right now
is that the health care costs are extremely high resulting in large budget deficits for the
government due to structural problems. As described in section 2.4 the major cost drivers are
on the primary care level and the secondary care level, mainly due to absence of health care
policies and lack of proper control and management on the policies that do exists. Meaning,
even if Curaçao gets a new hospital (at any cost) but if the policies remain unchanged or absent,
Curaçao will still be dealing with rising health care costs. Right now, the priority of the
government should be at fixing the structural problems within the entire health care sector. To
sustain Curaçao’s health care system, structural strategies to control and manage its health care
costs have to be assessed and implemented.
48
3. PILLARS OF A WELL-FUNCTIONING HEALTH CARE SYSTEM
When it comes to restructuring or reforming health care systems, knowledge of how a health
system functions and the pillars on which it is based should be studied. This chapter outlines the
pillars that form a well-functioning health system according to OECD (2010), WHO (2008) and a
research study performed by the World Bank (Jamison, D., et al., 2006).
These organizations have evaluated many health systems and their performances throughout
several studies worldwide and have developed international guidelines for restructuring.
During this literature review, the important factors of a well-functioning health system were
studied and are outlined in the following sections.
3.1 Health care systems in general
A health care system is more than a mix of services and medical sessions. It is a structure within
which people, organizations, and institutions work together to organize and allocate resources
for preventing and treating diseases and injuries. This structure has to rest on certain essential
pillars if it is going to work. A well-functioning health system responds in a balanced way to a
population’s necessities and expectations by:
 Improving the health status of individuals, families and the society
 Protecting the population against what threatens its health
 Defending people against the financial concerns of ill-health
 Providing universal access to people-centered care
 Making it possible for people to partake in decisions concerning their health and health
system.
Without strong guidelines and control management, health care systems do not suddenly
provide balanced answers to these challenges, nor do they make the most effective use of their
funds. As most health leaders know, health care systems are subject to powerful forces and
encouragement that often overrule rational policy making. Keeping health systems on course
requires a strong sense of direction, and rational investments in the various layers of the health
care system in order for it to provide the kind of services that produce results.
49
The pillars of a well-functioning health care system should comprise the following:
 Leadership and Governance
 Health Information Systems
 Health Financing
 Human Resources for health
 Crucial medical products and technologies
 Service delivery
Each pillar is further discussed in the following sections.
3.2 Leadership and governance
Each country’s particular environment and history is reflected in the way leadership and
governance is implemented, but common ingredients of good practice in leadership and
governance can be recognized. These include:
 Making sure that health authorities take responsibility for directing the entire health
sector and dealing with future challenges (including unexpected events or disasters) as
well as with current issues.
 Defining, through transparent and complete processes, national health policies,
strategies and plans that set a strong direction for the health sector, with:
 A preparation of the country’s obligation to high-level policy goals (health equity,
people-centeredness, comprehensive public health polices, effective and accountable
governance)
 A strategy for transforming their policy goals into its consequences for financing, human
resources, pharmaceuticals, technology, infrastructure and service delivery, with
appropriate guidelines, plans and targets.
 Mechanisms for liability and adaptation to growing needs.
 Active regulation through a combination of well-defined guidelines, obligations, and
incentives, backed up by legal measures and enforcement mechanisms;
 Effective policy discussion with other sectors and stakeholders.
 Mechanisms and formal measures to channel donor sponsorship and align it to country
priorities.
50
3.3 Health Information Systems
Decent governance is only possible with proper information on health problems, on the wider
environment in which the health system functions, and on the performance of the health
system. This specifically includes well-timed intelligence on:
 Evolution in meeting health challenges and social goals (particularly equity), including
but not limited to household surveys, civil registration systems and epidemiological
surveillance.
 Health financing, including through national health accounts and an analysis of financial
calamities and of financial and other obstacles to health services for the poor.
 Trends and needs for Human Resource for Health (HRH); on consumption of and access
to medications; on appropriateness and cost of technology; on distribution and
capability of infrastructure.
 Access to care and the quality of services delivered.
This, in turn, requires a variety of institutional mechanisms:
 A national surveillance and evaluation plan that specifies core indicators (with targets),
data collection and management, analyses and communication and use.
 Measures to make data accessible to all stakeholders involved, including communities,
civil society, health providers and politicians.
The significance of gathering, processing, and using data to improve health care cannot be
stressed enough. Health sector decision makers—whether care providers in small clinics,
managers of hospitals, directors within the drug chain, local political officeholders, or ministers
of health—ask a number of questions that must serve as the starting point for any discussion of
information. For example, are we reaching 95% of children under five with the recommended
vaccines? What are likely to be the main causes of death in the next 10 to 15 years? What social
behaviors are contributing the most to the spread of certain diseases? Where is the government
health expenditure going? What measures are effective against a certain disease? Are more costeffective methods available? The information for answering these types of questions generally
comes from the following six main sources:
Vital Events Registration provides data on births and deaths, as well as on marriages,
divorces, and migrations.
51
Health service statistics include information on consultations by patients, services and
diagnoses provided by medical practitioners. Health service statistics are essential to managing
public health services, recognizing health trends, and distributing resources efficiently.
Public health monitoring comprises a wide range of efforts to track and respond to disease
trends.
Census data that are correct and gathered regularly provide the basis for calculating important
ratios and designing consistent samples.
Household surveys are an actual way to get information about population demographics,
social characteristics, and dynamics on a steady basis between censuses. They can also be
extended to gather essential information about behaviors or certain health conditions.
Resource tracking includes measuring and supervising human resources, facilities, supplies,
and finances.
Health information is valuable and crucial in improving the efficiency of health services and the
cost-effectiveness of the health system. Health information systems are useful to decision
makers if they are to influence clinical choices, health system management, and public policy.
Furthermore, health systems are an important object of research. Identifying formal measures
that are more efficient at directing resources into effective health interventions can reduce
waste and improve health.
3.4 Health financing
Health financing can be a key policy tool to improve health and reduce health inequalities if its
primary goal is to facilitate universal coverage by eliminating financial obstructions to access
and preventing financial suffering and high expenditures. The following can assist in achieving
the desired results:
 A system to raise adequate funds for proper health care.
 A system to pool financial assets across population groups to share financial risks.
 A financial governance system sustained by relevant legislation, financial inspection and
public expenditure assessments, and clear operational rules to ensure efficient use of
funds.
52
3.5 Human Resources for health
Health workers are crucial in achieving health. A well-performing labor force is one that is alert
to the needs and expectations of people, and is rational and efficient thus achieving the best
results likely given available resources and conditions. Countries are at various stages of
development of their health personnel but mutual concerns include enhancing recruitment,
education, training and distribution; improving efficiency and performance; and improving
retention.
This requires:
 Arrangements for achieving adequate numbers of the right mix (numbers, variety and
know-how)
 Payment systems that produce the correct kind of incentives
 Regulatory mechanisms to guarantee system wide deployment and distribution in
accordance with requirements
 Establishment of job related standards, deployment of support systems and enabling
work environments
 Mechanisms to guarantee cooperation of all stakeholders.
3.6 Crucial medical products and technologies
Universal access to health care is greatly dependent on access to affordable vital medicines,
vaccines, diagnostics and health technologies of assured quality, which are used in a precisely
sound and cost-effective way. Economically, pharmaceuticals are the second largest component
of most health budgets and the largest part of private health expenditure in low and middle
income countries. The main components of a functioning system are:
 A medical products supervisory system for marketing approval and safety monitoring,
backed up by relevant legislation, enforcement mechanisms, and access to a medical
products quality control laboratory.
 National lists of necessary medical products, national diagnostic and treatment
protocols, and standardized equipment per levels of care, to guide procurement,
compensation and training
 A supply and delivery system to ensure universal access to necessary medical products
and health technologies through public and private channels, with focus on the poor and
vulnerable.
 A national medical products availability and price surveillance system
 A national program to promote rational and efficient prescribing.
53
3.7 Service delivery
Health systems are only as effective as the services they provide. These mainly depend on:
 Networks of close-to-client primary care, structured as health districts or local area
networks with the back-up of specialized and hospital services, accountable for defined
populations.
 Providing of a package of benefits with an ample and cohesive range of clinical and
public health interventions, that respond to the full range of health problems of their
populations.
 Standards, norms and directions to ensure access and essential measurements of
quality: safety, efficiency, integration, stability, and people–centeredness.
 Mechanisms to hold medical providers accountable for access and quality and to ensure
the voice of the consumer.
While countries frequently focus on increasing the quantity of health care—for instance, the
number of consultations or the rates of coverage—health care can be useless, inefficient, or
even harmful if it is not suitable for the particular conditions and consistent with the best
medical knowledge. A range of policy measures can affect the scope of good quality care. These
measures include direct efforts to identify proper care and verify if medical providers are
following evidence-based standards of practice. Direct measures involved training with
feedback from peers who detect consultations and processes in a health care setting.
Performance-based compensation is the way that providers can be induced to provide better
quality care. Other indirect measures include setting legal norms for care. Accreditation,
periodic recertification of knowledge and capability, and governmental protocols can establish
minimum standards by controlling entry into practice and instituting conditions for license
renewal. Paying attention to the quality of health care is not a luxury that only high-income
countries can afford, but another pillar of the health service system that has a major impact on
the cost-effectiveness and equity of interventions.
3.8 Health care system efficiencies in OECD countries and lessons learned
All over the world, health systems are dealing with financial dilemmas. When health care system
efficiencies were evaluated within OECD countries, the following was concluded (OECD, 2010):
There is a strong need to contain public spending on health care
Getting value for money in the health care field is a main goal in all OECD countries. Health care
spending per capita has risen by over 70% in real terms since the early 1990s. This is reflected
in a considerably healthier population. Indeed, life expectancy has increased, on average.
54
But, as a result of the run-up in expenditures, total spending on health care now accounts on
average for over 9% of GDP in the OECD, though with a wide cross-country variation (OECD,
2010).
And the countries that spend a high amount are not necessarily the ones that fare best in terms
of health results, thus indicating that there is the possibility of improving the cost-effectiveness
of spending. Health care spending indeed needs to be more effective. Otherwise, health care
demand will weaken public finances. The recent crisis and its impact on public budgets have
intensified obstacles to reform and made it more urgent. Public spending on health care is one
of the principal government spending items – on average it accounted for 15% of general
government spending in 2007 (more than 6% of GDP), up from 12% of government spending in
1995 (OECD, 2010).
Furthermore, population ageing, rapidly rising health care prices and costly advances in medical
technology are putting increased pressures on health care budgets. The OECD estimates, that
public health care spending could increase by 3.5 to 6 % of GDP by 2050 across the OECD
countries (OECD, 2010).
The efficiency of health care systems could be increased considerably, helping fiscal
merging.
Governments care both about the health status of populations and budget stability. There is no
doubt that healthier populations are important for successful economies, but could better health
results be achieved while cutting spending? One way of evaluating the efficiency of health care
spending treats life expectancy as the result of health spending. Life expectancy reflects not just
health expenditures but also choices of lifestyle, such as tobacco and alcohol consumption and
education levels. These issues have been taken into account when evaluating the efficiency of
health care spending. Various techniques and assumptions about the consequences of health
care spending on life expectancy have been tested and the results are compelling. Overall, they
suggest that (OECD, 2010):
 On average across the OECD, life expectancy at birth could be increased by more than
two years – while holding health care spending stable – if all countries were to become
as efficient as the best performers. By way of evaluation, a 10% increase in health care
spending would increase life expectancy by only three to four months.
 The possibility for efficiency gains varies widely across countries. In a majority of OECD
countries, however, continuing to improve health results would need increased health
care spending, though by a smaller amount than over the previous decade.
55
 By enhancing the efficiency of the health system, public savings would be high compared
to a no-policy-change scenario, amounting to almost 2% of 2017 GDP on average in the
OECD.
 There is no trade-off between accomplishing more equal health results within countries
and increasing the average health status of the population.
Policies and establishments to steer the demand and supply of health care services vary.
The new dataset on health policies and organizations shows that (OECD, 2010):
 The basic insurance coverage – measured by population covered, services included and
the degree of cost-sharing – is equally similar across countries.
 Some OECD countries depend greatly on centralized command-and-control systems to
direct the demand and supply of health services; in a few countries regulated market
mechanisms where competition driven by user choice and private insurance play a key
role. But more and more countries depend on a mix of the two.
 Different sets of policy tools often work in a corresponding way: for instance, countries
that use fee-for-services also depend on private providers while command-and-control
systems which pay set wages depend on standard-setting and rules, such as GP’s who
act as gatekeepers to the secondary- and tertiary care and allocations for medical
students.
There is no superior health care system
Numerous important differences in results and spending levels across countries can be noted. In
particular:
 Spending levels tend to be high in countries relying mostly on market mechanisms
(PAHO, 2009).
 Inequalities in health status are high in several countries. Interestingly, inequalities tend
to be fairly low in countries with a private insurance-based system. One reason may be
that regulations in these countries – such as the condition on insurers to enroll any
applicant and equalization schemes across insurers to reward for high risk enrollees –
can help limit the search for better-off patients and the desire to shed bad risks. These
and other potential favoritisms can be caused by market mechanisms if left unchecked.
Note that disparities are often caused by reasons that have little to do with the health
system itself, such as social status and education (WHO, 2008).
 Administrative costs are more likely to be higher in those countries where private
insurance plays the main role (WHO, 2008).
56
Moving towards best practice could produce significant efficiency improvements
Across and within country-group assessments allow spotting strengths and weaknesses and
recognizing areas where achieving greater uniformity in policy settings could produce efficiency
improvements. The key outcomes from the indicators are as follows:
 Reinforcing priority setting would contribute to improved efficiency. This would require
specific attention in countries that neither define the health benefit package specifically
nor use health technology (PAHO, 2009).
