link to interview in Malta Today
One flu over the minister’s head
Health minister LOUIS DEGUARA says the government is well equipped for the avian flu. Just cover your mouth when you sneeze
The shrill noise of three canaries tremble throughout the office of health minister Louis Deguara, somewhat apposite as the subject in question is the impending avian flu, the as yet distant influenza which the entire European mainland is bracing itself for.
Panic buttons have been pressed. Everybody is booking their supply of Tamiflu, the anti-viral drug considered by the World Health Organisation to be the frontline medicine if the flu hits. Dozens of pharmacies have taken deposits for the medicine from clients who fear there will be not enough to go around for the population at risk of being struck by the flu, a scary 25 per cent of the entire country.
The health minister wants to ease fears. If the avian flu does develop into a pandemic, it will require the collaboration of many countries. Everyone is developing their plan against the flu, with the European Commission coordinating the EU member states’ plan along with the WHO.
The present flu vaccine is incapable of providing sufficient protection against the avian flu, but the ministry is stocking 150,000 of the regular vaccines, due to arrive by October, to be administered to anyone over the age of 55, and other chronic sufferers. It is enough to cover the whole population at risk, and already beyond WHO obligations.
When the flu pandemic does hit, scientists will develop the appropriate vaccine against the flu, and the government has already ordered 360,000 vaccines for when these will be developed. In the meantime however, there will be the question of providing enough of the anti-viral drug of Tamiflu, the medicine which will be administered if people fall prey to the flu.
“The only way to mitigate the effects of the flu once it breaks out before the new vaccine is developed, is to have enough anti-virals to cover 25 per cent of the population. It will be administered only if you are diagnosed with avian flu, not the normal flu,” Deguara says. “Until the vaccine is developed, we will have enough anti-virals to cover a fourth of the population. We are in line. The first batch of Tamiflu will arrive at the end of this year. There is no chance whatsoever that we will be the first country to have the pandemic flu – it is declared.”
In the meantime, pharmacies have been busy collecting deposits from clients booking their Tamiflu supplies. Deguara says they are obliged not to give out any medicines without a prescription. “People cannot take Tamiflu because they sneeze. They can only be administered the drug if the doctor prescribes it. This is a system of double-checking: pharmacists cannot sell it without a prescription, and doctors should not prescribe the medicine unless they diagnose a case of avian flu.”
Were the people tricked? Deguara says the government cannot tell anyone not to order the medicine. “It is their business. But I can tell you that if 25 per cent of the people will be hit by the avian flu, the government will provide treatment for those people free – if you want to buy it, you can go ahead.”
Whether clients have been tricked or not, it will be the responsibility of the autonomous medical council to investigate whether there was ever a breach of ethics in the whole brouhaha that ensued. The health division cannot censor doctors, but it will be the medical council, which includes a 20 per cent representation of lay people, that can take action.
Down in the wards, doctors and the rowdy Medical Association, the doctors’ union, have been taking the government to task. The recent controversy surrounding the contracts to consultants and surgeons’ salaries saw government being silent on the matter, “ because so many of the letters published in The Times were not directed at government, but reacting to the story itself. What the government was just, and the MAM has legal channels to take recourse to.”
Now Manché’s contract has been renewed for just one year. Deguara denies pressure from MAM. “I think there are people who have an interest in selling the whole story as if this was specific to Manché only – it wasn’t. Any director whose contract ended, whoever was on contract with the health division, even our director general, was extended to a year. The same happened with the St Vincent de Paule’s director. This was done in the midst of discussions on health reforms with the unions. We want to change work practices and we did not want to renew contracts for three years if conditions had to change soon enough. We haven’t changed remuneration – it is just an extension for one year. It is a mistake to limit the whole story to Manché, because he was pushed into the whole affairs because we renewed other doctors’ contracts, and not the other way round.”
Deguara talks about the health reforms which MAM secretary-general Martin Balzan, in his unmistakable gruff tone, dubbed the work of a “sick mind”. The document leaked to MaltaToday revealed the first signs of impending reforms in the health sector, a division of competencies between government and hospitals, and most importantly new work practices.
“I think there are those who react typically like Balzan, but you have to look at things without being emotional. This was a document outlining government’s plans. No details. That document had to be followed through with discussions between the government and the unions. The discussions are still ongoing. And I think even Martin Balzan is reasoning differently because the MAM is attending these discussions. If they really thought they were the work of sick mind, they would have not joined the discussions. I think it shows maturity that we are trying to solve problems round a table, and I think it shows that comment was somewhat premature.”
In Deguara’s words, health reform might for the time being still be free of any plans to introduce payment for services, but he says he cannot ignore the question of sustainability that is affecting all health systems in the world.
“We cannot think that this problem won’t affect us as well. We want to make sure we get the best value for every pound we invest, because that is why we want to make our reforms. Despite criticism of our reforms by the opposition, our experiment at St Vincent de Paule has proved that the new work practices have guaranteed efficiency. We want that process to be expanded to other hospitals.
