Wed | Jan 16, 2019

Fixing Health: Who can pay let them pay

Published:Wednesday | September 23, 2015 | 12:38 AMDr. Alfred Dawes
Alfred Dawes

Healthcare is expensive. There is no question about it.
We have long moved from relying on simple history taking and physical examination by the doctor, complemented by simple tests to make diagnoses, and treatment with simple therapies. Nowadays, there is a greater reliance on more complex and expensive tests to make a diagnosis. Treatments have become more complicated as the nature of diseases change. Penicillin was a very cheap and effective antibiotic 70 years ago, and those who weren’t helped by it simply died.
Nowadays, we can save these lives with antibiotics costing hundreds of thousands of dollars.
As healthcare improves, so do the costs increase. To run a proper public health service requires money that the Government simply cannot afford at this time.
For too long both political parties have been playing political football with healthcare, to the detriment of the Jamaican people. Popular electoral decisions are often not in the best interest of the country in the long run.
It must end now!!
One would be inclined to believe that the majority of private care is reserved for the rich, but in reality a large percentage of the poor access private care due to the inadequacies of the primary healthcare system, especially in rural areas. The converse is true, as those who are well off choose public healthcare, especially for treatments such as surgery and chemotherapy that would be significantly more expensive privately.
This subsidisation of the ‘Haves’ at the expense of not bolstering primary care to the detriment of the ‘Have-nots’, is seen in other countries as shown in WHO (World Health Organization) reports.
The Government of Jamaica spends less than five per cent of the GDP on healthcare. A similar figure is seen in the private sector to bring the total expenditure on health to just under 10 per cent of GDP. The majority of the Government expenditure is on the hospitals that cost more to run and would more likely benefit those who can afford to pay.
With a neglected primary care system, the poor are forced to turn to the private practitioners for their non-urgent needs. General practitioners therefore, unsurprisingly, makeup the lion’s share of the private healthcare market in Jamaica.


No study has been done to see who accesses healthcare at hospitals and clinics and to what strata of society they belong. Without such data we are left with conjecture and political propaganda stating how the poor have been saved billions of dollars since the introduction of free healthcare.
Billions have indeed been saved but by whom? How much of these savings have been to the benefit of the well-off and the medical insurance companies?
Patients have been reluctant to use their health cards at hospitals, preferring to save the available funds for drugs, eye and dental care. This, in spite of campaigns to get persons to present their insurance cards while registering. Not paying for care at the public hospitals certainly would improve the bottomline for these insurance companies. But are the poor really being spared?
It is a common practice that whenever tests are not available in hospitals, the patients will have these tests done at private facilities. Poor patients who can’t afford to get these tests are left helpless. It seems prudent that if some persons can afford this practice then the government should benefit financially from their ability to pay. What if these services were kept in-house and the government uses the revenue to subsidise the tests for those who can’t afford to pay?
Supporters of the no-user fee policy, including the WHO, will say that it removed a barrier to accessing healthcare. In 2007/2008, prior to the removal of user fees in all public health facilities, there were 1,485,993 primary healthcare visits, 1,313,984 hospital visits, 1,609,441 pharmacy items dispensed, 2,909,365 lab tests and 38,453 surgeries.
Last year saw 1,637,910 visits in primary healthcare, 1,380,749 hospital visits, 2,968,227 pharmacy items dispensed, 5,968,227 lab tests and 66,321 surgeries.
Clearly the removal of user fees did not affect greatly the number of persons accessing basic services at the clinics and hospitals. Where the real burden has been felt financially are the labs and the pharmacies, not in the waiting rooms.
When the user fees were removed in 2007, the estimated shortfall in the budget was $2 billion. The budgetary allocation was increased by that amount, thinking that all would be well. What the Ministry of Health at the time did not anticipate was that this figure would be gobbled up by the pharmacies within six months, leaving a deficit in every area.
There have been gaps appearing and widening every year since, as drugs and testing reagents have to be purchased and with no additional allocation, the funds had to come from other areas such as the supplies, maintenance and capital budgets. This has led to the progressive decline in the state of the public health system.
Some will argue that the $2 billion is only a fraction of the health budget. That was, however, $2 billion in 2007 when the dollar was almost twice its worth now and without several years of double digit inflation. What would be its equivalent in 2015?
There are some truly destitute among us who need all the help they can get. They are the ones who will benefit the most by the reintroduction of user fees. They would be exempt from payment and have in-house testing and treatment that would normally be unavailable to them, because they couldn’t pay for it privately.
We have ways of identifying the most vulnerable, such as the PATH programme. Why not use them to identify the poorer patients and let who can afford to pay, pay? Afterall, every mickle mek a muckle.


* Research into the demographics of patients accessing healthcare at hospitals and health centres.

* Expand the PATH programme to cover healthcare or create a similar means of identifying the most vulnerable patients for payment exemption.

* Reintroduce a low user fee at hospitals and health centres.

* Patients should make a co-payment for drugs, tests and surgical services requiring special equipment and disposables, for example, orthopaedic implants.

* Enter into public private partnerships for testing facilities in-house.