Meeting of Directors of Social Security Organizations in the English-speaking Caribbean

Presentation by Dr. Ramon Figueroa,

Social Security Board

Belize

OUTLINE OF PRESENTATION

• INTRODUCTION- Case for NHI

• Conceptual Design:– Vision of the New Health System– Strategic objectives– Paradigm shift

• Pilot project– Package– Results

OUTLINE OF PRESENTATION

• Post-Pilot:– Extensions– Changes– Results

• Where we are now– Financing– Schedule of roll-out– Model

• Lessons learned

MEXICO

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INTRODUCTION• Population: 282,600 (2004 mid-year estimate)• Rural (141,600); Urban (141,000)• Land area: 23,000 squ. Km (8867 sq. Mls)• Administratively divided into six districts.• Multiethnic society (garifuna, maya, creole,

mestizo, chinese, East Indian, Mennonite)• Primary Income earners: Tourism, Agriculture,

shrimp farming.• GDP Per capita 3,753 US (2004).• Unemployment rate at 11.6 % (2004)• Poverty rate at 33.5 % (LSMS 02)• Health Expenditure (4.7 % of GDP); 52 % public

and 48 % private expenditures; 176 US per capita (1997)

INTRODUCTION (CONT.)• Challenges*:

– Ineffective and inefficient public system;– Under-funded health system;– Poor accountability, discipline, attendance and

“customer service”;– Few meaningful incentives within public sector;– Over-centralized command and control in MOH with too

many vertical programs;– Haphazard and limited growth of private sector;– Misallocation/insufficiency of resources in public sector.

*Belize Ministry of Health and Sports Health Policy Reform Project, Final Report, Prepared by CCC, August 7, 1998

VISION

“We envision a national health care system which is based on equity, affordability, accessibility, quality and sustainability in effective partnership with all levels ( sectors ) of government and the rest of society, in order to develop and maintain an environment conducive to good health.”

“Health Sector Reform is a process aimed at introducing substantive changes in the different structures and functions of the sector, with a view to increasing the equity of its benefits, the efficiency in its management, and the effectiveness of its actions; and through this to achieve the satisfaction of the health needs of the population. It is an intense phase of transformation of the health systems based on situations that justify and make it viable.”

HEALTH REFORM

STRATEGIC OBJECTIVES

1. Develop the function of MOH to become a strong regulatory and policymaking entity.

2. Decentralization of responsibility and accountability.

3. Development of internal market mechanisms.

4. High degree of flexibility.

5. Clear separation of financing and delivery.

6. Gradual introduction of competition in quality and efficiency.

7. Ensure greater accountability to patients.

8. Seek value for money.

PARADIGM SHIFT

PROVIDER

PURCHASER USER

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PILOT PROJECT• Population of 36,853 in economically deprived area of city.• Officially launched by PM on 9th Aug, 2001• Project was officially “ended” Feb 12th, 2002: Evaluation

conducted• Parameters: 1 physician team per 4,000 population

– Group practice model– Tendering process followed.– Evaluation of facilities to ensure basic standards met.– Contractual agreement established– Contractor Generals office involved.

• Included:

– Primary care providers- 4 (3 private and 1 public)-– Pharmacies-5 private – Laboratories-3 private – imaging services-3 private – Hospitals-3 (1 public and 2 private) – Ophthalmology-3 private –

1.1 Covered Services.

(i) General Medicine, including general consultations by the covered population, programmed consultations, emergency services during work hours in the PCP installations, and other services as stipulated by this agreement;

(ii) Nursing Services, including general consultations

by the covered population, programmed consultations, emergency services during work hours in the PCP installations, and other services as stipulated by this agreement;

(iii) Consultations with Pediatrician (5 hours per week) (iv) Consultations with Obstetrician (5 hours per week)

(v) Clinical Laboratory services offered in Belize (vi) Generic Pharmaceutical products included in the

National Formulary;

Services included

in the PHC Package...