 Assigning responsibility across government levels and organizations in a more
consistent way would lead to less duplication and enhanced accountability (PAHO,
2009).
 More balanced provider payment systems, for instance between performance-related
pay and set wages, would lead to a better match between demand and supply in health
care in many countries (OECD, 2010).
 A quality out-patient care sector is an essential condition for reaching high efficiency in
several countries. Targeting spending on this sector would yield more value for money
by reducing costly hospital admissions for conditions such as asthma and cataract
surgery (OECD, 2010).
 Where activity-based payment systems for hospitals have been introduced, it may be
necessary to simplify regulations on hospital staffing and equipment to enhance the
system’s ability to respond to demand and improve efficiency. By contrast, such
regulations may need to be reinforced where hospitals work with fairly flexible budget
limits (PAHO, 2009).
 Where choice is ample, providing better user information on the quality and prices of
health care services would raise competition (PAHO, 2009).
 Stricter gate-keeping would reduce the number of consultations in the countries where
they are high, or limit spending in the in-patient care sector (OECD, 2010).
57
In this chapter, the following sub question has been answered:
What are effective strategies for controlling health care costs based on international
standards? This chapter focuses on international standards for a well-functioning health
system and lessons learned in OECD countries.
To conclude: as discussed in sections 3.2 – 3.7, a well-functioning health system should be based
on the following pillars (Jamison, D., et al., 2006):
 Leadership and Governance
 Health Information Systems
 Health Financing
 Human Resources for Health
 Vital Medical Products and Technologies
 Service Delivery
Furthermore, it can be concluded that in theory there is no health care system that performs
better in delivering cost-effective health care. In fact, the efficiency evaluations vary more
within country groups sharing similar institutional characteristics than between groups.
Meaning, big-bang health system reforms are not guaranteed. Rather, it may be more useful and
effective for each country to adopt the best policy practices applied by countries in its own
group while using the most suitable elements from other groups (OECD, 2010). The latter will
be discussed in the next chapter by evaluating two countries within the Dutch Kingdom and two
Caribbean countries.
58
4. HEALTH CARE REFORMS IN THE DUTCH KINGDOM AND THE CARIBBEAN
This chapter discusses the health care systems of two countries in the Dutch Kingdom; Aruba
and The Netherlands, and the health care systems of two Caribbean countries; Jamaica and
Costa Rica. These countries were compared in terms of the health care reforms that have been
implemented. Aruba, Jamaica and Costa Rica were selected because of their relatively low GDP
rate spent on health care. Different strategies were applied in these four countries as a way of
enhancing health care, managing costs and sustaining their health care systems.
Rising health care costs is a world problem that has an adverse effect on economic development.
The proportion of GDP spent on health care has increased in almost all countries because of
changes in global trends. In 2010, 4.8% of the Jamaican GDP was spent on health care (World
Bank, 2013). Aruba spent about 9% of its GDP on health care (7th Annual Caribbean Health care
Conference, 2012). The increased health care cost in these countries is also caused by changes
in the epidemiology of diseases and the increase in occurrence of lifestyle diseases. This chapter
highlights health care reforms in the different Caribbean and Dutch Kingdom countries in order
to determine how these strategies can be implemented in Curaçao.
59
4.1 Health systems evaluation: Curaçao, The Netherlands, Aruba, Jamaica and Costa Rica
In table 3 the health system structures of mentioned countries are evaluated against the pillars of a well-functioning health care system (discussed in
chapter 3). Based on this evaluation, gaps within the health care system of Curaçao are identified.
Table 3. Health systems evaluation: Curaçao, The Netherlands, Aruba, Jamaica and Costa Rica
Country
Aruba
(4.3)
The Netherlands
(4.4)
Leadership &
Governance (3.2)
Health Information
System (3.3)
Health Financing
(3.4)
No private sector
involvement (i.e. no
competition).
One central system
registration and e-health
card for patients.
Largest share comes
from social
Insurance.
No educational
systems for medical
professionals.
One single Social Insurance
company manages and
controls the entire health
system with supervision of
the board of committees.
Automation of health
services and patient
records.
Government
contribution.
Reliant on expatriate
workers.
Very small amount
out of pocket
payments and
private insurance.
Fee for service
(secondary and
tertiary care) with
budget limit.
Fixed payment per
prescription item.
Fixed payment for
GP’s.
Highly qualified
medical
professionals.
Use of generics.
Sound legislations and
policies in place for the
entire health care sector.
E-health system in place
and still expanding
throughout the country.
No political influence on
operative health care
decisions.
High usage of technology
and electronic data.
Highly dependent on
private health insurance
companies (market
regulated).
Registration of health care
related data for research
and policy making
purposes.
80% is financed by
premium income.
Human Resource
(3.5)
Several payment and
accountability
systems in place for
medical professionals
and other players
within the field.
Periodic review and
renew of medical
licenses.
Pharmaceuticals
(3.6)
Use of generics.
Best Aruban
pricelist drugs only
are imported to
promote generics
use.
Service delivery
(3.7)
Quality care provided
by means of Universal
access and basic
health care package
(mandatory).
One private non-profit
50
hospital with different
branches.
Lack of specialized
and diagnosis care
facility.
Several measures
to reduce and
maintain drug costs
i.e.
‘Geneesmiddelen
vergoeding
Systeem’, ‘Wet
Geneesmiddelen
Prijzen’,
‘Preferentiebeleid’
and many more.
Quality care provided
by means of Universal
access and basic
health care package
(mandatory).
Patient-centered care
provided.
50
Country
Leadership &
Governance (3.2)
Jamaica
(4.5)
Sound accountability
system in place within NHF.
Proper legislation and
policies in place for all
players in the health care
field.
Health Information
System (3.3)
Due to the limited
availability of literature
specific on this topic this
information could not be
identified.
Health Financing
(3.4)
Mix of private and
public sources.
46% Government
contribution.
Human Resource
(3.5)
Due to the limited
availability of
literature specific on
this topic this
information could
not be identified.
Pharmaceuticals
(3.6)
Reference pricing
mechanism for
drugs.
Drug subsidy
program.
36% out of pocket.
16% private
insurance.
Costa Rica
(4.6)
Explicit and legally defined
mandates.
Strategic health policy in
place. Focus is on
promoting health as social
value.
One public entity for
providing health services.
Due to the limited
availability of literature
specific on this topic this
information could not be
identified.
Government
spending about 68%.
Private insurance
about 32%.
Service delivery
(3.7)
On its ways to
universal health care,
however, not there
yet.
Covers only 19% of
population.
High co-payment
therefore not
affordable for the
poor.
Due to the limited
availability of
literature specific on
this topic this
information could
not be identified.
Legislation in place
for the sector.
Use of drugs only
the ones on the
Official List of
Drugs.
Poor quality care in
rural areas.
Free primary and
emergency care.
Secondary and
tertiary care via
insurance.
About 90% of total
population is covered.
Comprehensive care
programs for entire
population.
51
Country
Leadership &
Governance (3.2)
Health Information
System (3.3)
Health Financing
(3.4)
Human Resource
(3.5)
Curaçao
(chapter 2)
Complex system and lack of
transparency.
Poor registration of health
care related data.
Government
spending about 55%.
Poor legislation and policies
throughout the entire
health care sector.
Poor use of technology.
Social insurance
about 30%.
Absence of legislation
for controlling
demand and supply
of medical
professionals.
Poor control and
management throughout
the layers of the health
system.
High degree of political
influence.
No accountability
systems in place for
medical
professionals.
Fee for service
(secondary and
tertiary care) without
budget limit.
Lack of decisiveness
Pharmaceuticals
(3.6)
Absence of
legislation to
control and
manage the
pharmaceutical
sector.
Poor use of
generics.
Service delivery
(3.7)
Many types of
coverage’s and
insurance schemes.
Outdated and poorly
maintained public
hospital with poor
quality care.
On its way to
universal access and
basic health care
package, however,
many obstacles
encountered and need
for amendments.
Fixed payment for
GP’s.
The following can be concluded from table 3:
Aruba’s and The Netherlands’ health systems are well developed (discussed in section 4.3 and 4.4) and provide ample insight in reforming Curaçao’s
health system. All four countries seem to have proper control and management systems, including health information systems, to monitor their
health care sector and all participating stakeholders. Especially in Aruba and The Netherlands proper legislation, policies and control mechanisms
are implemented in all ‘layers’ of the health system to steer the health care sector in the right direction.
52
4.2 Comparing health care costs on Curaçao and the rest of the world
The Health Accounts of Curaçao over the period of 2008-2011 show that with an average
16.1% of GDP, Curaçao has the second highest percentage of health care spending in GDP of the
65 countries surveyed by OECD (OECD, 2012). For countries such as Spain, Italy, Greece, Japan
and New Zealand, that have a similar per capita spending on health care spending as Curaçao, is
that their percentage of GDP is between 9-10%. Curaçao is approximately 40% above these
countries. The normalizing of Curaçao to the percentage of these countries involves an amount
of health care spending of 10% of GDP. In 2010 this corresponded to an amount of ANG 530
MLN. Compared with the actual health care expenditures in 2010 which were ANG 730 MLN
this would mean a reduction of ANG 200 MLN (28%) (‘Zorgrekeningen Curaçao 2008-2011’,
2012).
The health expenditure as a percentage of GDP were on Curaçao in 2010, 92% higher than the
average for the Caribbean countries, 100% higher than the Latin American countries, and 41%
higher than the OECD countries. The expenditure per capita (Purchasing Power Parity) in
Curaçao is 238% higher than the average for the Caribbean countries, 358% higher than the
Latin American countries, and 16% lower than the OECD countries. The comparison between
the 64 countries shows that health expenditure as a percentage of GDP in Curaçao (16.6%),
except for the USA (17.9%), is the highest of these countries (OECD, 2012).
In 2011 in the Netherlands, health expenditure was 14.9% of GDP. On Curaçao it was 16.6%.
This is 1.7 percentage points i.e. 12% higher than in The Netherlands. In 2011 in The
Netherlands, the per capita expenditure was € 5.392 (ANG 12.402). This means that Curaçao
with its ANG 6.006 per capita spends 52% less, compared with the Netherlands. If the
expenditure (Purchasing Power Parity) on Curaçao would be at the same level as in the
Netherlands this would correspond to ANG 12.402 per year i.e. ANG 1.011 per month per capita.
This corresponds to an amount of more than ANG 1.8 billion. As a percentage of GDP, this would
amount to 33%. The distribution between health- and welfare costs in Curaçao is 83% health
care and 17% welfare. In the Netherlands, this distribution is 80% health care and 20% welfare.
In 2011, health care costs in Curaçao were ANG 4.996 per capita and for welfare it was ANG
1.010 per capita. In the Netherlands it was € 4.314 (ANG 9.922) and € 1.078 (ANG 2.480)
respectively. Per capita on Curaçao for health care is 50% less than in the Netherlands
(‘Zorgrekeningen Curaçao 2008-2011’, 2012).
When health care expenditures of Curaçao in 2011 are compared with expenditures of Aruba in
2011, Curaçao spent an estimated amount of US$ 370 MLN and Aruba spent a total amount of
53
US$ 191 MLN. Several strategies to manage costs which were implemented by Aruba could be
implemented by Curaçao since both islands share similarities in population (development of
diseases), cost of living and other demographics. These strategies will be discussed further in
chapter 5.
Cuba, Curaçao and the Netherlands compared with 61 other countries in 2010 had the highest
percentage of public financing for health care expenditures (91%, 87% and 87% respectively)
(OECD, 2012). The financing structure of the expenditure however is entirely different. Cuba has
a more than 90% public funding. The Netherlands has a funding of 75% from social insurance.
And Curaçao has a funding of 57% public and 30% premium income. The per capita expenditure
(Purchasing Power Parity, PPP) also differs greatly in the three countries (PPP $ 431, PPP $
2.923 and $ 5.038 (‘Zorgrekeningen Curaçao 2008-2011’, 2012).
4.2.1 Cross case analysis: Curaçao, Netherlands, Aruba, Jamaica and Costa Rica
A cross case analysis has been performed between the four countries analyzed in section 4.34.6. This analysis highlights the health care expenditures as % of the GDP, the top two
expenditures within health care, and health financing in these four countries.
When the % of GDP spent on health care in these five countries are compared, Curaçao is
spending far more per capita on health care. Figure 9 provides an overview of the % of GDP
spent on health care by these five countries.
Costa Rica
Jamaica
Curacao
The Netherlands
Aruba
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Figure 9. Health care costs as % of GDP
Source: (‘Zorgrekeningen Curaçao 2008-2011’, 2012, ‘Centraal Bureau voor Statistiek’, 2012, 7th
Annual Caribbean Health care Conference, 2012, CSS, 2009).
When comparing the top two expenditures (Figure 10) in health care in Curaçao, Aruba and The
Netherlands, Curaçao is spending a vast amount on pharmaceuticals. As described in table 3,
The Netherlands and Aruba have effective strategies in place when it comes to drugs; this is also
notable in figure 10, where these expenditures are compared with Curaçao.
54
$900
$800
$700
$600
$500
Hospitalcare
$400
Drug prescriptions
$300
$200
$100
$0
Aruba
The Netherlands
Curacao
Figure 10. Top 2 expenditures per capita within the Dutch Kingdom
Source: (‘Zorgrekeningen Curaçao 2008-2011’, 2012, ‘Centraal Bureau voor Statistiek, 2012,
‘AZV’, 2012).
When looking at the per capita expenditures and comparing them to Aruba and the Netherlands,
the expenditures on drugs per capita for Curaçao rise far more above the expenditures of the
Netherlands and Aruba. Since these two countries are so closely related to Curaçao, there are
surely lessons for Curaçao to learn from Aruba and the Netherlands as described in table 3.
