A National Health Insurance (NHI) scheme would only work efficiently if, and only if, there are proper checks and balances in place ...especially to ensure that the pool of money goes in to a segregated fund for health and health alone...

The National Health Insurance debate

CFAL Economic view

We read recently in a local daily that Dr. Perry Gomez, the Progressive Liberal Party (PLP) candidate for North Andros and the Berry Islands said that under a PLP government National Health Insurance (NHI) would be implemented within the first year of coming to office.  While we are in the so-called ‘silly season’ and everyone and their brother are making promises, we would hope that some of the promises would be well reasoned outlining the attended cost and consequences for the wider community; the usual rhetoric is just not acceptable this time around.  We believe that members of the Bahamian electorate are a bit more discerning than most politicians give them credit for.

What is NHI?

The issue of a National Health Insurance was first raised back in August 2002, when then Prime Minister Perry Christie appointed a 15-member Blue Ribbon Commission to review the feasibility of a National Health Insurance Plan.  The committee was also mandated to determine the best way to make affordable healthcare available to all residents.  The appointment of the committee was a step towards the fulfillment of the then government’s promise to ensure that all patients receive the same access to healthcare regardless of their personal wealth or circumstances as outlined in the PLP’s manifesto, ‘Our Plan’.  In 2004, the final report was released.  It was the view of the committee that The Bahamas cannot afford to not have a National Health Insurance (NHI) scheme.  The committee also stated that NHI had to be mandatory and would only work if the government had adequate funding.   We have no difficulty agreeing with those observations but would urge the authorities and the public to take a closer and more objective look at the proposal.

What is National Health Insurance?  National Health Insurance is a form of social health insurance, which uses the principles of fund pooling and risk sharing to provide equity in access to care.  Individuals pay an ‘affordable’ amount on a consistent basis and in return are able to have their healthcare needs provided for, regardless of cost.

It is envisioned that this ‘cradle to the grave’ national healthcare coverage will cover persons who are currently excluded from private insurance plans such as individuals with pre-existing illnesses, newborn babies and those over 65.

The 125-page NHI report outlined the following eight specific recommendations for the Cabinet’s consideration:

1. National Health Insurance should be universal.

2. Legislation should stipulate the health insurance is compulsory for all residents.

3. National Health Insurance should be administered by the National Insurance Board.

4. A comprehensive benefits package should be offered.

5. Contributions should be set at a rate which is affordable for the majority.

6. Public and private providers should be offered the opportunity to join the National Health Insurance system.

7. All provider payment mechanisms should be considered for use with capitation being the preferred option.  (Capitation is a provider payment mechanism in which providers are regularly paid a stipulated amount per person for whom they agree to provide services during a defined period of time.)

8. A percentage of revenues should be set aside for purposes that ensure the stability of National Health Insurance.

The present system in The Bahamas, which employed persons contribute to, is a form of social security.  Our health system includes tax-funded care through government hospitals and clinics, and private care funded by direct user fees or private insurers.  The incentives that exist include pension, invalidity assistance, medical incentives, maternity benefits, some income replacement, temporary and permanent disability benefits, and health coverage for occupational injuries.  Basically, social health insurance currently exists only through the industrial injury component of NIB.

Recently, the present government implemented the National Prescription Drug Plan to assist some Bahamian residents, particularly the elderly and children under the age of 18 years.  It is estimated that the cost of this program is currently running around $5 million; a figure which we expect to only increase in the future.

Healthcare costs are one of the more vexing and challenging issues facing countries today and according to the latest information on the subject, average cost in the last five years increased annually by more than 10 percent.  With rapidly aging populations and the rising costs of modern medical technology, governments everywhere are finding it increasingly difficult to provide the funds required to meet healthcare needs of their respective populations.  Given that position, we would hope that before any decision is made to move forward with universal health coverage, the authorities would prepare a detailed cost analysis to use as a guide.  To do otherwise, we run the risk of committing to something which could surely place The Bahamas on an irreversible path to economic poverty.

Prior to 2008, it was estimated that only 51 percent of Bahamians had private health insurance.  Today, given the challenging global economic environment, the impact on the local economy and increasing levels of unemployment, we estimate that number at around 40 percent based on the increasing payouts by insurance companies.  For some, private insurance has become too expensive; persons in the lower income bracket and those living on the Family Islands are now less likely to have insurance coverage.

