The Tribune

By LARRY SMITH

AS WE move to reform medical financing in the Bahamas, the Pan American Health Organisation is currently updating the numbers contained in the Blue Ribbon Commission’s 2004 report on national health insurance.

The man who led that commission is now the Minister of Health, and by all accounts the intention is to implement NHI during this government’s term in office, so it is something we should all be paying attention to.

That 2004 report called for a mandatory 5.3 per cent payroll tax to pay for universal medical care, which was calculated to cost $235 million annually. But many health professionals said the demand for health services would far outweigh our capacity to deliver them. And since then, successive governments have been trying to strengthen the sector.

Health Minister Dr Perry Gomez offered some preliminary figures in the House of Assembly last week, putting Bahamian healthcare spending today at almost 10 per cent of our gross domestic product – which is about $8 billion a year.

So that would represent some $800 million in total annual spending – including public and private as well as overseas health spending. The private sector accounts for about half of this money, experts say.

The Blue Ribbon Commission recommended that the Bahamas adopt a financing system called social health insurance, which pools payments from all residents to pay for universal care. People could still use private insurance to cover areas not eligible for reimbursement by the public system.

Many countries around the world have implemented some form of social health insurance, including France, Costa Rica and Israel to name a few. However, the healthcare system Bahamians are most familiar with is the United States. The American system is funded privately, except for the poor and elderly.

However, studies show that the US system is better at delivering high costs than quality care. On average, Americans die sooner and suffer higher rates of disease and injury than people in other high-income countries, despite spending more per capita on healthcare than any other nation (about 18 per cent of GDP).

And according to a new report from the US National Research Council and Institute of Medicine, this health disadvantage exists at all ages from birth to age 75. Even those Americans who have health insurance, college educations, higher incomes, and healthy behaviours are sicker than their peers in other rich nations.

Comparing the United States to 16 countries – including Australia, Canada, Japan, and western European nations – the report put the US at or near the bottom in nine key areas of health: infant mortality; injuries and homicides; teenage pregnancies and sexually transmitted infections; prevalence of HIV and AIDS; drug-related deaths; obesity and diabetes; heart disease; chronic lung disease; and disability.

Partly this is attributed to structural problems that include the 55 million Americans without health insurance, fewer doctors per capita, less access to primary care and fragmented management of complex chronic diseases. Other contributing factors include lifestyle issues (such as diet) and the prevalence of guns.

The Affordable Care Act (otherwise known as Obamacare) enacted in 2010 addresses some of these issues. Starting in 2014, most US citizens and legal residents will be required to obtain health insurance for themselves and their dependents, or pay a small penalty. Without this provision the number of uninsured Americans would continue to rise.

Health spending was 17.9 per cent of US GDP in 2010 and is expected to reach 20 per cent by 2020 according to the Congressional Budget Office. The upshot is that the US spends far more on medical care than any other industrialized nation, but ranks 24th among 30 OECD countries in terms of life expectancy.

In fact, in 2012 the World Health Organisation ranked the French system (which combines private and public sectors to provide universal care) as the world’s best. In France, most medical bills are paid by the government from payroll and income taxes, with the remainder paid by supplemental private insurance.

And it is widely acknowledged that Singapore has one of the world’s best and most cost-effective universal healthcare systems. In Singapore the government subsidises most of the cost of a basic level of care for everyone. Patients can spend their own money on care beyond the basic level, while the government regulates prices.

Since the Blue Ribbon Commission report of 2004, a lot has happened in the Bahamian healthcare sector. A ground-breaking national prescription drug plan was implemented in 2010, a $75 million expansion of the Princess Margaret Hospital is nearing completion, and a 10-year health services strategic plan has been drafted mapping the way forward.

All of these initiatives were considered necessary precursors to the implementation of national health insurance, something which is supported by both the FNM and the PLP.

But the bottom line is this: Ideological arguments notwithstanding, experts say there is no single type of system “that performs systematically better in delivering cost-effective healthcare.”

According to the 34-nation OECD, both market-based and command-and-control systems have their strengths and weaknesses. “It seems to be less the type of system that matters, but rather how it is managed.”

And that is the key to the success of NHI in the Bahamas. Proper management is critical to the future health of our economy, as well as that of our citizens.

The Egyptian Enigma

Two years ago a mostly peaceful popular uprising of hundreds of thousands overthrew the military-backed government of Air Marshall Hosni Mubarak - the successor to General Anwar Sadat, who had succeeded General Gamal Abdul Nasser, who had overthrown the Egyptian monarchy way back in 1952.

Last week another popular uprising – this time involving millions of citizens – brought the military back following the one-year rule of a conservative Islamist named Mohamed Morsi. A leading member of the Muslim Brotherhood, Morsi was the nation’s first freely elected president.

Some have labelled this a coup while others call it a popular impeachment. The president, they say, would not compromise with opposition groups, despite a crumbling economy and deep concerns over his increasingly authoritarian rule.

General Abdel Fattah al-Sisi immediately handed over power to the chief justice, and called for early elections, a panel to review the constitution and a national reconciliation committee that would include youth movements. He said this roadmap had been agreed by a range of political groups.

Ironically, Morsi had appointed al-Sisi only last August to replace longtime military chief Mohamed Hussein Tantawi. The forced retirement of Tantawi was considered a major show of the Muslim Brotherhood’s strength at the time.

Meanwhile, the Muslim Brotherhood is on the defensive again. Founded in 1928, the Islamists were suppressed by the military from the 1950s, until they won parliamentary and presidential elections after the 2011 revolution. The results of these elections were controversial, but the Muslim Brotherhood was the only effective organised force at the time.

But they proceeded to alienate many Egyptians by a “power-grabbing approach”, as one critic called it. In his final speech before being removed, Morsi focused on the legitimacy of his rule, offering no compromise with either the army or the millions of protestors on the streets.

Many analysts felt that if he had struck a more pluralistic and positive tone he could have constructed a deal to save his presidency. In the end Morsi failed because he paid more attention to ideology than to governance, creating an “us against them” mentality which appeared to be leading towards another one-party state.

Hosni Mubarak was in power for 30 years and it took 18 successive days of popular protests to topple him, during which some 12,000 people were arrested. It took only three days to remove Morsi. As one protestor put it: “The revolution will not allow anyone to rule us in an authoritarian way – including the military. There were more cases of “insulting the president under Morsi than under Mubarak.”

Morsi was elected with a 51 per cent majority and adopted a winner-take-all majoritarian view of his authority. Last November he rammed through a new constitution that gave him far-reaching powers and placed his decisions above judicial oversight.

“The Brotherhood’s reluctance to engage in any kind of inclusive or consensual process left it politically isolated when dissenters began to coalesce against it,” said Egyptian journalist Sharif Abdel Kouddous writing in The Nation. ”Lacking any meaningful political channels to express their grievances, millions took to the street to call for change.”

At the same time, Kouddous said, the military needed political stability in order to enjoy their economic empire – which some estimate at 20 per cent of Egypt’s GDP. This led to Morsi’s removal. And if elements of the former military regime reassert themselves in a significant way, we can expect the cycle to continue with more mass demonstrations.

There is a message here for Bahamians too. Our electoral system also produces a winner-take-all government. And if our government is led by individuals with majoritarian and authoritarian attitudes, the damage to our democracy can be substantial. Free elections are not the only representation of a democratic society.

What do you think? Send comments to larry@tribunemedia.net

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