DISCUSSION over the sprawling issue of introducing a National Health Scheme (NHS) was narrowed down this week to the goal of rendering state hospitals financially and administratively autonomous, a necessary but ever-elusive precondition to adopting a full-scale universal coverage health system.
Autonomous state hospitals are a thing easier said than done – but when stakeholders can’t even agree on what should be said, getting to actually doing it becomes even harder.
The envisioned Cypriot NHS will see state hospitals attempt to stand on their own feet, with a finite annual budget calculated on the basis of medical services offered – a big departure from the current situation, where hospitals are basically arms of government, funded on an as-needed basis.
“The state will no longer pick up the tab for the operation of state hospitals,” a former health minister told the Sunday Mail on condition of anonymity.
“There will be a given budget for each hospital, and they’ll work with that. That’s autonomy.”
The obvious question, of course, is what happens if the budget isn’t enough – if a hospital simply runs out of money.
“There’s just no answer to that yet,” said head of state doctors’ union Sotiris Koumas, adding that the point is not addressed in the government’s proposed legislation.
“In theory, a hospital could be shut down if it goes out of money under the new regime. Bankruptcy rules apply.”
But before even getting to the point of considering what might happen if the money isn’t enough, the government needs to set up the universe in which state hospitals might function autonomously.
“Properly costing each item of health services, from a surgery to a simple visit in a clinic, is no simple feat,” the former minister said.
“It’s an absolutely necessary feat, so that the budget for individual hospitals can be worked out, but far from a simple one. This exercise is bound to take at least two years, and it’s going to require a lot of revisiting before it’s finalised with any degree of confidence. So I’m not sure how they can talk about introducing autonomy as of the start of next year.”
Earlier this week, Health Minister Giorgos Pamboridis, whom a cabinet decision seems to have entrusted with the sole mandate of pushing the NHS agenda forward as soon as possible, by essentially relieving him of all other duties, told parliamentary parties that the hospital autonomy bill will be submitted for discussion and approval within a month, and that a very ambitious – if unlikely – goal is for autonomy to be introduced by January 1, 2017.
“Nothing has been done on costing – how such a deadline can be met remains to be seen,” Koumas doubted.
But Pamboridis has bigger problems than the likelihood of missing the introduction deadline. Besides financial management, the new, autonomous structure will require that actual management – the day-to-day – be signed off to an independent government-appointed board of directors, much in the way other semi-state organisations like the power company or the telecoms provider are run. No-go, state doctors say.
“This is our primary disagreement,” Koumas told the Sunday Mail.
“We believe administration of state hospitals should remain with the health ministry even after autonomy has been introduced. For one thing, will labour issues hammered out with the government be adopted at face value by this new board? And, of course, there’s also the issue of bankruptcy – like Cyprus Airways, a semi-state that runs out of cash can be shut down, just like that.”
‘Efficiency’ is the government’s one-word response. A dedicated board of directors, featuring experienced managers, economists, and, of course, healthcare professionals, with a broad mandate and operational flexibility, can make faster and better decisions. It’s not a bad argument, but it does loop back to whether the board will be obliged to honour any agreements over terms of employment made with the government – there would be nothing to stop an independent board not answerable to the government, the doctors argue, from going its own way.
“Look, this isn’t really the point,” the former minister said with a smile.
“This government has wasted a year and a half trying to design a multi-payer system, in order to accommodate private insurance companies, before finally accepting that it can’t be done, because Cyprus is such a tiny market. The doctors don’t want a new, computerised system in which every transaction will be recorded – otherwise no money from the hospital’s budget can be released – making all income taxable.”
And then, of course, there’s the spin factor. In order to introduce the NHS, the government has to sell a moderate, but universal, tax-hike to the working population, pensioners, employers, and the self-employed, with no opt-out clauses.
Against these forces, Pamboridis has pledged that the hospital autonomy bill will be at the House by mid-July, but getting it approved is a different story altogether.
Pamboridis has his work cut out for him. Historically, the ministerial office he occupies has proven the most inhospitable and resistant to change. Over a period of 56 years, he is its 23rd occupant, meaning health ministers typically wear out less than half their term before they’ve had enough – or it has had enough of them.
Last week, rumours were rife that he, too, is on his way out, with President Nicos Anastasiades making a public spectacle out of taking over the NHS shambles and speaking out against efforts to “mislead” him, a reference falsely interpreted as targeting Pamboridis. In fact, the cabinet went the opposite way days later, assigning most of his responsibilities to the ministry’s permanent undersecretary, thus allowing him to focus all his energy on this seemingly impossible challenge.
“Look, if I had the chance to blow up the health ministry and build it again from scratch, I would,” one of Pamboridis’ predecessors said.
“You can’t have nurses and medical practitioners working administrative duties. They’re not trained for that, and they can’t do it well.”