Today the Nurses Association of Belize (NAB) added to the boom of resounding objections against the proposed integration of the Government’s largest hospital, the Karl Heusner Memorial Hospital, (KHMH), with Universal Health Services (UHS), a private medical facility owned by a group of doctors and Luke Espat, a well-connected businessman.
The NAB polled the views of KHMH nurses on Wednesday, and of the 93 who voted, 89 said no, 2 were undecided, and 2 voted yes. But what were they really voting on? The NAB accepts that the details of the proposal are, indeed, sketchy, but they reject the concept that has been presented to date.
NAB called the press to a briefing on Friday afternoon, December 15, to declare their position on the KHMH-UHS amalgamation.
The board of the Karl Heusner Memorial Hospital and staff reps met with the Minister of Health, Hon. Joe Coye, on Wednesday, but still they have no clarity about the proposal, and it is this uncertainty about the pros and the cons of the new UHS-KHMH relationship that has them worried.
Still, there are clear concerns that the nurses have expressed. Central to their concerns is their job security. Nurses question whether any of them will lose their jobs, or whether they will lose any of their employment benefits in the process of the transition. Will they have to change their worksite? they also ask.
Andrew Baird, practical nurse representative, said that they don’t see any possible benefits coming from this deal for the nurses or for the KHMH.
“Some nurses’ perception is clearly what Mr. Baird has said; however, some nurses are saying – and we have to share both perspectives because of the position that we stand in as an association – some nurses are saying, well, there will be increase of salaries, because the nurses over at Universal Health Services have a higher salary than those at Karl Heusner. Moreover a salary increase is overdue for nurses so that would have to come on stream in a way,” NAB president, Isabel Bennett, added.
The Nurses Association of Belize also represents more than 75% of 22 nurses at UHS, Bennett said. She added that though they were not included in the opinion poll, they have expressed, in preliminary discussions, similar concerns to those expressed by KHMH nurses.
She told the media that the NAB still has to “tread softly,” because the UHS board has not yet met with the UHS nurses there to inform them of the proposed amalgamation.
Lydia Alpuche Blake, nurse/anesthetist, questioned where the benefits of nurses will stand.
“The worry is that if there is this integration, who will amalgamate with who? Will KHMH go to Universal or will Universal come to KHMH?” she queried.
“Government will definitely have to come up with creative staff leadership structures, for consideration of the multi-sited hospitals, in light of the proposed Belize Health Authority,” said Bennett.
She explained that under the current proposal, Integral Health Services – UHS’s Southside component; UHS itself, and the KHMH, would come under this umbrella entity – the Belize Health Authority.
NAB reps and other nurses present at the press conference say that the experience they had when the KHMH transitioned from a full Government hospital to a statutory authority, the Karl Heusner Memorial Hospital Authority, is still fresh in their minds and casts a shadow over the proposed merger with UHS.
Blake said that they had to decide in less than a month if they would move over to the new authority. They say that they lost benefits in the process.
The root of the problem
This controversy emerged when the Government of Belize was called to make good on a sovereign guarantee it gave to the Belize Bank for a $17 million loan taken by Universal Health Services. UHS was not servicing the loan and it grew to just over $30 million. The bank was financing interest payments until this year, but decided to end that arrangement, and so—since the Government of Belize guaranteed the loan through the Development Finance Corporation—GOB had to settle the debt for UHS. It is doing so by giving a large chunk of prime real estate on North Ambergris Caye to the Ashcroft bank.
Now the Government is saying that it will get two-thirds ownership in UHS for having to settle the debt, but claims that (1) UHS will still have to pay back GOB for what it had to pay the bank, and (2) UHS will have to settle another $12 million debt it owes to the DFC.
Minister of Health, Joe Coye, told Amandala in an interview Thursday, December 14, that UHS would have to make arrangements to settle its DFC debt. According to our information, UHS will get another loan to pay off the DFC, but with Government then owning majority stake in UHS, this debt—in effect—becomes a Government liability.
According to Coye, the Public Finance Committee of Cabinet approved the UHS-KHMH agreement because it would help to bring closure to the UHS’s debt with the DFC, and bring them closer to the orderly liquidation of the DFC.
At the end of the day, UHS will owe Central Government and not the DFC. It will still owe whatever bank it borrows from to clear the DFC debt, so the debt burden of the UHS would not be alleviated under the proposed deal. The only thing that changes is the creditor – who the UHS owes.
The nurses today questioned how the UHS stakeholders would pay its loan with only a one-third ownership, when they could not pay their loan when they had 100% stake in the hospital.
