There have been no meaningful comments made by the government of The Bahamas in recent times regarding the proposed implementation of National Health Insurance (NHI) in January 2016. To put this in perspective, we are just about seven months away from the unrealistic kickoff date for one of the most significant initiatives since independence and we are not hearing from the people charged with overseeing the nation. This is not only concerning, it is unfortunate and unacceptable in a democracy - a government of the people, for the people and by the people.

The most information the Bahamian people have received of late emanated from the minister of health, Dr. Perry Gomez, and it was simply that the details of the first phase will not be revealed until the 2015/2016 budget has been presented in the House of Assembly. He further stated that the government "will move forward with great gusto" afterward to meet the referenced deadline. In other words, the Bahamian people need not worry about the details and cost of NHI but just trust the government to do the right thing.

In light of the foregoing, we would like to know the positions of the following stakeholders whose portfolios, areas of responsibility or constituents will be impacted by the proposed NHI scheme.

Prime minister and minister of finance
The minister of finance is responsible for overseeing the country's finances and has stewardship of the public purse. The minister is also ultimately responsible for the safe and soundness of the financial services industry. He can be likened to the chief financial officer of a private company but also doubles as chief executive officer in his capacity as prime minister with responsibility for the economy and country as a whole.

The Bahamas Chamber of Commerce and Employers Confederation (BCCEC), which represents employers in the private sector, in releasing its position paper lamented the lack of proper consultation with the private sector by the government. This comes after the Bahamas Insurance Association (BIA) had expressed similar concerns.

Questions
Why have you refused to meet with the private sector in relation to NHI? Do you believe that your dream of universal health coverage can be achieved without buy-in or support from the private sector?
Are you of the view that the country can afford NHI as proposed in the Sanigest report?
How do you propose to fund the NHI scheme? Can we still expect to pay a premium of around $2 to $3 to fund NHI, like you indicated?
In the immediate aftermath of the imposition of value-added tax (VAT) by the government, do you believe the Bahamian people can absorb additional taxes to fund NHI in a sluggish economy with high unemployment?

Minister of health
The ministry for which you are responsible is perhaps the most crucial one to the achievement of universal health coverage in The Bahamas. Unfortunately, it is also one of the most inefficient and ineffective ministries, and is also laden with alleged corruption and scandals.

With oversight of the Department of Public Health and Public Hospitals Authority, and by extension the Princess Margaret Hospital, it is difficult to comprehend how NHI could be implemented on top of such a dysfunctional system.

Questions
What has been or is being done with the infamous PHA audit report? What is your ministry doing to address the serious deficiencies and material weaknesses identified in that report? If your ministry cannot be relied upon to open the Critical Care Block on time and get it fully operational, do you believe all Bahamians (public and private) should entrust their healthcare to you?

As you are aware, PMH is constantly faced with long lines, inadequate infrastructure and lack of sufficient personnel. Why should a significant initiative such as NHI be implemented without first addressing these issues?

The Beck Group was engaged on a contract worth about $400,000 to develop a master plan for the development of PMH. Their report is expected in about one year and they have indicated that the final plan is an important first step ahead of implementing NHI. In light of this and the stated time frame, are we not putting the cart before the horse? How do you intend to strengthen the health system before the introduction of NHI? What will your ministry do differently to ensure the success of the proposed scheme?

Minister of labor and national insurance
The Ministry of Labour has oversight of labor-related matters within the country and has responsibility for the National Insurance Board. There have been concerns raised by the BEC chairman and MP for Tall Pines regarding the potential loss of jobs in private health insurance with the implementation of NHI. Individuals within that industry have also expressed similar fears. The minister also has responsibility for NIB, which is expected to play a major role in the implementation of NHI. He stated in June 2014 that the cost of NHI will not be released until after implementation, a comment that is difficult to understand in a democratic society.

Questions
Are the assertions regarding the potential loss of jobs in the private sector as a result of NHI valid? What will be the role of NIB in the implementation of the proposed NHI scheme?
Seeing that several concerns have been raised about the sustainability of NIB and the fund, as well as its ability to meet the future demands of Bahamians, why is NIB being drawn into the funding and administration of the proposed NHI scheme?
The report on the National Prescription Drug Plan and the concerns raised in relation to its funding raise valid points on its sustainability. In light of this and with a bigger price tag, do you think that NHI as proposed will be sustainable?
NIB expends some 25 percent of the revenue it collects on administration costs. In Trinidad and Tobago its equivalent to our NIB expended 4.6 percent of the revenue it collected on administration costs. Internationally the standard cost for administration of something like our NIB would be only two percent of revenues collected. Can we trust NIB to run NHI any better than it runs NIB and a far cry from international best practices?

Minister of financial services
The financial services industry in The Bahamas consists of the banking, insurance, securities and financial and corporate service sectors, among others. This ministry and the minister that heads the same have responsibility for the promotion of the financial services industry as a whole and not only international or offshore banks.

Questions
Why have you been so silent on NHI even though it promises to impact one of the main financial sectors you are charged with promoting?
What is your position on NHI and the level of engagement of the private sector in the design and implementation of NHI?

Minister of state for investments and minister of state for finance
These ministers in the Office of the Prime Minister and Ministry of Finance have oversight over investments and finance in The Bahamas; including local and foreign investments and the National Development Plan.

As members of the private sector, with one being a former head of the Bahamas Chamber of Commerce and the other having worked in the insurance industry, they should understand business, the economy and be able to appreciate the perspective of the private sector in this debate.

Questions
What is your perspective on the lack of real consultation with the BCCEC and private sector as a whole?
Do you believe that the millions of dollars invested by private health insurers over the years should be ignored in the implementation of NHI?
How do you think the private sector infrastructure and expertise should be leveraged in the introduction of NHI?
Companies are skeptical about investing in an environment of uncertainty. How do you explain the uncertainty surrounding NHI implementation and whether additional taxes will be levied to fund this scheme?
There has been talk about the establishment of a public insurance company to sell NHI. Do you support this approach and the use of taxpayers' funds to set up an insurance company owned by the government?
Do you believe that governments are more efficient in running such organizations?
Are the government's actions with respect to the insurance industry not just a "hostile takeover" of this private sector industry without any payment to its existing shareholders?
Is it not counter to what government has done and has been doing with other public corporations? Has it not been transferring ownership and operations to the private sector?
Hasn't the government been divesting ownership and operations of various government corporations like BaTelco, BEC and the garbage disposal facility?

Other stakeholders
The proposed NHI scheme will have significant impact on numerous stakeholders within the Bahamian economy. This is why the importance of collaboration between the government and the numerous stakeholders cannot be emphasized enough. In this regard, the following groups and institutions should articulate and communicate their positions on NHI sooner rather than later:

o Medical Association of The Bahamas
o Primary Care Providers Group
o Bahamas Pharmaceutical Association
o Doctors Hospital
o Coalition for Responsible Taxation
o Trade unions.

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