 Hello and welcome to another episode of Issues and Answers, a production of the Government Information Service. We are on NTN right now. We'd like to thank you so much for tuning in. My name is Jessie Léonce. In today's installment we are focusing on national health insurance, something that is surely on the way for St. Lucia, but of course so many things have to be put in place first. I would like to welcome my guests, the health planner and the corporate planning unit of the Ministry of Health and Wellness, Lauren James, as well as Chief Economist in the Department of Finance, Janaye Léonce, to speak to us about the progress that has been made so far and what is left to be done. Good day. Thank you so much for being here. Thank you for having us. We are definitely pleased to be here and to explain and sort of let the public know where we are with respect to national health insurance. Wonderful. I want to start with you, Ms. James. If you could just for the purposes, for the benefit of our viewers, give a definition of national health insurance and what it would mean for our population? Okay. I just, before I answer that question, I want to give a scenario. We have many cars on the road and we are required to insure our cars and we don't have insurance. We cannot be driving on the road and similarly for our houses. So why should our health be any different? National health insurance is really a prepaid mechanism for rich persons who can access health care without paying out of pocket for health care when they need to use it. So it's a system by which we are trying to encourage persons to take a more proactive approach to their health and to prevent them from going to health prices, which is eventually more costly for them. So it works almost like car insurance, house insurance is just for health insurance now, protecting you against any costly intervention that you may need in the future. Okay. From the administrative perspective, tell us the work that has been ongoing. But first of all, funding for this project, we know it's under the Health System Strengthening Project. Tell us a bit about what has been allocated for this venture. Well, currently we have under the Ministry of Health a $25 million World Bank project where we have approximately $5 million in place to put in place structures for health insurance. That doesn't mean, like I said in an earlier interview, that doesn't mean the $5 million is to, $5 million USD that is, is not to pay health insurance, but to put in the necessary structures to operationalize health insurance. That would mean things like legislation, you have your registration of the population and your health management information system and all the necessary structures in place. Okay. Speak to us about the initial phase of NHI in St. Lucia. What will it look like and what will it address in terms of coverage? Right now we are in discussion with private health insurance because they submitted proposals, but what we envisage is that it will encompass a range of services such as inpatient care, outpatient care, we would have surgical benefits, we envisage it to have air ambulance, but it's an ongoing discussion with the health insurance providers. It is not setting somebody, it is our vision for the health insurance to have those sort of coverage for the population. Okay. I want to now come to you Mr. Leonce, if you could just speak to us about, well we're venturing into welfare economics here. Speak to us about the, how it will augur well I should say for the population, for the countries, economics at this time for an injection of NHI. Thank you. Thank you for having me on the program. One of the things that we noticed was that St. Lucia actually has relatively high levels of out-of-pocket expenditures. So on average we spend almost four times the amount that is the World Health Organization and other institutions have indicated is the amount that a citizen should be paying out of pocket. Each dollar that you spend out-of-pocket, that is the money that could have been spent on other economic activity, education and what have you. And health care and paying for your health care has the potential to bankrupt many persons to the extent that they are not covered or they don't have health insurance coverage. When we dug a bit deeper we recognized that only 18% of the working age population has health insurance coverage and that made us look a bit deeper to see why is that the case and one of the issues that's contributing to that is the price of insurance policies, the design of insurance policies and also our attitudes and perceptions with respect to insurance. So one of the things the National Health Insurance Scheme is trying to do is to meet with the insurance providers and see to what extent we can design standardized products that can be at the price point that persons would be able to afford, but also design in a way that it may change the attitude and the perception with respect to insurance a bit. And to the extent that you could do that, a lot of the debilitating costs that persons need to incur should a health event happen to them, that would be spread given the fact that they have health insurance coverage and those monies can be spent on education, childcare and a whole host of other areas. So to Ms James's point, the pooling that insurance allows and facilitates has economic benefits as well. Okay, Ms James back to you, it would certainly also reduce inequity in our population as well. That's correct. Because you have persons over various classes not being able to afford insurance right now. What is the