Based on needs for a

population of 4,000

1.1 Covered Services.

(i) Health Prevention and Promotion (ii) Specific programs:

Detection, treatment and monitoring of patients with hypertension

Detection, treatment and monitoring of patients with diabetes (type 1 and 2)

Detection and monitoring of patients with HIV/AIDS Pre and Post Natal Monitoring, including consultations with

GP, iron and folic acid, 1 ultrasound exam, basic laboratory and blood test (including HIV and VDRL first trimester)

Minor Surgery that can be carried out in an ambulatory setting

Family Planning Counseling and Services Early detection of breast cancer using mamography in

women 50 to 65 years of age treated at PCP point of service, and 40+ high risk category

Early detection of cervical cancer using papanicolau screening in women from 30 to 65 treated at PCP point of service

Early detection of prostrate cancer in men over 50 years of age (every 2 years)

Detection and control of Tuberculosis Epidemiological surveillance

(iii) Radiological and Imaging Tests available and authorized in Belize, excluding Magnetic Resonance Imaging

(iv) Control and treatment of employment injury insurance cases at primary level

Services included

in the PHC Package

(cont…)

Specialist Services included in the Hospital Package...

• Obstetrics

• Gynecology

• Internal Medicine

• Pediatrics

• Surgery

• Orthopedics

• Ophthalmology

• Dermatology

• Outpatient Surgery

• Urology

• Neurology

Including all specialistservices

currently offered in Belize

•Contracting limited to budget cap of NHI•Contracting at pre-established Price•Contracting only with accredited specialists•Control of specialists consultations by hospital

ANALYSIS OF RESULTS

ResultsIntermediate ObjectivesFinancial sustainability

Area of Analysis Objectives No. Performance Prior To Pilot Results of Pilot

Financial Sustainability

1 60% of baseline survey respondents receive Healthcare free of cost

90% of the NHI Pilot sample receive healthcare free of cost

2 27% of baseline survey respondents pay more than $40 on a regular visit; out of pocket spending for yr 2000 was approx. 4 million (includes clinic/hospital, medication, lab, and X-ray)

$0 out of pocket expenditures during Pilot (includes clinic/hospital, medication, lab, and X-ray)

3 $189 per capita MoH spending in year 2000;$205 private

$220 per capita spending during Pilot (annualized);$ 189 MoH

Determine capacity of the system to adequately meet the healthcare needs of the population while maintaining financial viability

Source: NHI, Baseline Survey

Table 22. Analysis of Financial Sustainability

ANALYSIS OF RESULTS: Equity and Access

B. Respondents who are within 30 minutes walking distance to clinic 37% 50%

Source: University of Belize Pre-pilot survey data and SPEAR Post-Pilot survey data

Table 9: NHI improvement in physical access of health services

Supporting Facts Pre-Pilot Post-Pilot

C. Respondents who wait < 30 minutes once at clinic 38% 44%

Equity and access (cont.)

             In terms of access to specific services :

o      1. 55% of population of women 40-69 years of age were screened for breast cancer.

o       2. 51% of target population of men > 50 years of age were screened for prostate cancer.o       3. 31% of target population of women 30-69 years of age were screened for

cervical cancer.

At the Primary level, the ratio of GP/1000 population increased from 0.05 pre-pilot to 0.32 during pilot thus increasing accessibility of population to a General Practitioner. The ratio of Nurse/1000 population increased from 0.11 to 0.6 per 1000 population. Total clinic hours open to the public increased by 3.7 times/day (normal week days) but was only open for 4 hours on weekend.

            

Equity and access (cont.)

B. Respondents who need to see and have seen specialist 36 %

D. Respondents who cannot afford medication prescribed 24 % 2 %

E. Respondents receiving medication with no cost at point of service 34 % 100 %

F. Respondents who receive healthcare services with no cost at pt of service 60 % 100 %

G. Respondents who have been prescribed lab tests 37 %

Percent that received it with no cost at point of service 67 % 100 %

H. Respondents who have been prescribed imaging tests 41 % 35 %

Table 10: Improved access to the most appropriate level of careSupporting Facts Pre-Pilot Post-Pilot

Percent that received it with no cost at point of service 40 % 100 %

Source: University of Belize Pre-pilot survey data, and SPEAR Post-Pilot survey data

A. Respondents attended by GP 40 % 90 %

98 %

55 %

Efficiency and Productivity

              The volume of care delivered to the population was significant: • 1. 21,588 total consultations made by four Primary Care Providers[1].o       2. 495 total hospitalizations from one public and one private institution.o       3. 13,901 total prescriptions given out.o       4. 4,213 total imaging referrals made.o      5. 6,091 total laboratory referrals made.o     6. 688 total eyeglasses given to children between ages of 7 to 19.o       7. 129 total cataract surgeries performed.o      8. A total of 2,220 specialist visits were made.o       9. 1,100 people from outside the pilot project area received medical care        The primary care clinics improved the efficiency of the system as evidenced by a reduction in population seeking specialist care without a referral.

a. Prior to pilot implementation there were approximately 341 outpatient consultations per 1000 population per annum without a referral in Belize South Side, versus 76 per 1000 population per annum.

       b. Ninety percent of all respondents used the GP as means of entry into the system, versus only 40% prior to the pilot project.