Note, however, that with GOB owning two-thirds stake in UHS, UHS becomes a public hospital and so the UHS debt becomes public debt—hence the claim that “the new UHS loan to settle the DFC debt won’t have a government guarantee” is neither here nor there.
The “amalgamation” concept
No person we have interviewed to date could explain clearly what the proposed amalgamation would mean for the affected hospitals. Medical authorities have said that the proposal is for an amalgamation of services and not institutions. And while some have explained the proposal using these terms, others have said that what is proposed is not an amalgamation, but an “integration.” Still others have used the word “merger.”
The question remains: What is the real deal?
Officials say that Government’s intention is for the KHMH to be a gateway for UHS for critical care patients and the management structure of the KHMH would be restructured. Still, there are no details about this impending restructuring, and how it will affect the institutions and their staff.
What is GOB’s argument?
Minister Coye has said that there are two dimensions to this deal: the financial aspect – that is, the settling of the UHS debt; and (2) the improvement of access to medical services through the National Health Insurance Scheme, which Government intends to roll out by the end of 2007.
Government’s first argument is that the KHMH—which is touted as the national referral hospital—was never designed to take on tertiary level care. Under the proposed amalgamation, KHMH would focus on what Government describes as “general services,” while UHS would focus on “critical” care.
What Government has not explained is how they could have had a national referral hospital not designed to accommodate critical or tertiary care.
It is interesting that the KHMH doctors, in their statement to the media, said that the Government had promised to upgrade the KHMH, to enable them to undertake more tertiary level services, including improved radiology, nephrology/dialysis, and gastro-enterology.
But now the Government is telling KHMH to stick to secondary care and let UHS take care of tertiary care.
“Karl Heusner will in no way be adversely affected,” Coye argued. “Karl Heusner will be better off.”
Karl Heusner resources have been stretched too thinly, so you find you are not getting the quality care you’re supposed to get, Coye also told Amandala on Thursday.
Who will pay?
Coye claims that with UHS being a public hospital, people who cannot afford to pay for certain critical health care services would have access to them at UHS for free. But Government won’t pay for everyone.
According to Government, a “means-test-approach” would be used whereby those who can afford to pay, will be mandated to pay up to 100% of the cost, on one end of the spectrum, and those that can’t – the “indigents” – could get 100% of services free, on the other end of the spectrum.
The exact details of this aspect of the proposal have not been disclosed to us.
Shared concerns between doctors and nurses
The doctors and the nurses form the backbone of the KHMH, and statements to the media from both groups indicate clearly that they reject the proposed merger.
For their part, doctors say that the amalgamation is “not in the national interest.”
They add that those finances pledged to settle the UHS debt should, instead, be channeled into the KHMH, so that the general population of Belize would benefit.
They are also angry that they were not consulted before Government went public with its decision last week Thursday.
Subsequent statements issued on behalf of doctors say that the staff of KHMH had not been given an opportunity to have an input before the Cabinet decision was announced.
They say that they want the public to know that they reject the proposed amalgamation of the entities.
“The Universal Health Services’ debt of $44 million is the responsibility of Universal Health Services,” one statement said, adding that taxpayers did not receive the profits and should not be made to pay the bill.
What do the nurses want?
“We want to stress that we believe that we, as essential service providers, the nurses, need to be working closely with the Government on these issues that we presented,” said Bennett. “The NAB urges the Government to be in contact and in close consultation with us so that we can address duly the health issues of our nation.”
They also underscore that their input is “pivotal in the support of the health system of the KHMH and this nation.”
What next? Task forces analyze
The NAB reps told the media on Friday that even though they had raised their concerns at the meeting with the Minister on Wednesday, they did not get answers to most of them.
The Ministry of Health has commissioned a task force to report back to them by mid-January. On that task force, seats have been slated for reps from the Ministry of Health, Ministry of Finance, and the KHMH, with a possible space for UHS, said Minister Coye.
The role of the ministerial taskforce is to advise the Government on how to implement the amalgamation and make it viable to provide health care and service the debt, Coye added.
According to Bennett, they have also been trying to lobby for a seat on the task force, but so far to no avail.
The NAB is urging the ministerial taskforce to not just look at the physical assets, but the human resources as well.
In the meantime, nurses have set up their own task force with nurses from both institutions, UHS and KHMH. They have also engaged consultants, including Laura Longsworth, who is also a Caribbean Nurses Organization director. Bennett told the press that the task force has been meeting regularly to document the concerns and the issues raised by nurses about the amalgamation, and they report back regularly to the NAB.