significance of that aspect? I always like to use the real life examples when we speak to those issues. We've seen many persons now, young persons getting cancer and we see and we have donations sheets, we have dances, we have barbecues. That is what the health insurance is looking to get people away from. You have persons that no matter your race, your sex, your economic status that you are able to access this basket of service and there's no barrier to accessing that health, that basket of services. So that is how it really intends to reduce the inequity in health. Okay, now I want to talk about, you wanted to add a point. Just to add to that point, one of the notions that the state is looking to do is where persons are poor and vulnerable and what not to ensure that those persons can be provided with insurance policies that would allow them to access an array of services and benefits that they otherwise would not have. So I think Carries has been placed in the design of this that whatever is to be designed, the poor, the vulnerable and what have you would be proxy means tested to ensure that they meet the requisite standards for poverty and vulnerability so we're not just using ad-lib terms but proxy means tested until the extent that persons do meet the definition. I think the design phase that we are in now, in phisages that those persons would be able to receive the coverage. Wonderful. We're speaking on the national health insurance and the work that is going into it right now to achieve that for St Lucia. We're talking to Health Planner in the Corporate Planning Unit of the Ministry of Health and Wellness, Ms Lauren James as well as Chief Economist in the Department of Finance, Mr. Jeunais Léonce. When we come back, we will get into coverage. Stay with us. Amela, I noticed that you built your retaining wall on my property. You will have to give me my land back or compensate me for that. My contractor isn't dumb. I trust that he will not build anything on your property. Where is your proof? Let's go to court. This situation does not require you to go to court. Just like we have to go through mediation here. Mediation is a way people resolve conflicts like this. Someone, a third party, comes to speak to both parties. This person is called the mediator. The mediator is impartial. He or she makes sure that communication between both parties is effective and efficient. So the mediator is a judge? No. The mediator is not a judge. Judges, unlike judges, do not decide cases or impose settlements. Let me get a mediator to handle this retaining wall and that kitchen. Kitchen? Yes. Your kitchen also falls on my land. Let me call the mediator. Thank you so much for staying with us. This is Issues and Answers and we're talking National Health Insurance with Ms. Lauren James out of the Ministry of Health and Wellness. She is the health planner in the corporate planning unit and we have chief economist over from the Department of Finance, Mr. Jean-Ailéance. Ms. James, I want to get into NHI coverage. At this time, the purpose really is to provide all St. Lucians ultimately with affordable rates of health insurance here on Ireland. Talk to us about the coverage. The coverage is for all eligible residents of St. Lucia. That would mean even if you're from St. Kitts and Libes and you're authorized to work and live in St. Lucia and you are contributing, you will be eligible for coverage. It is our hope that all individuals regardless of age is covered, but that would be an ongoing discussion with the insurance companies. But it is our vision that all eligible residents and that would mean persons who are allowed to live and work in St. Lucia. Okay, and as we mentioned earlier, there are certain vulnerable groups that will be assessed to determine their ability to pay for that insurance. Alongside individuals who will be purchasing on their behalf, the state will also be purchasing in bulk. So tell us about that. So one of the things that we have been working with the World Bank and our other stakeholders as we are in the design element is to address which modality is best. So would it be best for the state to purchase all of the policies and then have persons who are poor and vulnerable receive from the state and also persons who are not poor and vulnerable but would like to purchase insurance to do that for the state as well or whether it may be best to have the state simply focus on the poor and vulnerable and allow your non-poor to be able to access through the employer, through a provider of their choice and so forth. So we are doing the analysis to see what permutation works best for us. What are some of the factors that are being considered? Well, with respect to coverage, one of the key aims for the state is to improve access. So most persons or most insurance products right now, once you get to 60 or 65, these products end. So to the extent that you are over 60 or 65, you often don't have health insurance coverage. So we are actually working with insurance providers to see if we could design products for those persons who are after 60, 65 so that they too will be able to have coverage. I'll meet at a smaller scale relative to what's the norm for your working age but we want all demographics to be covered by health insurance. What's happening now where you look at your working age population is only a small percentage of insurance there and when you look at your non-working age of 65 and above, they cannot have insurance even if they wanted to or they have the financial means to. So the discussion with insurance providers is to explore how the entire