Transcript No Slide Title

NHI In The Bahamas
• Nadeem Esmail
- Director, Health System
Performance Studies
• The Bahamas Chamber of
Commerce Forum
• March 21, 2007
Copyright © The Fraser
Institute, 2007
The Bahamas Health Care
System
Performance
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.
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
Performance: Cost
Health Expenditure, 2001
4.0%
Percent of GDP
3.0%
3.6%
3.3%
2.0%
1.0%
0.0%
Private Expenditure
Public Expenditure
ah U.
am S.
Ic as
e
Sw C la n
a
itz na d
e d
A r lan a
us d
t
N rali
o a
N F rwa
et r y
he an
rla ce
G
N e nd
ew rm s
Ze an
al y
G and
re
A ece
u
A str
ve ia
Po ra g
rt e
B ug
el al
g
Ire ium
D la
en n
m d
a
K rk
Sw ore
e a
H de
un n
ga
r
C Lu y
ze x
ch .
R.
U
Sp .K.
Fi ain
nl
Po and
la
nd
Sl It
ov al
ak y
Ja R.
pa
n
B
Percent of GDP, 2003
Age-adjusted Health Spending
18
16
14
12
10
8
6
4
2
0
Source: OECD (2006), PAHO (2007), BRC (2004). Calculations by Author. Note Bahamas 65+ Ratio from 2001
Performance: Access
Doctors
Iceland
Greece
Baham as
Slovakia
Netherlan
Czech R.
Belgium
Italy
Sw itz.
Norw ay
Austria
Ireland
France
Hungary
Average
Portugal
Denm ark
Sw eden
Spain
Germ any
Australia
Lux.
Poland
U.S.
N.Z.
Korea
Canada
Finland
United
Jap. (2002)
3rd
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Doctors per 1000 population (Age Adjusted, 2003)
Source: OECD (2006), PAHO (2007), BRC (2004). Calculations by Author. Note Bahamas 65+ Ratio from 2001
MRI Machines
Japan (2002): 29.9
MRI Machines Per Million Population
(Age Adjusted, 2003)
20
15
10
11th
5
0
d e a d tria nd rg aly 02) rk ge 0 6) in 02) ny da nd lia al ce lic r y lic 02) nd co
n
la Kor rlan us nla bou It (2 0 ma era (20 Spa (2 0 ma na ala tra rtug ran ub nga ub (20 ola exi
e
s
n
e
A Fi m
F e p Hu ep e
P M
Ic
er Ca Ze Au Po
S. De Av a s
m
.
it z
R
e
R ec
G
u
x
i
U
w
w
m
k e
h
S
lg
Lu
ha
ec
Ne
v a Gr
e
a
z
o
B
B
C
Source: Esmail (2006)
Sl
L
el A ux
gi u .
um st
ria
(
2
B
00
ah
am Ice 2)
as la n
(2 d
00
6)
A Ita
Sw ve ly
r
G itz a ge
re er
ec la
e nd
(
U 200
.S 2
.( )
D 200
en 2
m )
a
Fi rk
n
G lan
N er
ew m d
Ze any
a
C lan
ze d
c
Po h R
rt .
ug
a
Sp l
C ain
a
Sl nad
ov a
ak
F r R.
an
Po ce
l
H and
un
ga
M ry
ex
ic
o
B
CT Scanners Per Million Population
(Age Adjusted, 2003)
CT Scanners
Japan (2002): 78.3
30
Korea: 50.3
25
7th
20
15
10
5
0
Source: Esmail (2006)
B
a
N rb
ai . A ad
nt n os
K ti l
itt le
s s
&
G N
re .
B nad
er a
m
u
S C da
t. u
V b
M .& a
ar G
t
A i ni q .
rg u
D ent e
G om ina
ua in
de i ca
lo
C upe
a
Fr B n
en ah ad
c h am a
G as
Tr Mo ui a
in n na
. & ts
e
To rr a
ba t
g.
U
.
S
C P
ay ue A r .
m r t ub
an o a
R
Is ic
S l an o
ur d
in s
am
G
S u e
ai y
nt an
L a
A uci
ng a
u
A il a
ve
ra
B ge
A
ra
nt
. a C zi l
D n hi
om d le
in Ba
i c rb
a .
V
ir g U n R
r
i n ug .
Is u a
l.
y
J a (UK
m )
P ai
C an ca
Tu
os am
ta a
rk
s
& E Ri c
C cu a
ai ad
co o
s r
Is
l.
C B el
ol i z
o e
P mb
ar i a
ag
ua
P y
B er
H oli u
on vi
du a
ra
M
N e s
i c xi
V ara co
en gu
ez a
ue
E
l S H la
G alv ai ti
ua ad
te or
m
al
a
S
Beds Per 1,000 Population (Most Recent Year)
Hospital Beds
8
7
6
5
4
13th
3
2
1
0
Source: PAHO (2007)
Pa
r
M agu
a
G rti n ay
ua i q
de ue
l ou
pe
A
C
S t ol rub
. K om a
b
C i tts i a
ay &
m N
an .
Isl
D U .
P u o m .S .
er ini c
to a
B e Ric
rm o
ud
C a
Tu
ub
rk
a
s & Ch
i
C le
Su . I
rin sl .
a
C me
an
A v ad
a
Tr G era
in. r e ge
V & nad
S t ir gi n Tob a
. V I ag
i n sl . .
ce (U
nt K
& )
G
C Be .
os li
S ta ze
Fr ain Ri c
en t L a
c h uc
G ia
u
P a i an
na a
An
t. & A n m a
