November 21, 2006
 
My Fellow Bahamians,

For decades, successive governments of the Bahamas have promised all Bahamians that wherever they live in our outstretched archipelago, they could have access to affordable quality health care…and for decades, governments, well meaning as they were or may have been, try as they may have done, have failed to deliver on that sacred promise!

The time for this action is long over due. National Health Insurance (NHI), is not a new idea.  We have been preparing and discussing various aspects and proposals since 1984 when the first Working Party on NHI was established. That Working Party produced a report, but no further action was taken until 1991when an Ad Hoc Task Force was appointed.

We did not rush!

This Task Force, based on comments received from some groups on the proposed benefit package as well as the financing arrangements produced a revised Report.
Again, no further action for implementation was taken.

We did not rush!

In 2001, a further analysis was undertaken, when a study was conducted to examine the feasibility of focusing on catastrophic health conditions.
Again, no further action for implementation was taken.

We did not rush!

In the meantime countless numbers of Bahamians have continued to experience the hardships of paying for health care out of their pockets, while sacrificing some of the basic necessities of life for the well being of their families.  Everywhere we go, on every island, and in every forum, the average Bahamian, hotel workers, hospital workers, neighbours, family members, church members, are asking…“Why is it taking so long?”

In 2001, when the Heads of Government of the Caribbean countries met in The Bahamas, they concluded that their economic development and future as well as their national development were directly linked to the health of their people. Indeed, so convinced were they that they adopted the Nassau Declaration, that “The Health of the Nation is the Wealth of the Nation”.  Subsequently, a commission of distinguished citizens was appointed to review the health challenges of the region and to make recommendations as to how they might improve the health of their citizens. One of the recommendations which they made was the need for universal access to affordable quality health care (NHI).
 
 

The Blue Ribbon Commission
The Government of the Bahamas, in “Our Plan”, made a sacred promise to the people of The Bahamas to…“Introduce a national health insurance scheme”…that “will ensure all persons receive the same quality and standard of health care and the same access to health care regardless of their personal wealth or circumstances.”

Thus, in 2002 the Government established a Blue Ribbon Commission to examine the capacity of the health system to meet the health needs of the population and to recommend the most feasible financing arrangements for meeting those health needs. Members included representatives from the public and private sector, the Medical and Nursing Associations, Private Insurers, the Christian Council, Business Community and Civil Society.

Some of the alternative financing mechanisms which have been suggested by various groups but which, upon examination, the Commission found to be inadequate for our needs included:--

? Increasing public funding through new taxes or allocating a higher percentage of the budget to health;
? Increasing the charges for services at the public hospitals and health clinics;
? Promoting an expansion of private health insurance among groups which traditionally have little or no insurance coverage;
? Approaching external agencies such as PAHO, World Bank for concessionary resources or grants;
? Introducing Medical Savings Accounts (MSA’s);

The Blue Ribbon Commission, in its collective vision, recommended a universal and mandatory National Health Insurance Scheme as the most appropriate method of financing health services for the population of The Bahamas. They reported in 2004!

Still, the government did not rush!

The Components, Costs and Financing Report
Instead, a Steering Committee was appointed to check the components, costs and financing requirements of NHI and it reported in January of this year.

But the government did not rush then either.

The government sought further actuarial advice and we turned to the ILO experts for an actuarial assessment and in July of this year, the ILO experts gave the Bahamas’ proposal the “thumbs up” sign, indicating that they had never encountered a situation that was so ready for the benefits of a National Health Insurance Plan!

While attending recent conferences in Washington, Turks and Caicos Islands and Mexico City where I was invited to share our proposal with other countries, it became clear that countries on every continent already have or are implementing some form of National Health Insurance similar to the one, which we are introducing in the Bahamas, and for similar reasons. So, The Bahamas Government is not alone in its noble quest.

Fellow Bahamians, this time, in keeping with the promise made to you, my government will finally implement a NHI Scheme for The Bahamas.

