THE HEALTH SERVICE IN CRISIS

THE HEALTH SERVICE IN CRISIS

If you need an X-tray to determine whether you will live or die don’t count on Victoria hospital, the only place in the country that has such a machine. Your choice will be to either borrow money from friends and neighbours, then go into the black market to buy foreign exchange at two times the official rate so you could go to Singapore or Mauritius or ask God to postpone your day of reckoning for a few weeks or hope that Dr Ramados is about to make the donation of another “sophisticated” machine. For the main X-ray machine at Victoria hospital has been out of order for the past few weeks and no one knows when it will be repaired.

One lady patient of a private doctor who took to heart the recent government campaign on television against breast cancer, that all women above sixty should check their breasts for lumps discovered, when her doctor called the hospital, that she could not have an immediate X-ray done because the machine was out of order. She decided to go to Singapore instead but had to go through great expense buying foreign currency in the black market. A patient of a government doctor, who had an existing appointment to have an X-ray taken to determine the nature of a growth on his hand, was told to come back two weeks time. Even then it is not certain it will be working he was told. He cannot afford a trip to Singapore.

This latest evidence of the state of decay in our free health care system contrasts sharply with government propaganda that we’ve never had it so good under the rule of the Seychelles Peoples’ Progressive Front (SPPF) since 1977. The state of the X-ray machine is but one of the numerous symptoms of the problems facing the health service. This newspaper has already publicised a series of court cases of malpractice against foreign doctors working at the main hospital, all of whom come from the African continent.

The most important and high profile case against the Ministry of Health is yet to be heard in court. This involves a six year old girl who was taken to the hospital to have an object removed from her ear but died on the operating theatre table after being administered the wrong gas. An “investigation” by the Ministry apparently uncovered major problems in the supply of critical materials and medicines in a timely manner forcing technicians to cut corners to keep the system functioning. In an attempt to cover-up the deficiencies, management intimidates the professionals from revealing the true state of affairs to their patients.

In the wards patients have noticed that old, worn out and fading linens are being recycled, not sparing even the private wards where patients not connected to high officials of the SPPF have to pay a hefty room charge. The laundry service has been outsourced to a contractor willing to offer credit to the Ministry, thus saving it major embarrassment of having to use dirty linen on the beds when new patients come in.

Although the waiting time for the various services provided by the state health service system is not common knowledge or properly collated in analytical format, reports say that in many areas patients have to wait months and even years to see a specialist or get treatment. At the government eye clinic there hasn’t been an ophthalmologist for the past two years or more. The last one just packed up and left. This newspaper knows of patients who are waiting that long to see one in order to be prescribed glasses. Those who can afford it have given up hope and have gone to private clinics or make the expensive trips to Singapore. Those who cannot afford it borrow money from friends and relatives and stop paying their rent, loans, and electricity or water bills in order to save money for the visit to a private clinic or pay back the loan.

Even though the new budget is proposing to increase the allocation to the Ministry of Health next year, that Ministry has already spent its entire budget allocation within the first six nine months of the year and more. In spite of “unlimited” spending, the situation continues to deteriorate. The nurses, the bedrock of the healthcare system, are complaining that their workload has become untenable. Very often in the wards only one qualified staff nurse is available to service up to 85 patients at a time. A new pay package for nurses to try and entice the experienced nurses back is considered by most people as too little too late and futile. Many nurses have left not necessarily because of their low salary – although they deserve more – but because of a general disillusionment with the management and job dissatisfaction generally.

The nursing profession itself is in disarray. The Nurses Association of the Republic of Seychelles (NARS) has become a ward of the Ministry of Health. Their chief spokesperson is a doctor and highest civil servant in the Ministry rather than the “elected” official of the organisation who is a trained professional in her (or his) own right. The organisation has had very little influence over the pay review. NARS has become virtually another Government Owned Non-Governmental Organisation, an institution unique to Seychelles with the apt acronym GONGO.

The new budget proposes more money for the Ministry of Health, according to the Government. But it is doubtful if more rupees will solve the underlying problems of a major bureaucracy that appears to be out of control, festered with “professional” incompetents at almost every level or it cannot get the foreign currency as and when it needs it. Apart from incompetence at the highest level, which places us among the poorest countries in Africa, the healthcare system suffers from the same fundamental policy contradictions facing those developed countries where free healthcare at the point of use is the national policy.

The supreme irony is that the preferred healthcare system we all run to when we want the highest standard of professional healthcare, including for Presidents Michel and Rene, is Singapore. In Singapore healthcare is not free at the point of use not just for Seychellois but for Singaporeans as well. But Singapore’s healthcare system – how it is financed and delivered to patients - has been recognised as a viable model for third world countries, especially small ones such as ours.

In 1984 Singapore became the first economy to implement medical savings account on a nationwide basis. According to the World Bank, to this day the Medisave scheme remains the only example of an applied medical savings account programme integrated with the country’s health financing structure. This structure includes “individual Medisave accounts embedded in a broader financing framework that backs up the medical savings accounts with a cross-sectional catastrophic risk-pooling scheme called Medishield and a means-tested safety net for the poor called medifund… This three-tier package is backed by the government financing of supply side subsidies to public providers aimed at lowering the net price charged to patient” the World Bank report said.

When he abolished the 3 classes for admission at Victoria hospital after the coup d’etat in 1977, President Rene claimed he was abolishing privileges in healthcare, even though all classes saw the same doctors and were prescribed the same medicine, even for the third class that paid nothing (yes we had free healthcare in those days too). What the higher class paid for were only the bed and meals, not treatment.

In Seychelles today, there is a two tier health service for treatment; one for the poor or low income providing erratic and second rate healthcare at great cost to the whole country (but where the only main X-ray machine is out of order for weeks); another one which is delivered not in Seychelles but in Singapore or India, for the rich and the politically connected (the privileged) at great cost to the budget and pocket books. This is the other irony.

In Singapore, citizens are not obliged to go to the three government owned polyclinics for primary care. They are free to use the other three privately owned polyclinics clinics or other private clinics and even private hospitals where they get the same level of professional care on demand. The medical savings account takes care of their needs. In Singapore the medical institutions compete with each other to provide the most efficient but also one of the best available care in the world to all its citizens regardless of economic status. Citizens, regardless of economic status can also walk away from bad services but they don’t have to fly to foreign countries as we have to do with our free healthcare. In fact Singapore earns foreign exchange from its efficient but high standard healthcare provisions – such as from Seychelles citizens.

One hopes that Mrs Macsuzie Mondon, the newly appointed Minister of Health will take a well deserved trip to Singapore, not for shopping or medical treatment, but to ask its professionals to come and help us set up a similar internationally recognised, economically efficient but well funded and world class healthcare system. First, however, she must move her office from the hospital premises to Caravelle House, (helping the Pension Fund recover its money in the process) and allow competent professionals to manage the care delivery at the hospital and the government clinics without political interference.

Above all, she must allow and encourage a public debate on what a new and good health service for the country should be and how we should pay for it. She must know by now and should tell President Michel accordingly, that there is not such thing as a free lunch.