demographic age-wise can be covered and that to Ms. James Point, both persons who are citizens and also persons who are domiciled here, resident here or simply working here, they will be able to purchase products as well. So coverage is really intended to have all age demographics covered and that to have the policies so designed to allow any demographic to access. Okay and in keeping with that we also have seeing the note self-employed and the informal sector workers will be required to join the NHI. Speak to us about the significance of that aspect tying into your statement. Yeah thank you. I think COVID-19 and the pandemic has actually showed the importance of pooling. We saw when COVID hit that many persons who were not contributors to the NIC now needed to get benefits because there was no safety net under them given that they were self-employed so many persons had to fall back on the state for income support or what have you whereas persons who were NIC contributors they were able to benefit from the NIC scheme and I think in the discussions we have had with stakeholders to date there's a heightened sense amongst your self-employed and what not who typically would not have thought it best to purchase any sort of group product or what have you. That attitude, that mindset is changing a bit so I think those self-employed and what not who typically would opt out of pension contributions or what we are now proposing health schemes there is a new attitude, a new sense and they will be able to purchase and we are encouraging them to purchase insurance. Our intent is to really have broad-based insurance coverage for the entire populace, all age demographics and to the extent that you have that coverage many more persons will be able to access care and all sectors of the society would benefit in that given you can now access care you will have less persons trying to access care later on in their chronic disease or what have what you have now is that persons are choosing to not go to the doctor early up in their condition and where things become really severe really acute they present themselves to the Owen King or to Zitsen Jew facility and what not where it is now way more expensive to treat and it's way more debilitated from their standpoint so to the extent that you could encourage persons to have insurance coverage up front and be able to to see the doctor and have visits two three visits a year and so forth we're hoping it will stimulate some of that lateness that we are seeing. Okay and of course we are a population we are well known for our pre-existing conditions our chronic non-communicables I want to get into eligibility on that note but before I come to that I want to talk about the life of the coverage is there a time is there a shelf life for NHI will there be? Well most insurance products in the market right now have lifetime caps so you can get a $500,000 policy or $200,000 policy that covers your entire lifetime sorry what one of the things we are working if insurance providers to do is to sort of step away from that a bit and to essentially have whether it be a two or three annual caps which can be adjusted so your annual cap or your major medical limit let's say is $100,000 or $200,000 and to sort of move away from the lifetime caps it is a negotiating of the insurance providers but that's one of the issues that we are thinking to do as well and on the issue of eligibility you did indicate that there are many pre-existing conditions when you look at the market right now what you see is that many persons cannot get insurance because of a pre-existing condition so it's actually one of one of the discussion points that we have and to explore how can we move away from that so that anyone regardless of they having a pre-existing condition or not can purchase a product that is affordable because then otherwise it will simply be denied and to the extent that you have large swaths of the population denied not due to financial ability but simply the market does not cater to them that means that those persons now in terms of the economic situation and what not they have no recourse to any sort of reimbursement and they bear the full cost of their conditions so to the extent that you could shift and design insurance products to remove the barrier of pre-existing conditions that I think would be down to this society well okay understood but just to add to what Shana said and if we have to exclude persons with pre-existing condition then we exclude a huge segment of our population and we we're not able to get to get to where we want to be where we have persons managing the condition from going to further crisis so if we have to look at excluding those persons that would exclude a large proportion of our population because we have huge huge amount of positive hypertension diabetes and now we have cancer under rise so it would that's a that would be discriminatory in that sense yeah that's the intention no that's the intent yes that's the intent in terms of the overseas care that's something that we see come up you mentioned miss james persons raising funds for travel abroad where healthcare access is better but it but it also comes at a cost speak to us about how the coverage NHI will deal with that if there we have proposed a component in the package for that but that would have to be something I guess we'd have to look it out of the insurance provider the way it has to be something that is not provided on island if it's provided on island then it has to be accessed here but if it's something that's absolutely necessary it would have to be