We have NOT rushed.

The process has been steady, deliberate and responsible.

AT LONG LAST ACTION IS NOW BEING TAKEN !!!
My fellow Bahamians, tonight I am pleased to inform you of the steps taken by your Government to advance the introduction of National Health Insurance. I believe that this will come to be known as one of the most important social initiatives of our time, certainly in the last two decades.

Seven days ago, in keeping with his promise, the Rt. Honorable Prime Minister tabled in The House of Assembly, a Bill for the Establishment the National Health Insurance Scheme.  We believe that this Bill is the instrument for putting in place an effective system for sustaining the health, welfare and development of our country.

Good health is necessary to achieve and maintain a high quality of life. It is necessary for students to study and achieve good grades; it is necessary for workers to perform their duties and earn a living for their families;
and it is necessary for families to enjoy the benefits of their wealth. Health = Wealth, therefore, health should be protected at all cost.

Fellow Bahamians,
Good health is too important to be left to luck, cook-outs, sponsor sheets, charity or individual resources!  National Health Insurance, when introduced, will offer all residents of The Bahamas life health coverage and financial protection.  As proposed,

1. NHI offers timely access to a broad range of health services in The  Bahamas and abroad when necessary;
2. NHI offers coverage for all health conditions and persons with pre-existing illnesses will not be excluded;
3. NHI is affordable with everyone playing a part in sharing the cost of care.  Persons contribute according to their incomes and receive care according to their needs.  They will not have to beg, borrowing or dig deep into their savings to pay for health care;

4. NHI leads to improved care for all so that we have a more healthy and productive population.
5. NHI offers a choice of health provider in the public or private sector provider;
6. NHI offers respect and dignity when you seek care;

Implementation of NHI signals to employers, employees, health professionals, private insurers and civil society a responsible and caring government, one that is committed to the will of the majority and promoting and uplifting the standard of living for all residents, not just the wealthy or the privileged. The policies embraced also indicate a commitment to preservation of a healthy workforce needed to sustain a sound economic environment for business growth and development.  It is important to stress that, NHI is not socialized health care. It is social health insurance.  Insured persons contribute based on their income and receive care based on their need. NHI is not a tax, rather it is a down payment, when you are well, so that you can  get care when you are sick, without having to pay large amounts! They will receive quality care on a timely basis and with dignity!
What Will You Get?
The NHI will cover members for a broad package of essential and medically approved health services including:
? Outpatient care i.e. visits to health clinics,  general practitioners, specialists as well as to the casualty and emergency departments of hospitals;
? Prescription drugs and medical supplies;
? Laboratory and diagnostic services;
? Inpatient medical and surgical care
? Inpatient mental health care (for short stays);
? Overseas care not available locally;
? Emergency airlift/transport for patients from the Family Islands needing to get quick access to care in the main referral health facilities.
Earlier, I mentioned private insurance as one of the mechanisms, which we examined. In The Bahamas, the data indicate that less than 50% of the population has any form of private health insurance. This is valuable to some policyholders and provides a fair measure of protection in times of illness. However, when we looked closely we found unacceptable gaps and dire concerns with private insurance coverage. The benefit packages do not all provide the same level of coverage.  Many persons are consciously excluded from membership; and many others lose their membership when they retire or when they fall ill or are diagnosed with particular health conditions, especially if the cost is high. Too often we found that those who needed it most, when they needed it most, are deemed as ‘uninsurable’ and ‘sub-standard risks’ by insurers and cannot buy insurance.

For me as Minister of Health this is discriminatory, unfair and ungodly, but that is what happens with insurance for profit.
Surely, we can do better with an inclusive health insurance plan to which we all make contributions when we are healthy and working and from which we all benefit when we need health care.

