The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

National Health Insurance’s (NHI) purported $126 million financing “does not exist”, with the new Government yesterday said to have inherited “the challenge to identify a source of funds” for the scheme.

Dr Duane Sands, the minister of health, told Tribune Business that the former Christie administration had never properly set aside funding for its signature healthcare reform.

As a result, both NHI’s $100 million primary care phase roll-out - and the accompanying $26 million catastrophic care component - are currently being financed directly from the Consolidated Fund, the central fund in which all tax revenues are commingled.

“The $126 million for NHI was not sequestered. It was not set aside. It does not exist,” Dr Sands told Tribune Business. “While a commitment may have been made, those funds have not been placed in a separate fund that can be drawn down on.

“While there may have been a commitment to spend up to $126 million for NHI, the challenge for that administration, had they done it, and now this administration, is to identify a source of funds.”

When it came to the $26 million catastrophic care allocation, the Minister added: “I don’t believe a single dollar was spent in terms of therapy and care for the catastrophic component under the previous administration. Unless that was spent somewhere I’m unaware of, it was never funded.”

Dr Sands implied that the former administration’s failure to properly identify, and set aside separate funding for NHI, was especially concerning when it came to accountability and transparency in managing the public finances.

With NHI’s primary care phase launched just prior to the general election, the scheme is effectively being financed on a ‘pay-as-you-go basis’ through the Government’s central financing pool, which makes it harder to control expenditure, plus eliminate waste, fraud and inefficiency.

The Christie administration’s last NHI consultants, the KPMG accounting firm, said in a report that “approximately $60 million in new government expenditure” would be required to finance the $100 million primary care phase.

With new or increased taxation ruled out as a funding source, the KPMG report implied that the previous government was using a portion of its Value-Added Tax (VAT) windfall to finance NHI, with the $40 million balance coming from monies ‘re-allocated’ from the likes of the Ministry of Health and National Prescription Drug Plan (NPDP).

Many observers will also interpret Dr Sands’ comments as further evidence of NHI’s rushed pre-election implementation, with the Christie administration viewing the scheme as a key element in its bid to return to office.

Critical parts of the NHI governance and healthcare delivery structure were not in place when NHI launched last month, including the proposed merger of the Public Hospitals Authority (PHA) and Department of Public Health into a Bahamas Health Services Authority.

Nor was the proposed doctor payment mechanism in place, with the NHI public insurer contract yet to be awarded, and no private insurers signed up to act as regulated health administrators (RHAs) under NHI. The NHI Authority has instead been paying physician providers directly.

Dr Sands, who was among the NHI scheme’s most vocal critics while in Opposition, told Tribune Business that the new government had yet to decide whether it will proceed with awarding the public insurer management contract to Aetna and its Bahamian partner, Family Guardian (Bahama Health).

The duo were selected as the preferred bidder by the former government, but no contract was signed. Dr Sands said: “There has been no specific decision made as it relates to the public insurer.

“Let me say that we are currently reviewing all of these proposals that are on the table, and we’ll make a determination as to what we’ll happen once we have a full assessment of the bigger picture.”

Dr Sands said the “bigger picture” was the 2017-2018 Budget that the Minnis administration will unveil in the House of Assembly tomorrow, with NHI and similar government-run programmes “feeding into that”.

“It’s more global picture and we’ll nail down the specifics as we go,” he explained.

Dr Sands said the new Government had little choice but to make NHI work, given the Bahamian people’s clear desire for universal health coverage (UHC). 

“I think we’re up to just shy of 20,000 people who have enrolled,” he said. “Bahamians have made it very clear they’d like to see the NHI programme continue, function and have a positive outcome for the citizens of the Bahamas.

“That is the mandate, the charge my team intrinsically now has, so we’ve got to make it happen. How we will make that happen in the broader context of delivering healthcare in a system that already has UHC in place, the rubric is to make it better under NHI while avoiding some of the pitfalls of the previous approach.”

Asked to identify these “pitfalls”, Dr Sands said one was the lack of co-ordination under the former Christie administration, with no single Cabinet minister or ministry given clear, sole responsibility for the scheme.

“One of the challenges we spoke about was that there was no real ownership of the programme by any particular member of Cabinet,” he told Tribune Business. “Sometimes it was in the hands of the Minister of Health, sometimes it was in the hands of the Attorney General, sometimes it was in the hands of the Prime Minister, and sometimes it was in the hands of the Minister of Grand Bahama.

“Sometimes it was in the Ministry of Health, and sometimes it was in the Prime Minister’s Office. There were projects being run out of the PHA, Ministry of Works, NIB, the Office of the Prime Minister and so on.”

Dr Sands said there had also been “a significant reliance on external consultants” by the former Christie administration to the detriment of Bahamian healthcare professionals.

“Many of the local experts felt there opinions were not being considered or respected, and I think that was fatal or a telling flaw to the approach to NHI,” he added, “and there was an intentional lack of consideration for the views of many professionals across all aspects of healthcare delivery whose views were just dismissed.” 

Dr Sands added that there was also “a disconnect” between the former government’s NHI promises and the scheme that ultimately emerged, and was launched, in April 2017.

“There was precious little similarity between what was rolled out and what was promised,” he told Tribune Business. “At this point, Bahamians are not interested in looking backwards. We’re in office. They’re asking: What will NHI bring for Bahamians?”