accessed overseas but it's something that we are factored into the package and it's in the discussion of the companies insurance companies and just just just to that point the the health strengthening project program is looking at ways within which some of the very same issues where it's not offered here and whatnot what can be done to strengthen the health system here to sort of reduce the the need and in some cases it is the need to go to go overseas so to the extent that you could invest in the the capital stock and the human resource that solution needs to be able to offer some of those services not all but at least some of those services it would put us in a situation where you would not need that many persons flying to martini flying to columbia and whatnot okay going back to to the the qualifications for accessing any giants in st lusia you just have to be a resident you don't have to be a st lusia national yeah that would be correct so that's what it would obtain would the individual if the person is coming for less than a year what are the obligations in terms of paying or contributing toward the n h i yeah i think that's that's one of one of the issues we've we've been grappling with in terms of the length of period where it becomes that you were you're sort of required or or encouraged to do that i think a year is is good now we are we are looking towards a situation where persons can opt in if if they choose to and particularly if they are here more than the for tax purposes 183 days is usually considered where you were where you were sort of tax resident so i think we are looking at that that time period as sort of a a threshold and then once you are over that period then it's definitely available to you so that's that's one of the modalities that we are looking at okay what about st lusians in the diaspora who are considering getting insurance through st lusians n h i can they we we would have to we would have to discuss that i we are not settled on on that point as as yet but it is something that would be looked at with all stakeholders okay and what about persons who would have recently moved into st lusia how soon would they be able to capitalize on the part of n h i i think that was about the same because for example um i once lived and worked in um sinkets and i contributed contributed to the the um n i c and it was only after six months i could have claims to the n i c so it would have to be something to that effect with those conditions okay so we are due for another break do stay with us this is issues and answers we're going to be going into our final segment after this break continuing on with the stakeholders of n h i stay with us studio 758 acid creations and the royals and lusia police force good god thank you so much for staying with us this is issues and answers we're talking national health insurance and we are speaking to mr janai leon's chief economist in the department of finance as well as the health planner in the corporate planning unit of the ministry of health and wellness miss lauren james thank you so much guys for being here so far it has been insightful i want to get into stakeholders at this time um what impact will n h i have on the health care sector and we're talking from the administration the ministry all the way down to health care workers and nurses on the beat and so on that's a good question um as you know government spends approximately a hundred and that's the hundred and thirty hundred and forty million dollars a year to the health sector and right now we only recoup about five million the other five million that we receive is from n i c has a contribution to health it um would benefit the health care system in terms that we will be able to recoup monies to plow back into our health system to provide more services for the people um we would also have um in terms of our population they'll be able to access health care on a timely basis so that they would avoid going to those health crises um or avoid it altogether or delay it in terms of our health system we are i think that it would impact the health system in terms of quality that we would hold our health providers accountable for the outcomes um it would um probably encourage more persons to go to those health providers because we plan on roping in the private sector so they'll probably see a larger population in a larger influx of persons in their day practices we expect that persons would come out now because they have access now okay so less of a burden on the health care system in terms of finances because we and we intend to by roping in the private we intend to like spread out the the patients what it would be less of a burden on the public health system okay and by which time performance-based financing would have been in full swing the other services through the 8D project would be in uh as well and as um not to cut you short but as you know the world bank project also aims to strengthen primary care so yes the gaps we identify in the primary health care into the equipment infrastructure we will be um upgrading those to deal with the influx that we anticipate okay so now what what of the governing body for NHI the governing body um that is still being worked out but we um are looking at something more like a central health regulatory authority which would regulate the whole insurance company in terms of the benefits package the the providers of health services the insurance providers the patient registration and all that um kind of thing to do with NHI so we foresee something like that but it's still under consideration that would