Island Council Meeting February 9th 2009
Commissioner Maria Buncamper-Molanus
Agenda # 8 Topic: (AZV-Project) National Health Insurance Project
On September 11, 2007 the Executive Council Of St. Maarten approved, in
principal, the review of the present health insurance system, considering
the concept of a national health insurance system for Country St. Maarten.
Research was done and discussions were held including members of the Island
Council. You may recall the document at the basis of this discussion being
that which was prepared by BMC titled "Met the welvaart stijgen de kosten".
It is clear that the way forward and goals to be achieved in country SXM
should be that of universal health care to guarantee access to health care
services for all residents.
Being realistic about the size of the informal economy, the consideration
for the establishment of an emergency fund for uninsured undocumented
The documents related to the research and discussions are:
1. The discussion paper "Alternative Contribution Systems";
2. the proposed basic package for the National Health Insurance Country St.
3. The "Terms of Reference" i.c.w. the bidding process for the future
exploitation organization for the N.H.I.;
4. The Project organization planning in terms of time needed to introduce
5. The proposal by "Keesen Actuarissen" for the preparation of a scenario
model to determine the appropriate premium structure and level.
All these documents have been submitted to the members of the Island
Mr. Chairman, allow me now to continue with providing the council with a
synopsis of each of these documents:
Based on the discussion regarding the paper "Alternative Contribution
System", it became obvious that the choice for a premium or contribution
system could not be solely based on an evaluation of several alternatives.
The current and future level of health care, the basic healthcare package,
the increasing cost and the aging are all factors that must be considered.
As a result of the consultation rounds with several stakeholders a preferred
package was identified. This package would be based on that which is
currently available in the Netherlands including the AVBZ care. This would
be the basis for our N.H.I system.
The objective of the T.O.R. is to guide the selection process of the future
local, regional and international insurer, as the professional exploitation
organization of the National Health Insurance. With this T.O.R. the bidding
process can be organized.
The T.O.R. is still in draft form because several issues still have to
receive a final decision before we can proceed. These issues are:
– The legal structure of the organization (Public or Private),
– the premium (will it be income based or a nominal amount, or a
– as well as the final decision on the basic health insurance package has
to be made.
In the T.O.R. a project organization is proposed consisting of the
– Stuur groep: responsible for achieving the objective which is the
implementation of the NHI – its members: Project Manager Constitutional
Affairs and several directors.
– Project management
– Committee of Experts: for the development of certain aspects, such as the
premium structure, communication and legislation.
– And an advisory committee: These are the stakeholders in the field who
can advice Government about the implementation (with the ins en outs).
January 1st 2010 has been targeted for the implementation of the N.H.I.. It
is for this reason that we must intensify the preparation for the
implementation of the N.H.I.. In line with this a duo-project management
team is proposed. Two experienced senior policy advisors have been selected
from within the Government organization, namely Drs. M. Koopman and Drs. R.
Finally, the company Keesen Actuarissen gave a demonstration of interactive
scenario models of national health insurances. Mr. Laurence H.M. Keesen, an
actuary established on Curacao, proposes that a scenario model be designed
specifically for St. Maarten. This scenario model will provide valuable
insight into the questions related to how we should pay for the national
health insurance for the people of St. Maarten. Here again the question on
whether this should be based on:
1. a nominal amount or on the level of income of those paying into the
national health insurance.
2. taking into consideration the short and long term aspects;
3. demographic factors such as aging;
5. economic growth;
6. and inflation.
The model consists of several parameters which can vary. Examples of the
a. Economic growth
c. Birth rate
f. Salary structures
g. Interest rates
The value of these parameters can be changed and within seconds the
consequences on the financing or cost of the NHI system can be established
immediately. It is for this reason that the scenario model is a powerful
policy tool/instrument to be used in the critical process of determining the
premium necessary to pay for the cost of the basic health insurance package.
With the Scenario model you will be able to show or demonstrate the
consequences of the choice for example of level of the premium.
This scenario model will also give us the ability to make the right
decisions now, to secure the feasibility on the long term. ……… In other
words, avoid major miscalculations that could lead to flaws in the decision
making for this major health reform.
Avoiding what has taken place in the Netherlands Antilles and in Aruba,
whereby the NHI are threatened by bankruptcy resulting in all sorts of
inconveniences, such as periodic increases in premiums, late payments to
healthcare providers, continuous reduction of the healthcare package, just
to mention a few.
The proposal made by Keesen Actuarissen for the development of the scenario
model for the N.H.I. for St. Maarten is USD 57.600.
The decision to present one proposal to the Island Council includes
considerations such as:
1. time factor;
2. no other actuary known;
3. experience / expertise (scenario model) with both health insurance and
The Island Council is requested to approve the NHI project; phase 1 to 3 of
the development of the scenario model for an amount of NAF 58.320,– and NAF
20.000 for travel expenses.
Should the proposal receive approval by the Island Council the following
resolution will be established:
THE ISLAND COUNCIL OF THE ISLAND GOVERNMENT OF ST. MAARTEN
That On September 11, 2007 the Executive Council Of St. Maarten approved, in
principal, the review of the present health insurance system considering a
national health insurance system for Country St. Maarten;
that the company Keesen Actuarisses made a proposal for the development of a
scenario-model to facilitate the critical decision process regarding the
final choice of the premium and basic package;
that the Scenario – model is a powerful policy tool in order to enable the
calculation into the future of the financing of the National Health
Insurance system for Country St. Maarten.
Having read the letter of the Executive Council of January 9th 2009;
To approve phase 1 through 3 of the development of the scenario-model,
– Phase 1: establishing the requirements of the scenario model;
– Phase 2: the collection of data;
– Phase 3: building the scenario model.
To approve the amount of NAF 58.320,– for phase 1 through 3 and NAF
20.000,- for travel expenses.
Start: February. Phase 1is expected to be completed in 2 months. To be
followed by the fundamental decision making about NHI package, contribution
system and executing agency in IC.
Mr. Chairman, when assuming the responsibilities that come with country
status, we should aim to improve the service government provides to its
citizens. With this in mind the Island Government has embarked on developing
a National Health Insurance System for the people of St. Maarten, which will
provide improved service to its people. The debate today covers a portion
of the many activities required to realize this NHI system, certainly a very
important portion that requires our keen attention and good, founded
Mr. Chairman with these final words I conclude my presentation and appeal to the Island Council for its support.