• Nadeem Esmail Nadeem Esmail - Director, Health System Director, Health System

Performance StudiesPerformance Studies

• The Bahamas Chamber of The Bahamas Chamber of Commerce Forum Commerce Forum

• March 21, 2007March 21, 2007

Copyright © The Fraser Copyright © The Fraser Institute, 2007Institute, 2007

NHI In The BahamasNHI In The Bahamas

The Bahamas Health Care The Bahamas Health Care SystemSystem

PerformancePerformance

Comparing Apples with ApplesComparing Apples with Apples

Bahamas’ GDP per capita ($16,852) larger than all Bahamas’ GDP per capita ($16,852) larger than all nations in Americas except Canada and US in 2002/03nations in Americas except Canada and US in 2002/03

Most nations other than Canada and US significantly Most nations other than Canada and US significantly below Bahamas—average of $7,156below Bahamas—average of $7,156

Bahamas’ GDP per capita ranks in the lower third of Bahamas’ GDP per capita ranks in the lower third of OECD nations in 2002 (ranked ahead of Hungary, OECD nations in 2002 (ranked ahead of Hungary, Slovak R., Poland, Mexico, and Turkey)Slovak R., Poland, Mexico, and Turkey)

Comparing Bahamas’ performance with OECD nations Comparing Bahamas’ performance with OECD nations a reasonable approach. Comparisons with Americas a reasonable approach. Comparisons with Americas also insightful where comparable OECD data is also insightful where comparable OECD data is unavailable.unavailable.

Comparing Apples with ApplesComparing Apples with Apples

5.2% of The Bahamas’ population was over age 65 in 5.2% of The Bahamas’ population was over age 65 in 2001 compared to an OECD average of 14.2%2001 compared to an OECD average of 14.2%

8.4% of The Bahamas’ population was over age 60 in 8.4% of The Bahamas’ population was over age 60 in 2001 compared to an Americas average of 9.72001 compared to an Americas average of 9.7

Performance: CostPerformance: Cost

Health Expenditure, 2001Health Expenditure, 2001

3.6% 3.3%

0.0%

1.0%

2.0%

3.0%

4.0%

Pe

rce

nt

of

GD

P

Private Expenditure Public Expenditure

Age-adjusted Health SpendingAge-adjusted Health Spending

0

2

4

6

8

10

12

14

16

18

Per

cen

t o

f G

DP

, 200

3

U.S.

Baham

as

Icel

and

Canad

a

Switz

erla

nd

Austra

lia

Norway

France

Nether

lands

Ger

man

y

New Z

ealan

d

Gre

ece

Austria

Avera

ge

Portugal

Belgiu

m

Irela

nd

Denm

ark

Korea

Swed

en

Hungar

yLux.

Czech

R.U.K

.

Spain

Finla

nd

Poland

Italy

Slova

k R.

Japan

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

Performance: AccessPerformance: Access

DoctorsDoctors

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5Doctors per 1000 population (Age Adjusted, 2003)

Jap. (2002)United

FinlandCanada

KoreaN.Z.U.S.

PolandLux.

AustraliaGermany

SpainSweden

DenmarkPortugalAverageHungary

FranceIrelandAustriaNorway

Switz.Italy

BelgiumCzech R.

NetherlanSlovakia

BahamasGreeceIceland

3rd3rd

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

MRI MachinesMRI Machines

0

5

10

15

20

MR

I M

ach

ines

Per

Mil

lio

n P

op

ula

tio

n (

Ag

e A

dju

sted

, 20

03)

Icel

and

Korea

Switzerla

nd

Austria

Finlan

d

Luxem

bourgIta

ly

U.S. (

2002)

Denmar

k

Averag

e

Bahamas

(200

6)

Spain

Belgiu

m (2

002)

Germ

any

Canada

New Zeala

nd

Australia

Portugal

France

Czech

Repub

lic

Hungary

Slovak

Rep

ublic

Greece

(2002

)

Poland

Mex

ico

11th11th

Japan (2002): 29.9Japan (2002): 29.9

Source: Esmail (2006)Source: Esmail (2006)

CT ScannersCT Scanners

0

5

10

15

20

25

30

CT

Sca

nn

ers

Per

Mill

ion

Po

pu

lati

on

(A

ge

Ad

just

ed, 2

003)

Lux.