“I think we are probably the only country in the world where the health minister and the division plans, provides the service, and controls the service. Today everyone knows that this does not lead to efficiency. We think these roles should be separated functions. One of the fundamental aspects of the reform is to give patients a voice for those decision which concern him. Through the use of autonomous councils, the representatives of government are in the minority and there is are patients’ representatives.
“This is the reform we are talking about. Work practices which no longer suit our needs have to be changed. And it takes two to tango – in this case it’s going to take some 4,700 employees to tango – the lack of flexibility across the whole sector stifles our performance. Now we have a target date for the opening of Mater Dei, discussions have started with unions already on the grounds of that plan, before the new hospital opens.”
Questions abound on whether the new hospital, a smaller one than St Luke’s, will be able to take the problem of overcrowding that plagues the hospital. A place will have to be found for 100 chronic sufferers every year. Deguara says St Vincent de Paule is being extended, but this cannot be the norm for the upcoming ten years. Instead, a public-private partnership means the government will be subsidising stays in private homes for the elderly, whilst Mellieha will be hosting a new home for 150 elderly people. Deguara is confident – the new hospital will have a greater turnover through new work practices which will see more patients leaving hospital earlier, and hopefully more private consultants turning in for work at Mater Dei for some hours during the week.
For many, Mater Dei remains a symbol that toasts government’s inability to rein in the spiralling costs of a project that has grown bigger and bigger ever year. Ten years in the offing, the hospital awaits official completion in 2007. Deguara today is no longer concerned with the building of the hospital. He brushes off judgements about the fact that he was sidelined by the PM, who upon taking the finance portfolio, negotiated a final completion date for Mater Dei.
Deguara disagrees, the minister whom Labour press reports outline him as the first victim of a reshuffle. “The Mater Dei and Foundation for Medical Services portfolio was always under the Prime Minister, even during Fenech Adami’s administration. The job was only delegated to me. The building aspect, where financial decisions were being taken, were undertaken by myself and the finance minister – the most clear example being the tender for the supply of medical equipment, where the health division’s decision was overruled by the minister of finance. When Gonzi became finance minister, I met him and told him that since he was also minister for finance, he might as well not delegate the building part to me. I told him there was no reason why the finishing of the hospital should be in the health minister’s hands since this was a building project.
“The building does not need to be in my hands. The medical aspect remains in the health minister’s hands once the building is being built, for example migration, the new work practices – we are the lead ministry.”
Pressed on whether Deguara had failed to finalise a D-Day for Mater Dei, the minister says he was always present for meetings between the PM and Skanska, the Swedish construction giants responsible for Mater Dei. “When you are deciding on a contract, this requires the powers of a minister which could neither be myself nor parliamentary secretary Tonio Fenech. You have to remember this was not the project it was at the start – Gonzi arrived at a stage when this project had expanded.”
The millions required to run the new health ‘monster’ are also not worrying Deguara. “At the end of the day, we will have to see this only when the hospital will finally open. It will be expensive to run if we run it with the present system. One of the things we are discussing in health reform is to run our hospital at a lesser cost and efficiently. We will carry out independent assessments when the hospital will open to see whether we are getting value for money.”
Mater Dei will also be hosting the new microwave incinerator which has been in the offing for long, running through the painful process of long drawn-out tender disputes after the fiasco it encountered when the winning tenderers could not supply the goods when the parent company in America was declared bankrupt following the incarceration of its owners.
Once again, the whole process has been stalled by tenderers who have not been shortlisted and are contesting the decision in court. St Luke’s incinerator will remain without a microwave solution until it closes, where instead the chimney will be upgraded with new filters. Pietà has yet to wait for cleaner air.
“The tender is right now in the same process it has been in since 1998, where someone holds up the whole process because they were not shortlisted. One of them filed an injunction in court. Five have been shortlisted, and I am sure that once one will be chosen the others will object. Clearly, the law states that when somebody wins a tender and have deposited a bid bond, there is nothing we can do until they fail to deliver their service – the process has to wait until this is cleared. The solution can be that the public should be mature enough to trust the government to hand out a direct order. But that will always be contentious. So let’s be above suspension and play by the rules.”
Deguara also doesn’t rule out medicines being one day chargeable to the public. Until today, there are no plans yet. He says the Nationalist opposition had criticised Labour’s decision to charge 50c on every prescription because of its anti-social nature and the expense it would have led to.
“We had remarked that the countries which introduced cost-sharing did so to reduce waste but this had never worked anywhere, let alone our country. Time proved us right. Whilst the number of prescriptions decreased, the number of items exploded. You would have more items placed on a smaller number of prescriptions. We never objected to the 50c, but the anti-social way it was introduced. In this case it didn’t even discriminate by exempting widows, elderly, addicts – this was 50c for everyone. This actually increased costs.”
I tell Deguara, as the man who had called for ‘decisive decisions’, that the PN government’s own eco-tax failed to discriminate between environmentally-friendly products and those which harm the environment. The effects of government’s ‘decisive decision’ was welcomed with general disillusionment all round.
“A characteristic of a responsible government is to take necessary decisions which may not be pleasing to the people. There’s a price to pay for everything.”