Reviewing the hospital user-fee policy
I have read Chris Tufton's piece in The Sunday Gleaner (February 8, 2015) urging a review of the hospital no-user-fee policy that has been in place since April 2008.
There can be no objection to reviewing the policy. Indeed, every government policy must be reviewed continuously or periodically to measure its efficacy, relevance and applicability. There are, however, some stubborn realities that will confront any such review.
Hospital user-fee policies, over the years, have all emphasised the proviso of 'ability to pay' with the declaration that no one should be turned away because of inability to pay. The practicality of that, however, has always been problematic. Jamaica does not have the institutionalised foundations on which affordability can be properly determined. Unlike, say, the USA, where income tax filing is mandatory, there is no effective basis on which to determine the real income of an individual.
The fact that a vast number of Jamaicans are informal income earners (hustling, small-scale buying and selling, etc) makes it extremely difficult to establish a proper database. I personally know of many cases of extremely poor patients who didn't make it through the assessment process.
Even if that hurdle were to be overcome, the stark realities of unaffordability would be faced. The picture that emerges from macroeconomic data and measures such as the Survey of Living Conditions are mind-concentrating:
Per Capita Income (2013)
Quintile Weekly Income (J$)
1st Quintile 3,241
2nd Quintile 5,205
3rd Quintile 7,890
4th Quintile 12,024
5th Quintile 30,184
Total Population 11,699
Any reimposition of user fees, therefore, will have to factor in the target group. What can reasonably be expected to be collected from 60 per cent of the population whose per capita income is less than $8,000 per week, given the inescapable cost of food, shelter, transportation, etc? If the target is to be those in the top two quintiles, it must be borne in mind that many of those don't utilise the services of the public hospitals but, instead, go to private doctors and facilities.
One of the most revealing pieces of information that emerged when the arrangement was examined in 2007-2008 was the fact that of the total amount billed for user fees, less than 20% was actually collected. Even after making allowance for collection inefficiencies, it was obvious that many of those who were being billed simply didn't have it to pay. At that time, the cost of a hernia operation was being billed at $35,000. A large number of Jamaicans had never ever seen that amount of money in one bundle!
It is easy to say that some can, in fact, pay and should pay. How that is to be determined without being arbitrary or subjective is one thing. The cost of setting up the machinery to do the assessment and the actual collection has to be factored into the calculations in order to determine what would be the net inflow to the government's coffers.
The workings of the administrative apparatus are another thing. There was the much-publicised case of a woman at Cornwall Regional Hospital who required an urgent medical procedure for which the cost was stated at some $60,000. Her family frantically gathered the funds, but by the time they got to the cashier to pay, the woman had died.
The resource crisis facing the health sector has to be addressed. One of the proposals in the JLP 2007 manifesto, that I regret we did not succeed in implementing, was the consolidation of wage deductions (NIS, NHT, etc) into a single social-security deduction from which a portion would be dedicated to financing health care.
Another proposal, the need for which was recently stressed by the president of the Jamaica Medical Doctors Association, is the upgrading and greater utilisation of primary health-care facilities (health clinics) to deal with cases that do not require hospital treatment but constitute a significant part of the patient load that hospitals currently have to deal with.
By all means, undertake a review. But let us not simply set fees and content ourselves by saying all who can afford may come or claim to put in place special arrangements for those who fall below that threshold for, with the best of intentions, many will still fall through the cracks.
There is empirical evidence that because of the user fees that obtained prior to 2008, many persons were forced to rely on bush medicine and many died because of their inability to access treatment. It must be borne in mind as well that the treatment of communicable diseases, a major issue in the health-care system, has implications not only for the patient but the entire population.
n Bruce Golding is a former prime minister of Jamaica. Email feedback to firstname.lastname@example.org.