Austria

Belgiu

m (2

002)

Icel

and

Baham

as (2

006)

Italy

Avera

ge

Switz

erla

nd

Gre

ece

(200

2)

U.S. (

2002)

Denm

ark

Finla

nd

Ger

man

y

New Z

ealan

d

Czech

R.

Portugal

Spain

Canad

a

Slova

k R.

France

Poland

Hungar

y

Mex

ico

7th7th

Japan (2002): 78.3Japan (2002): 78.3

Korea: 50.3Korea: 50.3

Source: Esmail (2006)Source: Esmail (2006)

Hospital BedsHospital Beds

0

1

2

3

4

5

6

7

8

Beds P

er

1,0

00 P

opula

tion (

Most R

ecent Y

ear)

13th13th

Source: PAHO (2007)Source: PAHO (2007)

Hospital DischargesHospital Discharges

0

50

100

150

200

250

Dis

char

ges

Per

1,0

00 P

opul

atio

n (M

ost R

ecen

t Yea

r)

28th28th

Source: PAHO (2007)Source: PAHO (2007)

Performance: OutcomesPerformance: Outcomes

Infant Mortality (OECD)Infant Mortality (OECD)

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Rat

e p

er 1

,000

Liv

e B

irth

s (2

003)

Mexico and Turkey not shown

Source: OECD (2006), Source: OECD (2006), PAHO (2007)PAHO (2007)

Est. Infant Mortality (Americas)Est. Infant Mortality (Americas)

0

10

20

30

40

50

60

70

17th17th

Source: PAHO (2007)Source: PAHO (2007)

Mortality <5 (Americas)Mortality <5 (Americas)

0

10

20

30

40

50

60

70

Canad

a

Cuba

U.S.

Mar

tiniqu

e

Guadelo

upe

Chile

Virgin

Isl. (

US)

Puerto

Rico

Barbad

os

Costa

Rica

Neth. A

ntille

s

Urugu

ay

Frenc

h Guian

a

Bahamas

Argent

ina

Trin. &

Tob

ag.

Saint L

ucia

Jam

aica

Mex

ico

Panama

Venezu

ela

Avera

ge

Ecuad

or

St. Vin

c. & G

ren.

Surinam

e

Colom

bia

El Salv

ador

Brazil

Nicara

gua

Belize

Paragu

ay

Hondu

ras

Domini

can R

ep.

Guatem

alaPeru

Guyana

Bolivia

14th14th

Source: PAHO (2007)Source: PAHO (2007)

Haiti not shown

Equality of Child SurvivalEquality of Child Survival

0.5

0.6

0.7

0.8

0.9

1Source: WHO (2000)Source: WHO (2000)

Medically Avoidable Mortality Medically Avoidable Mortality (MAHC)(MAHC)

0

20

40

60

80

100

120

140

160

180

200

Mo

rta

lity

pe

r 1

00

,00

0 (

20

00

)

Source: WHO (2004) Calculations by AuthorSource: WHO (2004) Calculations by Author

Mortality from Breast and Colorectal Mortality from Breast and Colorectal CancersCancers

28.40%

39.50% 38.30%

48.00%

58.60% 57.20%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Ag

e-S

tan

da

rdiz

ed

Inc

ide

nc

e/M

ort

alit

y, 2

00

2

Incidence of Mortality from Breast Cancer Incidence of Mortality from Colorectal Cancer

OECD Avg. Bahamas Americas Avg.

Source: Ferlay et al. (2004), Calculations by authorSource: Ferlay et al. (2004), Calculations by author

High cost system.High cost system.

Relatively good access.Relatively good access.

Average or below average Average or below average performance on quality.performance on quality.

Performance broadly reflective of Performance broadly reflective of Bahamas’ income position but Bahamas’ income position but outcomes/quality lagging.outcomes/quality lagging.

