1. Nadeem Esmail -Director, Health System Performance Studies The Bahamas Chamber of Commerce Forum March 21, 2007 Copyright © The Fraser Institute, 2007 NHI In The Bahamas

2. The Bahamas Health Care System

3. Performance

4. Comparing Apples with Apples  Bahamas’ GDP per capita ($16,852) larger than all nations in Americas except Canada and US in 2002/03  Most nations other than Canada and US significantly below Bahamas—average of $7,156  Bahamas’ GDP per capita ranks in the lower third of OECD nations in 2002 (ranked ahead of Hungary, Slovak R., Poland, Mexico, and Turkey)  Comparing Bahamas’ performance with OECD nations a reasonable approach. Comparisons with Americas also insightful where comparable OECD data is unavailable.

5. Comparing Apples with Apples  5.2% of The Bahamas’ population was over age 65 in 2001 compared to an OECD average of 14.2%  8.4% of The Bahamas’ population was over age 60 in 2001 compared to an Americas average of 9.7

6. Performance: Cost

7. Health Expenditure, 2001

8. Age-adjusted Health Spending Source: OECD (2006), PAHO (2007), BRC (2004). Calculations by Author. Note Bahamas 65+ Ratio from 2001

9. Performance: Access

10. Doctors3rd Source: OECD (2006), PAHO (2007), BRC (2004). Calculations by Author. Note Bahamas 65+ Ratio from 2001

11. MRI Machines 11th Japan (2002): 29.9 Source: Esmail (2006)

12. CT Scanners 7th Japan (2002): 78.3 Korea: 50.3 Source: Esmail (2006)

13. Hospital Beds 13th Source: PAHO (2007)

14. Hospital Discharges 28th Source: PAHO (2007)

15. Performance: Outcomes

16. Infant Mortality (OECD) Mexico and Turkey not shown Source: OECD (2006), PAHO (2007)

17. Est. Infant Mortality (Americas) 17th Source: PAHO (2007)

18. Mortality <5 (Americas) 14th Source: PAHO (2007) Haiti not shown

19. Equality of Child Survival Source: WHO (2000)

20. Medically Avoidable Mortality (MAHC) Source: WHO (2004) Calculations by Author

21. Mortality from Breast and Colorectal Cancers Source: Ferlay et al. (2004), Calculations by author

22.  High cost system.  Relatively good access.  Average or below average performance on quality.  Performance broadly reflective of Bahamas’ income position but outcomes/quality lagging. Health Results: Getting What We Pay For

23. Policy Guidance

24. Understanding Australia, Sweden, and Japan  Top-ranked healthcare outcomes.  User fees or co-payments.  Parallel private medical treatment  Private hospitals competing to supply publicly funded care.

25. Understanding Austria, Belgium, France, Germany, Japan, Luxembourg, and Switzerland  No Waiting Lists.  User fees or co-payments.  Parallel private medical treatment  Social Insurance Financing  Private hospitals competing to supply publicly funded care.

26. Policy Issues

27. Sustainability  A new mandatory premium that increases with income could cost the economy in terms of economic growth by decreasing the incentives for investment, risk-taking, entrepreneurial activities, and working.  Future growth rates of spending in The Bahamas are not likely to differ from that in developed nations, where health expenditures are growing faster than the overall economies. This relates to both ageing and benefit levels.  According to recent research on the introduction of government insurance in the United States, the future cost of NHI is likely to exceed current estimates because current cost and intensity figures on which they are based will expand significantly following its introduction.

28. Sustainability - II  According to the Steering Committee on NHI, The Bahamas would have to experience sustained economic progress to implement “fully functional and progressive” NHI, which is not in keeping with recent experience.  Cost sharing? Cost recognition by users and insured?  How do you deal with new and expensive medical technologies?

29. Access & Quality  Greater competition will provide for greater availability of care and a higher standard of care than might be found in a less competitive environment. This has implications not only for the delivery of services but also for the financing of services in terms of both insurance and remuneration.  Limiting competition with contracts, as proposed by the current legislation, could have the effect of limiting competition to those providers who are preferred by the commission.  Greater competition in the insurance for services would also provide for better outcomes

30. Access & Quality - II  Output based remuneration schemes are, generally, preferable to non-output based schemes.  Cost sharing is also important in terms of making better use of resources and controlling expenditures  Privatization and private contracting of current publicly run/managed activities would improve the quality and efficiency of service delivery  How do you deal with new and expensive medical technologies?

31. A Few Thoughts

32. This discussion is not intended to dissuade Bahamians from implementing an NHI program. Rather, it is intended to inform their decisions about NHI and assist them in ensuring that the program which is ultimately implemented is one that works both for citizens today and for the nation tomorrow. Beware the Pitfalls of Ill Conceived Policy

33. It seems that many of the discussions in The Bahamas to date discuss primarily the short-term state of affairs while only giving a brief nod to the realities that will come to bear in the longer term. Beware the Pitfalls of Ill Conceived Policy