The comparison of the financing related specifically to health care as part of the total care
system of Curaçao with that of the Netherlands (2010 figures) shows that in Curaçao health care
is financed for 57% out of public resources. In the Netherlands this is 13%. This puts a major
pressure on total government expenditures (‘Zorgrekeningen Curaçao 2008-2011’, 2012). On
Curaçao, 30% is funded by premium income. Both in Curaçao and in the Netherlands the private
funding is 13%. If Curaçao wishes to use same or similar financing to the Netherlands then, 44%
of the health care expenditure would have to shift from government to citizens and
organizations. This is an amount of ANG 317 MLN, a burden of ANG 2.333 per capita
(‘Zorgrekeningen Curaçao 2008-2011’, 2012). An overview of the health financing in the 5
countries evaluated is provided in figure 11.
Costa Rica
% by Public funding (Government)
Jamaica
% by Social Insurance (Premium
Income)
Curacao
% by Private Insurance
The Netherlands
% Out of Pocket
Aruba
0%
20%
40%
60%
80%
100%
Figure 11. Financing of health care costs
Source: (‘Zorgrekeningen Curaçao 2008-2011’, 2012, ‘Centraal Bureau voor Statistiek, 2012, 7th
Annual Caribbean Health care Conference, 2012, CSS, 2009).
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4.3 Aruba and Its Health care System
This section presents the reform in the Aruba health care system. It shows the structure of the
system and the basic aspects that made it possible for Aruba to control and manage its health
care costs. Reforms in the sector involved reorganization of the Department of Public Health
and the introduction of the general health insurance plan (AZV, ‘Algemene Ziektekosten
Verzekering’).
4.3.1 Health care System and its Structure
The Department of Public Health is the sole provider of health care services through the
operation of different medical services such as psychiatric, ambulance, and public health
laboratories. The reorganization of the Department of Public Health was aimed at the
automation of the public health labs, expansion of the occupational health department and
combination of other services in order to enhance efficiency. The general health insurance plan
ensures equal and universal access to health care in order to ensure uniformity, cost
effectiveness, and high quality. Universal access is ensured by mandatory enrollment; every
legal citizen is eligible and there is no risk-selection or risk-adjustment based on age, sex,
income or medical history (‘AZV’, 2012). The government improves management of medical
costs and effective control of health care expenditure by having a universal health care plan.
The island has a wide range of medical specialists and operates through a single private
nonprofit hospital, the Dr. Horacio Oduber Hospital. The hospital has different branches offering
psychiatric as well as inpatient care. It also has public health labs and an occupational health
center. In case of specialized diagnosis and care not available on the island, patients are referred
abroad to countries such as Venezuela, Costa Rica, or the Philippines (7th Annual Caribbean
Health care Conference, 2012).
4.3.2 The General Health Insurance Plan
The objective of the Aruban health care system is to provide equal access to a guaranteed and
comprehensive package of health benefits, with the possibility of supplementary insurance by
private companies (‘AZV’, 2012).
The health benefits within the basic health care packages are as follows:
Hospital Services, Medical Specialist (on referral), Family physician, Prescription Drugs, Dental
Care (for children -18yr), Physiotherapy, Midwives, Medical Devices, Laboratory tests, Overseas
Services on referral (‘AZV’, 2012).
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The insurance scheme entails solidarity by contributing in line with one’s ability to pay or
financial capacity (premium % of income) – in kind delivery, no reimbursement and no copayments or, no deductibles. Furthermore, this scheme also consists of single payer contracting
with private providers. With this structure, there is better cost-control and quality-assurance by
reducing bureaucracy, administrative simplification and collecting uniform and reliable
(medical and financial) data in a central database. Financing is done by payroll-taxes and fiscal
contribution, payroll taxes shared by employer and employees and no re-insurance scheme (7th
Annual Caribbean Health care Conference, 2012).
The following types of remunerations are used for the providers of medical services and drug
providers (7th Annual Caribbean Health care Conference, 2012).
 Fee for service (hospital, medical specialists, laboratories, overseas services, budget cap
per year, except for overseas services),
 Fixed payment for family physicians (fixed payment per capita (inscribed) with cap on
number of inscribed persons per practice) and fixed payment for paramedics (fixed
payment per session (physiotherapist) or per delivery (midwife)).
 Drugs: only drugs on the Positive List (Best Aruban Pricelist (BAP) to promote generics
and maximum prices for brand-names based on an agreement with the drug-importing
agents)
 Drugs: fixed payment per prescription-item for delivery-costs
4.3.3 Why Aruba is successful in managing its health care costs
The health care system in Aruba is highly effective because the general health insurance plan
ensured that all citizens in the island have a medical cover that ensures health services such as
primary care, secondary care, and ambulance services (7th Annual Caribbean Health care
Conference, 2012). Aruba is successful in managing the costs of care as well as reducing
expenditure of individuals and the government on health care (Boas, 2006). This enables people
to access health care on a universal platform and reduces the disparities arising from
differences in income levels. This is because individuals get all medical services necessary for
their condition irrespective of their income levels because of the general insurance cover.
Access to specialists such as obstetricians, physical therapists, and dentists ensures the
promotion of overall public health. Reorganization and expansion of the medical center and
automation of services enhances the management of costs and patient records in order to
ensure efficient provision of care (PAHO, 2010). Merging of services was also effective in
enhancing efficiency thus increasing the ability of the cover to ensure efficient provision of
medical services. The small size of the market as well as the health care providers reduces the
57
possibility of having many health care insurers. This means the general health care cover from
the Department of Public Health is efficient in providing services to the citizens of Aruba. The
system also coordinates with international health insurance providers who provide coverage
for tourists and international travelers during their stay on the island (PAHO, 2010).
Before AZV was introduced in 2001, the average increase of the health care costs was about 910% per year. This annual increase of 8.3% in 2002 declined to -0.9% in 2004 (Boas, 2006).
Table 4 shows that the introduction of the general health insurance plan and reorganization of
the health care system on Aruba is successful in managing its health care costs. The increase
rate of 3-3.5% is a global trend which is managed in a controlled way (7th Annual Caribbean
Health care Conference, 2012).
Table 4. Health care expenditure overview Aruba 2010 – 2012
Source: 7th Annual Caribbean Health care Conference, 2012
Figure 12 provides an overview of the medical expenditures per service of Aruba in 2011.
Figure 12. Distribution of medical expenditures by Service in 2011
Source: 7th Annual Caribbean Health care Conference, 2012.
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4.3.4 Challenges and Recent Developments
Like other countries, Aruba is also dealing with aging and degeneration of health of the
population, growing prevalence of chronic diseases and lifestyle (overweight) diseases i.e.
heart-diseases and diabetes. Aruba’s focus should be on quality improvement; more value
instead of volume.
Some of the challenges in the provision of health care on the island have been the absence of
health care support services such as breastfeeding promotion policies and obesity prevention
(PAHO, 2010). Lack of these strategies reduces overall health in the country thus increasing the
cost. Another challenge in the system is that it does not have competition. The system consists
of as single general health insurance policy provided by the government. The size of the market
does not enable adequate development of a private health insurance sector, which makes the
government a monopoly in the provision of health covers (PAHO, 2010). The general insurance
health plan cover does not provide for referral services abroad. This makes access to health care
costly in cases where specialized treatment and diagnosis is required. The absence of such
provisions means patients have to cover them with out of pocket payments.
The Aruban health care system is further developing in the following areas to increase the
quality of health care and manage the total health care expenditures (7th Annual Caribbean
Health care Conference, 2012):
 Further digitalize communication with and between providers (claims, electronic
patient file, tele-medicine);
 Introduce Diagnosis-related group (DRG) payment based on performance for hospital
services and medical specialists;
 Consolidate primary health care (family-physicians) through support of nursepractitioners;
 Improve procurement of overseas services;
 Introduce tendering for specific drugs (cost-drivers)
4.3.5 Conclusion
The health care system in Aruba is well developed despite its having only one hospital (section
4.3.2 – 4.3.3). The introduction of a general health insurance cover was meant to ensure the
provision of equal and universal health care. The provision of a basic package to consumers
enhanced their ability to access primary care services and secondary care services. The plan is
effective in enhancing service delivery in the system. The effectiveness of the system in
providing care is hampered by the inadequacy of the educational systems to provide
59
professionals. The system has to rely on expatriate workers thus increasing the cost of health
care. To conclude, Aruba’s health care system is able to provide quality care by introducing the
general health care insurance plan and managing its health care costs by administering all
transactions related to health care in one central system (efficiency) and implementing
strategies such as fixed payments for physicians and drug prescriptions. Just like Curaçao and
most other countries, Aruba is also spending the largest share of its health care budget on drugs.
However, Aruba is able to manage drug costs by having certain strategies and policies (as
discussed in section 4.3.2) in place.
4.4 The Netherlands and Its Health care System
This section presents the reform in the Dutch health care system. It shows the structure of the
system and the ups and downs during its reform process. The Dutch system was ranked first in
the 2009 Euro Health Consumer Index report. The margin of victory seemed basically due to the
fact that the Dutch healthcare system did not seem to have any really weak spots, except maybe
some scope for improvement regarding the waiting time situation. Other factors that
contributed to its success are the country’s e-Heath and Pharmaceuticals (Euro Health
Consumer Index, 2009).
4.4.1 Health care system and its structure
Health care in the Netherlands can be divided in several ways: three echelons, in somatic and
mental health care and in 'cure' (short term) and 'care' (long term). GP’s form the largest part of
the first echelon (primary care). Being referenced by primary care is mandatory for access to
the secondary and tertiary care (Hasekamp, 2006).
An important feature of the Netherlands health care system is that premiums may not be
connected to health status or age. Risk variances between private health insurance companies
due to the different risks presented by individual policy holders are rewarded through risk
equalization and a common risk pool. Funding for all short-term health care is 50% from
employers, 45% from the insured person and 5% by the government. Children under 18 are
covered for free. Those on low incomes receive reimbursements to help them pay their
insurance. Premiums paid by the insured have been different throughout the years (2011: €
170; 2012: € 220; 2013: € 350), with a variation of about 5% between the several competing
insurers, and yearly deductibles of €220 (‘Zorgverzekering Nederland’, 2012).
The basic health care package highlights the minimum health insurance deal that should be
offered and the details of reasonable costs that the coverer should consider. The government
introduced provisions such as tax credits for the poor to ensure the cover is affordable. The
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insurance companies are obligated to accept all applications for insurance. They are prevented
from risk assessing to deny coverage to the high-risk patients, and all individuals are required to
purchase the basic package to avoid a fine of up to 130% of the premium cost. The money
contributed from taxable income goes to the health insurance fund and it is contributed to
insurers for risk equalization (Hasekamp, 2006).
4.4.2 Health care Financing
Health care in the Netherlands is financed by a dual system that was introduced in January
2006. Long-term treatments, particularly those that involve semi-permanent hospitalization,
and also disability costs such as wheelchairs, are covered by a state-controlled mandatory
insurance. This is laid down in the General Law on Exceptional Health care Costs (‘Algemene
Wet Bijzondere Ziektekosten’) which first came into effect in 1968. In 2009 this insurance
covered 27% of all health care expenses (Centraal Bureau voor Statistiek, 2012).
For all regular (short-term) medical treatment, there is a system of mandatory health insurance,
with private health insurance companies. These insurance companies are obliged to provide a
package with a well-defined set of insured treatments. This insurance covers 41% of all health
care expenses. Other sources of health care payment are taxes (14%), out-of-pocket payments
(9%), additional optional health insurance packages (4%) and a range of other sources
(Centraal Bureau voor Statistiek, 2012).
80% of health expenditure is paid from public funds especially social insurance. In terms of the
financing for health care, the AWBZ scheme pays for 43% of all health expenditure. For acute
care, individuals are insured publicly under the sickness fund act (‘Ziekte Fonds Wet’) 37% or
privately insured for 15% of the expenditure (Hoogervorst, 2004).
4.4.3 Challenges and recent developments
When comparing the Dutch health care system with other Western countries it seems to be
quite effective but not the most cost-effective (Boston Consulting Group, 2011). An assessment of
the 2006 Dutch health insurance reforms published in Duke University's Journal of Health
Politics, Policy and Law in 2008 raised concerns regarding the Dutch system. The analysis found
that market-based competition in health care may not have the advantages over more publicly
based single payer models that were originally proposed for the reforms (Boston Consulting
Group, 2011).
Another problem which The Netherlands is confronted with is the healthcare insurers. Health
insurers spend the funds made available to them at their own discretion. There is little public
61
supervision, unlike the normal supervision of financial institutions. The expenditure of the
health insurance companies, which are not at all or barely controllable, is also concerned with
the creation of 'regulation' for health care institutions and providers. On the one hand premium
funds are spent without any control in efficiency; on the other hand bureaucracy is created that
leads to workload at health care institutions and providers. This is at the expense of the time
available for the patient without it being clear if it is the case for improving the quality of care or
the reduction of cost (‘VvAA’, 2013). In 2012, health insurers spent less than they received in
premiums. Various media reported that in 2012 health insurers booked about 1.4 billion in
profits. This is much more than the profit in 2011, which was "only" 600 million. 1.3 billion
profit came from the basic health insurance premiums and about 100 million came from the
supplementary insurance premiums. The profit was partly because the fees for drugs were
lower than expected. The costs of specialist medical care did not increase, while revenue from
investments exceeded expectations (http://www.artsennet.nl/Nieuws/Nieuws-uit-demedia/Artikel/130830, 2013).
