Time to review no-user-fee policy?
Chris Tufton, Guest Columnist
The volumes of concern and protest from both patients and doctors at the May Pen Hospital this past week are yet another example of a Jamaican health sector in crisis.
Patient claims of very long waiting hours to see a doctor and a shortage of beds and medical supplies are yet another manifestation that this critical social-service infrastructure is inadequate to support the demands of those who seek access and attention.
Doctors, nurses and medical administrators seem equally challenged as they struggle to cope with the demands of patients. The chief medical officer at the May Pen Hospital, addressing concerns raised by patients this past week on a television newscast, seemed to suggest that some patients are contributing to their own demise and adding to the pressure on the system by not taking their medication on time and in its entirety.
Meanwhile, the Government's response this week in a statement said more money would be allocated in the Budget this year for public health and that this would help to alleviate the challenges that currently exist within the system.
Given Jamaica's debt burden and limited capacity to respond to needs of this kind through the routine budgetary process, it seems hardly likely that much will change in the new budgetary cycle, even with an increased budget.
The health minister, still trying to recover from criticisms of his ministry's management of the chik-V outbreak, will be hard-pressed to respond to the needs of the system, and both patients and health-care providers in the public health system are likely to be critical and display dissatisfaction in the foreseeable future.
The reality is that the Government may have no choice but to rethink its approach to public health provision, which includes a re-examination of the no-user-fee policy in public hospitals. This is an issue that this Government had announced it would do in the past but seemed timid to do so because of the perceived political consequences. But aren't these consequences likely anyway, given the crisis in the system?
If patients are turned back without adequate care when they visit these health facilities, will they not be equally dissatisfied with the State? With an election cycle fast approaching, rational thinking may be lost to traditional approaches to political expediency. If this is to be the case, expect little to be said on user fees, at least until after the next general election.
It was in 2008 that the Jamaica Labour Party Government, having earlier made it a critical part of its election campaign manifesto, abolished health care user fees in all public health facilities, except the University Hospital of the West Indies. At the time, the government of the day justified this move on the basis that the poor were being deprived basic health care because of their inability to afford access to these facilities.
This position ran contrary to a general thrust in developing countries, supported and encouraged by multilateral institutions like the IMF and Word Bank, for cost sharing in public health facilities, as part of the mechanism to improve the quality health-care provision.
This general trend started in the 1980s, but Jamaica has had a few policy shifts on this issue. As far back as 1968, Jamaica's health authorities have been revising fee structure in public health institutions. In 1975, fees were removed but reintroduced in 1984 and revised upwards in 1993, 1999 and 2005.
By early 2007, the then Government announced it would remove user fees for Jamaicans 18 years and younger to guarantee universal access to the young, but this was to be expanded to the entire country after the general election later that year.
In 2010, as part of the assessment of the new policy, the Government announced that access to public health-care facilities in the two years since user fees were abolished had increased by 16.3 per cent and 7.5 per cent, respectively, giving credence to the argument that more people were accessing due to the no-fee policy.
At the same time, there are those who have argued that while this may be the case in some circumstances, because there is no cost barrier to accessing the service, access is sought by patients, even in cases where it's not warranted by the health-related symptoms they were experiencing. What is clear is that pressure on the system since the no-user-fee policy has increased and there is again a call for its revision.
A Caribbean Policy Research Institute (CaPRI) survey done back in May 2013 examined, across all parishes and 14 health-care facilities, the perception of both health-care professionals and patients on the impact of the no-user-fee policy on the quality of the service provision in hospitals.
The survey is available on the CaPRI website for public viewing. The general summary of the study suggests that the no-user-fee policy has negatively affected the quality of public health care provisions in areas such as availability of medical supplies, hospital staff morale, patient processing and waiting times, and general attention to patients by doctors.
Significantly, also, the survey confirmed that more than 65 per cent of both patients and hospital staff (doctors and nurses) were of the view that the no-user-fee policy should at least be revised to include ensuring that those who can afford to pay should pay, while guaranteeing access to those who can't afford to pay and the disabled. The challenge here would be the screening or means-testing by the authorities to determine who can or can't afford to pay to ensure that the poor have access.
Further, there seems to be no doubt that the key stakeholders, including health providers and patients, are dissatisfied with the system as it is now. This does not mean a consensus on abolishing the policy.
However, it does appear, at least from the CaPRI survey and subsequent anecdotal exposure in the media, that the policy of no user fees was not sufficiently accompanied by adequate assessment and provision for the anticipated increase in demand on the public health system.
Going forward, it seems clear that the system needs reviewing. Among the options that should be considered is a hybrid model to allow some sort of tiered fee structure based on improved screening of socio-economic circumstances. Otherwise, significant increases in the budget for public health care will be necessary to alleviate the immediate crisis, an unlikely scenario because of Government's financial constraints.
Government and Opposition need to be bold and engage in a constructive debate on this issue and set aside the political advantages at this time.
Both major political parties may want to bear in mind, as they contemplate this policy review, that there seems to be limited political and even less national developmental advantage in maintaining a policy that is so broken that it is threatening the health and progress of a nation.
Chris Tufton is co-executive director of the Caribbean Policy Research Institute, a public policy think tank based at the University of the West Indies, and a former minister of government. Email feedback to firstname.lastname@example.org and email@example.com.