In the Ministry of Health we are faced, I am faced, on a daily basis with requests from desperate Bahamians who are in distress because they do not have the funds or have the level of insurance coverage to meet their health needs.   For example:

Consider this! I was returning to my office in the first month after my appointment to be confronted by a young mother accompanied by members of her family. She was in tears because her 16 year old daughter was in the Intensive Care unit of the hospital, having been diagnosed with a blood disorder, which could not be treated in The Bahamas. She was told that the child would have to be transferred to the United States of America where appropriate treatment was available but it would cost her $300,000. She had no money. Her family with all the will in the world could not raise that amount and no charity of any kind could be found. The child died within days! I have her letter right here in my hand…it would bring tears to your eyes!
It takes cash to care!

A young single working mother of three children went to one of our clinics complaining of a headache. Eventually the doctor told her she needed a CT scan. The cost was $300. She did not have it. Eventually she arranged to borrow it and got the scan done. Some weeks later she went for a follow up visit. She was told that she needed another scan to measure her progress. She still had more than $250 to pay on the first loan. She couldn’t borrow any more. What was she to do?

It takes cash to care!

I received a letter from the daughter of an elderly lady whose children are in desperate need of $50,000 to treat her health condition that can only be provided overseas.  They have pooled their personal resources and held fund raisers. Nevertheless these efforts have fallen far short.  The health system can only assist with $3,000.  As the Minister of Health I am expected to help and to care.  We simply do not have the resources.

It takes cash to care!

Believe me, there are many stories of this nature which highlight the need to provide universal access to affordable care with dignity and on a timely basis.

Consultations
Fellow Bahamians, this government has consulted widely on the issue of National Health Insurance, starting with the Blue Ribbon Commission.  We have held town meetings, information sharing meetings and consultative meetings.  We have met with Parliamentarians and Senators. We have met repeatedly with the representatives of Medical Association of the Bahamas, who represent the doctors. We have made it a point that every time we have had consultants from abroad they met with the doctors!

We have met with the Bahamas Dental Association (New Providence), at their request and we have met and had consultations with the membership and executives of the Grand Bahama Medical and Dental Association, the executives and members of the Nurses Association of the Bahamas and of the Bahamas Nurses Union.

We have had discussions with the Junior Hospital Doctors Association and the Bahamas Doctors Union.
We have met with representatives of the various Allied Health Professional groups.
We have had meetings and consultations with executives of Doctors Hospital Health System, The Chamber of Commerce, the Grand Bahama Port Authority, the Bahamas Hotel Association, Straw Vendors and the Taxi Cab Union.

We have had numerous consultations and other meetings and presentations with the major private insurance groups.

We have had discussions and consultations with the Trade Union Congress (TUC) and the National Congress of Trade Unions (NCTU).

We have met with the Bahamas Christian Council representatives. We have met with the Roman Catholic priest grouping and we have addressed the Anglican Synod at their last conference.

We have had discussions and consultations with a variety of government agencies, the Bahamas Human Resources Association, and the staff of the National Insurance Board.  This list is by no means complete.

The NHI team has also held meetings with other government agencies, the Institute of Chartered Accountants, National Council on Older Persons, Central Bank Management, Staff of the Cabinet Office, and staff at St. Augustine’s College.  Town meetings were held in New Providence and many Family Islands including Abaco, Cat Island, Andros, Grand Bahama, San Salvador and Rum Cay. These meetings will continue.

In addition the team has diligently addressed, in writing, communications received from interest groups regarding their concerns.

Fellow Bahamians, we cannot wait and do not need the system to be perfect before the introduction of NHI.  We do recognize the need to upgrade the public health sector and plans have been developed to do this in the short medium and long terms.

As we speak, I am working diligently with a dedicated and motivated team of local health administrators on a Health Systems Strengthening Project aimed at minimizing the various shortfalls with which we must deal on a daily basis.

They are working on recruiting more staff in all the categories; upgrading the Information Technology systems and harmonizing them; reforming staff culture and attitudes in preparation for the new way of doing things that will be ushered in with NHI.

