Health Care: The Nation Deserves Better

For far too long (50 years to be precise!) we have contented ourselves with just taking the ball from the British and running with it — without much reflection on the real needs of a new, emancipated post-colonial citizenry. The nation deserves better

Healthcare is defined as “the diagnosis, treatment, prevention and management of disease, illness, injury, and the preservation of physical and mental well-being in humans.” (Wikipedia). An efficient, caring National Health Service (NHS) is essential for the provision for these services because people do fall ill, meet with accidents and emergencies arise all the time.

Needless to say that all this cost money — a lot of money! But this money has to be found because people’s aspirations for a happy, healthy and productive life can only be met if they are in good shape. Some wise man has rightly said that a healthy nation is a wealthy nation. But as Dr RN Gopee says “to create (that) wealth every society needs a healthy population.” (MT 02-Mar-2018). So Health=Wealth=Health…

NHS Budget

Almost every week, we get newspaper reports of lack of equipment, vital equipment waiting to be repaired, shortage of medication, shortage of staff and long waiting lists that drive ordinary working folks to seek private medical treatment at great cost. But given the financial constraints of the Government of Mauritius (GM), this is not surprising!

In the first 10 years of the millennium (2001-2010), GM expenditure on the NHS amounted to a mean average of 2.13% of GDP. The corresponding figure for next 6-years (2011-2016) was slightly better at 2.37% (Table 1). 

 

Table 1: GM expenditure on the NHS

Year   % GDP spent    Total GDP     GM Health    GM Health
             on Health          USD-bn         Budget           Budget                                                                                                                                     USD-bn         MUR-bn

2011         2.46                       11.52               0.283                       9.34
2012         2.29                       11.67               0.267                       8.81
2013         2.37                       12.13               0.287                       9.47
2014         2.36                       12.80               0.302                       9.97
2015         2.37**                    12.16               0.288                       9.50
2016         2.37**                    11.68               0.276                       9.10

Exchange rate USD/MUR = 33

** Extrapolated from 2011-1014 figures 

Straightaway the reader would have noticed that there has been no increase in the Health budget to compensate for any increase in staff and material costs (think PRB, the rise in the cost of medication/equipment and new treatment coming online). So, in spite of all the hype and hyperbole from every Finance Minister on Budget Day, the level of services would have a priori declined over the years. This is something of which chronic users are only too aware; Mo Ibrahim and other obscure index notwithstanding. On the other hand GM simply does not have the cash.

Comparison

In 2014, we spent 4.80% of our GDP on health services — split almost 50/50 between the public and the private sector. Thus, for a middle-income country, we are found not only lagging behind the developed nations but also shockingly compare badly — very badly — with several developing African states (Table 2).

Table 2: % GDP on health services

2016                            Income Per Capita             Percentage of GDP
Country                          USD 000                         Spent on Health-care
USA                                   61.6                                      16.6
Euro Area                        40.0                                      10.4
UK                                     38.8                                      9.9
Afghanistan                     0.6                                        8.2
Liberia                              0.5                                        10.0
Maldives                           9.9                                        11.4
Malawi                              0.3                                        11.4
Sierra Leone                    0.7                                        11.1
Mauritius                       11.7                                      4.8

The figures are so eloquent that they do not need much comment. One would naturally expect the rich OECD countries to spend considerably more than Mauritius. But the absolute shocker is that countries which are poorer than us — in some cases much poorer — spend a larger percentage of their GDP on their health services. Thus Malawi with a meagre IPC of just USD 0.3k spends 11.4% whilst Mauritius  with a much greater IPC of USD 11.7k spends a shameful 4.8%. Even Afghanistan which has been ravaged by armed conflict continuously since the 1980s spends 8.2%.

Solution

My friend Keshraj never tires of telling me “do not criticize without suggesting possible solutions.” He would therefore never forgive me if I did not end this piece with some suggestions. Essentially we need to pump more money (and resources) into the NHS. But GM does not have the funds to increase the NHS Budget. However the money is out there; we just need to be bold enough to tap into the source.