be more it's like the governance structure that would um oversee NHI okay and what sort of training is has there been any training or will there be any training for health care workers to prepare them for the introduction of NHI yes we do have a component under our health insurance project for training of um for capacity building for our health care workers so we will be tapping into that so whatever training that they may need that we will be doing that okay and what sort of engagement in terms of consultation that's also in the plans as well yes okay wonderful um we know the private sector they were the private insurance companies are definitely looking forward to seeing how this is fleshed out but what sort of um how will the the implementation of NHI affect the private insurance companies I think in the discussion with the insurance providers what we have indicated to them is that their market is going to is going to increase significantly right now each of the private sector insurance companies are really servicing a relatively small small market a few hundred to a few thousand um clients to the extent that you could broaden that out and service maybe double or even triple that it does allow them to receive some economies of scale to the extent that you as an insurance provider are now working with a larger pool of of persons those premiums that you're getting from a much larger pool also can read down to you to strengthen your your your product offerings and to also lower your costs over over the long the long term ideally that is that is the hope but essentially it allows them to be to be larger stronger by servicing a larger pool of of persons because what's happening right now due to the price points the attitudes and the current regulatory setup very few people are coming so they're only essentially reaching the choir to the extent that you could be structured in market where the entire audience has insurance coverage and is serviced by your different insurance providers it makes everyone better off not only the the state but your insurance companies are now stronger and larger refer a significantly enhanced pool of persons paying premiums and what have you okay but so i um to watch and i said it's not an intent to crowd out the current insurance market it's more less to augment it because if persons already have insurance like myself we just encourage persons to just if it covers the bare the bare bare minimum that we outline we encourage persons to just stick with their policy and they don't have necessarily have to purchase a new insurance policy with no intention to crowd out um what currently exists okay Mr. Layhouse I know we spoke a little bit about how the NHI will benefit the population our economy and so on but how does the government intend to make this project sustainable because an investment of this magnitude uh I can't think of a better word than recoup yes how are you able to recoup yes I think Ms. James spoke to it earlier what what do you see now both your San Jude Owen King and some of your other facilities while they provide services to the public due to the fact that the vast majority of the public does not have insurance and the price points are so low even when persons pay for the services that they receive from Owen King or what not what they are paying for is relatively relatively small given that it's a highly subsidized uh venture to the extent that you have the entire populace or a significant percentage having insurance coverage you can then now have some of that cost being borne by your insurance providers and that redounds to the to the benefit of the state by now being able to to build a provider more so than an individual so the the pooling of premiums across the entire populace allows it to be an injection of monies into the system that the providers of healthcare whether it be in the private sector the public sector can levy claims against that pool that's housed by your insurance providers and therefore recoup way more than what what is happening now that increase our monies that you are now able to recoup you can now plow that back into some level of sustainability and it becomes a positive cycle we we believe okay and so final question before we wrap up uh what do you do if you already have um private health insurance and for the individuals who may be saying how much is the premium i'm ready to pay let's get this thing signed off on okay the premium is still being worked out of the insurance companies we will be engaging them for over the next few weeks to work that out and if you have health insurance um already once it meets the bare minimum that we outline then you are encouraged to keep it or if you choose to buy the one another health insurance then you are free to do so okay that's really really really unsure what we are attempting to do is set a standardized flow for insurance coverage and insurance products in the in the marketplace and to encourage persons to at least have that flow as it were or better okay wonderful uh thank you very much mr genaille leance a chief economist within the department of finance and i need to reference the people because there's so many words for your your department um miss james lauren james a health planner in the corporate planning unit of the ministry of health and wellness i'd like to thank you both for being here just elucidating us letting us know where things are at right now in terms of the journey toward nhi here in st lucha uh we've come to the end of another installment of issues and answers my name is jessie leance signing off for now goodbye