g
B a ui ll
a
r
B a bu
ha da
J a ma
m s
ai
c
Br a
G azi l
u
D A rg y an
om e a
ini ntin
ca a
n
M R.
M ex
on i c
o
B a tser
r
rb at
E c ado
s
N uad
i ca o
ra r
g
E l B o ua
S a li v
l ia
H v ad
on o
d r
U ura
ru s
gu
a
Ve P y
ne er
G zu u
ua e
te la
m
ala
Discharges Per 1,000 Population (Most Recent Year)
Hospital Discharges
250
200
150
100
28th
50
0
Source: PAHO (2007)
Performance: Outcomes
Ic
el
a
Ja nd
Fi pa
Swnla n
ed nd
C
N
ze
or en
ch
w
Re Sp ay
pu ain
Fr bli
G ancc
Po ree e
G rtu ce
er g
m al
an
Sw B It y
e
itz lg aly
iu
D er la m
en n
m d
A ar
N Au ust k
Lueth str ria
xe erl ali
m an a
bo ds
Ire urg
U K C la
ni or a n
te ea n d
N
d ( ad
ew
K 2
Ze O ing 002a
al EC do )
U an D m
ni d A
te (2 v
d 00 g.
S 2
t )
Sl
Poa te
ov
ak Hu lans
R ng d
e
B pu ar y
ah b
am lic
as
Rate per 1,000 Live Births (2003)
Infant Mortality (OECD)
Mexico and Turkey not shown
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Source: OECD (2006),
PAHO (2007)
Est. Infant Mortality (Americas)
17th
Source: PAHO (2007)
Mortality <5 (Americas)
Haiti not shown
14th
Source: PAHO (2007)
C
J hi
N apa le
o n
P rwa *
ol y
an *
d
G U.K *
r e .*
A ec
us e
Fr tri a *
Ireanc *
N
l a e*
n
N e th
e w e Ita d *
rl a ly
Ze n *
al ds
*
S
w S and
itz pa *
A erl i n*
us an
C tral d*
C ana ia*
z
D ec hda*
en
Lu Ge maR.*
xe r m rk
m an *
b
Ic o u y *
B el a rg*
el n
gi d*
F
i um
U
ni S nla *
te we nd
d
O S t den*
E a *
C te
P D As *
D ortu vg
o g .
B min al *
ar i c
ba a
S K dos
lo or
v e
H ak a*
un R
g .*
C C ary*
o
C l o ub
os m a
ta b i
A Ri ca
v
A P ar era a
nt a g
. g e
A & B uay
rg a
en rb
t .
B Me ina
Tr aha xi c
in U m o*
. & ru a
s
V To gua
e
b
n a y
A
m Gez g.
er r ue
i e
S c as nadla
ai A a
nt v
S
t.
L g
S Vi n J am uci .
t. . a a
Ki & i c
tts G a
& re
P N n.
S ana ...
ur m
in a
a
D Ni B me
om ca eli
in rag ze
ic u
an a
G
ua P R.
te e r
m u
B ala
E T ra
l S ur zi
al k e l
v a y*
H B o dor
on li v
d i
G uraa
E uy a s
cu n
ad a
H or
ai
ti
Equality of Child Survival
1
Source: WHO (2000)
0.9
0.8
0.7
0.6
0.5
nc
Ja e
A pa
us n
tr
a
C li a
an
S ad a
w
ed
en
S
pa
N
N o in
et rw
h
er ay
la
nd
s
D Ita
N en ly
ew m
Ze ark
al
G an
er d
m
a
Fi ny
nl
A an
ve d
ra
g
A e
us
U G tri a
ni re
te e
d ce
S
ta
P tes
or
tu
g
Ir al
U ela
.K n
.( d
1
B 99
ah 9)
am
as
Fr
a
Mortality per 100,000 (2000)
200
Medically Avoidable Mortality
(MAHC)
180
160
140
120
100
80
60
40
20
0
Source: WHO (2004) Calculations by Author
Mortality from Breast and Colorectal
Cancers
60.0%
Age-Standardized Incidence/Mortality, 2002
OECD Avg.
Bahamas
Americas Avg.
58.60%
57.20%
50.0%
48.00%
40.0%
39.50%
38.30%
30.0%
28.40%
20.0%
10.0%
0.0%
Incidence of Mortality from Breast Cancer
Incidence of Mortality from Colorectal Cancer
Source: Ferlay et al. (2004), Calculations by author
Health Results:
Getting What We Pay For

High cost system.

Relatively good access.

Average or below average
performance on quality.

Performance broadly reflective of
Bahamas’ income position but
outcomes/quality lagging.
Policy Guidance
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.
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.
Policy Issues
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.
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?
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
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?
A Few Thoughts
Beware the Pitfalls of Ill Conceived
Policy
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
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.