With respect to upgrading of facilities, we are currently carrying out and planning a comprehensive programme which will include construction of mini hospitals in George Town, Exuma and Marsh Harbour Abaco. Architectural works in both cases are complete and they will soon go out to tender.

There will be a new Primary Care Centre in Freeport and a new hospital to replace the Rand.
A new polyclinic/mini-hospital is nearing completion in Inagua as well as Grand Cay Abaco.
We have cleared land for a new polyclinic in Eleuthera.
We will break ground for a new clinic in Smith Bay Cat Island next month.
We are planning a new clinic in Rum Cay.
The new subdivision in Sandy Cove will have a new polyclinic and there will be satellite clinics in Sandy Point and Crossing Rocks, Abaco.
We will shortly begin the renovations of the polyclinic in Nicholls Town, North Andros and repairs at the Johnson bay Clinic in South Andros.
The Mangrove cay clinic, which recently experienced a fire, will be repaired.
We are constructing a polyclinic in Glinton’s, Long Island.
The clinic at Spring Point Acklins will be extended and a morgue will be constructed.
In New Providence, we will repair and upgrade facilities at the PMH while we plan a new hospital on a site to be determined. A new CT scan machine owned by the PHA will be commissioned next month. Radiologists, which have been in short supply, have been recruited and this should reduce the waiting times for procedures in that department.
As a result of the planned relocation of certain services out of the PMH, space will be provided for some of the more essential services to be better accommodated.
Several of the polyclinics in New Providence are slated for upgrading and the relocation of services. An announcement about this will be made soon.
New accommodation has been found for some of the specialty services provided by the Department of Public Health. These include the PACE, SCAN and the Food Handler’s programme.
A National Blood Bank facility is scheduled to be opened in the New Year.

What Will NHI Cost?
The question of the cost of the services has been raised as well as from where will the money come?

There will be no reduction in government expenditure for health.  The government will pay its contribution for its staff and will fund infrastructural development.  It will also cover the cost of providing services for the genuinely indigent.
Contributions to NHI will be based on ability to pay.

Yet, the overall contribution of each person will be small compared to the premium charged by private insurers for lesser benefits. All employees earning will pay 2.65% of their monthly earnings up to a maximum of $5,000.00. For example, an employee earning about $1000 per month will only be required to contribute $26.50 per month. For someone earning $3000, the contribution will be $79.50. Someone earning at the ceiling of $5000 and above will contribute $133 per month.  Employers will match the contribution of their employees.

People who work for themselves will pay 5.3% of their earnings.

Pensioners who have a substantial income will be asked to pay 2.65%. Those pensioners, with low income, who cannot afford it, will be covered by a contribution from the government. They will not have to pay a copper!
Let me repeat, with NHI,  persons who reach retirement age or have to retire early for other reasons and who now experience difficulties in getting or meeting premium obligations for private health insurance will not have to worry. With NHI, they will still be protected! It is this lifelong protection, offered by NHI, from the cradle to the grave that will provide a significant measure of re-assurance that one will not be marginalized or pauperized by health bills during the long years of retirement.

Children up to the age of 18 (or 25 if they are pursuing tertiary education) will be covered by the contribution of the government and their parents.

Non working spouses will be covered by the contribution of their working spouse.

