Editorial | National Health Insurance Plan Green Paper – useful start
The May 7, 2019 tabling of Government’s Green Paper on a National Health Insurance Plan (NHIP) by Minister of Health and Wellness Dr Christopher Tufton is an important juncture in the long-running debate about how best to increase and sustain financing for an inclusive, efficient and effective healthcare system in Jamaica. A Green Paper represents the broad outline of Government’s thinking on the subject and is an invitation for public comments and feedback prior to the finalisation of policy.
The vision set out in the document is ambitious and has been on the national agenda since the 1960s. During the debate around the introduction of the National Insurance Scheme, thought was given to a health insurance component. In 1974, there was a Green Paper on a National Health System, with a contributory health insurance scheme.
There was a Green Paper on a mandatory National Health Insurance for Jamaica in 1997, which did not advance due, in part, to the then deepening crisis in the Jamaican financial sector. The endemic low economic growth since the 1970s, along with the expanding public debt at the time, have made the funding of healthcare in general very difficult over the years.
In 2003, in the face of growing calls for improvements in healthcare, and coming out of the debate around the 1997 Green Paper, the National Health Fund (NHF) was introduced. The NHF was largely funded by ‘sin taxes’, which went to pay for a limited range of drugs and health conditions. Some funding from the NHF also went to improving conditions in the health infrastructure and for general healthcare.
Jamaica’s healthcare system has never been adequately funded. Care is generally below accepted standards, despite the dedicated efforts of the health professionals. This limitation in funding and resultant poor service has been a major challenge for ministers of health over the years, facing the backlash from a dissatisfied population.
Some well-intentioned reforms, like the ‘no user fee’ policy, served to expose the weaknesses of the system by driving more patients into the inadequate public health facilities, leading to more dissatisfaction.
In addition to public expenditure via taxes, the Jamaican population today is called upon to pay out-of-pocket expenditure for healthcare of over 28 per cent of gross domestic product (GDP). This is a burdensome figure. Any amount above 20 per cent of GDP exposes families to impoverishment once there is a serious health crisis. With pension and private health insurance coverage being below 20 per cent of the Jamaican workforce, many families face great financial burden from major illnesses.
HEALTHCARE REFORM NEEDS SERIOUS FINANCING
The current Green Paper is proposing a strategy for universal care that correctly starts with the need for adequate financing.
The three fundamental components of the proposed NHIP are: mandatory registration of all legal residents of Jamaica, allowing for a pooling of resources; membership guarantee and entitlement; and a defined basket of services.
The Green Paper recognises that the Government will have to subsidise the payments for the poor and vulnerable (such as PATH beneficiaries, children up to 19 years old, and adults over 65). The potential subsidy for these groups could be very large, depending on the composition of the benefits package the society settles on, as well as the degree of compliance in registration and payment.
Subsidies will have to be met by revenues, either from new sources or budgetary reallocation. The Government has focused most attention on the benefits package and governance issues in the NHIP Green Paper. It skillfully skirted proposals for new sources of revenue. This, presumably, will be expected to emerge from stakeholders during the planned consultations around the Green Paper.
The large number of stakeholders with an interest in the NHIP – including all the players in the health sectors (public and private), private health insurance providers, the NHF, taxpayers, patients, political and civic groups, NGOs, private sector, and the general public – could make consensus difficult to achieve on all aspects.
The necessary time and resources will therefore have to be devoted to the consultation process, if the debate around the Green Paper is to be successful and the national objective of finally launching a universal health insurance scheme is to be achieved.