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Let them pay! - Survey reveals Jamaicans still want the rich to pay for healthcare; new taxation for the sector

Published:Sunday | November 13, 2016 | 12:00 AMEdmond Campbell and Anastasia Cunningham
The survey revealed that although the no-user-fee policy led to increased use of public health services – particularly among the poor – the lack of funding resulted in poor service, overworked staff, lack of supplies, lack of proper equipment, among other things.
Dr Myrton Smith, president of the Medical Association of Jamaica.

Although the majority of Jamaicans believe that the health-care system has taken a significant plunge for the worse in the eight years since the Bruce Golding administration removed user fees in the public hospitals, they admit that they would strongly object to a widescale reintroduction. Instead, they believe that to alleviate some of the stress being faced by an overburdened, underfunded public-health system, the Government should introduce a payment scheme that would only exempt poor Jamaicans, as well as implement taxation for the sector.

This was revealed in a recently conducted Gleaner-commissioned survey of the health sector, conducted by Johnson Survey Research Ltd.

Polling 1,200 men and women between ages 18 and 65 and over during the month of September, the study sought to gauge Jamaicans' view of the health-care system and the improvements needed, including the controversial no-user-fee policy. Ever since the Government abolished it in 2008, it has been a contentious issue, with calls from all quarters for the Government to come up with a more sustainable solution. The main complaint has been that there were inadequate resources to match the increase in persons now making use of the free services, which has led to a rapid deterioration of public health care.

In the survey, 31 per cent said health care has got worse, compared to the mere three per cent who thought it had got better. Twenty-two per cent said they saw no difference since the no-user-fee policy came into effect, while 16 per cent said they did not know.

At the same time, 49 per cent of the participants do not want the Government to reintroduce user fees, while 41 per cent believe that they should.

In order to deal with the shortfall in the under-resourced sector, 18 per cent support some form of increased taxation (another two per cent want new ones), while 12 per cent think the Government should charge those who can afford to pay and only allow poor Jamaicans to access the services free of cost. Others felt it was a matter for the Government to work out.

At least one medical organisation is in support of some form of payment scheme in the public health sector. The Medical Association of Jamaica (MAJ) is calling on the Government to retain the no-user-fee policy for only the vulnerable and introduce some form of national health insurance scheme - a policy that the Government now has under review.

"What we say is that even if the answer is not reintroducing user fees right across the board, then the Government should at least look at retaining a no-user-fee policy for the vulnerable in society," MAJ's president, Dr Myrton Smith, told The Sunday Gleaner, echoing sentiments captured in a survey of healthcare professionals in 2013 by the Caribbean Policy Research Institute (CAPRI), whose then co-executive director, Dr Christopher Tufton, is now the health minister.

In his call for the national health insurance scheme, he said, "Healthcare is extremely expensive all across the world and as a population we are underinsured. It's probably less than 30 per cent of the population that has private health insurance and that now creates a problem in terms of financing and affording healthcare."

Public sector user fees were temporarily abolished during the 1970s but reinstated in 1984.

With the declaration that "there must be universal and free schooling and healthcare as the beginning of justice for the poorest countries of the world", at the 2005 World Health Assembly, 189 countries pledged to move away from user fees in public healthcare facilities and schools. It was also at that assembly that the G8 group of wealthy nations agreed to assist countries that wanted to stop imposing user fees.

In 2007, the Jamaican Government introduced no-user fee for children under 12 at any public health facility. In continuing its commitment to universal access to healthcare, a year later user fee was removed for services at public hospitals for all persons, except the University Hospital of the West Indies.




In the survey, when the pollster drilled to determine the basis for the views expressed, they found that among those who say the system has worsened, the largest chunk (48 per cent) were concerned with the general quality of the service being delivered, while 39 per cent complained of long waits at the institutions - a recurring response from the participants.

Seventeen per cent highlighted inadequacy in the public hospitals of the drugs patients are prescribed, while a similar proportion (16 per cent) complained of inability to repair equipment - two issues that go to the centre of the economics of free healthcare.

At the time of the removal of user-fees, it is estimated that the government was giving up around J$2 billion a year in actual income and several billions more in unpaid bills. This foregone cash, plus more to off-set higher costs from an expected growth in patient visits, was to be covered by increased central government allocations.

But government spending on healthcare, although it rose initially, has not kept pace with what health experts say has been an exponential growth in demand for services. In fact, more recently it has declined in real terms in the face of fiscal constraints. For instance, the J$53 billion budget for the current fiscal year, of around 3.3 per cent of Gross Domestic Product (GDP), is roughly equivalent to what was spent in 2015/16 when inflation is taken into account.

Although less money, in real terms, is paying for the treatment of more patients, it is this rise in numbers, and the fact they are not called on go into their pocketbooks, that underpin the support of those who say the system has improved. Fifty-six per cent of those who feel the system has improved give as their evidence the fact that more people are being treated; for 39 per cent it is the fact that service is not dependent on ability to pay.

Perceptions on whether the public health system has either improved or deteriorated are split along gender lines, with 29 per cent of men believing the former and 44 per cent the latter.

The MAJ's Smith is not surprised that more women say the system has worsened, as he said they were more likely to come in contact with it, both as users and facilitators of children.

On the matter of the reintroduction of user-fees, gender and age appear to play a more significant role in determining positions. Just over half (51 per cent) of men say no, against 39 per cent who would countenance it. Women are more evenly split, with 42 per cent in support and 48 per cent against.

The greatest support (48 per cent) for user fee is the 55-64 age group, while the strongest opposition is among young people: 58 per cent among those between 18 and 24; 52 per cent for those in the 25-34 cohort, and 46 per cent and 48 per cent, respectively, in the 35-44 and 45-54 age groups. Surprisingly, for older persons likely to be heading into retirement, opposition to paying tapers off substantially: 36 per cent among those ages 55 to 64, and 33 per cent among those 65 or older.