IF THE government bills for the introduction of the national health system (Gesy) are not passed in parliament by next month, the entire effort will go down in flames in the heat of the brewing presidential election campaign, according to Health Minister Giorgos Pamboridis.
In an interview with the Sunday Mail in his eighth-floor office at the ministry, Pamboridis, the protagonist of the most serious effort to date to introduce a universal-coverage health system, addressed an ongoing behind-the-scenes effort to switch from a single-payer plan, where the state collects contributions and pays healthcare providers via the state’s Health Insurance Organisation, to a multi-payer system that would include private insurers.
The idea of letting private insurance firms in on the Gesy action is anathema to several political parties, most of all communist Akel, so, despite broad-strokes consensus on the need to introduce the system, it’s a potential deal-breaker.
“There is a law that fleshed out the type and form the system would take, and it’s a single-payer system,” the minister said of the 2001 law that first described what Gesy would look like.
“President Nicos Anastasiades campaigned [for president in 2013] on a multi-payer insurance system that would foster competition between insurers. But sensing strong political opposition, and since this is a secondary issue in terms of the introduction of the system, he backed down and accommodated parties’ demand for a single-payer system, in return for their pledge to press ahead. There was a historical compromise last summer.”
There was another reason. The health ministry’s advisers said that a multi-payer system in populations less than one million could not incur the synergies Anastasiades had envisaged on the campaign trail.
“The advice we got was that synergies arising from the competition between public and private insurers to the benefit of consumers – that is, patients – cannot be observed in populations less than one million,” Pamboridis said.
“But we are missing the forest for the tree here. The point is whether we have universal coverage, not whether it will be paid for by a private or a public organisation. It is a non-issue raised by those who want nothing to change.”
Speaking of whom, Pamboridis did not shy away from naming names – or close enough to count, anyway. Every health minister since the voting of the 2001 law has blamed “interest groups” and “powerful centres” for their failure to push the main project on their desk – or, arguably, any desk.
“Organised groups – trade unions, organised private doctors, private clinics, insurance companies,” he listed in rapid-fire succession that suggested this wasn’t the first time he was asked the question.
“I call them ‘the unholy alliance’, because I fail to see what a nurse at a public hospital could possibly have in common with an insurer.”
Appointed in the summer of 2015, Pamboridis was assigned the impossible task of sorting out what has been fittingly termed “the single greatest reform project in the history of the Republic of Cyprus”, which had already claimed two ministers in this administration alone. (And another three in the previous one. And four before that.)
“What had not been done in preparing to introduce the reform was the detection of the true intentions of the various stakeholders and political parties,” he said.
“When I took over, I realised people were paying lip-service to the Gesy idea, but no one was interested in actually doing anything about it. It had been a convenient inconvenience.”
That was one of the key mistakes he made as a new minister, Pamboridis said – crediting “certain stakeholders and some political parties with good intentions, who had in fact aimed at scuppering the entire effort all along”.
“Another was that I trusted key people, who were supposedly committed to the idea of reform, but turned out not to be,” he said.
“I made a mistake there, I was betrayed by people who were institutionally obliged to support my policies but actually undermined them – from within the ministry.”
Mistakes and betrayals notwithstanding, two government bills on Gesy currently under discussion at parliament, and likely heading for a vote in mid-June, were a huge breakthrough – a “turning point”.
“My intention had been to provoke open debate, so that those who seek to block the Gesy effort would be exposed,” the minister said.
“We achieved this by submitting the bills to parliament. Nothing will be done in secret any more. Go there, say what you have to say, and people will be listening.”
The timing is interesting, to say the least. Gesy, very high in Anastasiades’ campaign-trail stump-speech bullet points, was left to fester for nearly half the administration’s term, until Pamboridis was recruited in mid-2015 to revive it – all coming to a head right along the start of the re-election campaign. Politics being what they are, is it going too far to wonder whether it might have been planned this way?
“I don’t think so – I’d know if that were the case,” Pamboridis said with a chuckle.
“It just took the government time to recover from the 2013 slaps in the face – it took time for the economy to recover. Also, every minister in this chair since 2001 would not touch any medium- or long-term issue, because ‘these will be solved with Gesy’. This had a multiplier effect, because the health system the British colonists left us with had long exceeded its shelf life – it outlived itself by many decades. Inevitably, many years’ worth of cracks in the system were revealed. By then, patients had matured as a movement and started vocally demanding reform. Something had to give, and we didn’t have many options other than the existing plans, because going back to the drawing board would have taken us another 20 years.”
But this coincidental coming together of various elements to create the perfect storm that might just allow Gesy to edge through still leaves it in parliament at a very difficult time. Campaign season in Cyprus is never easy, but a one-billion-a-year reform would be impossible to negotiate.
Pamboridis said he is “greatly concerned” about the timing of the House vote, “which is why my goal is to nip the problem in the bud”.
“These bills have to be voted by June,” he said.
“Otherwise, the issue will be burned in the heat of the campaign – again.”
But what if we get Gesy introduced and then its cost balloons, crippling the economy? This has been the most recent of arguments by detractors.
“How would we run over budget?” Pamboridis wondered.
“Gesy planning includes a spherical budget, with funding allocated to each medical service or specialty according to credible estimates, worked out by various studies and reports.”
A 2013 study by German consulting house Mercer is unreliable because it draws on data from 2011 and 2012, when the state of the economy was very different, another popular hole-poking argument goes.
“There is actually a very simple way to assess the validity of this argument,” Pamboridis smiled.
“Go back and check the Mercer study’s predictions for the years since its publication. They were spot on.”
One of the key tenets of national health systems is universality – everyone pays and everyone shares in the benefit – a concept predicated on helping those unfortunate enough to be struck by disease. But how much fairness is there in everyone being forced to chip in to pay for healthcare for, say, a chain-smoker who got lung cancer? Or anyone else who has wilfully put himself in harm’s way?
“There are two approaches here,” Pamboridis replied.
“Let’s call the first one the accounting approach, which says it’s not fair and thus these people should be either excluded from Gesy or burdened with extra cost.”
The second approach – “let’s call it the humanitarian one” – says that everyone is free to do what they want, and it is “the mother’s obligation”, Pamboridis said pointing at himself, to cover her children’s needs.
“A mother doesn’t regard her child as good or bad,” the minister explained.
“It’s the Christian view of the prodigal son, if you like.”
For his part, he said, he subscribes to the state-as-mother philosophy, but believes that those who obviously burden the system should be forced to pay – “not when they need it, but when they are actually causing the burden”.
“Smokers should be taxed on cigarettes, and the tax should go to the hospitals. Or those who drink sodas and leave themselves open to diabetes should also pay – not when they are hospitalised, but when they are knowingly putting themselves in harm’s way by consuming sugary drinks.”
Smokers are already taxed. Around 70 per cent of the price of a pack goes to the state. Some countries abroad are now mulling a sugar tax on soft drinks and some cities in the US have already implemented this policy
This, of course, is another debate entirely. There’s no way to bring so many moving pieces together at the right time, and, despite his impatient and combative public persona, Pamboridis however seems to be getting good at moving the chess pieces into place. This close to making history, compromise is too small a price to pay.