Recently, it was published in the media that the Dutch health care system is dealing with
fraudulent claims from hospitals. According to health insurance companies in The Netherlands,
in 2010 about 6.2 million was declared fraudulently. The fraud is facilitated by the billing
system DBC (‘Diagnose Behandel Combinatie’). The system provides default rates for different
treatments. Often a hospital submits the standard price, while only one consultation took place.
Not only is the DBC system prone to fraud, but also the PGB (‘Persoongebonden Budget’)
system, which gives the patients the opportunity to purchase care, seems to be prone to fraud as
well. In 2012, health insurers noted that fraud in the PGB’s increased from 400,000 euros to 1
million (www.zorgvisie.nl/Financien/Nieuws/2013/5, 2013).
As a response to the fraudulent claims, the Dutch Healthcare Authority (NZa) is performing
research to get a better view of the health care fraud cases. Furthermore, there are plans to set
the ‘Trekkingsrecht’ for the PGB system, which means that budget holders will not receive the
money on their own account but through the social insurance
(www.zorgvisie.nl/Financien/Nieuws/2013/5, 2013).
As for fraudulent claims via the DBC systems, the Dutch Healthcare Authority reported that
hospitals are required to indicate whether or not a treatment is covered by the insured care. On
the declarations, Hospitals also have specify on the invoice certain health activities that were
performed in order for insurance companies to control and detect possible fraud more easily
(www.nrc.nl/nieuws/2013/05/10/, 2013).
62
4.4.4 Conclusion
The Netherlands is described as a multitude of health insurance providers competing with each
other, and being separate from caregivers and hospitals. Also, The Netherlands undoubtedly has
the best and most structured arrangement for patient organization participation in healthcare
decisions and policymaking in Europe (Euro Health Consumer Index, 2009). Financing agencies
and healthcare amateurs such as politicians and bureaucrats seem farther removed from
operative healthcare decisions in The Netherlands than in almost any other European country.
The Netherlands scores very well in all sub-disciplines, except waiting times and access, where
the score is average (Euro Health Consumer Index, 2009).
The Netherlands was ranked first in a study when comparing the health care systems of the
United States, Australia, Canada, Germany and New Zeeland. Affordability is guaranteed through
a system of income-related payments and individual and employer-paid income-related
premiums Zealand (Reuters, 2010).
The reforms in the health care system were successful in improving health care for the citizens
because all citizens contribute to the system first by paying a flat rate premium to the insurer of
their choice (Schut, Greb, & Wasem, 2003). The reforms were successful because the two-tier
system of state coverage for the poor and private insurance for the rich was removed.
It introduced a new system that was less complex and more patient centered. The new system
combined universal health care and competition among insurers thus improving efficiency
(Schut & Van de Ven, 2005). The system also guarantees universality in the provision of health
care with the open enrollment system, which prevents risk assessment.
The first lesson is that the Dutch health system may not control costs. To date, consumer
premiums are increasing. Second, regulated competition is unlikely to make citizens happy;
public satisfaction is not high, and anticipated quality is down. Third, consumers may not
behave as economic models projected, remaining responsive to price incentives (Rosenau and
Lako, 2008). If regulated competition with individual mandates performs poorly in promising
circumstances such as the Netherlands, how will this model fare in Curaçao, where quality and
cost challenges are even greater?
4.5 Jamaica and Its Health care System
Jamaica’s health system functions relatively well and its primary health care system has been a
model for the Caribbean region. The World Health Organization (WHO) 2000 World Health
Report ranked Jamaica eighth in the world in terms of health system efficiency, in that it has
good health outcomes at relatively low costs. In the Pan-American Health organization/WHO’s
63
(PAHO/WHO’s) evaluation of performance of the essential public health functions in 2001 and
2011, Jamaica has made progress in eight of the eleven functions and had significant progress in
human resources development and training in public health. However, it did not do as well as it
did in 2001 in the areas of “monitoring, evaluation and analysis of health status”; “development
of policies and institution capacity for public health planning and management”; and
“strengthening of public health regulation and enforcement capacity” (PAHO, 2012).
However, even with a low economic growth and a similar cost of living to Curaçao, Jamaica’s
total health expenditure, as a percentage of GDP, has been between 4 and 6 % in the last decade.
Total health expenditure was about US$680 million in 2009 (5.1 % of GDP), equivalent to
US$228 per capita in 2009 (Shiyan Chao, 2013). This makes it worthwhile reviewing Jamaica’s
health care system and strategies used to manage total health care costs.
4.5.1 Health care System and its Structure
Jamaica’s health system involves a mix of the public and private sectors. The public sector is the
primary provider of public health and hospital services, while the private sector dominates
ambulatory services and the provision of pharmaceuticals. The public sector includes the
Ministry of Health (MOH) and its agencies; four Regional Health Authorities (RHAs); and an
extensive network of secondary and tertiary care facilities. Act. The Ministry is responsible for
policy, planning, regulating, and purchasing functions, while the four RHAs are in charge of
health service delivery. The RHAs are responsible for delivering health care services to all 14
parishes (Shiyan Chao, 2013).
The private sector plays a key role in health care. Private health care is provided by GP’s and
specialists, private laboratories and pharmacies, and a few hospitals. Nongovernmental
organizations (NGOs) also provide ambulatory care, targeting the poorer regions of the
population. The past decade has witnessed a growing private sector, particularly in the areas of
ambulatory health services and pharmaceutical supplies. The private sector delivers 75 % of all
ambulatory care and 82 % of all pharmaceutical purchases (Gordon-Strachan and Brenzel
2010).
Economic recession, high unemployment, and global health care cost escalation have made it
increasingly difficult for households to afford health care. With the establishment of the Jamaica
National Health Fund (NHF) in 2003 and the abolition of user fees at public facilities in 2008,
the Government of Jamaica has taken steps toward achieving universal coverage. NHF
Individual Benefits include subsidies on a range of prescribed pharmaceuticals for patients
suffering from one of 15 specific chronic diseases. Beneficiaries are required to make a high
copayment, ranging from 25 to 53 % of the cost of the drugs (Shiyan Chao, 2013).
64
The framework that guides NHF operation is choice of provider by members, competition
among service providers, and shared governance and responsibilities with key stakeholders.
Figure 13 displays the NHF overall structure and programs.
Figure 13. Organization Structure of the NHF
Source: 7th Annual Caribbean Health Care Conference, 2012
Institutional Benefits
The NHF provides Institutional Benefits in the form of grants to two sub funds—the Health
Promotion Fund and the Health Support Fund. The Health Promotion Fund finances public and
private sector health promotion and disease prevention programs, and takes up at least 10 % of
NHF revenues. The Health Support Fund assists public agencies by financing infrastructure
development; the operations of the Health Support Fund take up at least 15 % of annual NHF
revenues (NHF, 2009).
Individual Benefits
The NHF responded to the need for the public sector to help individuals address their Noncommunicable diseases (NCD). One of the major functions of the NHF is to provide an Individual
Benefit Package, and more than 50 % of the NHF budget since its establishment has been
allocated for Individual Benefits. NHF Individual Benefits include subsidies toward a range of
prescribed pharmaceuticals for patients with specific chronic diseases (NHF, 2009).
65
Eligibility
All residents of Jamaica (except tourists, in-transit passengers, and temporary workers with a
work permit for less than one year) suffering from NCDs are eligible to enroll in the Jamaica
Drug for the Elderly Program (JADEP) and/or the NHF Card Program.
Beneficiaries over 60 years of age enroll in the JADEP, while the NHF Card Program subsidizes
drugs for people of all ages. Beneficiaries of the NHF Card Program are automatically enrolled in
the JADEP at the age of 60. Those among the eligible population need to apply to be enrolled in
the NHF or JADEP (NHF, 2009).
Benefit Packages
The NHF Individual Benefit package is a drug subsidy program that covers 15 chronic illnesses:
arthritis, asthma, benign prostatic hyperplasia or enlarged prostate, diabetes, ischemic heart
disease, breast cancer, epilepsy, high cholesterol, major depression, rheumatic heart disease,
glaucoma, prostate cancer, psychosis, vascular disease, and hypertension. NHF Individual
Benefits cover only drugs prescribed by a registered medical practitioner or provided by
authorized providers. The Medical Review Committee of the NHF Board periodically reviews the
NHF Individual Benefits to include or exclude specific drugs. NHF subsidies are set at a fixed
dollar value and are based on a reference pricing mechanism. The reference price is determined
by the lowest available price of the active pharmaceutical ingredient. The subsidy is then set at
80 % of the reference price (NHF, 2009).
Co-payments
Co-payments under the NHF are relatively high. The NHF provides a subsidy toward the cost of
the list of agreed drugs, based on the best market prices. Beneficiaries are required to make a
copayment toward the cost of their drugs. The copayment for drugs has ranged from 25 to 53 %
(NHF, 2009).
Provider Participation
The NHF provides policy guidelines for providers participating in the NHF Individual program.
To be eligible to participate in the NHF Individual program, providers need to meet the
appropriate professional and medical standards required for accreditation by the NHF.
Providers are not allowed to refuse services to NHF beneficiaries. The NHF providers are paid
subsidies based on the price for the agreed drugs set by the NHF, and the remainder of the costs
is covered either by commercial health insurance or out-of-pocket payments. Providers are
required to prepare complete and accurate claims for the NHF payment, and to maintain
adequate records, which are subject to audit by the NHF. All providers submit electronic claims
and are reimbursed electronically within 10 working days of providing the service (NHF, 2009).
66
4.5.2 Health care financing
Financing for the health sector has been through a mix of public and private sources. The total
health expenditure, as a percentage of GDP, has been between 4 and 6 % in the last decade.
Total health expenditure was about US$680 MLN in 2009 (5.1 % of GDP), equivalent to US$228
per capita in 2009. The public sector accounted for 46 % (US$ 312.8 MLN) of total health
expenditure, while private health insurance covered 16 % (US$108.8 MLN), and out-of pocket
payments made up 36 % (US$ 244.8 MLN). Figure 14 provides an overview of the financing flow
in the Jamaican health system (NHF, 2009).
Figure 14. Financing Flows in the Jamaican Health Sector, 2009
Source: 7th Annual Caribbean Health Care Conference, 2012
The NHF had three sources of revenue at inception: (a) the tax on the consumption of all
tobacco products; (b) a payroll tax, which is collected in conjunction with the National
Insurance Scheme, which provides primarily for pensioner benefits; and (c) a special
consumption tax, mainly from alcohol, petroleum, and motor vehicles. The tax collection
mechanisms are obligatory contributions, and companies are required to make payments to
meet their NHF obligations. The revenue mechanisms are studied and adjusted periodically to
ensure the financial sustainability of the NHF (NHF, 2009).
Public financing comes mainly from general taxation. The MOH receives its budget from the
central government and transfers about 86 % of its budget to RHAs for providing health care
67
services. The government also provides funding for the NHF to subsidize drugs for patients who
suffer from NCDs and to invest in public health programs and health infrastructure. Less than
20 % of the population was covered by private health insurance in 2009, mainly through
employee health plans in medium and large establishments. There have been no major changes
in sources of financing in the last decade. After the abolition of user fees in 2008/09, there were
slight increases in both government and private spending on health (Shiyan Chao, 2013).
The most pressing worries in the public health sector are the growing demand for care and cost
of services, compounded by the need for resources to meet these costs. The government is the
main payer and provider of health services and faces many problems in financing the full range
of primary, secondary, and tertiary health services. The supply of services has not been able to
match the increasing demand. The demand and costs are driven up by demographic,
epidemiological, technological, and social factors. Limited economic growth and lack of fiscal
space has made it difficult to expand the coverage to meet increasing demand (Shiyan Chao,
2013).
4.5.4 Conclusion
Jamaica’s health system is being severely challenged by persistent and reemerging infectious
diseases, including dengue and HIV/AIDS, and by the rapid increase in NCDs and injuries. The
aging of the population, technological advances, and increasing demand for health care have
been driving up the costs of health care. At the same time, the country is experiencing limited
economic growth and carrying heavy debts, thus limiting fiscal space. These factors are
threatening the sustainability of the health system.
Based on the assessment carried out under the UNICO (Universal Health Coverage) study
(Shiyan Chao, 2013), Jamaica’s approach to universal coverage has produced mixed results. On
the one hand, people have access to free care at public health facilities, and the NHF subsidizes
drugs for people with NCDs and the elderly, so it seems that Jamaica is in the process of
reaching universal access. On the other hand, the NHF covers only 19 % of the total population,
and with a fairly high copayment. The rich have benefited more from the NHF Individual
Benefits. Furthermore, this move has had the effect of further widening the gap between the
poor and the better-off population. Increased use of public health services has put a heavy
burden on the public health system, which was already considered inefficient and lacking in
human resources and with poor infrastructure and equipment. Due to increased use of the
private sector, the NHF’s drug subsidy program and the elimination of user fees have not
resulted in a decrease overall of out-of-pocket health expenditures. In the end, the poor pay a
higher share of their income for health care (Shiyan Chao, 2013).
68
While in theory, Jamaica has reached universal access to health care in practice; such coverage
is incomplete and inadequate. The elimination of user fees did not guarantee universal access to
care, particularly for the poor. However, by using and following the above mentioned strategies,
Jamaica is able to manage its health care costs. Moving forward, the government needs to invest
wisely in the health sector to reach real universal coverage. The NHF can function as an
important element for the ultimate goal of providing universal access to health care in Jamaica.
4.6 Costa Rica and Its Health care System
The health sector is defined as the group of centralized and decentralized public institutions
that have an explicit and legally defined mandate to provide health services to the population.
The objective of the strategic health policy of Costa Rica is "to advance from disease
management toward health promotion, positioning health as a social value and directing and
leading the interventions of social actors toward surveillance and control of the determinants of
health, in an evidence–based and equitable manner" (CCSS, 2009).
