The Tribune

• Ex-minister: Health financing ‘not doing job’

• $975m Dorian pledge ‘not plucked from space’

• NHI debate ‘fraught with political land mines’

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

The Bahamas will always be “playing catch up” with public health infrastructure needs that could amount to $200m just to upgrade community clinics, a former Cabinet minister has revealed.

Dr Duane Sands, former minister of health, told Tribune Business that heightened expectations - especially in Family Islands demanding medical services of a quality that matches Nassau - meant the pressure will continually be on the government to improve the public healthcare system.

Acknowledging that human capital, and not just physical infrastructure, requires upgrading, he added that the $975m financing offer made by the P3 Group at the Hurricane Dorian pledging conference in 2019 was an accurate reflection of how much investment the Bahamian public healthcare system actually requires “if you could have everything you wanted”.

Speaking as 50 percent of a $40m Inter-American Development Bank (IDB) loan is set to be allocated to replacing and/or rebuilding nine Family Island clinics, Dr Sands said The Bahamas had “done as well as we could” in maintaining those facilities given the “incredible” cost even though at least one is currently housed in a condemned building.

He conceded that the government’s present mechanism of financing public healthcare via the Public Treasury/taxpayers “is not going to do the job”, and reiterated that user fees for those who have insurance or “the ability to pay” but currently do not will have to be levied at the Princess Margaret Hospital.

Describing the debate around healthcare financing as “fraught with political land mines”, especially as National Health Insurance (NHI) continues to roll-out, Dr Sands said The Bahamas will likely have to “bite the bullet” in meeting the demands and expectations of its population.

“This is an ever-evolving situation, and when you look at the number of clinics - just shy of 100 around The Bahamas - with changing codes in terms of what is the standard, it’s incredibly hard to keep up,” Dr Sands said of maintaining multiple facilities scattered across the archipelago.

“The expectations that would have sufficed ten years ago, now communities demand more. The expectation is that the high level care provided in The Bahamas happens not only on New Providence and Grand Bahama. What was fine ten years ago is no longer good enough. I think we’re going to be on this road for ever of catch up, catch up, but the goal posts keep moving.”

Citing the desire of Family Island mothers to give birth in those locations as one example of increased public demands, Dr Sands said necessary improvements were not just restricted to “bricks and mortar”. He added that The Bahamas presently lacked the “clinical expertise” to operate the mini-hospitals in Abaco and Exuma as there were simply no x-ray technicians, pharmacists and lab technicians available to staff them.

Pointing to the shortage of nurses as another “human capital” deficiency, the former Cabinet minister said “more than a couple hundred million” may be required to resolve all the public health clinics’ needs. And to complete Princess Margaret Hospital’s maternal health tower, new ward and emergency room would likely run into another $250m.

“A decision was made a very long time ago to bite these needs off in chunks we can digest,” Dr Sands told this newspaper. “At the Dorian conference there was a lender that pledged $900m or so, P3. That number did not come out of space. That number was a reflection of if you could have everything you wanted in The Bahamas in terms of health infrastructure, what would it cost.

“That’s where that $900m-plus came from. That would have been based on conversations that would have been had, and determinations that if money was no object, we would do this, this and that.”

The Government ultimately did not take up the P3 offer, which was more a public-private partnership (PPP) financing arrangement, but Dr Sands said providing Nassau-type medical services in the Family Islands “comes at a cost” especially when air evacuations and ground transportation are brought into the equation.

The IDB report justifying the proposed $40m loan exposed the significant physical deterioration of several public health clinics, with the facility located at Smith’s Bay, Cat Island, presently housed in “a condemned building”. The Fresh Creek clinic in Andros, meanwhile, is based in a property that is “in a severe state of disrepair”.

Both areas are to get brand new clinics, while the facilities at Black Point in Exuma, Mangrove Cay in Andros and Rock Sound in Eleuthera will also be replaced by new builds. The former two are presently based in “inadequate rental” accommodation.

Besides the five new facilities, which will cost between $1.63m and $3.6m to construct, the clinics in Abaco, Andros, Long Island and Bimini will also be retrofitted and upgraded. Abaco’s primary health centre was damaged by Hurricane Dorian, while Bimini’s has “a leaky roof” that requires repairs.

Asked whether the Government had done a poor job in maintaining these facilities, Dr Sands pointed to the challenge of maintaining the same infrastructure across multiple islands given the Government’s limited finances.

“I don’t think so,” he replied. “I wouldn’t say we have failed to maintain them It’s just been incredibly expensive. We’ve done as well as we could. As we introduce the concept of universal health care, that concept requires improvement.”

With NHI just one part of healthcare financing reform, Dr Sands said The Bahamas has to “collect more from persons who have the ability to pay” for using public healthcare services as well as repatriate some of the hundreds of millions of dollars that Bahamians spend on medical treatments abroad to “take the load off the public purse.

“It really is appreciating that the current method of healthcare financing is not going to do the job,” he said, “and we have to define a different way that is not only economically acceptable but socially and politically palatable. I suspect this debate is going to have to continue for a while, but that we will have to bite the bullet and do it. This is a challenging issue, and has so many things mixed into it because of the politics of healthcare financing.”

Arguing that The Bahamas was no different from the US and UK, with Medicare/Medicaid and the National Health Service (NHS) respectively, Dr Sands added that “NHI is fraught with political land mines. When you start promising everything to everybody for nothing, you end up not providing much to most people”.

He said The Bahamas needed to make healthcare financing “palatable for everyone”, with NHI requiring much planning as primary care is made accessible to all ahead of the hoped-for introduction of secondary treatments.