The National Coalition
For Health Care Reform

Article - 15th March, 2007

WHAT SHOULD BE DONE TO PROVIDE BETTER HEALTH CARE COVERAGE FOR ALL BAHAMIANS?
Find out where the National Coalition For Health Care Reform stands on the issues related to the proposed NHI!

The National Coalition for Health Care Reform (NCHCR) has repeatedly noted that it supports improvements to the health care system that will bring tangible and sustainable benefits to the Bahamian People. We are not simply about objecting to the creation of a National Health Care Plan. What we do believe however is that there is a better, more efficient, more effective way to ensure that Bahamian get access to the best possible health care at the best possible prices.

This series of articles will take an in-depth examination of the key principles of the NCHCR and demonstrate what significant issues we have with the current plan proposed by Government. We will also point out alternative approaches that we believe will lead to real and tangible improvements to the delivery of health care in our Country.

The Coalition is comprised of a wide range of organizations – from medical associations, to workers unions, to advocacy and research bodies, to private sector organizations. A casual look at our membership list would reveal the vast range of constituencies and viewpoints represented in the Coalition.

Therefore, at the outset of our exercise, it was important for us to agree upon the core principles and views that we share. These are encapsulated in our Statement of Purpose which articulates the eight guiding principles that we collectively agree should shape the health reform process in the country. So while our member organizations may articulate specific views and opinions that are in addition to the points highlighted in the Statement of Purpose, each member has subscribed at a minimum to the views expressed in the Statement.

Part Three of the series highlights the third principle in our documented Statement of Purpose.

3. True and Meaningful Consultation and Consensus: Reform dictates that the principal stakeholders must be equitable partners in the articulation, development and execution for improvements to the health care system.

The third principle that governs the National Coalition for Health Care Reform speaks to the essence of what we believe ought to shape the way in which the Bahamas, under any government, ought to approach the issue of the wholesale reform of health care within the country.

Initially, the member groups of the coalition were pleased to hear that the government would be engaging in a consultative approach to such an important national undertaking. We recognized that it would be critically important that all of the key stakeholders actually put all of their collective thinking and experience behind a venture that will impact, in such a significant way, upon the quality of life and the social and economic opportunities that we all enjoy.

Sadly, we must report that the effort of the various committees and task forces commissioned by the government, even up to now, have done little in the way of true and meaningful consultation. As we outline below, there has certainly been much activity and much public relations exercises. However, while we still hold out hope, the NCHCR has yet to see a commitment to the level of tangible and real consultation that is necessary if we are ever to shape a renewed health care system that represents the best thinking and the most suitable approach for our beloved country.

So, what has happened in respect to consultation on the proposed National Health Insurance (NHI) system? Going back to the Blue Ribbon Commission on health care, the members and staff of the Commission took great effort to meet with individuals to explain to them what the government had intended to do. In these meetings, little information was provided to the participants that would have assisted in forming a reasoned opinion. Whatever critical feedback was obtained through this exercise never made it to the Blue Ribbon Commission report. Instead, the report in large part only noted the names of the groups and individuals with which it had consulted. The report did not detail any critical remarks it received from this exercise.

At the next phase, the then Minister of Health, Dr. Marcus Bethel, led a delegation of the NHI task force that met with many key groups within civil society. These meetings revealed the skeletal structure of the proposed NHI through a short PowerPoint presentation and a small brochure. At these forums, questions were fielded from the audience, yet no other information was provided by the task force that would provide a basis to the proposed structure and strategy developed by the task force. Thus again, the participants could not and did not know upon which presumptions and analysis they were to base their opinions and shape their alternate "solutions" for health care reform. Further, as the process moved forward, it became increasingly clear that any constructive criticism or alternate approaches would not be entertained.

The consultations were in fact little more than public relation exercises. The task force and their spokespersons controlled the information flow. Depending on the audience, the pitch was based on an emotional appeal to a "world where all your medical bills would be paid for" (by somebody else of course) and one in which "no one would ever have to have a cook out because grammy needed an operation". Indeed, there is no evidence to suggest that the initial shape and structure of the proposed NHI has been amended at all due to the feedback received as a result of these "consultation exercises". The consultation was one-way. The task force spokespersons defended their positions and their analysis. They were not at these events to change their minds - to obtain the best possible thinking on a key point. Indeed, it was clear that there was never the intent for the exercise to be interactive, only informative.

The Coalition shares a different view on what consultation in this exercise should look like. Do we have all the answers? No, of course we do not. We know enough however to believe that we must approach this exercise with only the essential goal in mind. To us, that critical aim is NOT just to create a National Health Insurance scheme. (In fact, we believe that a part of the problem is that the solution was framed long before the problem was defined. Now, the task force is seeking to fit the problem into a pre-cast solution, as opposed to being free to look for the best solution). Our national aim must be bigger than a National Health Insurance scheme. We must look for the best possible way to improve and ensure the access to quality, reasonable and timely health care for all Bahamian residents.