      

Effectiveness and Quality

Five major protocols were developed during the Pilot Project: Asthma, Diabetes, Hypertension, Congestive Heart Failure, and Myocardial Infarction.

  All physicians and nurses participating within the provision of services in the Pilot were trained in the use of the protocols.

Medical Audits were conducted to evaluate the application of the Asthma, Diabetes and Hypertension protocols at the primary level.

Effectiveness and Quality

A. Respondents that wait < 30 minutes for lab tests 48 % 58 %

Respondents that have test results explained to them 89 % 100 %

B. Respondents that wait < 30 minutes for imaging tests 58 % 69 %

Respondents that have test results explained to them 90 % 99 %

Source: NHI data and University of Belize Pre-pilot survey data, and SPEAR Post-Pilot survey data

Table 18: Explanation of tests and treatments

Supporting Facts Pre-Pilot Post-Pilot

C. Respondents that receive full treatment explanation from doctor 58 % 89 %

Effectiveness and Quality

A. Respondents that believe they are receiving the best healthcare possible 20 % 61 %

B. Respondents that are always treated with courtesy and respect 59 % 90 %

C. Respondents that spend more than 15 minutes with GP 37 % 75 %

Source: NHI data and University of Belize Pre-pilot survey data, and SPEAR Post-Pilot survey data

Table 19: Perception of healthcare

Supporting Facts Pre-Pilot Post-Pilot

Respondents that feel that doctor always explains treatment fully 58 % 88 %

Effectiveness and Quality

BFLA 86 %

IHC 85 %

BMA 81 %

Source: NHI/MOH survey data and Sanigest International Analysis

Table 21: Percentage of Patient Satisfaction by PCP

PCP Qualification

MRHC 75 %

Effectiveness and Quality

Private 89 %

Public 69 %

Source: NHI/MOH survey data and Sanigest International Analysis

Table 22:Patient Satisfaction Survey Results by Hospital

Hospital Percentage Satisfaction

Effectiveness and Quality

Table 24: Protocol implementation

BMA 75 % 75 % 57 %

BFLA 63 % 75 % 57 %

IHC 75 % 75 % 57 %

Source: NHI protocol evaluation data and Sanigest International Analysis

Provider Asthma Hypertension Diabetes

MRHC 50 % 75 % 57 %

SOCIAL PARTICIPATION

BFLA 3442 8 % 10 % 2 %

BMA 4650 3 % 12 % 9 %

IHC 8743 8 % 3 % -5 %

MRHC 4447 9 % 7 % -2 %

Source: NHI data system

Table 14: PCP members and transfers

PCP Members per PCP

Members transferred to another PCP as a

percentage of total members

Members transferred to the PCP as a percentage of total

membersDifference

Total 21282 7 % 7 % 0 %

2001: Before reforms

MOH39%

SSB and others

1%

Private60%

Estimated Out of Pocket Expenditure 2000 (South Side Population)

Clinic/Hospital $296,298

Medication $386,680

Lab $312,560

X-ray $1,034,279

Total $2,029,817

Source: University of Belize Pre-pilot survey data

Expected Contribution by Economically Active Population during 6 month period

Population Belize South Side 36,850

Economically Active Population

35,000

Yearly contribution/person 32

Total yearly contribution $4,179,130

6 months $2,089,565

Source: Ministry of Health data; NHI data; Sanigest analysis

After NHI Introduction 2002

NHI38%

Copayment3%

Private25%

MOH34%

The NHI South Side Project-Post-Pilot

• Extensions (5 total from Feb 12th, 2002 to May, 2003)…addendums-Adjustment of Hospital package, introduction of co-payments (support services)– Financial limitations (SSB financing scheme)

• New Contracts June 2003-March 2004– PMPM changed from $7.03 to $6.30 (70/30)– Changes in package of services: co-payments, limited

hospital services (deliveries).• Extended April to Dec 2004;• Extended Jan05 to March, 2006)

standards for Incentive payments (70/30)

Performance Checklist for monthly evaluation (simulation)

Item Standard max Dr 1 Dr2 Dr3 Adm  

  payment amt          

from Encounter Form: monthly data            

Efficiency Indicators: (70%)   #REF!          

