On April 1, 2008, the ruling Jamaica Labour party delivered on one of its main campaign promises and abolished user fees in hospitals and clinics all across Jamaica. Jamaicans no longer had to pay for services such as: registration, doctor’s consultation, diagnostic services, hospital admission, surgeries, medications, physiotherapy, ambulance and maternal services.
Prior to this, persons were required to pay a nominal fee for said services. No one was forced to pay and no one was denied access because of inability to pay. Even at that, it remained a challenge for the system to maintain needed supplies and personnel to ensure that quality service was delivered.
Two years after the abolition of user fees, it is estimated that the government has foregone well over JA $4billion (about USD 47million) in fees for services (1). This approach to financing healthcare, though well intentioned, has created more problems for the already overburdened system. The policy failed to address fundamental issues such as provision of equipment, man-power needs and access to drugs.
The system is threatened by a severe shortage of all cadres of health workers especially nurses, doctors and pharmacists with an annual attrition rate of up to 15% for nurses as a result of migration (2).
There is overcrowding and long waiting periods at the facilities. Hence the initial surge in the number of persons accessing the services after the abolition of the user fees soon leveled off and in some areas actually declined (3). Some rounds of annual household surveys indicate that the abolition of user fees actually impedes one in five persons from accessing health services (4).
Persons are put on “priority” waiting lists for surgery only to be given several months, to a year for the surgery.
For many patients in the hospitals, their relatives have to source needed drugs and sometimes even medical supplies for their treatment because these are not available in the hospital pharmacy.
Many patients with chronic diseases have gone several weeks or months without their medications because they are waiting for supplies from pharmacies, which have none.
No one would oppose abolition of user fees for those who cannot afford it but those who can pay for the services should be allowed to do so. Ironically, all major employers in Jamaica provide health insurance for their employees and in fact the government spends large sums of money every year in contributions to health insurance premiums for employees.
Quality health care requires adequate funding. In 2009/2010 financial year, the government of Jamaica allocated only 5.3% of its annual budget to health(5) as opposed to the recommended 10-15%. The system simply cannot support this policy. A blanket abolition of hospital user fees has only further weakened the system.
Access to inadequate care is just as frustrating as no access. Too often, governments especially in developing countries play politics with healthcare and sacrifice sound policies or the implementation thereof for political gains.
References:
1. http://www.jamaica-gleaner.com/gleaner/20100410/lead/lead1.html#disqus_thread
2,4. http://webapps01.un.org/nvp/frontend!policy.action?id=1649
5. http://www.jm.undp.org/files/GOJ%20National%20Report%20to%20UNAMR-Final.pdf
Social, Cultural & Behavioral Issues in PHC & Global Health 
August 15, 2010 at 5:45 pm |
I think this case brings up an important debate in international public health namely the effect of user fees on efficiency and equity in health care system. Proponents have argued that “nominal” user fees make health programs more sustainable, reduce the moral hazard that arise from free medical services and increase decntralization and accountability because at least in some cases introduction of user fees have been accompanied by greater autonomy of hospital administration leading to better quality services that are more responsive to local needs.
The opponents of user fees, including my self, argue that in low-income countries like Jamaica vast numbers of people live below the $1 a day poverty line. Moreover acces to health care is limited partly because majority of the population lives in rural areas and urban hinterland while hospitals and other medical services are concentrated in large cities. In a situation like this there are hidden costs like travelling from the rural area to city center for medical care, out-of-pocket cost of medicines, lost wages because family members have to serve as care-givers in face of shortage in nursing staff. Combining these hidden costs of medical care with the extreme poverty means that even “nominal fees” seriously reduce access to health care for the poorest in the society.
Authors like Paul Farmer have pointed to the collective ethical responsibility of the rich both in poor countries and in rich countries to ensure adequate access of the poorest people everywhere to a decent minimum of primary care services. Research has also indicated that user fees may not be the right solution and in fact may be counterproductive (by reducing utilization of services) and inequitous (see the following papers for why user-fees is not the right strategy in LIC).