The Costa Rican Social Security Fund (CCSS) is the only public entity that provides health
services to the various groups of the Costa Rican population. The CCSS has been organized
functionally by level of care, and geographically into seven planning regions. Primary care is the
responsibility of Basic Comprehensive Health Care Teams (EBAIS), located across the 103
health areas of the country. The secondary level provides specialty care services, inpatient care,
and surgical treatment in basic specialties. This level encompasses 10 large clinics, 13
peripheral hospitals, and 7 regional hospitals; these facilities also provide oral health and
microbiology services. The tertiary level provides specialized care in three national general
hospitals and five national hospitals specializing in gerontology, women's health, pediatrics,
psychiatry, and rehabilitation (CCSS, 2009).
The social security system in Costa Rica has three components: 1) health services (known as
health insurance), which are the responsibility of the National Insurance Institute (NII), and of
the CCSS; 2) economic benefits, which cover pensions and subsidies; and 3) social services,
which help families faced with critical socioeconomic issues, by supplying cash transfers and
services (Giedion, Villar & Ávila, 2010).
According to the current Costa Rican health model, all primary care and emergency care is
guaranteed, whereas secondary and tertiary care requires enrollment in some form of
insurance. Throughout the country's 103 health areas, 991 EBAIS health care teams are in
operation, 40 of which serve the indigenous population. The total population covered by the
69
EBAIS teams is 4,471,407. In addition, 66% of health centers are also concentrated in these
regions (Giedion, Villar & Ávila, 2010).
The Advisory Committee on Drug Quality is in charge of reviewing and proposing standards in
the field of drug quality as well as monitoring implementation of the Central American
Technical Regulation on Pharmaceutical Products. Since 1982, the CCSS has kept an Official List
of Drugs in line with the National Drug Formulary (PAHO, 2013).
Costa Rica has a universal and collective medical social security system, the coverage of which
expanded from 87.6% to 91.9% of the population over the course of the 2006–2010 period.
However, some 369,000 people are still uninsured. The core challenge for the health system in
the coming years is the financial sustainability of the CCSS. For health services users, the major
difficulties are the long wait times to obtain appointments for care at health facilities and the
limited availability of those slots (PAHO, 2013).
The universal health care strategies applied in the system ensure that all individuals get basic
health care irrespective of their socioeconomic status. The CCSS also introduced a regime to
eliminate the uninsured by providing them with state provided insurance in order to enable
them access to primary care (Montenegro Torres, 2013).
The comprehensive manner used in allocating contribution to health insurance enables the
system to provide equal access to 100% of the population. It also has many mid-level health
workers in its payroll and runs many health care facilities built in efficient locations in relation
to the public. The comprehensive care programs also enable the system to provide care
programs for population groups such as the elderly, adolescents, women, adults, and children
(CCSS, 2009). Contributions from the state consisted of 18.35% of the total health care costs
before the reforms, but it declined to 7.3% in 2001 because of increased contributions from the
private sector. According to budget liquidation figures for the CCSS in 2008, the total health care
expenses increased with 3%. The system was able to manage the costs although they did not
reduce them after the health care reforms (Sáenz, Bermúdez, & Acosta, 2010).
Between 2006 and 2010, total health expenditures as a percentage of GDP increased from
7.81% to 10.9%. Government spending on health as a percentage of total health outlays
declined from 69.0% to 68.0%, whereas private expenditures increased from 31.08% to
32.59%. Per capita health expenditures increased from US$ 410 to US$ 668.49, whereas the
government's overhead cost per capita increased from US$ 283 to US$ 450. In 2010, 86% of the
government's overall health expenditures came from CCSS funds (WHO, 2013).
70
4.7 Conclusion of Chapter
In this chapter, the following sub question has been answered: ‘What strategies have been
implemented by other countries to manage their health care costs’.
This chapter analyzes different strategies and reforms implemented in health care systems, in
different countries. It shows that all countries are dealing with rising health care costs through
different policies and plans. Universalization2 of the system is a key theme in all countries
because the target is to ensure equal provision of health care for all individuals (according to
international norms as described in section 3.1). The structure of the health care system is
determined by the size of the market and the presence of private sector players. The analysis
shows that some countries have managed successful health care sectors with the involvement of
the private sector such as the Netherlands, Jamaica, and Costa Rica.
Aruba, on the other hand, provides effective health care for its citizens without private sector
involvement in insurance or provision of services. By determining the components of the basic
package, the system ensures that all individuals can access basic health care and provides room
for additional services covered by private insurers. Financing through private insurance
companies in the Netherlands enables the reduction of complexity in the two-tier system used
earlier. Preventive health care in Costa Rica proved essential in reducing cost and enabling
people to improve their health conditions. The different financing structures used show that the
success of a health care plan depends on institutional and cultural factors and differs across
countries.
71
Universalization refers to a health care system which provides health care and financial protection to all its citizens. Universal health
care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.
2
5. POLICY FRAMEWORK DESIGN
Curaçao is dealing with health care costs that are constantly rising and have now reached an
unmanageable risk. While the introduction of the basic health care package makes important
strides in reducing costs, much more is needed to rein in the rising cost of health care. In
chapter 3 the pillars of a well-functioning health care system have been described. Based on
that, a best practice analysis performed on the four countries as described in section 4.3 – 4.6
and interviews with experts in the field, the shortcomings and barriers in the health care system
of Curaçao were identified in section 4.1. These rising costs did not occur overnight. Due to
shortcomings in the health system and lack of proper control and management throughout the
entire health care sector, Curaçao has come to this point.
The following shortcomings and barriers were identified while assessing the Health System
of Curaçao as discussed in chapter 2:
The lack of proper control and inefficiencies has eventually resulted in an uncontrolled increase
in the health care costs. There has never been good insight into the costs due to the lack of a
uniform registration system. Information about the development of health care is very limited.
How much each of the participating health care sectors costs is missing. This makes it difficult to
analyze and monitor the factors leading to high costs (Epidemiology Unit, GGD, personal
communications, January 2013).
In the organization of health care on Curaçao there is no integration and insufficient
cooperation between the various components and stakeholders within the health care sector
(Post, 2002).
Patient files i.e. health records information are not linked to a central system where medical
providers have access, which makes it very difficult for them to monitor and connect health care
providers to share and collect data. Due to this, there is a lack of adequate and up-to-date health
information (Epidemiology Unit, GGD, personal communications, January 2013).
There is no consistency in the legislation of the health care organization, creating a complicated
and less transparent structure. There is a lack of proper legislation and policies within the
entire health care sector of Curaçao (Post, 2002).
Due to lack of proper knowledge and skills, GP’s may not be able to perform as ‘gate keepers’
which allow to lower costs at the secondary level. Secondary level care is provided without any
control in efficiency and effectiveness. There are no protocols for GP’s or specialists when it
comes to providing quality care (Post, 2002).
72
Another factor that leads to high costs is the organization of the drug industry. Both the
importer and the pharmacist earn a profit margin on most medicines. The import of generic
drugs is very limited (Vugt van, 2007).
A proper breakdown of the costs of the participating health care sectors is missing, therefore,
decision and policy makers do not have an understanding of where to take measures
(Epidemiology Unit, GGD, personal communications, January 2013). The recent measure taken,
i.e. the introduction of BVZ has caused major dissatisfaction among the population. Several
media reported that the government did not foresee this because thorough research before the
introduction was lacking.
Health care costs have increased to such a level that immediate measures were taken to reduce
the burden from the governments’ total expenditure without anticipating the consequences. Up
till today, changes and corrections are made to the ‘BVZ’ law which was introduced on February
5th 2013.
5.1 A policy framework for health cost management on Curaçao
As we have seen in chapter 2 and section 4.1, when comparing Curaçao’s health system, the
current health care system is troubled by many factors. Current funding is not being used
efficiently and is not directed to get the most out of health gain. The current structure of the
health care delivery system does not provide enough incentives for improvement in efficiency.
There are stark deficiencies in health care quality and regulation is weak. This state of concerns
indicates a major handicap for Curaçao in the information era where quality of human capital of
a nation determines economic growth development. An improvement in health systems and
infrastructure is vital to assure Curaçao’s health system’s future.
It is necessary to considerably overhaul the existing system through an ample set of reform
measures for Curaçao’s health system to become sustainable on a longer term. The vision for
Curaçao in the area of health should be ‘to raise a healthy society through delivery of quality
health care services to all citizens’. To realize this vision, Curaçao has to focus on health
development with the mission of ‘creating an affordable and efficient health care system,
paired with preventive and curative measures and creating a persistent public-private
partnership’.
As described in section 3.2 one of the first and most important pillars of a well-functioning
health care system is leadership and governance. Curaçao needs decisive leaders with a sense
of urgency and proper steering capabilities to direct the reform process, only then will the
reform of Curaçao’s health system succeed.
73
A host of structural and effective measures are required to realize the above vision and mission.
The strategies suggested aim at cutting costs and restructuring the health care system in the
short term and long term. These strategies are provided in the following sections.
5.1.1 Strategies for cost control and management within the health care sector
(I) Government’s role in reforming the health system of Curaçao: the government needs
to step up (with a sense of urgency) and take its responsibility in creating policies and
laws throughout all the layers within the health system. As mentioned in section 2.4 due
to lack of policies and regulations, Curaçao has reached an uncontrollable increase in
health care costs. Proper regulatory mechanisms together with policies, have to be
implemented as soon as possible to control the cost increase.
Recommendations:
There are three broad categories of regulations that cover health care, namely: drugrelated regulations, practice-related regulations and facility-related regulations. Criticalservice related regulations such as accreditations and mandatory quality assurance
systems are absent. The regulatory mechanism (supply, demand, drug industry etc.) is
extremely weak. Regulations on all levels of the health system have to be assessed,
addressed and developed to gain cost effectiveness.
Universalization of the system2 is a key theme in all countries because the target is to
ensure equal provision of health care for all individuals (as discussed in section 3.1).
A basic package will lead to a more equitable health care system (everyone is entitled to
basic care and there should be freedom to take additional insurance). In determining the
basic package and limiting care claims, international standards such as described in 2.6,
should be taken into account.
Given the small scale, competition between health insurances with market mechanism
does not seem to be appropriate for Curaçao. For an island with only 150,000
inhabitants, it is more logical to implement one health insurance organization that
coordinates with all stakeholders involved in the health system. The analysis shows that
healthcare sectors can be successful with the involvement of the private sector.
However, it does not seem to deliver the desired results as was expected in the
Netherlands (section 4.4). For Curaçao it seems more logical to lean towards the health
system setup in Aruba (section 4.3) due its small scale and similarities in cost of living
and demographics. The general health insurance coverage in Aruba ensures the
74
Universalization refers to a health care system which provides health care and financial protection to all its citizens. Universal health
care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.
2
provision of equal and universal health care. The Aruban plan is effective in enhancing
service delivery in the system. Aruba’s health care system is able to provide quality care
by introducing the general health care insurance plan and manage its health care costs
by administering all transactions related to health care in one central system (efficiency)
and implementing strategies such as fixed payments for physicians and drug
prescriptions. Curaçao should assess the Aruban system thoroughly and implement the
policies and monitoring mechanisms that ensures Aruba’s success in being able to
manage their health care costs.
The recommendations above are the most urgent measures that should be taken as soon
as possible to keep health care affordable and reduce unnecessary costs. The
government is already working on implementing the most evident measures to reduce
costs (section 2.5). It is recommended to ensure that these measures are truly carried
out and implemented. Supervision, control and coordination are crucial in implementing
these measures. On BES islands, when these measurements were implemented, it
resulted in savings of 60% of their total health care expenditure (RNW, 2012). This may
be used as an indication of savings for Curaçao as well.
The following recommendations go more into detail based on the bottlenecks identified in
section 2.4.1 - 2.4.5 which leads to high costs.
(II) Cultural factors that lead to high health care costs: by developing better health
awareness among the population, citizens will work more actively on their health. The
importance of influencing behavior through a mentality program is crucial in Curaçao.
Primary preventive awareness means preventing diseases by (cultural) lifestyle factors.
An effective preventive approach can prevent disease onset (effective prevention
programs will lead to less demand for care and medications, meaning less costs).
Although attention is given to prevention (by GGD in collaboration with various
foundations and SVB), currently there is still too little consistency in preventive
measures. There is still lack of supervision, cooperation and control among the
stakeholders.
Recommendations:
An effective preventive approach with more dedication, ingenuity, cooperation and
coordination between all stakeholders. Such coordination should be initiated as soon as
possible, perhaps resulting in a broad-based island prevention plan with coordinated
actions. Especially primary prevention (healthier life style) should be better addressed.
75
The tendency to go to the doctor for every little complaint should be prevented by a
behavior changing campaign, which is supported by the doctors and continued up to the
office of the GP’s.
Informative and interactive website (example: www.cz.nl). This website could be used as
a best practice. Very interesting is the page 'Do I go to the doctor with this complaint?".
In this section a sort of self-diagnosis is made and an explanation/medical advice is
given and what self-care remedies may be used and when one should go to the doctor
(or not).
Issuing of free brochures (K-pasa could serve as an idea) with all kinds of health tips and
self-care advice for most common ailments for which you do not (or do) have to go to
the doctor. These can be easily spread in every corner of the island (just like the K-pasa).
Health education in all schools at least once per week: students should be educated on
the benefits of a healthy lifestyle (do’s and don’ts) and the consequences of an unhealthy
lifestyle (various disease developments). There should be consistency in providing these
educational sessions and they should be coordinated and monitored.