1. Productivity per GP team/day 28-36 pts/shift #REF! $529 $529 $529    

2. Rational drug usage (items/encounter) <=2 $1,985 $662 $529 $529    

3. Rational imaging usage(items/encounter) <=1 $1,985 $662 $529 $529    

4. Rational Laboratory usage(items/encounter) <=4 $1,985 $662 $529 $529    

               

Quality Indicators:(20%)   #REF!          

from Surveys/Inspections (bi-annual):              

5. Patient satisfaction: survey >=80% #REF!       $756  

6. Medical Records Compliance >=99% $756       $756  

7. Medical Audits 70% $756       $756  

Administrative Indicators:(10%)   #REF!          

8. Unreported Encounters/Activities<0.5% Margin of error #REF!       $567

9. Data entry errors <1.0% Margin of error $567       $567  

CLINICAL RECORD AUDIT RESULTS (AUGUST 2004)

• MRHC ………….78 %

• BFLA…………….63 %

• IHC………………61 %

• BMA……………..45 %

PATIENT SATISFACTION SURVEY RESULTS

PCP IHC BFLA BMA MRHC

2001 85 % 86 % 81 % 75 %

2003 85 % 82 % 81 % 72 %

2004 91 % 92 % 93 % 89 %

FINANCIAL PERFORMANCE (2004)

• Expected expenditure to date should be 100 %(April to Dec 04)Total NHI Expenditure……………81.4 %

PCP expenditure………..96 %Lab expenditure…………76.5 %Imaging expenditure……47.6 %Pharmacy expenditure….71 %Ophthalmology…………..25.7 %Hospital services…………88.9 %

NHI Expenses by Institution June 2001 to May 2003

CDS 1%

BDC 7%

HEC 1%

BCVI 1%

BVC 1%

Brodies 3%

1st Choice 6%

UHS 25%

BMA 39%

P Sector7%

G Care1% BFLA 8%

BMA Per type of service June 2001 to May 2003

BMA Hospital, 46.80%

BMA SSClinc, 23.09%

BMA Lab, 15.43%

BMA Pharmacy, 3.30% BMA Diag Centre,

6.80%

BMA Specialist, 4.58%

BMA SSClinc

BMA Lab

BMA Diag Centre

BMA Pharmacy

BMA Hospital

BMA Specialist

SUMMARY

• Contracts extended up till March of 2006 for the South Side of Belize City.

• PMPM adjustment..($4.41 + $1.89 presently)• Expenditures kept under control using Monthly

Incentive Scheme (performance benchmarks)• Cabinet decision to roll to the South of country,

based on the public sector strengthening.– Long term financing source still a question.– Medium term financing by SSB, MOH, Gob.

Budget Projection for Roll Out.

 

Roll Out of NHI

       

  2005-2006 2006-2007 2007-2008

Total Budget $ 11,386,211 $ 19,427,670 $ 26,918,622

SSB Contribution $ 5,000,000 $ 5,000,000 $ 5,000,000

MOH Contribution  $ 1,086,127$ 5,885,264 (estimate) $ 8,008,267 (estimate) 

Gov Contribution  $ 5,300,084  $ 8,542,406  $ 13,910,355

 Administration  $ 860,879  $ 1,019,592  $ 1,153,787

Draft Schedule for Roll-Out

• 2005-2006……South Side Belize+ Toledo+ Stann Creek.

• 2006-2007……Add North of Belize District + Corozal + Orange Walk

• 2007-2008……Add Cayo District.

NEW MODEL (Flexibility)

• Scenario: Rural, remote areas, poor accessibility, poor/limited infrastructure; population of approximately 30,000; multi-culture (Garifuna and Maya predominantly); highest poverty pockets; lowest literacy.

• Based on Public Health System.• Apply contractual model with incentives

built in.• Monitoring and Evaluation of performance.

LESSONS LEARNED

1. Turf War.

2. Perception of privatization

3. PR/PI Campaign (Marketing NHI)

4. Institutional strengthening.

5. Monitoring and evaluation.

6. Leadership.

7. Political advocacy

8. “Window of opportunity”

THE END

THANK YOU !!!!!