There are a number of questions that need answers.  How much will this plan cost?  (Back in 2004 estimates were pegged around $200 million-plus, which we felt were too low at that time).  Who will pay for those who cannot afford to pay?  What will be the impact on the private insurance industry?  What impact will it have on the fiscal deficit?  (This should be of particular relevance to future generations).

Concerns remain

Historically, the Bahamian government has been a principal source of financing environmental and healthcare expenses for citizens of The Bahamas with an annual expenditure of over $267 million in the 2011/2012 budget or nearly 16 percent of total recurrent expenses which computes to almost four percent of the country revised GDP (another story for another day).

It is estimated that the private insurance companies spent nearly $230 million in 2011, which gives us a total healthcare expenditure bill of nearly $435 million or 5.4 percent of the revised GDP.  In the 2004/2005 fiscal budget, the government allocated approximately $187 million for health expenditure.  In 2004/2005 it was estimated that healthcare expenditure stood at approximately $340 million or 7.10 percent of GDP, of which $70 million was spent by the people, $102 million spent through private health insurance, and the rest by the government.  In comparison, in 1985, total public expenditure amounted to approximately $56 million or only 2.70 percent of GDP.

It is our view, based on historical cost data and future projections, that the cost of a national healthcare plan going forward would be in the region of $500 million to $750 million; equivalent to nearly half of our recurrent expenditure and as such, would not leave much room for other important infrastructure projects.

We generally agree with the conclusion of the commission’s report that a social health insurance system for The Bahamas would provide more equity in access to healthcare, more stable funding of public health costs, and fewer ‘free riders’, or people who benefit without contributing.  Setting up such a national healthcare system involves more than just taxing the people but will require legislation and the creation of responsible bodies.

Two critical issues are ensuring compliance and public accountability.  We are also mindful, however, that there are those who have little faith in governments operating such healthcare initiatives due to a propensity for such operations to become instruments of political patronage and the widely shared view that government institutions are relatively poorly managed.  In the last analysis, we believe that the scheme would only work efficiently if, and only if, there are proper checks and balances in place especially to ensure that the pool of money goes in to a segregated fund for health and health alone.

•CFAL is a sister company of The Nassau Guardian under the AF Holdings Ltd. umbrella. CFAL provides investment management, research, brokerage and pension services. For comments, please contact CFAL at: column@cfal.com

Mar 07, 2012

thenassauguardian

Caribbean Blog International

The PLPs believe that their Urban Renewal policy, which is still in existence in a new form, is the answer to all prayers... They are fooling themselves... The social deterioration in this society is so deep that it will take more than urban renewal to bring it back to health

Crime should not be used by politicians

tribune242 editorial



IT would be a tragedy if this country's escalating crime were to become an election football.

Crime in the Bahamas has been steadily building from the politically violent sixties into the drug violent seventies and eighties until it is now hitting a crescendo in our time.

The PLP believe that their Urban Renewal policy, which is still in existence in a new form, is the answer to all prayers. They are fooling themselves. The social deterioration in this society is so deep that it will take more than urban renewal to bring it back to health.

"The government must send a clear and strong message to criminals that they will be swiftly caught and swiftly punished and I am not satisfied that this is being done under this present government," Opposition Leader Perry Christie told a press conference, called yesterday to discuss the escalating crime.

Maybe justice under this government is not swift enough for Mr Christie, but nor was it swift enough during Mr Christie's administration when the backlog of court cases grew out of all manageable proportions.

Under both governments -- PLP and FNM-- we have been complaining about the justice system. In our opinion it needs a complete overhaul.

So on this score, no fingerpointing can be justified.

The problem on our streets is obvious - most crimes are being committed by criminals killing criminals, all out on bail when they should be behind prison walls. And as the Commissioner of Police has often commented, the police can't be blamed. They do their part by arresting and taking the offenders to the bar of the court, where the lawyers with their crocodile tears bleat for their release, and the courts send them on their merry way to terrorise society. Witnesses could not be killed, if those who threaten them were in jail.

We hope that when the House reconvenes after the summer recess legislation will be introduced to curb the courts in its release of persons who could be a danger to society. When that debate takes place there shouldn't be a squeak from the Opposition about interfering with a judge's discretion.