(III)
Primary care; prescribing and referral behavior of GPs:
The ineffective prescriptions for medication, referring to the secondary care and
the unnecessary reference to research labs by GP’s (see section 2.4.2) can be
avoided by the following recommendations:
Implement (‘Nederlands Huisartsen Genootschap’) NHG standards
(www.nhg.org) or equivalent protocols (evidence based), which are included in
care providers’ contracts. Supervision by the insurer on compliance should be
performed. Performance based protocols and standards for GP’s can be acquired
from the Netherlands or Aruba, because these are already used (should be
adapted where necessary).
Monitoring and supervision on (in) efficient behavior of GP’s by analyzing
prescription and referral data (‘spiegel informatie’). Publishing or exchanging
this data among GP’s and specialists will increase accountability.
76
Introduce incentives strong enough to reward the rational behavior of GP’s and
penalize financially (or even exclusion) GP’s in case of inefficient behavior.
In the future, permit only physicians with a general practitioners accreditation to
practice. Making compulsory training and continuing education for all GP’s with
emphasis on dealing with the treatment protocols. GP’s should make use of an
electronic prescription system.
To support effective referral to specialists, explicit agreements need to be made
by the insurer with the GP’s on minimum performance (in terms of small and/or
special operations and minor surgical procedures) by GP’s. GP’s should be
compensated with higher fees where necessary.
To support effective referral of GP’s for laboratory tests: explicit guidelines need
to be provided by the insurer to the GP’s on what types of lab tests are covered
or not covered within the insurance package. GP’s should be rewarded with
higher fees if they have to deal with high-risk groups and activities that support
the gatekeeper function.
Netherlands or Aruba may be used as best practices as these measures are
widely implemented within their health systems (Vugt van, 2007).
(IV)
Secondary care level: there is ample evidence that too many services are
provided by the specialists, where these services do not necessarily need to be
done by the specialists (see section 2.4.3).
Recommendations:
The (easy) access to secondary care (for each specialty) should be structured
better by having the GP write a referral for specifically designated diagnosis. Reduce the
validity of the referral to for example three months. The insurer has to make further
agreements with the specialists to refer the patient back to the GP when the specific
requested examination or treatment is completed.
77
Further research by insurer to determine if relatively common (minor) operations by
specialists really need to be executed by the secondary care. A GP performing as the gate
keeper should be able to perform minor operations (CTG, 2005).
Define explicit guidelines by the insurer to the specialist on what types of routine
examinations are (not) covered within the insurance package.
Introduce performance (evidence) based payment system.
(V) Pharmaceuticals: to reduce and control the increase of drug costs the following
recommendations are made:
Reduce profit margin of importers to 20% or less.
Reduce profit margin of pharmacies to 25% or less by introducing a dispensing fee
(‘recept regel vergoeding’). These two measures have already been taken by the
government (section 2.5 & 2.6).
Introduce maximum prices for drugs by law (similar to the ‘Nederlandse Wet
Geneesmiddelenprijzen’, which can be used as best practice). A form of this law is also
used on Aruba (Vugt van, 2007).
Introduce a preference list for drugs (similar to ‘preferentiebeleid’ in the Netherlands,
which can be used as best practice). This means, only drugs specified by the insurer will
be covered. Aruba is also using such a list for all insured via ‘AZV’ (Vugt van, 2007).
Examine the conditions, possibilities and feasibility of self-exploiting pharmacies by the
insurer. In this case, the insurer would import preferably only generics, have a
preference list and have maximum prices regulations. This could result in substantial
cost reductions.
Supervision of marketing activities of drug manufacturers by Health Inspection as
marketing activities by drug manufacturers influences prescribing behaviors of medical
providers. Furthermore, it also influences the purchasing behavior of the importer and
pharmacies (Vugt van, 2007).
The Netherlands or Aruba may be used as best practices as these measures are widely
implemented within their health systems (Vugt van, 2007).
78
(VI)
Other factors leading to high health care costs: as discussed in section 2.4.5,
these are the overcapacity of medical professionals, poor use of technology and
the inefficiency within the hospital which lead to high costs.
Recommendations:
It is extremely important to achieve a supply (care providers) and demand (care)
planning regarding the overcapacity of medical providers (both GPs and specialists and
paramedics) with the standards associated. It is therefore recommended to introduce
the law for limiting medical providers as soon as possible (as discussed in section 2.4.5).
There is a range of health information systems on the market. Investing in a health
information system will be costly but in the long run it will not only be cost efficient but
also increase the quality of health care. There is an urgent need for health care related
data and its associated price tags. Use of technology and automation of patient data
leads to efficiency and therefore cost savings. Further investigation is necessary to
explore the options, available resources for planning and implementation.
In addition to organizing the hospital as an integrated medical specialist company
(section 2.5) many other measures should be taken that will contribute to both, the
quality of care delivery in the hospital, and the reduction of costs. The following
recommendations are related to the promotion of offering quality care within the
hospital:
- Improving the logistics within the current hospital.
- Taking measures to ensure that the length of stay is reduced.
- Participating in projects that improve the quality of hospital care (best practice
from the Netherlands can be used i.e. ‘SnellerBeter’).
- Participation of hospitals and clinics in a ‘quality monitoring system’ so that,
tertiary care in Curaçao can be compared with other countries in promoting
quality care. The Health Inspection could take the initiative to start with this
project.
5.1.2 Restructuring the health care sector of Curaçao
Figure 15 provides a general overview of the current tension field of the health care sector. The
Ministry of Finance (MOF) provides the public financing to the Ministry of Health (MOH). The
implementing organizations falling under the MOH are: ‘Geneeskunde en Gezondheidszaken
(G&GZ)’, ‘Landbouw Veeteelt en Visserij, (LVV)’, ‘Veerinaire Zaken (VZ)’, ‘Milieudienst (MD)’ and
79
‘Volksgezondheid Instituut Curacao (VIC)’. Since the introduction of ‘BVZ’ (discussed in section
2.6), ‘SVB’ has been appointed as the implementing organization of ‘BVZ’ and therefore, also
falls under the management of the MOH. The tension field of the health care sector on Curaçao
also consists of the following participating stakeholders: hospitals (private and public), private
insurance companies, other private health related institutions, medical providers (specialists
and GP’s) and the pharmaceutical industry. VIC was founded in 2011 and provides an essential
added value to the evidence based improvement of the health care system and strengthens the
accessibility, quality and financial manageability of public health in Curaçao. VIC published
‘Zorgrekeningen Curaçao 2008-2011’ in December 2012. All these participating stakeholders,
that provide health care services, are part of the tension field of the health care sector. However,
as discussed in chapter 2 and section 4.1, in the organization of the health care there is no
integration and insufficient cooperation between the various components and stakeholders
within the health care sector. There is no consistency in the legislation of the health care
organization, creating a complicated and less transparent structure. There is a lack of proper
management (leadership) and control (governance) throughout the entire health care sector.
MOF
LVV
G&GZ
MOH
VZ
MD
PRIV.INSR.
SVB/BZV
Other HRI
MP
HOSPITALS
GP
VIC
PHARM.
Figure 15. – General overview of the current health care sector on Curaçao
Source: (Epidemiology Unit, G&GZ, Manager Cure, SVB, personal communications, 2013,
www.gobiernu.cw).
Figure 16 provides an overview of the future health care structure of Curaçao based on the
recommended strategies in section 5.1.1. Within this health care structure, all pillars of a wellfunctioning health system (as discussed in chapter 3) are embedded. All layers (i.e. participating
stakeholders) within this health care structure have to be thoroughly assessed and proper
legislation and policies must have be developed and implemented (VIC could serve as the
Research entity). A commission (COM) should be formed by the MOH. This commission should
80
be able to operate politically independently, but fully supported by the government. Members of
this commission have to be skilled, with a health care background and have to be decisive in
decision-making. This commission will take the role of leadership and governance, making sure
that all participating stakeholders and organizations existing within the health care structure
are controlled and monitored. Based on international & local research, decisions need to be
made for regulations and policy development within all layers of the health care system. This
commission has to be supported by a Research entity (VIC) and a Control & Management team.
With the support of the VIC and the C&M team, the commission will be able to foresee issues
and dissatisfaction by communicating regularly with all stakeholders involved. Discussions and
communication should take place at least once quarterly. Furthermore, the care and cure
departments should be decentralized which, will provide better cooperation and coordination
among the involved stakeholders. The most efficiency will be achieved when a health
information system is implemented. Connecting with the registry office (Kranshi) & Tax
Inspection will provide better monitoring on insurance payments and income level (when
should one pay premiums etc.). A Health Information System (HIS); all providers are connected
to one central system including Financial functions, Diagnostic functions and payment
performance systems (protocols for quality care imbedded) for GP’s & Specialists. HIS data can
be used for research purposes and policy and cost effective decision making. Public health can
be monitored by means of data and where necessary preventive programs can be developed
based on disease development.
81
MOF
MOH
CBS
VIC
COM
C&M
DRUG
MANUFAC.
1 x PQ
DISC.
GP ASSC.
SPEC. ASSC.
PHARM.
ASSC.
HOSPITAL
ASSC.
CARE
ASSC.
INSURER
(ONE)
‘BVZ’
PREVENT.
ASSC.
HIS
PRIVATE.
INSUR.
REG.OFFICE
TAX COLL.
Figure 16. The future health care structure of Curaçao
It is logical that such a reform process will take time and financial resources. Health care reforms
may take up to 3 – 5 years, depending on decision making and resources available (OECD,
2012). The main financial investment to reform the health system of Curaçao will be in the use
of technology, a Health Information System. Thorough research has to be carried out on Health
Information Systems suitable for Curaçao. The financial investment in a Health Information
System varies throughout countries depending on economies of scale, requirements etc. (WHO,
2008).
In this chapter, the following sub question has been answered:
 What strategies will lead to a financially stable health care system on Curaçao.
Based on the factors leading to high health care costs (discussed in section 2.4), this chapter
outlines the strategies that have to be implemented to manage costs in those areas. These
strategies (discussed in section 5.1.1) are summarized below:
82
 Government’s role: there are three broad categories of regulations that cover health
care, namely: drug-related regulations-, practice-related regulations and facility-related
regulations. Regulations on all levels of the health system have to be assessed, addressed
and developed to gain cost effectiveness. Universalization of the system is a key theme
in all countries because the target is to ensure equal provision of health care for all
individuals (as discussed in section 3.1).
 Managing the demand for care: An effective preventive approach with more
dedication, ingenuity, cooperation and coordination between all stakeholders. Such
coordination should be initiated as soon as possible, perhaps resulting in a broad-based
island prevention plan with coordinated actions. Especially primary prevention (aimed
at healthier life style) should be better addressed.
 Primary care; prescribing and referral behavior of GP’s: monitoring and supervision
on (in) efficient behavior of GP’s by analyzing prescription and referral data (‘spiegel
informatie’). Publishing or exchanging this data among GP’s and specialists will increase
accountability.
 Secondary care level: the (easy) access to secondary care (for each specialty) should be
structured better by having the GP write a referral for specifically designated diagnose
and reducing the validity of the referral to, for example, three months. The insurer has to
make further agreements with the specialists to refer the patient back to the GP when
the specific requested examination or treatment is completed.
 Pharmaceuticals: Introduce maximum prices for drugs by law. Introduce a preference
list for drugs. Examine the conditions, possibilities and feasibility of self-exploiting
pharmacies by the insurer. Supervise marketing activities of drug manufacturers by
Health Inspection as marketing activities by drug manufacturers influence prescribing
behaviors of medical providers.
 Other factors leading to high health care costs: it is extremely important to achieve a
supply (care providers) and demand (care) planning regarding the surplus of medical
providers (both GPs and specialists and paramedics) with the standards associated. Use
of technology and automation of patient data will lead to efficiency and therefore cost
savings. Last but not least, improving the logistics within the hospital.
These strategies will lead Curaçao to a financially stable health care system, as it has been the
case for the countries that were evaluated (chapter 4). The most important condition is that
these strategies are carried out and implemented under the strict supervision of the government.
Determination and authorization from the government is a must, only then the reform of
Curaçao's health system will succeed.
83
6. PANEL OF EXPERTS: POLICY FRAMEWORK VALIDATION
The proposed strategies to reform Curaçao’s health system in this master thesis have been
evaluated by a panel of experts which provides a validation of this policy framework.
6.1 Evaluation Questions for each chapter
The following questions were asked to all panel experts when evaluating each chapter of this
master thesis:
1. Are the contents of this chapter clear?
2. Are there any missing key points in this chapter? On which points would you advise me
to add additional information within the scope and objective of this research? If so,
which are these?
3. Do you agree with the conclusion of this chapter? If not, what should be changed or
improved in your opinion?
4. What is your opinion of the proposed Policy Framework in terms of adequate, realistic
and/or useful for the situation in Curacao?
5. What needs to be adapted or improved to the proposed policy framework?
6. Master thesis in general: after reading this master thesis, would you like to convey any
additional information related to the health care situation on Curaçao?
6.2 Important remarks by panel of experts
A list of the experts that contributed to this master thesis can be found in annex 1.
6.2.1 Evaluation Chapter 2
‘The main cause of the high health care costs is that all possible care is provided to the population
of Curaçao regardless of the costs and ability to pay, which is very noble but unrealistic’ (Pinedo,
D.).
‘Uninsured patients, both local and foreigners, also contribute to the high health care costs’
(Pinedo, D.).
‘It is also important to note the high costs of private labs and X-ray clinics. The profit made in this
area of care should be again spent in care and not go into the pockets of individuals’ (Pinedo, D.).