Management is Critical:-
We recognize that careful management is critical for the success of the NHI. In this regard, we have made explicit and direct provisions for rigorous management of NHI in the several of the key instruments and administrative arrangements for NHI. These include:--
Legislation, already tabled with specific provisions for the management, governance and accountability of NHI;
 IT systems—institution of a computerized, data intensive IT system covering registration with smart cards for all members, contributions from workers employers and pensioners; and on-line, real-time processing of claims by health service providers; the use of the smart card when you go to the doctor or the pharmacy will mean that you will not need a copper to get your care if you are making your contribution!
Contracts—establishment of contractual agreements with health service providers specifying the terms for being part of the network, just as they do now for private insurance, (including provisions for reviews and de-listing) as well as with other agencies such as the National Insurance Board (for registration of members and collection of contributions) and the Ministry of Social Services (for timely and accurate data on the poor);
Utilization and Performance Reviews-
A formal programme of utilization reviews will be used to evaluate the pattern of provider behaviour against benchmarks for similar providers to prevent fraud. This will be linked to the NHI’s system of incentives and penalties for providers;
Medical Panel
An executive medical panel charged with adjudicating on overseas referrals will be in place, undertaking pre-authorisation clearances in relation to expensive procedures and taking action on providers as recommended by the team conducting the service utilization reviews;
Actuarial reviews will be conducted at regularly ---recommended every 3 years—to determine and suggest actions for solvency and sustainability of the NHI Fund;
 Policy on payment of health bills by non-members
There must be a clear understanding that NHI is not ‘free’ and will only be responsible for health bills incurred by members of the Plan while non-members will be required to make their own arrangements to pay their bills. This will require strong commitment by policy and decision makers to eliminate compromise on this critical aspect of NHI sustainability.

What then is the recipe for success in designing and implementing an appropriate NHI plan for any country? The essential ingredients are:
Public Will
Political Will
A carefully selected competent, committed and strong team
Accurate and timely information
A national sense of urgency.
A dedicated team of selfless stakeholders working together
Ongoing communication, genuine dialogue and collaboration
Maintaining focus on the shared vision
Striving for excellence, but remembering that it does not have to be perfect to be effective

Moving forward and staying on track without being deterred by detractors! The perception, if you listen to the detractors, is that there is no need for social heath insurance; but the facts tell me differently and the people of the Bahamas say otherwise. We need to put in place a system to provide equal access to health services for all regardless of their socio-economic status.

I believe, as does my government, that the street sweeper, with a young family, who has lung cancer deserves the same access and level of care as does the Prime Minister with his young children if he gets lung cancer.

I can recall the introduction of National Insurance back in 1974, there was much the same objections.  The naysayers said then that it could not work and predicted bankruptcy, but Bahamians have come to realize the “power” of pooling resources.  They have come to realize that for some National Insurance is all they have.  The National Insurance Fund has grown to $1.5 billion, $5,000 for every man, woman and child in The Bahamas.  Today, through pooling our resources, everyone is entitled to sickness benefits, maternity benefits, disability benefits, industrial injury benefits, and thank God, a pension when they retire!

Unlike private insurance, NHI will provide portable insurance. That means that when you change jobs you do not lose coverage. It means that if you miss one or two payments, you do not lose coverage.
I say that our role as the Government is to protect everyone in the population against the financial burden of health care.  Full protection at best is a long term objective but I would rather start somewhere than stay where we are.  The implementation of NHI would be, at this point in our history, the greatest expression of social solidarity.

No one has had the nerve to say that they do not support the principle of NHI. But supporting the principle is not enough. We have to make NHI available to the people!

If I can sound this call for solidarity amongst my people; if I can stand as mediator between the high and low risk groups in my nation,  if I can get us to take our health seriously, then like the song said “my living shall not be in vain”.

If the truth must be told, it boils down to an issue of how we feel about each other.
Who are we Bahamians?

Do we care enough about ourselves, our families, our communities, and our country to help the least of our brethren as they try to help themselves?

Can we allow our fellow citizens to live in pain or die for lack of money?

We must convince those Bahamians who have much to share just a little with those Bahamians who need more.

As mediator I must stand with my hands outstretched between everyone, regardless of political affiliation or regardless of social status and regardless of wealth.

Let us make this thing called National Health Insurance work.  We can make it work. We must make it work!
For me and for The Bahamas the TIME FOR ACTION IS NOW!!!

Thank you and goodnight.