The only way to cut down on many of these murders is to keep these persons with long criminal records in prison until trial -- not only for society's sake, but, as has already been shown by the number of their bodies in the morgue, for their own sakes.

And if judges will not exercise their discretion with this objective in mind, then legislation is the only solution. Society cannot have it both ways.

The same analogy can be drawn by the rules that now have to be followed when one travels by air. No one likes to be searched -- it is demeaning and interferes with a person's rights and freedoms. However, for the sake of safety, travellers are willing to relinquish some of their freedoms.

It is the same with the judiciary when one has to make a choice between the exercise of a magistrate's discretion and the mayhem on the streets. We can't have criminals laughing at the courts.

They must understand that if they do wrong they will be punished -- swiftly and severely. And until their date in court, they will be incarcerated, not out on the streets pushing up the murder count.

In the meantime, this society has to be analysed as to what has gone wrong, what has caused us to move from a once courteous, decent people to what we see today.

To find a cure, we need parents, teachers, psychiatrists and a whole gamut of professionals to work together to try to save the next generation.

Persons complain that no one respects our institutions. That is true, and the reason is that many of the people who head them do not understand that in their positions they have to lead by example -- if they do not respect themselves, or their organisation, they cannot expect anyone else to have respect. Members of the House of Assembly should take note.

The breakdown of family life is our greatest tragedy - no father in the home, the mother out to work and the children left at home to join the village gang. In the old days when the mother was at work, the grandparents took care of the children.

Today children are having illegitimate children, so that when the young mother is at work, the grandmother is still young enough to hold down a job and so is the great grandmother.

As a result no one is at home to guide and correct little Suzy and Johnny. A great burden is put on the schools, not only to teach these little ones their ABC's, but also their manners, to point out what is right and wrong, and to make them understand that for every right there is a corresponding duty, and when they break the code, there are consequences, and those consequences can be serious.

Instead of pointing the finger of blame, these politicians should get back to basics. They should start with an examination of themselves, determined to lead by example, and then move on to helping society get back on course.

September 16, 2011

tribune242 editorial

Caribbean Blog International

Educating Women on The Deadly Disease HIV/AIDS in The Bahamas

The HIV/AIDS transmission rate in The Bahamas is an important success story

Rapid Growth Of HIV In Females

By Candia Dames

candiadames@hotmail.com

Nassau, The Bahamas

29th November 2004

Women in The Bahamas have caught up with men in new HIV cases, prompting serious concerns for health officials.

Although the number of new HIV infections declined for a third consecutive year in 2003, the fact that more and more women are being infected with the virus that causes AIDS means that there needs to be renewed focus placed on educating women on the deadly disease, according to Nurse Rosa Mae Bain, director of the HIV/AIDS Centre.

Last year, 289 cases of HIV were reported. This compares to 332 in 2002- 385 in 2001 and 404 in 2000, according to health officials. Around the world 38 million people are infected.

In the early years of the epidemic, men far outnumbered women in new cases.

But that has changed.

The ratio of males to females is now 1:1. The disturbing trend is a global one, according to health officials.

So it is no coincidence that women and girls are the focus of this year’s World Aids Day on December 1.

“We as women have caught up with and in some countries have even past the men,” she said.  “Consequently, we need to focus in on women being able to negotiate safer sex practices.  That is crucial.  We need not to be getting infected.”

She said, “Women, because they account for all these single homes are the people out there providing that nurturing to the bulk of our children.  So the message that we want to give is ‘look, you men support our women.  Provide them with the support so that they can use preventative methods so that they do not become HIV infected’.”

Nurse Bain said women are particularly vulnerable because they tend to allow their partners to take the lead in safe sex practices.

Around the world this week, it will be a time of remembrance for the millions of people who have died from AIDS.  It will also be a time to focus on the 14 million children who have been orphaned by the disease.

Nurse Bain said AIDS orphans are also a serious concern in The Bahamas, but she said new drugs are making it possible for people to live longer, which means that the numbers of orphans are getting smaller.

Because of antiretroviral medications, she said, there are also fewer and fewer babies who are becoming infected with HIV from their mothers.

The percentage is now down to 3 percent, according to Nurse Bain.

