Many may not have twigged it, but this country is facing, from an opposite perspective, Obama’s dilemma. Obama’s problem is how to bring healthcare closer to the people, especially those that need it most. Malta’s problem is how to keep healthcare close to the people, especially those that need it.

Just as for Obama this was and is no election gimmick, so too in our case, the commitment given by the Nationalist Party that healthcare was and will remain free was not an election gimmick, was not a knee-jerk reaction inspired by the repeated taunts by the Opposition that the next PN government would introduce payments.

Since this issue is rarely talked about and since the air is full of complaints about the multiple disservices one finds at Mater Dei and at local health centres, many have assumes that this was just an election promise the government can’t seem to find its way out of.

On the one hand, it’s true that healthcare costs the earth. Every study from anywhere in the world shows that medicines get dearer, and that caring for sick people is becoming much more complicated, requires considerably more expertise and interaction between experts, costlier apparatus, and far more extended post-operational recuperation than before.

People are living longer, therefore the caring profession has to be substantially enlarged so as to cater for more elderly clients suffering from a series of illnesses, rather than the old one-sickness-gets-you syndrome.

By all accounts, therefore, at least as many other people see it, there is no way how in this day and age healthcare can be free.

Let us put it into graphic terms: as long as healthcare was rather rudimentary, which we must admit it was in the not so distant past, the country could afford it. The question is can the country, even abstracting from Mater Dei and all its added recurrent expenditure, afford the same overall coverage for a longer time-span, facing a multitude of new illnesses, using so many apparatus whose lifespan turns them into obsolescence before you know it?

Abstracting from the various healthcare systems in use around the world (we will get to this later), the argument to forget election promises and to start demanding payment is a very strong one. If you want excellence in healthcare, so the argument runs, you must finance it adequately.

Everybody agrees that the healthcare obtainable in the US (for those who have the right insurance cover) is impeccable. You pay, you get care.

So too, runs the argument, in private hospitals in Malta. Or at least that was the theory before problems started to emerge even there. You pay, you get care.

There have been many profound policy changes from the time the decision was taken to build a new hospital that one tends to forget all the contortions.

The new hospital began life as a small, second hospital, the San Raffaele. Then it was going to be a not so small hospital. Then it lost the San Raffaele tag. Then a five-page report suggested that maybe Malta needs one new hospital instead of two (this makes some sense, in a way). Then a cap was decided upon to limit the number of beds it was to have (apparently the exercise at the basis of this was done in August, when the proper time to have a parameter should have been January, when most people are recovering in hospital). Anyway, that was when they had the opportunity to build an extra floor but then, in view of this cap, someone decided to place the services on top, so we cannot build an extra floor. And so every winter we find that the hospital is too small to take all patients. And this at a time when the population is ageing and the elderly get colds more often and need hospitalisation more frequently.

This is just one of the problems that bedevils healthcare. The new hospital is not just new but awesome: everybody agrees that the hospitality aspect of the new hospital is superb: the rooms far better and the meals no comparison to what used to be served.

Equally, however, the new hospital brought to the fore old problems that have not been tackled: from an incredible amount of shift times to all sorts of inherited practices and ‘rights’ – from surgeons and nurses down to ambulance drivers.

And some problems were never that bad at the old St Luke’s Hospital: no such long queues at the Emergency Department and even the present Outpatient service leaves much to be desired. And the more paperwork is involved, even in these times of computers, the more things tend to get muddled.

So many have come round to the idea that if we want the hospital to work, we must pay more. Well, the 2004-2008 government did just that (and upset relatively the entire country), but so far it does not seem to have stopped the haemorrhage of newly-graduate doctors going to better jobs in the UK, which led to many gaps in the manning of health centres that many had to be closed which is also why people tend to flock to the Emergency Department.

That, and the sight of so many people who could afford to pay and who queue for free healthcare, free medicines, free anything – and the argument to try and stem the flood and also to recoup part of the outlay become very cogent. Which is what Alfred Sant did when he introduced a ‘tax’ of the small sum of 50c on free medicines. Which is also why a variant of the POYC, which would have people paying for their medicines and then refunded by the government needs to be carefully looked into and the people assured it is not payments coming in by stealth.

Time and again, the Labour Opposition, which had smarted under the PN onslaught in 1998 on this 50c tax, watched eagle-eyed to see how and where the PN government would bring in payment under one form or another.

And, let’s say it, so did we. We all expected payment in some form or other to be introduced. And when GonziPN committed itself to not bring in any payment whatsoever, we must have all thought this was more a reply to a PL taunt than a real commitment.

Even today, you can still find people who tell you healthcare will bring this government to its knees because it will either be forced to introduce payment or else the country’s finances will break down under the weight of healthcare.

But they, we, may all be wrong, very wrong. For if we think enough about it, providing quality healthcare for free is very central to what the Nationalist Party’s vision is for the country. This is central to the Christian Democrat global view. It also goes a long way back in Malta’s case, to British colonial times, and earlier to the Knights’ healthcare. It is also central to what the PN meant by a higher quality of life it promised as a result of EU accession in 2003.

Promising free quality healthcare is thus no election gimmick. Had it been just a gimmick, this government would be, by now, well up the creek, because you cannot promise something like that and not keep it, or keep it when it is patently unsustainable.

The problem therefore facing this government may appear to an outsider as trying to square the circle, but this would not be the first time this happened. Politics as the art of the impossible rather than the art of the possible.

In my reading, the government as a whole still has to get this election commitment as a given, in other words, not as an election gimmick, and to get down to build a policy around it.

Which brings us back to Obama. Who faced, or still faces, incredible difficulty in extending healthcare cover in the face of huge resistance that he is socializing healthcare if not introducing communism in the heart of free capital. Over the past months, he had to trim his sails and retract some of the commitments, which brought fire from the Democratic left. The way ahead is not clear at all, especially in these difficult times for the American economy.

But the USA is not the only role model possible. Europe as a whole is less capitalistic than the USA and the panorama of healthcare models in Europe, while varied, is of intense interest – from the National Health Service of the UK (that may not be the right model to look at, seeing what has become of Tony Blair’s and Gordon Brown’s spend, spend, spend frenzy) to the Scandinavian welfare state models.

More to the point, however, may be some micro-level attention to issues at ground-floor level – the elimination of long-standing abuses, the smoothing out of procedural snags, enforcing discipline and orderliness and removing the queue-jumping that bedevils anything to do with private medical practice.

This is no call to post a 2009-style Danny Cremona at the gates of Mater Dei and boot all doctors out, nor to wholesale importation of foreign doctors and consultants. There is no need for an eyeball-to-eyeball confrontation but there sure is need for the laying down of a policy line and ensuring it is kept right through. There is also need to reassure the country that a change in the minister does not by any means mean a change of policy. (It should not happen, but we have seen it happen many times)

And also, I add, to keep the people informed about what will happen to such an essential political commitment.

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