84
‘I see you draw conclusions about the introduction of BVZ, in particular that the financial targets
would not be met without substantiating this. The total care expenditures of 2013 are developing
in accordance with the calculations done in the ‘Memorie van Toelichting’. The anticipated cost
reductions will be achieved. Management costs will be lower than expected and the operational
result will be as calculated in the ‘Memorie van Toelichting’. In other words, the implementation of
BVZ is ‘in control’. Calculations were done including government officials’. (Westerhof, R.). This
information has been updated in section 2.7.2, 2.8 and 3.9.
‘Curaçao has an average cost increase of 6% in 2008-2011. This percentage is in line according to
your research. Whether these rates are 'good' is not known, since the characteristics of these
countries’ health services are not known. Thus, this is an observation. Curaçao seems to go along
with the observed international costs increase; this does not mean it is ‘good’. In other words, these
percentages should be evaluated against the health care structure of a country’ (Croes, R.).
‘The ‘not understanding’ and ‘not managing’ of the changes in the health profile of the citizens and
financial aspects of a country usually lead to financial deficiencies. These deficiencies are usually
an indication of an inadequate financial management. It is often a ‘chicken and egg’ discussion in
the sense that health care must compete with alternative uses of the tax and premium amounts.
This approach is ultimately a political decision’ (Croes, R.).
‘Provide a more clear motivation on why extensive attention is paid to the project NHN in the
master thesis since this project is essentially not just about ‘bricks and mortar’ (a new hospital
building) but is an enabler for the much needed restructuring of the health care’ (Croes, R.). Costs
analysis is one of the main objectives of this research. The health care costs have been
increasing continuously as this can be noted in section 2.3, table 1. Policy and Management costs
increased with a substantial amount in 2011 (22%). It seemed logical to discuss the causes of
these incidental costs in the section policy and management costs.
‘I find the information when comparing countries insufficient and inadequate fact based. Which
strategies are actually applied and how do you measure that they have worked? Measuring is
different than stating people’s opinions’ (Westerhof, R.). Within the scope of this research the
information provided on the countries that have been evaluated are based upon literature and
not only people’s opinions. Costa Rica and Jamaica could not be evaluated extensively due to the
limited availability of literature specific on this topic (in particular financial statistics). As for
strategies proposed in this policy framework, these are based on best practices already
85
operational in The Netherlands and Aruba. Furthermore, restructuring the health care of a
country is a world problem and organizations such as WHO, PAHO and OECD have many
literature and best practices reviews which was also studied during this research from which
Curacao can learn. Proposed strategies are based upon researches carried out in different
countries, in particular the countries that were evaluated during this research.
‘I am missing the spending per capita in PPP$ of the countries that you are evaluating. Percentage
of the GDP is an indication but says nothing if you do not compare this also with the PPP$’
(Westerhof, R.). The PPP$ for Curaçao and The Netherlands have been compared in section 4.2.
The PPP$ in Curaçao was compared against the average PPP$ in the Caribbean countries (i.e.
Jamaica, Aruba) and average PPP$ in the Latin American countries (i.e. Costa Rica). Average
PPP$ was used for Jamaica and Costa Rica due to the limited availability of financial data for
these two countries.
‘The motivation and characteristics of why Curaçao should lean more towards the health care
structure in Aruba (as mentioned in section 4.3) is missing in chapter 5’ (Croes, R.). This
information has been processed in section 5.1.1 page 74.
‘I disagree with reduction in number of GPs will be cost effective. I believe it will be the opposite.
Less GP’s means more referrals to specialists because the GP’s will not be able to handle the
demand, specialists in turn will provide more care and thus leading to more costs. Overcapacity of
GP’s can only be beneficial in terms of less waiting time, which means that patients will be treated
faster. This will lead to patient satisfaction and diseases will be addressed quicker, which is also
cost effective’ (Pinedo, D.). Local studies (Post, 2002, Van Vugt, 2007) have observed that the
overcapacity is one of the causes that lead to high health care costs on Curaçao. Both studies
have suggested taking measures to come to a reasonable supply and demand. According to
international studies, the price of the product would decline with overcapacity but because
there is no real market mechanism present in the health sector, and because the prices are fixed,
overcapacity does not lead to lower prices of medical procedures but to a volume increase at
constant prices, thus leading to increased costs (Vugt van, 2007). Therefore, it is advised to
calculate the current demand and supply of care based on international standards suitable for
Curaçao.
86
‘VIC (Public Health Institute) has no place in your current and future health care structure of
Curacao. If you are discussing Health Information Systems and Health Indicators, then this is the
domain of VIC’ (Westerhof, R.). This information has been corrected in section 5.1.2 and 5.1.3.
This master thesis has been evaluated by five experts in the field. These experts have worked
and experienced the health care sector in Curaçao for many years. The remarks received were
valid and additional information has been provided to their remarks and questions. Initially, 5
experts agreed to evaluate this master thesis. Within a time frame of 4 week, 3 of these experts
provided their feedback. Overall, the remarks received were positive. Remarkably, none of the
panel experts provided specific feedback on question 4 and 5 (What is your opinion of the
proposed Policy Framework in terms of adequate, realistic and/or useful for the situation in
Curacao? What needs to be adapted or improved to the proposed policy framework?). The
remarks provided by the panel experts have been processed in chapter 6.
87
7. FINAL CONCLUSIONS & RECOMMENDATIONS
Every country’s aim is to have a health care system that not only provides affordable- and
quality care but also manages its health care costs in order to sustain its health care system.
Worldwide it was found that the health care costs increase at a faster pace compared to the
overall economic growth. Causes are global trends such as an aging population, higher life
expectancy and also the appearance of new diseases that require both more research and other
expensive medications and thus lead to increased costs. However, with continuous assessments
and improvements within the health system, several countries are able to manage their health
care costs.
7.1 Conclusions
Curaçao is suffering from constantly increasing health expenditures resulting in large budget
deficits. Curaçao is currently in a financial crisis and an official designation letter (‘Aanwijzing’)
from the Federal Government (‘Rijksregering’) was issued, indicating that drastic cuts have to
be made, especially in the health care costs. Health care costs have drastically risen over the
years and put major pressure on the expenditures of the Government (section 2.3).
After the official designation (‘Aanwijzing’) from the Federal Government (‘Rijksregering’), the
government took the following measures:
To cut costs in health care, the law ‘Landsverordening Basis Verzekering Ziektekosten’ was
introduced on February 5th 2013. However, due to major dissatisfaction among the population
(government officials and retirees) and players in the health care field, up till today, changes
and corrections have been made to the BVZ law which was introduced on February 5th 2013.
Another measure which was taken to manage costs was the merger of BZV with SVB. The
merger of BZV and SVB was supposed to result in economies of scale and cost reductions
through better efficiency and coherence in tariffs, however, in practice the merger did not result
in any savings (section 2.5).
During this research the actual factors leading to high health care costs on Curaçao were
identified. These are: cultural factors, prescribing behavior of the GP’s and the specialists,
overcapacity on the supply side of health care, lack of regulations and policies within the entire
health care system, lack of regulations and policies in the drug industry, poor use of technology
(inefficiency) and last but not least, poor control, supervision and management within the entire
health system (section 2.4).
88
After assessing international standards for reforming the health care system to gain efficiency
and manage costs, the following can be concluded: big-bang reforms are not guaranteed. Rather,
it may be more useful and effective for each country to adopt the best policy practices applied
by countries in its own group while borrowing the most suitable elements from other groups.
Furthermore, according to international standards, for a well-functioning health system, the
system should be based on the following pillars: Leadership and Governance, Health
Information Systems, Health Financing, Human Resources for Health, Vital Medical Products
and Technologies and Service Delivery (chapter 3).
To gain more insight in to health care reforms and cost management, two countries in the Dutch
Kingdom and two countries in the Caribbean were evaluated. From this assessment, the
following can be concluded: all countries are dealing with rising health care costs through
different policies and plans. Universalization of the system is a key theme in all countries
because the target is to ensure equal provision of health care for all individuals. The structure of
the health care system is determined by the size of the market and the presence of private
sector players. All four countries have proper control and management systems, including
health information systems, to monitor their health care sector. Especially in Aruba and The
Netherlands proper legislation, policies and control mechanisms have been implemented
throughout the entire health care system to steer the health care sector in the right direction
and manage health care costs (chapter 4).
7.2 Recommendations
It is wise to learn from the lessons learned by other countries where cost control measures have
been implemented. It is important to realize that the recommendations proposed in this master
thesis are to reduce the collective cost of health care which will raise dissatisfaction among
some stakeholders as this will ‘hurt in their wallets’, in particular, healthcare providers who
currently produce more than required and all those who benefit from the drug chain. It will be
only logical to anticipate dissatisfaction and counteraction from this group. And therefore, it
should not be expected to reach consensus with all stakeholders.
It is also essential that the government defines a coherent package of measures together with
the insurer. Otherwise, controlling the functional behavior of the GP does not make sense if the
patients are not better informed and called on their demand behavior. Designing better care
contracts between the insurer and healthcare providers will have to be accompanied by
incentives that actually result in the agreed performance of quality and efficiency.
To conclude this research, the main research question, ‘What strategies are necessary to increase
the control mechanism within the health care system to improve the management of health care
89
costs in the short term and what strategies will lead to a financially stable health care system on
Curaçao on a longer term’ has been answered below:
The first step of this reform process should be the formation of a commission that assesses all
current legislation and policies within all the layers of the health system. Gaps and barriers are
identified in section 4.1. Best practices from other countries should be analyzed, and where
necessary these should be amended and implemented as soon as possible. Proper legislation
within the entire health system will lead to cost efficiency.
The government has already taken this first step (some of these are already in process as
mention in section 2.5 & 2.6). However, the commission should be the enforcing entity (with a
sense of urgency) that monitors and makes sure that these measures are indeed effectively
implemented. The project NHN should be seen as the opportunity to prepare and realize the
reforms within Curaçao’s health system. Many of the reform strategies proposed can and must
be implemented much earlier. Ideally, the necessary reforms should be implemented at the time
the new hospital opens its doors.
The second step should be to provide universal health care access to the population of Curaçao.
This should be done in cooperation with all participating stakeholders. The ‘Health Commission’
should perform as the decision making entity in case of disagreements among stakeholders.
The third step in this reform process is, to increase quality of care and increase cost efficiency
and cost effectiveness, thus investing in a Health Information System is a must. The
implementation of a Health Information Systems needs leadership, governance and vision of the
government together with the cooperation of all stakeholders involved for it to be successful.
The implementation of the recommendations in this master thesis requires first a strong and
clear direction from the government, which has been lacking in recent years (chapter 2). A
government that recognizes the need for cost control and reduction should not hesitate in
taking the right measures to gain control. Many plans have been written and recommendations
have been drafted in the past, waiting for the government to take actions.
The costs are fairly high, but there are enormous payoffs in long-term investment in health care.
Such investments can not only raise the quality of life for the population but also make the
health care industry in Curaçao a great force for economic growth. Health care reform is urgent
and strong government commitment is the key to its success. Curaçao needs decisive leaders
with a sense of urgency and proper steering capabilities to direct, only then the reform of
Curaçao’s health system will succeed.
90
REFERENCES
Algemene Ziektekosten Verzekering Aruba. Gecombineerd financieel verslag AZV 2012. Verslag
van de Raad van Commissarissen, p 8-24.
Annalise Marketing Intelligence. (2013). Inzicht in geldstromen zorgverzekeraars. VvAA.
Arnell, S. (2012, October 31). Sint Maarten’s Health System reform. 7th Annual Caribbean Health
Care Conference, Hilton Curaçao.
Boas, G. (2006). Rapport National Health Accounts Financieel Overzicht Gezondheidszorg 2001 –
2004 Aruba. Maastricht Health Economics Research and Consultancy Agency (MHERCA).
Boas, G. (2005). Financieel Overzicht Gezondheidszorg (FOG) 2002-2003. Utrecht: MHERCA.
Boston Consulting Group (2011). Zorg voor Waarde.
CCSS. (2009). Estados financieros del Régimen No Contributivo de pensiones (Financial
Statements of the Pensions Non-contributive Regime). San Jose, Costa Rica: Caja Costarricense de
Seguro Social.
Centraal Bureau voor Statistiek Nederland. (2012). Zorgrekeningen uitgaven (in lopende
constant prijzen) en financiering Nederland. Retrieved December 22, 2012, from
http://statline.cbs.nl/StatWeb/publication/?DM=SLNL&PA=71914ned&D1=a&D2=(l-2)l&VW=T
Centraal Bureau voor Statistiek Nederland. (2012). Gezondheid en zorg in cijfers 2012. Retrieved
February 15, 2013, from http://www.cbs.nl/nl-NL/menu/themas/gezondheidwelzijn/publicaties/publicaties/archief/2012/2012-c156-pub.htm
Clark, M. A. (2002). Health sector reform in Costa Rica: reinforcing a public system. Woodrow
Wilson Center Workshops on the Politics of Education and Health Reforms (pp. 1-23). Washington
D.C.: Tulane University.
CPB (2010). Economische verkenning, zorguitgaven scenarios 2011 – 2015. no. 203.
CTG. (2005). Prestaties en maximumtarieven voor huisartsenhulp m.i.v. 1 januari 2006. College
Tarieven Gezondheidszorg (CTG).
Cushnie, A. (2010). A Case Study of Jamaica’s Health Financing System and its Impact on the
Performance of the General Health System. Masters Thesis for the degree of Master of Science in
International Health . Jamaica: Royal Tropical Institute (KIT).
91
Daley, C., Gubb, J. (2011). Health care systems: The Netherlands. Retrieved Jan 20, 2013, from
http://www.civitas.org.uk/nhs/download/netherlands.pdf
Delnoij, D. M., Hendriks, M., Brouwer, W., Spreeuwenberg, P. (2006). Differences between
insurance organizations: do consumers perceive differences in important areas? European
Journal of Public Health, 16 (1), 29-42.