“If we look at the statistics closely we would find that not one mother who attended the clinic, who took her medication, who kept all her appointments had a baby born HIV positive,” she said.  “That three percent was because we had a cohort of pregnant persons who did not attend so consequently they did not receive the medication and their baby was born positive and that’s why we’re still at three percent.”

She said the reduction in the transmission rate in The Bahamas is an important success story.

Another success, she said, is that the children who were born with the virus are living to see their teen years.

“Yesteryear, most of our children died before their first birthday, but with the use of anti-retrovirals or the use of AIDS medication as we call it- these children now look good, they feel good, they’re in school and we need to go to another level and provide them with a home setting.” 

The Bahamas is The Only Country in The Region that is Witnessing A Downward Trend in New HIV Cases

Anti-AIDS Education Programme Yields Positive Results Throughout The Bahamas

New HIV Cases Decline 

By Candia Dames

candiadames@hotmail.com

Nassau, The Bahamas

15th November-2004

The number of new HIV cases reported in 2003 declined for the third consecutive year, but health officials say there are still serious concerns regarding the spread of the deadly virus in the country.

Last year, 289 cases were reported.  This compares to 332 in 2002; 385 in 2001 and 404 in 2000, according to newly released numbers from the Infectious Disease Division of the Princess Margaret Hospital and the Department of Public Health.

The most recent figure is also the lowest number of cases reported in a given year since officials reported 710 cases in the period 1986-1988.

Director of the HIV/AIDS centre Nurse Rosa Mae Bain reported that The Bahamas is the only country in the region that is witnessing a downward trend in new HIV cases.

She believes this positive trend has resulted from a consistent anti-AIDS education programme throughout The Bahamas.

“We’re marketing the condom use because it’s crucial that everybody who has sex with somebody knows the status of their partner,” Nurse Bain said.  “If they don’t know, then they need to protect themselves with the condom.”

Her department is also getting set to launch a marketing campaign promoting the use of the female condom.

“They’ve been available for a while, but we’ve not really pushed it,” she said.

Officials of the National AIDS programme have also expanded their outreach in schools, working with grade six students encouraging them to delay the initiation of sexual activity.

“What we are also doing is training them if they are sexually active to protect themselves, that is crucial.  They need to know about the availability of condoms, how to store them; how to use them; how to put them on and how to take them off,” Nurse Bain said.

The new numbers also show that the sexually active age group 15 – 44, continues to be the main group of people infected with the virus that causes AIDS.

AIDS is the leading cause of death in the age group 15 – 29.

The National AIDS programme has monitored the epidemic since 1983.  As of December 31, 2003, there was a cumulative total of 9,725 total HIV infections, 4,758 cases of AIDS and 4,697 persons who are non-AIDS HIV positive.

Of the total 4,758 cases of AIDS, 3,309 have died.  Of the total 9,725 infections, 6,920 occur in young adults between the age group of 15 – 44.  The ratio of males to females infected with HIV is now 1:1.

Nurse Bain said there is still a serious concern as it relates to older men passing the virus on to young girls.

It’s a dilemma authorities continue to tackle.  They say because of the high numbers of single mother homes, many girls are often easily enticed by material possessions and are therefore more inclined to have sex with men who can provide these things.

“We’re very well aware that approximately 70 percent of our babies are born to single parents,” Nurse Bain said.  “Because of that, within the home-setting, there is not the male figure…we want to send a message out there, ‘Older men, please leave our young girls alone.’”

There is another practice of grave concern.

Nurse Bain said there are many girls who are engaged in rectal sex as protection from getting pregnant.  They also see it as a way of having sex and remaining virgins.  But she said there is serious danger in this practice.

“Once the lining of the rectum is torn and somebody has HIV, [men] can pass that on very, very quickly to our young girls,” she said.  “This is a concern for both male and females.  Next to blood transfusion, rectal sex is the easiest way to get HIV infected.”

The first clinical case of AIDS was reported in1983 and confirmed on post mortem in 1985.  The first confirmed case of AIDS was reported in The Bahamas in August 1985 when antibody elisa testing became available, according to the Bahamas National HIV/AIDS Programme.

The Bahamas has the highest annual incidence rate of AIDS in the English speaking Caribbean, and is among the three nations with the highest incidence rates in the world.