Health Results:Health Results:Getting What We Pay ForGetting What We Pay For

Policy GuidancePolicy Guidance

Understanding Australia, Sweden, and JapanUnderstanding Australia, Sweden, and Japan

Top-ranked healthcare Top-ranked healthcare outcomes.outcomes.

User fees or co-payments.User fees or co-payments.

Parallel private medical Parallel private medical treatmenttreatment

Private hospitals competing to Private hospitals competing to supply publicly funded care.supply publicly funded care.

Understanding Austria, Belgium, France, Understanding Austria, Belgium, France, Germany, Japan, Luxembourg, and Germany, Japan, Luxembourg, and

SwitzerlandSwitzerland

No Waiting Lists.No Waiting Lists.

User fees or co-payments.User fees or co-payments.

Parallel private medical Parallel private medical treatmenttreatment

Social Insurance FinancingSocial Insurance Financing

Private hospitals competing to Private hospitals competing to supply publicly funded care.supply publicly funded care.

Policy IssuesPolicy Issues

SustainabilitySustainability

A new mandatory premium that increases with income could cost the A new mandatory premium that increases with income could cost the economy in terms of economic growth by decreasing the incentives for economy in terms of economic growth by decreasing the incentives for investment, risk-taking, entrepreneurial activities, and working.investment, risk-taking, entrepreneurial activities, and working.

Future growth rates of spending in The Bahamas are not likely to differ Future growth rates of spending in The Bahamas are not likely to differ from that in developed nations, where health expenditures are growing from that in developed nations, where health expenditures are growing faster than the overall economies. This relates to both ageing and faster than the overall economies. This relates to both ageing and benefit levels.benefit levels.

According to recent research on the introduction of government According to recent research on the introduction of government insurance in the United States, the future cost of NHI is likely to exceed insurance in the United States, the future cost of NHI is likely to exceed current estimates because current cost and intensity figures on which current estimates because current cost and intensity figures on which they are based will expand significantly following its introduction.they are based will expand significantly following its introduction.

Sustainability - IISustainability - II

According to the Steering Committee on NHI, The According to the Steering Committee on NHI, The Bahamas would have to experience sustained economic Bahamas would have to experience sustained economic progress to implement “fully functional and progressive” progress to implement “fully functional and progressive” NHI, which is not in keeping with recent experience.NHI, which is not in keeping with recent experience.

Cost sharing? Cost recognition by users and insured?Cost sharing? Cost recognition by users and insured?

How do you deal with new and expensive medical How do you deal with new and expensive medical technologies?technologies?

Access & QualityAccess & Quality

Greater competition will provide for greater availability of Greater competition will provide for greater availability of care and a higher standard of care than might be found in a care and a higher standard of care than might be found in a less competitive environment. This has implications not less competitive environment. This has implications not only for the delivery of services but also for the financing of only for the delivery of services but also for the financing of services in terms of both insurance and remuneration.services in terms of both insurance and remuneration.

Limiting competition with contracts, as proposed by the Limiting competition with contracts, as proposed by the current legislation, could have the effect of limiting current legislation, could have the effect of limiting competition to those providers who are preferred by the competition to those providers who are preferred by the commission.commission.

Greater competition in the insurance for services would Greater competition in the insurance for services would also provide for better outcomesalso provide for better outcomes

Access & Quality - IIAccess & Quality - II

Output based remuneration schemes are, generally, Output based remuneration schemes are, generally, preferable to non-output based schemes.preferable to non-output based schemes.

Cost sharing is also important in terms of making better use Cost sharing is also important in terms of making better use of resources and controlling expendituresof resources and controlling expenditures

Privatization and private contracting of current publicly Privatization and private contracting of current publicly run/managed activities would improve the quality and run/managed activities would improve the quality and efficiency of service deliveryefficiency of service delivery

How do you deal with new and expensive medical How do you deal with new and expensive medical technologies?technologies?

A Few ThoughtsA Few Thoughts

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

Beware the Pitfalls of Ill Conceived Beware the Pitfalls of Ill Conceived PolicyPolicy

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

Beware the Pitfalls of Ill Conceived Beware the Pitfalls of Ill Conceived PolicyPolicy