The National Coalition
For Health Care Reform

Article - 7th June, 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 Eight of the series highlights the eighth principle in our documented Statement of Purpose.

8. Phasing In Health Care Reform: An Implementation Strategy should incorporate a "Phase-In" approach, giving priority to those areas of public health that are most critical. This is to provide the opportunity to adjust to a new health care system, while permitting the underlying infrastructure the time to expand to meet increased demands.

This is the eighth and final installment in the ongoing series of articles published by the NCHCR. In this and the previous seven installments, the NCHCR has articulated and explained in detail the eight core principles that we are convinced must represent the foundation of comprehensive health care reform in the Bahamas. In each of these articles, we have reiterated our belief that the government should commit itself to a sound national health care plan that improves and ensures that all Bahamians have access to timely and high quality health care services.

In this final installment we examine our commitment to the notion of the implementation of a comprehensive national health care plan that is “phased in” over a number of stages, giving priority naturally to those areas of public health that are most critical and where help is most needed.

This stands in contrast to the plans of the National Health Insurance (NHI) task force, which has recommended a full implementation of full national health insurance coverage at the outset with all benefits and features introduced upon commencement of the plan. This would mean that upon day one, customers would be able to present themselves to the public facilities for the full range of procedures and services that are covered by what the task force has shaped to be a very comprehensive plan.

The NCHCR strongly believes that such an approach would be untenable and would create a scenario where the integrity and sustainability of the national health care plan would be fatally compromised at the very outset. The current administrative and physical infrastructure of the nation’s health care system simply does not have and will not soon be able to obtain the requisite capacity to address the demands that a comprehensive plan will place upon it.

A quick discussion with any health care provider within the public system will reveal that the current public infrastructure is already stretched beyond its original planned capacity. The system, in many cases, cannot handle the case loads that are presented to it. The evidence from international experience indicates that when national health insurance plans are introduced, the numbers of persons coming forward for medical care and treatment increase substantially; as persons are informed that a “new” health insurance plan provides coverage for their condition, they naturally approach health care providers for treatment.

Indeed in the Bahamas, there is a pent up demand for many critical services, as persons now are forced to live with painful and debilitating conditions simply because they cannot afford private care and the public system cannot accommodate them. When they are presented with new NHI cards and told that their illnesses are now covered, they will come without delay to the public institutions for immediate care. Given that the current health care system is struggling to adequately address its current case loads, one can only imagine the incredible stress that will be placed on the system when new and entitled NHI policy holders present themselves for service. There will not be sufficient hospital rooms, operating theaters, and health care professionals to care for them. Instead of timely and quality health care for all Bahamians, we will more likely get long wait times for procedures and high levels of frustration for both the customer and the health care provider.

In addition to the challenges to the physical capacity of the health care system, the administrative infrastructure for public health care will need substantial institutional rebuilding and strengthening in order to be able to adequately manage a system as incredibly complex and involved as a national health care plan. It will take some measure of time to identify and implement the processes and institutional machinery that can efficiently and accountably manage patient case loads, the flow of claims and premiums, the relationships with the health care providers within the system, the maintenance of protocols that ensure privacy and confidentiality, and the adjudication of complaints, conflicts and other issues that will arise on a regular basis. The government’s very own Blue Ribbon Commission (BRC) Report that gave rise to the current NHI proposal had itself detailed that before the NHI could be introduced, there are some 39 steps toward full institutional reform that must take place if the national health care plan was to be implemented successfully. Yet, while the legislation for NHI had been put forward and approved by Parliament – with the intent at the time for launch within a 24 month span, there has been little evidence that the reform of the administrative framework for health care management had commenced in any serious way. And clearly, the very sound recommendations of the BRC report will take several years for the government to implement properly.

What these realities point to is the fact that the public health care system is no where near a place where it could today (or anytime soon, for that matter) handle the needs and demands of fully comprehensive national health care plan. The physical plant requires significant upgrade; substantial work needs also to be undertaken to revamp and strengthen the management of the public health care system.

Yet, the NCHCR does not claim that these challenges should mean that we abandon the goal of a full national health care plan. For the Coalition, it means simply that the process must be done in phases, with a recognition both of what we can comfortably do immediately and what are the most pressing health needs in the community.

The Way Forward

An examination of many modern national health care plans demonstrate the reality that a large number of them only evolved into comprehensive plans over a significant period of time. Indeed, we have current examples of countries within our Caribbean basin who have researched the feasibility of universal health care coverage and – realizing the limitations of their resources and infrastructure – have decided to reduce the scope of their ambitions initially and take on only what can realistically and comfortably be delivered.

Such is the nature of our recommendations. It is imperative that, as a nation, we commence the journey toward a point where we can assure the full range of necessary medical care for all Bahamians on a timely basis. However, given the very limited capacity that we currently face, we must be honest in our expectations and realize that it would be better to focus on areas of greatest concern, of greatest need. To that end, the NCHCR proposes the following:

• Articulation of a multi-year phased approach to the implementation of a national health care system that must have as an initial priority the physical upgrade of the public health facilities and the full scale reform of the administration of the public health system.

• The introduction of a national prescription drug plan for the elderly, the indigent and those with chronic and debilitating life-long illnesses.

• The introduction of a catastrophic care fund that will be used to defray expenses of uninsured persons related to catastrophic illnesses due to major trauma or serious chronic conditions.

• An additional levy upon the current National Insurance premium to be used to fund the initial phase of the national health care plan and underwrite the financing costs for the resources needed to expand the physical and managerial health care infrastructure.

This approach will not only address the most critical needs and the most vulnerable populations within our community at the very outset, it will provide the opportunity to slowly and prudently build upon successes and address weaknesses. It will also provide the economy and the health care system (both private and public) opportunity the time to acclimatize itself and adjust to the new demands that are placed upon it.

The Coalition believes firmly that as a nation we must find a collective and sustained response to the need for quality health care for all Bahamians. We recognize at the same time that we must be prudent and judicious as we embark upon what will likely be the most important public policy initiative of our generation. There is no doubt that we have the resources and the talent to create a world class health care system that assures access for all. However, to move our collective goal, we have to take our time and appreciate that it will take time for us to achieve the comprehensive health care system to which we all aspire.

• The current public infrastructure is already stretched beyond planned capacity. In the Bahamas, current evidence suggests significant pent-up demand.

• The above means that upon introduction, the current infrastructure will not be able to meet the demand for services. This will put significant stress on the system, leading to long wait times and high levels of frustration to the customer and health care professional.

• Just as importantly, the administrative infrastructure needs substantial institutional rebuilding and strengthening. As noted above, the government’s own BRC report indicates that the institutional reform must be addressed before the introduction of NHI.

The BRC acknowledges the impact which lifestyle has on the cost of providing health care and places emphasis on preventative care and public education.

• A phased approach is the most logical one to take as it afford the system an opportunity to better manage cost and provide tangible results and at the same time allow for a system which is affordable and manageable.

• A plan should be developed that provides a linkage between the strengthening of the system and the service offerings. There are some services that are not feasible to offer with the current infrastructure and should be phased in as the strengthening of the system takes place.

• It is recommended that the phase in approach should focus initially on high priority health issues. This includes funding inpatient care, a national drug plan for designated chronic disease, catastrophic care, and a Medicare plan for senior citizens.

Go back to Part Seven of this Series.