But first and foremost, we need to carry out a thorough Organization and Methods study of the NHS. And instead of just talking about it (it’s been at least 20-years now!), computerize all patient files. Both these measures will save on time and money. Computerization will also help avoid mix-ups; which undeniably happen sometimes with fatal outcomes!

Funding

Shedding crocodile tears, politicians decry the widening gap between the rich and the poor whilst deftly introducing policy measures that actually boost this phenomenon. Like halving the Corporate Tax from 30 to 15% — the same rate that the working man is made to pay. Where is the principle of fairness in this? Make the rich richer and the “trickle-down effect” will take care of the rest, went the argument from the self-styled Gurus.

Unfortunately the world is now finding out that the “trickle down” theory and even the John F. Kennedy famous “a rising tide lifts all boats” were chimeric illusions that beguiled humankind for decades. So I’m afraid it’s back to the basic honesty of schoolboy Economics which tells us that Equity, Redistribution of Income/Wealth and General Welfare can ONLY be achieved by the transfer of income/wealth from the rich to the rest. PC this may not be, but it is the naked truth!

(A) To begin with, scrap the mandatory CSR which is a not-so-clever way to recycle profits to create jobs for the boys and the girls internally; and leave it to each Corporate to spend whatever they wish on CSR. In 2015, corporates paid taxes amounting to Rs 9.8bn to the MRA. A special levy of 5% in favour of a special NHS Fund would bring in Rs 3.267bn. This would still leave the effective corporate rate at a very favourable 20% (Table 3).

 

Table 3  : Average Top Marginal Corporate Rate 2017

Region                   Average %         No of Countries

Mauritius                  15.00                           1

EU                                  22.45                        28
N. America                   23.51                         31
OECD                            24.66                        35
S. America                    27.27                        11
BRICS                           28.32                         5
Africa                            28.53                        40
USA                               38.90                        1
UAE                               55.00                        1

(B) The labour force comprises of 400k workers. As a rough guide, let the 150k lower paid contribute Rs 100 and the rest pay Rs 200 per month. This can be graduated so that higher earners contribute substantially more. That’s an easy Rs 780k+ pa into the NHS Fund.

(C) As promised prior to its launch, direct all contribution from Lotto to the NHS Fund instead of the Consolidated Fund. That’s another Rs 392k (2016 figures).

(D) When our citizens go abroad, they need to buy adequate health cover which would pay for any medical expenses that may arise during their visit. On the other hand foreigners receive free treatment in Mauritius. This generosity must stop, and they must be made to pay. Another source of income?

(E) QED! A total of Rs 4.439bn+ in the kitty of the NHS Fund.

Private Medicine

In his last Budget, Indian Finance Minister Arun Jaitley announced that his government would provide free health cover to 43% of the population. That is 100m families — comprising 500m (yes half a billion!) individuals — would be insured for INR 500k each. And the Indian PCI of USD1.9k is only 1/6 of Mauritius’s!

In spite of GM mouthing for years that it wants to encourage private medicine, all we have had so far is a measly tax relief on the first Rs 12k of premium paid on health insurance, while the cost of medical treatment has risen substantially. I am certain that, if deduction was allowed for the full premium, more people would be encouraged to take up private cover. With the result that by shifting yet more patients towards the private sector, this would release more NHS facilities for the needy.

We have to remind ourselves that it is not only the rich who go for private treatment. Many poor working people are driven to take that route. So it behoves us to implement measures that would enhance general welfare. A simple policy would be to encourage Charity Status Private Hospitals (CSPH) through a different tax regime.

Virtuous Circle

By just taking these relatively easy, doable steps in the first instance would result in (i) an increase of 50% in the NHS budget, and (ii) a better health service for everyone. Remember Health=Wealth=Health… a very virtuous circle!

But we need to act urgently. Sitting on our laurels whilst patting ourselves on the back is no longer an option, for we really have not done as well as we like to imagine! For far too long (50-years to be precise!) we have contented ourselves with just taking the ball from the British and running with it — without much reflection on the real needs of a new, emancipated post-colonial citizenry. The nation deserves better.

If we have got any local/diasporic Aneurin Bevans in the wings, pray let them come forward!

 


* Published in print edition on 13 April 2018

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