Once we are able to shift our focus to the real purpose of this exercise, then we can look at different ways to get us to a place where Bahamians have accessible and affordable health care service - as opposed to looking at a way to introduce a National Health Insurance plan, even if there are better ways to achieve the goal.

If we then assume that our goal is quality health care for all, then we maintain that we must cast aside partisan and other special interests and create an atmosphere where all Bahamian stakeholders can collectively access the same information, the same studies, the same analysis and work through the key issues, challenges and opportunities to come to a consensus as to the best way forward for improving the delivery of health care throughout the country.

Thus, the consultation steered along this path would represent a true dialogue and exchange of ideas. It would be a robust and dynamic series of exchanges that can and would bring elements of global best-practices, as well as those innovations in health care peculiar to the Bahamas that have already demonstrated their value. Such an approach would, at the end of the day, permit the government and country to come up with the best possible plan, without any pre-determined prejudice toward or against any particular mechanism.

In particular, one cannot understate the importance of engaging the full medical community in the formation and development of a national health plan. It is this group that the policy makers will call upon to implement and actively participate in any national health scheme. Moreover, it is the health care professionals who know the system best - they know where there are critical stress points within the infrastructure; they are best suited to say what encourages and discourages waste and abuse throughout the health care network.

In France, as has been the experience elsewhere, the National Health Insurance network has been shaped by the doctors within the system dating back to the early origins of the their plan in 1928. And as the system grew and matured, it was led by the physicians and health care professionals of the country. The French policy makers have recognized throughout the years the importance of having their system driven by and through the personnel who knew it best. While our National Health task force has crafted certain aspects of the Bahamian proposed plan from the French model, it is unfortunate that they did not recognize the importance of that consensual element in the development of a working national model in France.

In addition to allowing the full participation of civil society generally and the medical community specifically in the design of a national health care plan, the other key feature must be a willingness to have full and transparent disclosure of the information that underlies the plans and proposals being put forward by government. To date, the national health care task force has either been unable or unwilling to provide very basic information to the Coalition and its members on a timely basis. As mentioned earlier, we have been repeatedly asked to share our views. However, we have not been able to access the same information that the task force used to generate its proposals. Thus, we are seldom in a position to agree with or refute information being presented by the task force as factual or accurate.

The Coalition has formally requested some 11 reports that we feel the task force must have had in order to develop the NHI to this point. Only 4 of these reports have been forthcoming. Often, our members have been greeted with responses such as "we have to await Cabinet approval" as if what is being requested represented a state secret. Even worse, we were told that information such as an economic impact assessment were still being developed - even though the bill for the provision of NHI had already became law. Why the assessment was not completed and publicized BEFORE the matter went to Parliament is extremely troubling. It suggests that the groundwork was not completed and the nation does not know if such as system can reasonably be expected to be maintained and sustained.

The Way Forward

What does the Coalition recommend? On this point our recommendation is very straight-forward and represents what ought to happen when any government seeks to introduce legislation with such a far-reaching and long term impact upon a nation.

• The government should engage in a legitimate way with the full range of stakeholders to examine all possible solutions and alternatives to attain the policy goals of universal and quality health care.

• This consultation should represent a true dialogue and exchange of ideas that can bring elements of global best-practices and innovations in health care within The Bahamas to come up with the best possible plan, without any pre-determined prejudice toward or against any particular mechanism.

• In particular, the full medical community must be an integral part of the formation and development of a NHI plan - as opposed simply to being offered to be a voluntary participant once the plan has been formalized. This has been the approach in France and other jurisdictions and has been hailed a key contributor to the robust foundation upon which these NHI schemes have been built.

• To permit stakeholders to sensibly consult and comment upon the government's NHI plan, the government must commit to full disclosure of all pertinent information and analysis. Otherwise the legitimate perception will be that the government is cherry-picking the information that backs their arguments while suppressing data that may undermine their precepts.

• A mechanism should be put in place for providing transparency, consultation, negotiation and dispute resolution as well as timely and full disclosure of the system's performance and finances once a system is in place.

The experience from other countries point to a clear reality: The countries which have been able to implement sustainable and high quality health care reform took the time to engage their stakeholders in meaningful and deep consultation. These efforts took years in some cases and created hybrid solutions that are neither true public sector networks nor private sector systems. These countries have been able to take the best practices from around the world and couple it with the best thinking from their own jurisdictions to create unique reform efforts that work for that particular country, with its own unique culture, geography and history. Is it possible that we could collectively have the courage and foresight to do the same?

Go forward to Part Four of this Series.

Go back to Part Two of this Series.