AN essential component of regulatory authority is independence. Regulatory independence ensures objectivity and removes conflict of interest. It is also vital that regulatory authorities are subjected to appropriate judicial oversight to ensure that they conform to acceptable standards and are not exposed to abuse of power or authority.

It’s a matter of fact that sectors within any system of governance across the world may at intervals contended with inordinate and/or inappropriate pressures being brought to bear on regulatory authorities. Consequently, it’s ideal that systems are designed in a fashion where opportunity for these pressures or inappropriate advances to be successful are limited.

Case for independent regulatory authority in the health-care space

This independent regulatory model has been successfully replicated in the health-care space in several developed economies. It is possible to achieve the same in Jamaica and other developing countries. It’s important to note that without universal, fair, and independent enforcement of regulations and standards, arbitrariness and inconsistencies tend to triumph. Additionally, without effective oversight there are intrinsic tensions which may occur between different parts of the health-care ecosystem. In such an environment, other considerations impose pressures on facilities and payers to devolve to less-than-optimal standards for financial gains or convenience, especially when those facilities or payers may enjoy a cozy relationship with the regulators. A facility, for example, may not want to maintain optimal standards of care or practice evidence-based medicine given monetary savings. An insurance company or third-party payer, for example, may favour facilities offering low minimum standards of care to reduce insurance payouts and increase profit margins. Physicians may choose not to expend the effort, time, or resources to engage in ongoing continuing medical education requirements. How this independence is designed and maintained is not quickly or easily answered. Total independence in such an agency is often not practical as there does need to be some judicial oversight to prevent abuse. We cannot depend on always having people with the nation’s best interests at heart. Without appropriate oversight, personal interests and relationships often cloud objective, fair and uniformed enforcement of regulations and standards.

Absolute power sometimes corrupts absolutely. A process of checks and balances is therefore always necessary to ensure that the inherent objective of regulation is not harmed. Various countries approach this problem in different ways. In the United States, regulatory authorities exist both at the Federal and State level and are usually part of the executive branch of government but protected from executive interference using the judicial system. Theoretically, oversight will occur from the President at the federal level and the relevant governor at the state level. However, the powers and responsibilities of these regulatory agencies are prescribed by legislation. Despite this, the regulatory system in the United States can sometimes be affected by political considerations.

Lobbying from political parties and private interests can influence legislation and regulatory authorities’ remit, responsibilities, and decision-making. One example is Medicare (the dominant health-care payer for elderly Americans). Legally, Medicare cannot negotiate for lower drug prices despite a patient population that should give it significant bargaining power. This inability to negotiate results in higher costs both to Medicare and to the patients it serves. By contrast, in the United Kingdom, the National Institute for Health and Care Excellence (NICE) assesses new medications that come to market. The cost-effectiveness of new medicines is balanced by how much quality of life is improved given the cost. If the medication cost is too high for the improvement received, the medication is not approved and cannot be used within the National Health Service. This arrangement makes it less susceptible to direct political influence.

Need to eliminate corruption and political interference

Some countries have an established culture of intolerance of corruption and political interference in the public sector. Singapore and the Nordic countries tend to score high on government transparency and public sector efficiency measures and generally have a low risk of corruption. Unfortunately, like many other nations, we have many examples of both corruption and political interference in our public sector arrangements. An interesting example for us may be health-care delivery in Sweden. Sweden has a federal system of governance. The regulatory authority for health care occurs at three levels. At the national level, the Ministry of Health establishes principles and guidelines for care and sets the political agenda. The Ministry also evaluates health-care delivery at the lower levels and ensures that policies are followed. The actual delivery of health care is decentralised and provided regionally among 21 counties. Each county has a health-care board which is a political body and is elected every four years. These boards have the responsibility for actual health-care delivery. Interestingly, they have responsibility for both private and public health care. Private providers must contract with the county health boards who set prices. Swedish health-care policy is that every county council must provide residents with good quality health-care services and work towards delivering good health to the entire population. The municipal level is responsible for things such as water supply, waste disposal, and social welfare services. In the Swedish system, political interaction at a national level occurs at the health care ministry. In electing a board every four years, the citizens of each region choose their own health-care delivery team, who are then directly accountable to the citizens. The Ministry of Health also provides oversight and ensures that standards are followed and maintained. This model may not be directly applicable to a small island state, but some features may be helpful in our model of health-care delivery. The standards are set nationally and apply equally to both public, and private health care systems, so unequal access and quality of care are eliminated.

Furthermore, even though the standards are set at the national level, the actual delivery is managed at the local level by an elected body accountable to the local citizens and not prone to control and manipulation by the national government. This allows adjustments to be made for local conditions. In Jamaica, we may find that we need more focus on psychiatric services in the Kingston and St Andrew areas or that there is a greater need for STI services in tourist areas, etc.

In Jamaica, we will have to decide what uniform standards and regulatory arrangements are most suitable to our realities. Ideally, we can agree on minimally acceptable standards of care based on the best medical evidence for all aspects of our health care system/health-care delivery. These standards should be met regardless of where our citizens seek care (public or private sector). These standards must be universally applied to ensure that all citizens receive optimal healthcare irrespective of their social or economic status.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107