Departement of Economic Affair. (2011). Curaçao Economic Outlook 2011; En route towards the
strengthening of new country Curaçao. Government of Curaçao. Ministry of Economic
Development, p 113-122
Department of Economic Affair. (2010). Curaçao Economic Outlook 2010; The crossroad to an
autonomous country within the Dutch Kingdom. Island Territory of Curaçao. DEZ. (2010). Dienst
Economische Zaken, p 98-102
Douven, R., Ligthart, M., Mannaerts, H., Woittiez, I. (2007). Een scenario voor de zorguitgaven
2008-2011. CPB, no. 121.
Duits, A. (2012, October 30). Value-based health care in communities with limited resources. 7th
Annual Caribbean Health Care Conference, Hilton Curaçao.
Fontilus, P., Vos, G. (2002). Notitie n.a.v. de Discussienota BZV/DEZ, Prijs- en inkoopmanagement
in de geneesmiddelenkolom.
Fontilus, P. (2005). Nu moet het, nu kan het!; kostenbeheersing in de geneesmiddelenvoorziening
op de Nederlandse Antillen. NASKHO Post Graduate Course.
Gerstenbluth, I., Wijk van, N. Ph. L. (2004). Statistisch Overzicht van de gezondheidszorg Curaçao:
1996 - 2000. GGD Curaçao, Dept. Epidemiology & Research Unit.
Giedion, U., Villar, M., Ávila, A. Los sistemas de salud en Latinoamérica y el papel del seguro
privado. Madrid: Fundación MAPFRE; 2010. Retrieved January 20, 2013 from
http://www.mapfre.com/ccm/content/documentos/fundacion/cs-seguro/libros/los-sistemasde-salud-en-latinoamerica-y-el-papel-del-seguro-privado.pdf
Gordon-Strachan, G., & Brenzel, L. (2010). Rapid Assessment of the Impact of the Economic Crisis
on Health Spending in Jamaica. World Bank Working Paper, World Bank, Washington, DC.
Hemel van, L. (2007). Verpleegkundige concepten en methoden. Garant-Uitgevers NV, p 45
92
Hoogervorst, H. (2004). Speech Minister Hans Hoogervorst (Health, Welfare and Sport) The
Netherlands. Retrieved Jan 24, 2013, from OECD Health Ministerial Meeting:
http://www.oecd.org/dataoecd/21/19/31752956.pdf
Huizing, N. (2012, October 30). Quality of Health care – Initiatives to promote quality of health
care. 7th Annual Caribbean Health Care Conference, Hilton Curaçao.
Jamison, D. T., Breman, J. G., Measham, A. R., Alleyne, G., Claeson, M., Evans, D. B., Jha, P., Mills, A.,
Musgrove, P. (2006). Pillars of the Health System. Priorities in Health,ed., 155-178. New York:
Oxford University Press, Chapter 7, P 155-177.
Kalma, D. (2012, October 31). Country update BES: Introduction of a new general Health
Insurance. 7th Annual Caribbean Health Care Conference, Hilton Curaçao.
Knappen, M., Boot, J. (2005). De Nederlandse gezondheidszorg. Bohn Stafleu van Loghum,
Houten.
Maarse, H. (2007). Health reform - one year after implementation . Retrieved Jan 22, 2013, from
Health Policy Monitor: http://www.hpm.org/survey/nl/a9/
Mercera, C. (1993). Discussie nota Financieel Overzicht Gezondheidszorg Nederlandse Antillen, p
3-7
Montenegro Torres, F. (2013). Costa Rica Case Study: Primary Health Care Achievements and
Challenges within the Framework of the Social Health Insurance. Universal Health Coverage
(UNICO) studies series; no. 14. Washington D.C.: The World Bank.
Muiser, J. (2007). The new Dutch health insurance scheme: challenges and opportunities for better
performance in health financing. Geneva: WHO.
Müge, O., Laing, R. (2005). Pharmaceutical Tariffs: What is their effect on prices, protection of
local industry and revenue generation?. The Commission on Intellectual Property Rights,
Innovation and Public Health. WHO.
National Health Fund (NHF) Jamaica. (2012, October 31). Overview NHF Jamaica. 7th Annual
Caribbean Health Care Conference, Hilton Curaçao.
National Health Fund (NHF) Jamaica. (2012, October 31). Health Promotion & Illness Prevention
Programs. 7th Annual Caribbean Health Care Conference, Hilton Curaçao.
NHF. (2009). The NHF Annual Report. Kingston: The National Health Fund Jamaica. Ministry of
Health and Environment.
93
Organization for Economic Co-operation and Development (OECD). 2012. StatExtracts.
Retrieved December 22, 2012, from
http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#
Pan American Health Organization (2012). Development of policies & institutional capacity for
health planning and management. Retrieved December 22, 2012,
from http://new.paho.org/hq/index.php?option=com_content&view=article&id=4022%3Aresu
ltados-fesp-05%3A-desarrollo-de-polunticas-y-capacidad-instituc-de-planificac-y-gestiun-materia-sp&catid=3376%3Ahss021101-performance-measurement-ofephfs&Itemid=3621&lang=en
Pan American Health Organization (2013). Costa Rica, Country profile. Retrieved January 20,
2013 from
http://new.paho.org/saludenlasamericas/index.php?option=com_content&view=article&id=31
&Itemid=31&lang=pt
Pan American Health Organization (2010). Health care profile: Aruba. Retrieved Jan 26, 2013,
from http://www.paho.org/english/dd/ais/cp_533.htm
Post, D. (2002). Pijnlijke keuzes bij schaarse middelen; De gezondheidszorg nader bekeken.
Rijksuniversiteit Groningen, Instituut Sociale Geneeskunde.
Radio Nederland Wereldomroep. Medicijnimporteurs hanteren woekerprijzen op Curaçao.
Retrieved January 20, 2013 from http://www.rnw.nl/caribiana/article/medicijnimporteurshanteren-woekerprijzen-op-cura%C3%A7ao
Rijksinstituut voor Volksgezondheid en Milieu, RIVM. (2010). Zorgbalans 2010. Retrieved
December 22, 2012, from
http://www.gezondheidszorgbalans.nl/onderwerpen/kosten/zorguitgaven/zorguitgaven_bbp.
Rijksoverheid (2011). Rijksministerraad geeft Curaçao aanwijzing. Retrieved October 3, 2012,
from http://www.rijksoverheid.nl/nieuws/2012/07/13/rijksministerraad-geeft-Curaçaoaanwijzing.html
Ringeling, A. (2012, October 30). National Health Insurance Aruba (AZV). 7th Annual Caribbean
Health Care Conference, Hilton Curaçao.
Rosenau, P., Lako, C. (2008). An Experiment with Regulated Competition and Individual Mandates
for Universal Health Care: The New Dutch Health Insurance System. Journal of Health Politics,
Policy and Law 33 (6): 1031-1055.
94
Sáenz, M. d., Bermúdez, J. L., Acosta, M. (2010). Universal Coverage in a Middle Income Country:
Costa Rica. Washington DC: World Health Organization.
Schut, F. T., VandeVen, W. P. (2005). Rationing and Competition in the Dutch Health Care
System. Health Economics, 14 (6), 59-74.
Schut, F. T., Greb, S., Wasem, J. (2003). Consumer Price Sensitivity and Social Health Insurer
Choice in Germany and the Netherlands. International Journal of Health Care Finance and
Economics, 3, 117-138.
Shiyan, C. (2013). Jamaica's effort in improving universal access within fiscal constraints.
Universal Health Coverage (UNICO) studies series; no. 6. Washington D.C.: The World Bank.
Siddiqi, S., Masud, T., Nishtar, S., Peters, D., Sabri, B., Bile, K., Jama, M. (2008). Framework for
assessing governance of the health system in developing countries: Gateway to good governance
Elsevier Ireland Ltd.
Staten van Curaçao (2013). Landsverordening Basis Verzekering Ziektekosten.
Staten van Curaçao (2013). Memorie van Toelichting (Landsverordening basisverzekering
ziektekosten) no. 3. 16 januari 2013, p 1-16.
Stichting ISOG 2000 (2008). Integraal Zorgbeleid: Basis concepten.
The WorldBank. (2013). Health expenditure, total (% of GDP). Retrieved January 31, 2013, from
http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS
The World Bank (2012). World Development Indicators. Retrieved February 13, 2013, from
http://data.worldbank.org/data-catalog/world-development-indicators
USONA (2013). ‘USONA antwoord op 10 veel gestelde vragen over Nos Hospital Nobo’. Retrieved
May 28, 2013 from http://www.usona.an/nos_hospital_nobo/
USONA (2013). ‘Presentatie Staten 20 maart 2013’. Retrieved June 25, 2013 from
http://www.usona.an/nos_hospital_nobo/
USONA (2013). ‘Openbrief 28 maart 2013. Retrieved June 25, 2013 from
USONA (2013). ‘Beantwoording Statenvragen maart 2013’. Retrieved June 25, 2013 from
95
Verschuren, P., Doorewaard, H. (2010). Designing a research project. Eleven International
Publishing, The Hague.
Vugt van, F. (2007). Zorg voor de kosten: een onderzoek naar mogelijkheden tot kostenbeheersing
en –reductie in de gezondheidszorg op Curaçao. Public Consultancy Nederland.
Vugt van, G. W. M. (2006). Rapportage over de quick scan (nul-meting) inzake de sturingsrelatie
Eilandbestuur Curaçao – (gesubsidieerde) stichtingen. Public Consultancy.
Vugt van, G. W. M. (2006). “De Doorstart”; notitie Nieuwe subsidiebeleid voor het Eilandgebied
Curaçao. Public Consultancy.
Westerhof, R., & Felida, P. (2012). Zorgrekeningen Curaçao 2008-2011. Volksgezondheid
Instituut Curaçao (VIC).
Wikipedia (2012). Zorgverzekering Nederland. Retrieved April 23, 2013, from
http://nl.wikipedia.org/wiki/Zorgverzekering_(Nederland)#Premie
World Health Organization (WHO). World Health Statistics 2011. Retrieved August 15, 2012,
from http:www.who.int/whosis/whostat/en/index.html
World Health Organization (WHO). National health accounts estimates. Global Health
Expenditure Database. Retrieved January 20, 2013 from
http://apps.who.int/nha/database/DataExplorerRegime.aspx
World Health Organization (2008). Framework and Standards for Country Health Information
Systems. WHO Library Cataloguing-in-Publication Data.
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ANNEXES
1. Panel of Experts:
Drs. Croes, R. RA
 Former advisor to the Aruban Government regarding preparation, organization and
implementation of the General Health Insurance (AZV).
 Former director of AZV between 2003-2009.
 Founder and Director of Medwork Caribbean N.V (advisory on health care and health
care reform).
Mr. Westerhof, R.
 Mr. Westerhof, together with Drs. Felida, have performed the research ‘Zorgrekeningen
Curaçao 2008-2011’, which was published by ‘Volks Instituut Curaçao’ in December
2012.
 Mr. Westerhof also performed the forecast cost saving on BVZ in the ‘Memorie van
Toelichting Landsverordening Basis Verzekering Ziektekosten’ of January 16th 2013.
Drs. Pinedo, D.
 General Practitioner for 27 years on Curaçao (Shell, ‘Centro Medico Aesculapius’)
 Former Medical Director and General Manager at SEHOS from 2005-2009
 Currently, Board Member of ‘Fundashon Prevenshon’
97
2. List of Interviewees
- Drs. R. Croes, Director, Medwork Caribbean N.V.
- Drs. G. Spijker, Manager Cure, SVB
- Drs. I. Gerstenbluth, Epidemiology Unit, GGD
- Mr. R. Westerhof, ‘Zorgrekeningen 2008 – 2011’, VIC
- Mr. R. Anandbahadoer, ‘Beleidsmedewerker’, Ministry of Finance
3. List of websites consulted
www.vic.cw (Volksgezondheid Instituut Curaçao)
www.overheid.aw (Gobiernu di Aruba)
www.azv.aw (Algemene Ziektekosten Verzekering Aruba)
www.en.wikipedia.org/wiki/Health_care_in_Costa_Rica (Health care in Costa Rica)
www.who.org (World Health Organization)
www.paho.org (Pan American Health Organization)
www.theworldbank.org (Health development indicators)
www.oecd.org (Organization for Economic Development)
www.ctg.nl (College Tarieven Gezondheidszorg)
www.cvz.nl (College voor zorgverzekeringen)
www.gipdatabank.nl (themasite over medicijnen en hulpmiddelen van het College voor
zorgverzekeringen)
www.huisartsvandaag.nl (medische portal)
www.igz.nl (Inspectie voor de gezondheidszorg)
www.kiesbeter.nl (programma KiesBeter: consumenteninformatie en benchmarks over de
zorg)
www.lhv.nl (Landelijke Huisartsen Vereniging)
www.medicijngebruik.nl (DGV, het Nederlands instituut voor verantwoord medicijngebruik)
www.nza.nl (Nederlandse Zorgautoriteit)
www.rvz.nl (Raad voor de Volksgezondheid en Zorg)
www.sfk.nl (Stichting Farmaceutische Kengetallen)
www.snellerbeter.nl (programma SnellerBeter: prestatie-indicatoren in de zorg en
voorbeeldprojecten)
www.vektis.nl (centrum voor informatie en standaardisatie voor de zorgverzekeraars)
www.zn.nl (Zorgverzekeraars Nederland)
www.zorgvisie.nl (Zorg Visie, magazine voor beleid en management voor de gezondheidszorg)
www.ziekenhuizentransparant.nl (kwaliteitscriteria ziekenhuiszorg)
99

here - Medwork

Transcription

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