1. Nabyonga et al. “Abolition of cost sharing is pro-poor: evidence from Uganda” Health Policy and Planning, 2005, 20(2): 100-108
2. Sepehri & Chernomas “Are user charges efficiency- and equity-enhancing? A critical review of economic literature with particular reference to experience from developing countries” Journal of Intl. Development, 2001, 13:183-209
3. Xu et al. “Understanding the impact of eliminating user-fees: Utilization and catastrophic health expenditures in Uganda” Social Science and Medicine 2006, 62, 866-876
4. Palmer et al. “Health financing to promote access in low income settings- how much do we know?” Lancet, 2004, 364:1365-70
5. Lagarde & Palmer “The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence?” Bulletin of the WHO, 2008, 86: 839-848
The way forward is for the governments to realize that basic primary care services are a fundamental human right to be provided free of charge to everyone and should be financed through taxing the rich or by channeling funds from other less important government services (perhaps from bloated defense budgets or government expenditure on ostentatious projects or perks for high government officers and legislatures).
August 15, 2010 at 8:07 pm |
I agree that basic health care is a fundamental human right but this is one right that has to be paid for somehow. Healthcare no matter how basic, costs money especially if it will have to be sustainable. Universal health insurance in my mind is a good option. In Cayman Islands for example, there is universal access to health care supported mainly by health insurance. The government provides health insurance for all its employees and their families, and for the indigents. Also, it is mandatory by law for all employers in the Cayman Islands to provide health insurance for every employee including domestic employees. In this way the rich and the healthy pay for the poor and the sick. In making the health insurance company bear the cost of the services, the government is able to recover some of the money paid as premium for its employees and dependants and also assure the quality and sustainability of the services.
August 18, 2010 at 3:25 am |
I am thrilled that you are bringing attention to this issue, as I had hands on experience with this policy when I spent a week in Jamaica on a medical mission this past winter. I worked with a team offering primary care, and we focused mainly on trying to screen patients for high blood pressure and diabetes, two chronic conditions that affect a large proportion of the Jamaican population. As part of our work, we aimed to refer those with a positive diagnosis to the Jamaican Health System to receive follow up care and monitoring, and to have prescriptions filled. However, as you mentioned, this was very difficult to accomplish, despite the “free” health care that is now available in Jamaica. Many patrons of our clinic lived in rural areas which are an expensive taxi ride away from the closest hospital. Even if they can make it to the hospital clinic, they must wait a very long time to be seen (usually requiring them to take an entire day off from work, and thus losing income they need to feed and house their families), and then it is not unusual for the pharmacy to not be able to fill the prescriptions because they do not have the drugs in stock. The only alternative is then to pay exorbitant fees to get the medication they need from a private source. As a result, many people rely heavily on the free care provided by mission teams. While this does provide some relief, it results in very inconsistent care and makes it almost impossible to track the effectiveness of treatment over the long term. There are also private physicians, and while they are also not supposed to charge fees, they do prioritize their wealthy clients who are able to pay them for their services. This has left the impoverished majority of the population without access to specialties such as gynecology and dentistry.
Through conversations with mission leaders and health care workers, it quickly became clear that the state of the health care system in Jamaica has created a lot of discontent in the population. I spoke with a doctor at the local hospital, and she expressed a great deal of frustration at not being able to get resources to properly care for her patients. Two of the most glaring deficiencies were that the hospital did not have a functioning operating room (a hurricane had taken the roof off several years before, and there was no money to repair it), and also lacked incubators for premature babies (they must be transported by ambulance to the next biggest town and many do not survive this trip). After seeing the deplorable condition of the health care facilities there, it is appalling to hear that the government is only allocating 5% of its budget to health care. In order to move their country forward, the Jamaican government needs to make a greater commitment to the health of its population.
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